Contact us:
+1 (520) 226-8615
Email:
[email protected]
Aquifer Case Study Developmental Evaluation and Screening
For SUBJECTIVE AND OBJECTIVE ASSESSMENT of he patient, patient history, differential diagnosis, etc. ORDER NOW for comprehensive assistance and an assured A+ SCORE.
This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned.
To support your work, use your course textbook readings and the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.
Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings.
Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.
For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.
The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam. Aquifer Case Study Developmental Evaluation and Screening
Click here for information on how to access and navigate Aquifer.
This week, complete the Aquifer Case titled Pediatrics 02: Infant female well-child visits (2, 6, and 9 months).
To Access the Assigned Case: Click on Aquifer Family Medicine then under \’Cases\’ type Pediatrics in the search bar and the Pediatrics cases will appear.
Apply information from the Aquifer Case Study to answer the following questions:
Discuss the history that you would take on this child in preparation for the well-child visit. Include questions regarding her growth and development that are appropriate for her age.
Describe the developmental tool to be used for Asia, its reliability and validity and how Asia scored developmentally on this tool. Is she developmentally appropriate for her age?
What immunizations will Asia be given at this visit; what is the patient education and follow-up?
Your first patient in pediatric clinic is Asia, a 2-month-old little girl who is brought to the clinic by her mother, Karen Foster, for a checkup and shots. This is her first visit to this clinic. Aquifer Case Study Developmental Evaluation and Screening
As part of your orientation, your preceptor, Dr. Clark, takes a few minutes to remind you about the components of a well-child visit:
TEACHING POINT
Interval History
Development
Growth
Diet History
Family History
Social History
Physical Exam
Anticipatory Guidance
Immunizations and lab work
Aquifer Case Study – Developmental Evaluation and Screening
You ask Mrs. Foster how Asia has been doing. She replies that everything has been “going great.” Because this is the baby’s first visit, you obtain a birth history: Aquifer Case Study Developmental Evaluation and Screening
“Were there any complications or infections du ring your pregnancy? Did you take any medications? Did you use any drugs or alcohol?”
“I had no problems except for a urine infection at the beginning of the pregnancy. It was treated with an antibiotic. Other than that, I didn’t use any medications and I didn’t drink alcohol, and I never have used any drugs.”
“Was your doctor concerned with your prenatal screening labs for HIV, syphillis, hepatitis B, or group B strep?”
“No, not that I can remember.”
You glance at Asia’s chart and confirm the following about her birth:
Delivery date: Two days post due date
Birth weight: 7 lbs, 11 oz (3.48 kg)
Perinatal course:
“Do you remember them telling you at the hospital that Asia passed her hearing test?”
“Yes, she did. I remember because someone else I met in the hospital had a baby that did not pass and they were deciding where the baby would go for definitive testing. They told her not to worry too much because the nursery test was just a screening test and can have false results, and more intensive testing was needed.” Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
Nutrition Guidance
Breast Milk
Formula
Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to breastfeed. Available formulas include those made with:
There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas).
There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements.
Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics:
References
Why Formula Instead of Cow’s Milk? American Academy of Pediatrics. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Why-Formula-Instead-of-Cows-Milk.aspx. Updated November 21, 2015.
Teaching
Early Growth
Most babies lose a little weight right after birth, then may regain their birth weight as early as 1 week of age, but are definitely expected to have regained their birth weight by 2 weeks of age.
Question
Of the following, which best reflects the caloric requirement of most healthy term babies in the first 1 to 2 months of life? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
The correct answer is
Aquifer Case Study – Developmental Evaluation and Screening
TEACHING POINT
Caloric Requirements of 1- to 2-Month-Olds
Term infants | Infants born at >37 weeks gestational age require 100 to 120 kcal/kg/day. Average daily weight gain for term infants is 20 to 30 grams. |
Preterm infants | Infants born at < 37 weeks gestational age require 115 to 130 kcal/kg/day. |
Very preterm infants | Infants born at < 32 weeks gestational age require up to 150 kcal/kg/day. |
Asia’s height and weight growth chart
You wash your hands and proceed to the physical exam portion of the visit, starting with Asia’s measurements.
Asia’s Measurements
You determine that Asia’s growth is appropriate.
Tips for Examining a 2-Month-Old
Babies at this age have not yet developed stranger anxiety, but you may want to perform auscultation of heart and lung sounds early in the exam, especially if they are quiet and calm. Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
Growth Parameters
Weight and Length
Head Circumference
Growth Chart
Asia’s height and weight growth chart
You wash your hands and proceed to the physical exam portion of the visit, starting with Asia’s measurements.
Asia’s Measurements
You determine that Asia’s growth is appropriate. Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study – Developmental Evaluation and Screening
Tips for Examining a 2-Month-Old
Babies at this age have not yet developed stranger anxiety, but you may want to perform auscultation of heart and lung sounds early in the exam, especially if they are quiet and calm.
TEACHING POINT
Growth Parameters
Weight and Length
Head Circumference
Growth Chart
TWO-MONTH PHYSICAL EXAM
Asia does not cry when you place her on the table; in fact, she smiles at you immediately.
Your examination findings:
Vital signs:
General: Active, alert, and nontoxic appearing
Head, eyes, ears, nose and throat (HEENT): Anterior fontanelle is soft and flat. Red reflex is present bilaterally; sclerae nonicteric. Mild neonatal acne is present. Lips are moist and pink. Tympanic membranes clear bilaterally. Palate is intact.
Lungs: Clear bilaterally, with equal air movement.
Heart: Regular rate and rhythm with no murmurs. Femoral pulses present bilaterally.
Abdomen: Normal bowel sounds, no masses or hepatosplenomegaly; abdomen is soft, nontender, and nondistended.
Hips: Ortolani and Barlow maneuvers negative bilaterally. Aquifer Case Study Developmental Evaluation and Screening
Genitalia: Normal female genitalia.
Neurologic: Tone is normal. Moves all extremities equally. Moro reflex is present and symmetric. Toes are upgoing bilaterally on Babinski maneuver.
Skin: There are no rashes, except for erythematous papules and pustules on the cheeks..
Back: No sacral dimple or hair tuft present.
TEACHING POINT
Moro Reflex
This reflex is elicited by an abrupt change in the infant’s head position and consists of two parts:
The reflex is present at birth and disappears by age 4 months.
The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.
DEEP DIVE
Aquifer Case Study – Developmental Evaluation and Screening
Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th edition, Philadelphia: Lippincott; 1999.
Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 4th ed., St. Louis, MO: C.V. Mosby; 2002:58.
CONTINUE
TWO-MONTH DEVELOPMENT
Expected tasks for age
Asia’s physical exam so far is normal, so you proceed to the developmental screen. Aquifer Case Study Developmental Evaluation and Screening
Mother’s Observations of Asia
Your Observations
Asia’s development is appropriate for her age.
TEACHING POINT
Developmental Surveillance and Screening
Evaluating a child’s development may take place routinely during the well-child visit and at any other patient encounter if the examiner or parent has concerns, even during an acute visit or hospitalization.
Developmental Surveillance
Checking milestones (comparing a child’s behaviors to expected behaviors by age) is known as developmental surveillance.
Developmental surveillance generally includes assessment of milestones in four domains.
If the child is not capable of passing the milestones in any of the four areas at or near the appropriate age, then these areas are of concern for possible delay and should be followed up or further testing or evaluation should be done. Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study – Developmental Evaluation and Screening
Developmental Screening
Surveillance is not as sensitive or specific as using a validated developmental screening test to pick up true developmental or behavioral abnormalities.
Screening with a validated tool is recommended at 9, 18, and 24 months of age.
For more information on developmental screening, see the AAP’s Policy Statement and Aquifer’s tool for learning the milestones, which includes videos demonstrating expected milestones in all four domains at each recommended well-visit age (2 months, 4 months, 6 months) from birth to age 5.
DEEP DIVE
References
2009 Glascoe FP, Roberstshaw NS, Ellsworth & Vandermeer Press, LLC, 1013 Austin Court, Nolensville, TN 37135. http://www.pedstest.com.
Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118(1). Policy statement reaffirmed by the AAP November 2014 http://pediatrics.aappublications.org/content/118/1/405.full.
CONTINUE
TWO-MONTH ANTICIPATORY GUIDANCE
At this point you reassure Asia’s mother that she has a very healthy baby, and you ask her if she has any questions. Mrs. Foster wonders when she should start giving Asia solid foods and whether she should give her vitamins. She also asks when she will sleep through the night: Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
Anticipatory Guidance at the 2-month Visit
Solid Foods
Child Care
Sleep
Safety
References
American Academy of Pediatrics. Choosing a Child Care Center. http://www.healthychildren.org/English/family-life/work-play/Pages/Choosing-a-Childcare-Center.aspx.
Wagner, CL, Greer, FR, and the section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents: American Academy of Pediatrics Clinical Report. Pediatrics 2008;122(5); 1142-1152. http://pediatrics.aappublications.org/content/122/5/1142.full.
Mrs. Foster tells you that she bought a new car seat for Asia and asks you where she should place it in the car.
Question
Which of the following positions is most appropriate for Asia at this age? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answer is C.
TEACHING POINT
Car Seat Safety
Under 2 years of age (and not over the manufacturer’s weight or height requirement for seat) | Rear-facing car safety seat, restrained in the rear seat |
Between 2 years and 4 years of age | Forward-facing car safety seat, restrained in the rear seat |
Between 4 years and 8 years of age | Belt-positioning booster seat, restrained in the rear seat |
Over 8 years of age | Lap-and-shoulder seat belts for all who have outgrown booster seats, restrained in the rear seat |
13 years of age and older | Lap-and-shoulder seat belt, rear or front seat |
Aquifer Case Study – Developmental Evaluation and Screening
Which of the following vaccines will you give Asia today at her 2-month visit? Select all that apply. Aquifer Case Study Developmental Evaluation and Screening
Resources
Link to the CDC’s webpage for current immunization schedules for children and adolescents.
Information on how to talk with parents about immunizations.
The best options are indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answers are A, C, D, E, F, G.
The appropriate immunizations for Asia today are her first doses of:
She should also receive her second HepB (C); her first was given in the nursery before discharge. (If a child has not received a HepB in the nursery, HepB #1 should be administered at the first office visit.)
The MMR (B) and HepA (H) vaccines are not given until 12 months of age.
Dr. Clark returns and verifies the information you provided. After asking if Ms. Foster has any other questions or concerns (she doesn’t), you and Dr. Clark record the orders for the vaccines and then ask Ms. Foster to schedule the next checkup, when Asia is 4 months old. Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study – Developmental Evaluation and Screening
TEACHING POINT
These are the vaccines and the number of doses of each that children should receive through 6 years of age:
Vaccine | Immunizes Against | Number of Doses |
DTaP | Diphtheria, tetanus, pertussis | 5 |
IPV | Polio | 4 |
Hib | Haemophilus influenzae type B | 3 or 4, depending on the vaccine manufacturer |
PCV13 | Pneumococcus (13 strains) | 4 |
MMR | Measles, mumps, rubella | 2 |
Varicella | Varicella | 2 |
RotaV | Rotavirus | 2 or 3, depending on the vaccine manufacturer |
HepA | Hepatitis A | 2 |
HepB | Hepatitis B | 3 |
(Adolescent immunizations are discussed in other relevant cases in Aquifer Pediatrics.)
Seasonal Influenza
Routine annual influenza vaccination is recommended for all persons aged ?6 months who do not have contraindications.
Combination Vaccines
Combination vaccines represent one solution to the issue of increased numbers of injections during single clinic visits, and may be used instead of their equivalent component vaccines if licensed and indicated for the patient’s age. Examples of combination vaccines are Pediarix® (DTaP, Hep B, IPV) and Pentacel® (DTaP, IPV, Hib). Aquifer Case Study Developmental Evaluation and Screening
Vaccine Adverse Events
Common side effects of immunizations include redness or swelling at the injection site, fussiness, and low-grade fever. Significant health problems that occur after immunization should be evaluated immediately and reported to the CDC’s national vaccine safety surveillance program, VAERS. The risks of adverse effects are far outweighed by the risks of serious consequences from contracting the diseases themselves, so the AAP recommends routine immunization of all healthy children.
References
Resources
Link to the CDC’s webpage for current immunization schedules for children and adolescents.
Information on how to talk with parents about immunizations.
CDC’s Vaccine Adverse Event Reporting System (VAERS
CONTINUE
http://www.immunize.org/talking-about-vaccines/responding-to-parents.asp
https://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html
Today is Asia’s 6-month birthday, and she is here for her well-child visit. Aquifer Case Study Developmental Evaluation and Screening
You review her chart and see that she had a 4-month well-child visit with Dr. Clark. He did not have any concerns about Asia. He administered all of the required vaccines and documented that he provided anticipatory guidance.
After playing with Asia and getting a big smile from her, you get an interim history, as well as an updated diet and developmental history, from her mother.
“How has Asia been doing since I last saw her? Has she been sick at all or has she been in the hospital?”
“She’s been doing great. Over the last couple of months, she has really become interactive and playful. She’s a lot of fun.
Healthwise, she has had a couple of colds, because I had to put her in daycare when she was 3 months old. But she hasn’t been sick enough to see the pediatrician or go to the hospital.”
“Is she still taking formula? How much? Have you been feeding her solid foods?”
“She still takes formula, but now she takes about 8 oz four times a day.
She eats prepared baby food: fruits and vegetables and rice cereal. I was thinking about starting her on some meats, but I’m not sure if she’s ready for them.”
You note this question and tell Asia’s mother that you will bring her a handout on feeding infants: https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx
“Does she roll over or sit by herself? Is she talking?”
“She’s been rolling over for a couple months, but she just started sitting by herself.
She babbles a lot, but she doesn’t say any words yet. She loves to laugh a lot.” Aquifer Case Study Developmental Evaluation and Screening
CONTINUE
QUESTION REGARDING GROWTH
Aquifer Case Study – Developmental Evaluation and Screening
Asia’s 6-month height and weight growth chart
You want to check Asia’s growth chart to make sure she has grown appropriately. You measure her head circumference yourself and plot the following on the growth curve:
Weight: 7 kg (15.4 lbs)
Length: 65 cm (25.6 inches)
Head circumference: 43 cm (17 inches)
Question
By what ages should an infant double and triple his or her birth weight? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answer is C.
TEACHING POINT
Typical Early Childhood Growth Patterns
Most healthy infants will double their birth weight by 4 to 5 months and will triple their birth weight by 1 year of age. In addition, most children will reach double their birth length by age 4 years. Aquifer Case Study Developmental Evaluation and Screening
Former preemies, small for gestational age babies, and others with chronic health issues do not always follow this pattern, and there are separate growth charts available for these special populations.
In 2006, the World Health Organization (WHO) released a new international growth standard which reflects how infants and young children grow under optimal nutritional conditions. The WHO standards establish the growth of the breastfed infant as the norm and provide a better description of ideal, rather than typical, growth patterns. WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2 Years of Age.
https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts
SIX-MONTH PHYSICAL EXAM
Aquifer Case Study – Developmental Evaluation and Screening
You wash your hands and prepare for the physical exam. Before you approach Asia, you notice that she is sitting on her mom’s lap with good head control and that she is very curious about her environment. You take her from her mother and place her on the examination table. She cries initially, but you are able to engage her by smiling and playing with her.
TEACHING POINT
The Red Reflex
Description
The red reflex is the red or orange color reflected from the fundus through the pupil when viewed through an ophthalmoscope approximately 10 inches from the patient. It gives direct information about the clarity of the eye structures and therefore is a substitute for a careful fundoscopic exam, since a 6-month-old will not hold his or her gaze long enough for the examiner to visualize the retina consistently. Examination of the red reflex should be performed in a darkened room. In infants with more darkly pigmented skin the reflex may appear more gray than red.
This reflex should be elicited in all infants and children, beginning at birth.
Absence of a symmetric red reflex or the presence of leukocoria (white pupil) may indicate underlying abnormalities, including:
A pediatric ophthalmologist should be consulted immediately if leukocoria, an abnormal or asymmetric red reflex, or signs of nonaccidental trauma are identified on physical examination. Aquifer Case Study Developmental Evaluation and Screening
References
Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th ed., Philadelphia: Lippincott; 1999.
CONTINUE
SIX-MONTH DEVELOPMENTAL EXAM
Aquifer Case Study – Developmental Evaluation and Screening
Developmental Observations About Asia
Question
Has Asia performed the expected developmental milestones for a 6-month-old infant?
The best option is indicated below. Your selections are indicated by the shaded boxes. Aquifer Case Study Developmental Evaluation and Screening
SUBMIT
Answer Comment
> The correct answer is A.
Yes, Asia is performing to the expected level on developmental surveillance.
Aquier’s tool for learning the milestones.
TEACHING POINT
6-Month Developmental Milestones
Gross motor | · Rolls over
· Sits unsupported · No head lag when pulled to sit from supine |
Fine motor | · Reaches for objects
· Looks for dropped items |
Language | · Turns toward voice
· Babbles (i.e., use of repetitive consonants: ba-ba-ba or da-da-da) (When the child says da-da-da, the family reinforces the sounds by praising the infant; then the infant makes the connection of the sound to the father.) Aquifer Case Study Developmental Evaluation and Screening |
Social/Adaptive | · Feeds self
· Demonstrates stranger recognition, the prelude to stranger anxiety |
References
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition (2008), an AAP publication.
After telling Mrs. Foster that Asia looks very healthy, you move on to anticipatory guidance. Even though Asia is not crawling yet, now is the time for her parents to childproof the home: Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
Toddler-Proofing the Home
There are several steps parents or guardians should take to childproof their home – before children begin crawling and walking. These include:
In addition, the number for poison control should be kept near the phone.
Question
Besides home safety, what are additional topics you could discuss with Asia’s mom regarding anticipatory guidance at this age?
The suggested answer is shown below.
SUBMIT
Answer Comment
TEACHING POINT
Anticipatory Guidance at the 6-month Visit
Car seat placement: The car seat should still be in the back seat, facing the rear. Aquifer Case Study Developmental Evaluation and Screening
Use of walkers: The AAP has recommended against the use of walkers because of the risk of injury, especially when there are stairs in the home. In addition, walkers do not teach children to walk any earlier than they otherwise would.
Dietary changes:
Developmental changes:
The AAP’s website HealthyChildren.org has much more information on anticipatory guidance and well-child care for parents and professionals.
Aquifer Case Study – Developmental Evaluation and Screening
https://www.healthychildren.org/English/Pages/default.aspx
Reviewing Asia’s immunization record, you confirm that she received her 4-month immunizations at that well visit. You ask her mother if she has had any difficulties with her previous immunizations. She reports some fussiness for a few hours, but she denies fever or other problems. Aquifer Case Study Developmental Evaluation and Screening
You decide to review the current year’s immunization requirements and recommendations.
Mrs. Foster asks you which immunizations will be given today:
You opt to hold the third IPV until the 9-month visit; the parent has been 100% adherent with office visits, and this will reduce the number of injections for this visit to four (there is flexibility for the third polio injection; it needs to be given anytime between 6 months and 18 months).
You and Dr. Clark bring the visit to a close by asking Mrs. Foster if she has any other concerns or questions. She does not, and you ask to see her back when Asia is 9 months old for another well-child visit.
TEACHING POINT
Annual Review of the Immunization Schedule
Members of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and American Academy of Family Physicians meet annually to formulate an immunizations schedule that is as evidence-based as is possible. The current year’s immunization requirements are available from the CDC.
TEACHING POINT
Acetaminophen and Vaccines
The use of antipyretics for the prevention of fevers associated with vaccine administration merits careful consideration. The prophylactic administration of acetaminophen has been associated with decreased antibody concentrations for some vaccine antigens, although all concentrations remained in the protective range. Aquifer Case Study Developmental Evaluation and Screening
https://www.cdc.gov/vaccines/schedules/
INTERIM HISTORY: AGE 6 TO 9 MONTHS OLD
Asia at 9 months, with her mother
It is now three months later, and Asia has come to the office for her 9-month health maintenance visit.
You enter the exam room to find Asia smiling and playful in her mother’s lap. She looks healthy and appears to have grown well since her last visit. You sit down to take an interim history from her mother.
“How has Asia been doing since I last saw her? Do you have any concerns?”
“She’s doing great. She’s just growing up so fast. I have no concerns.”
“Is she still taking infant formula? What foods is she eating now? Is she having any problems with diarrhea or constipation?”
“Yes, she’s still taking the same formula. She drinks at least three 8-ounce bottles a day. She’s eating strained vegetables and fruits as well as lots of finger foods like crackers and toast. We gave her some chicken last week, and she seemed to like it. Her bowel movements are regular, usually two a day.” Aquifer Case Study Developmental Evaluation and Screening
Because Asia is now drinking less than 32 ounces a day of vitamin-enriched formula, you recommend Asia be supplemented with an over-the-counter infant liquid multivitamin.
“Is she napping during the day? How is she sleeping at night?”
“She takes a morning and afternoon nap, and then she sleeps through the night.”
DEEP DIVE
Aquifer Case Study – Developmental Evaluation and Screening
References
Shelov S, ed. Caring for Your Baby and Young Child: Birth to Age 5. American Academy of Pediatrics. New York: Bantam; 1998.
Asia sits on the exam table.
Mrs. Foster seems to be very happy with how Asia has been doing. On this visit, the nurse has already obtained Asia’s measurements and plotted her growth (shown above).
When you review the PEDS developmental screening form that Mrs. Foster completed, you note that she has no concerns.
You now want to know if Asia has met her 9-month developmental milestones. Aquifer Case Study Developmental Evaluation and Screening
Question
Of the following, which are developmental milestones that you expect to see in a developmentally appropriate 9-month-old infant? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answers are A and C.
Review the Developmental Milestones at a Glance: Infancy or Aquifer’s tool for learning the milestones to see what is expected by this age.
Thinking about the various anticipatory guidance topics that are appropriate to review with Asia’s mother, you decide to discuss the 12-month milestones.
TEACHING POINT
12 Month Developmental Milestones
By the time a child is 12 months old, developmental milestones include: Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study – Developmental Evaluation and Screening
Asia on the exam table
Asia seems to be right on track for her growth and development.
Asia’s mother has undressed her, and Asia lets you put her on the examining table.
You begin your exam in the least intrusive way, by auscultating her heart and lungs:
Chest/lungs: Symmetrical expansion, no retractions. Bilateral breath sounds are clear and symmetric.
Heart: Regular rate and rhythm, normal S1 and S2; no murmurs, gallops, or rubs.
Abdomen: Slightly distended. Active bowel sounds. A firm nodular mass is palpable on the right side extending below the subcostal margin approximately 6 cm. Its diameter is also about 6 cm and it does not appear to cross the midline. No splenomegaly.
CONTINUE
NINE-MONTH PHYSICAL EXAM CONTINUED
You have discovered an abdominal mass and are very concerned as you complete your exam. Here are the remainder of your findings: Aquifer Case Study Developmental Evaluation and Screening
Head, eyes, ears, nose and throat (HEENT)::
Neck: Supple, no masses.
Lymph: No cervical, axillary, or inguinal adenopathy.
Skin: Normal turgor. No jaundice. Pale nail beds.* Healing bruise on forehead. (Her mother tells you that she bumped her head on the coffee table when she pulled herself to standing.) No other bruises and no petechiae noted.
*The more the skin is pigmented, the less the skin can be used for detecting pallor. Inspection of conjunctivae, nail beds and mucous membranes will be more helpful.
Neurological: Alert and appropriate. Normal tone and symmetric movement of all extremities. Sitting well and pulls herself to stand. Crawls on exam table.
GU: Normal female genitalia.
SUMMARY STATEMENT
You begin thinking of what could be causing an abdominal mass in an otherwise healthy and asymptomatic infant.
Question
Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers. Aquifer Case Study Developmental Evaluation and Screening
Guidelines for summary statements.
Your response is recorded in your student case report.
SUBMIT
Answer Comment
Asia is an asymptomatic, thriving 9-month-old girl incidentally noted to have a RUQ mass and pallor on routine well-child care exam. She has no lymphadenopathy, splenomegaly, or jaundice.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: Asia is female, 9 months old, and thriving.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
You consider the summary you’ve just written:
Asia is an asymptomatic, thriving 9-month-old girl incidentally noted to have a RUQ mass and pallor on routine well-child care exam. She has no lymphadenopathy or jaundice. Aquifer Case Study Developmental Evaluation and Screening
Question
Which of the following are on your differential diagnosis? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answers are F, G, H, I, J.
TEACHING POINT
Aquifer Case Study – Developmental Evaluation and Screening
Serious illnesses may cause a decrease in growth and even weight loss, but normal growth should not eliminate serious diagnoses from your differential. Aquifer Case Study Developmental Evaluation and Screening
Condition | Discussion |
Hepatic neoplasm | · Although rare in children this age, an hepatic neoplasm (whether malignant, such as hepatoblastoma, or benign) can cause an asymptomatic abdominal tumor and must be considered in a young infant with an asymptomatic RUQ abdominal mass.
· Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis. |
Hydronephrosis | · An obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, sometimes manifesting as a flank mass.
· In the newborn, a multicystic kidney may cause such an obstruction. · While possibly asymptomatic, hydronephrosis causing a 6 cm palpable mass would usually present with a urinary tract infection. |
Neuroblastoma | · The most frequently diagnosed neoplasm in infants; more than half of patients present before age 2.
· The tumor may present as a painless mass in the neck, chest, or abdomen. · Children with an abdominal neuroblastoma may be asymptomatic; however, they may also appear chronically ill and may have bone pain from metastases to the bone marrow or skeleton. · Fever, pallor, and weight loss are frequent presenting symptoms. · Neuroblastoma is a likely diagnosis in an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice. |
Teratoma | · This is a rare malignant tumor.
· A teratoma may present as a painless abdominal mass without other symptoms or it may cause pressure effects on neighboring structures resulting in abdominal or back pain, nausea, vomiting, constipation, and/or urinary tract symptoms. · A rare form of cancer (which in itself is rare in children), teratoma should be considered, even if it is quite low on the list. |
Wilms’ tumor (nephroblastoma) | · This is a likely diagnosis in a child with an asymptomatic RUQ abdominal mass who has no lymphadenopathy or jaundice on exam and who is growing and developing normally. Aquifer Case Study Developmental Evaluation and Screening
· These tumors are often discovered by the parents or on routine examination. · The masses are generally smooth and rarely cross the midline. · Associated symptoms occur in 50% of patients and include abdominal pain and/or vomiting; patients may also be hypertensive. · The median age at diagnosis is 3 years. |
Consideration of the five more likely diagnoses for Asia:
Hepatic neoplasm (F) is consistent with her presentation and should be included in the differential. (More details about this condition are on the pages that follow.)
Asia’s age and the finding of pallor argue against hydronephrosis (G); however, it should be on the differential diagnosis, albeit lower than other causes.
Asia’s appropriate growth and lack of lymphadenopathy do not rule out neuroblastoma (H).
A teratoma (I) should be considered, although it is unlikely and Asia’s pallor and lack of symptoms argue against this diagnosis.
While Wilms’ tumor (J) should remain on the differential diagnosis, Asia’s age and the finding of pallor are two factors that argue against this diagnosis. Aquifer Case Study Developmental Evaluation and Screening
The following diagnoses are much less likely and would not be included in your initial differential diagnosis:
While an appendiceal abscess (A) may have fewer symptoms than acute appendicitis, a patient would typically have abdominal pain, fever, nausea, or anorexia.
Congestive heart failure (B) can lead to palpable hepatomegaly from right-sided heart failure; however, children with CHF have poor growth and very poor exercise tolerance.
Constipation (C) is the most common cause of a left-sided abdominal mass (especially in the LLQ from palpable stool in the sigmoid colon), usually mobile on palpation. It would not be palpable as an immobile RUQ mass. Also, typically there are other signs, such as a history of hard and/or infrequent stools.
Fatty liver disease (D), an increasing problem due to childhood obesity, could cause some palpable hepatomegaly, but this would just be a palpable liver “edge,” however, and not a full abdominal mass.
An hepatic abscess (E) can cause an abdominal mass. However, the child would typically have symptoms of hepatic dysfunction. An abscess can cause fevers, abdominal pain, malaise, and anorexia. Aquifer Case Study Developmental Evaluation and Screening
DISCUSSING EXAM FINDINGS
Aquifer Case Study – Developmental Evaluation and Screening
After finishing your exam, you tell Asia’s mother that you will discuss all that you have discussed with Dr. Clark and will return with him.
Question
Dr. Clark asks you, “After I confirm your physical exam, if I agree with what you have found, how do you suggest we break this potentially terrible news to the family?”
The best options are indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answers are A, B, C, D.
TEACHING POINT
Introducing Difficult News
There are a number of acceptable ways to introduce a difficult topic such as a serious diagnosis to the family. Of course, as the family begins to understand the enormity of the diagnosis, they may not be ready to receive any more information.
Some recommendations:
Aquifer Case Study – Developmental Evaluation and Screening
Dr. Clark confirms your physical exam findings.. After discussing the plan with Asia’s mother, lab work and imaging are ordered. You follow up with Dr. Clark the next week and he says that after the initial round of tests, Asia was admitted to the local children’s hospital, and additional testing was obtained.
You review the results of Asia’s tests:
CBC with differential:
Lab Value | Conventional | SI |
WBC | 10.0 cells x103/?L | 10.0 cells x109/L |
Neut | 35% | 0.35 |
Lymph | 60% | 0.60 |
Mono | 5% | 0.05 |
Hgb | 8.0 g/dL | 80 g/L |
Hct | 25% | 0.25 |
MCV | 82 ?m3 | 82 fL |
Plts | 243,000 mm3 | 243.0 x109/L |
Associated pediatric reference ranges in conventional and SI units.
Urine vanillylmandelic acid (VMA) and urine homovanillic acid (HVA): Significantly elevated.
Chest x-ray: Normal chest. No metastases.
Bone scan: Normal. No metastases.
Abdominal ultrasound : Retroperitoneal mass arising from the adrenal gland that does not cross the midline. The tumor has heterogenous consistency with both solid and cystic elements. Aquifer Case Study Developmental Evaluation and Screening
Abdominal ultrasound
Plain abdominal radiograph: Large mass in the right upper quadrant.
Plain abdominal radiograph
Abdominal CT scan: Retroperitoneal mass arising from the adrenal gland. Does not cross the midline. Heterogenous consistency with both solid and cystic elements. Diffuse stippled calcification with invasion of the renal parenchyma. No lymph node enlargement.
Abdominal CT scan
Technetium-99 bone scan
Technetium-99 bone scan
Bone marrow aspiration/biopsy: Histopathology reveals “small round blue cells” or small, uniform cells containing dense, hyperchromatic nuclei and scant cytoplasm, forming small cell rosettes.
Bone marrow aspiration/biopsy
TEACHING POINT
Initial Testing
Initial workup for abdominal mass
CBC with Differential
Catecholamine Metabolites (VMA and HVA)
Chest x-ray
Skeletal Survey
Abdominal Ultrasound
Abdominal x-ray
Abdominal CT
Imaging | Laboratory | |
Neuroblastoma | · CT scan may reveal calcifications and a heterogenous mass with cystic areas representing either hemorrhage or necrotic tumor.
· Metastases are primarily to regional lymph nodes and to the liver, bone marrow, and skeleton. · Chest radiograph will reveal any lymph node involvement in the chest or additional tumors that may present in the posterior mediastinum. |
· Histopathology reveals “small round blue cells” or small, uniform cells containing dense, hyperchromatic nuclei and scant cytoplasm, forming small cell rosettes.
· Urinary HVA/VMA will be elevated in 90-95% of cases. · A CBC may reveal anemia or other cytopenias that are secondary to bone marrow infiltration. |
Wilms’ tumor | · Ultrasound may identify the mass as intrarenal.
· On CT scan the mass may be heterogenous with areas of low density representing necrosis. A pseudocapsule may be observed because of the sharp demarcation between tumor and normal renal parenchyma. · Pulmonary metastases may be identified on chest radiograph. · CT scan of the chest is indicated to visualize areas of lung below the level of the dome of the diaphragm. |
· Laboratory findings may include hematuria. Aquifer Case Study Developmental Evaluation and Screening |
Hepatic tumor | · Radiograph of abdomen will demonstrate hepatic enlargement with hepatic tumors.
· CT scan will show tumor and origin of tumor. · Chest CT is indicated to look for pulmonary metastases. |
· Diagnosis is dependent on histologic examination.
· Laboratory studies of liver function are usually normal but liver enzymes and bilirubin may be elevated in 20% of cases. Aquifer Case Study Developmental Evaluation and Screening · Alpha-fetoprotein levels will be increased in most patients. |
Teratoma | · Teratomas and germ-cell tumors are best identified with CT scan.
· Tumors appear as well-defined masses with both solid and cystic components. · Teratomas are identifiable on plain x-ray only if calcified components, such as teeth or bony fragments, are present. |
Aquifer Case Study Developmental Evaluation and Screening |
Constipation | · Constipation causing a palpable abdominal mass can readily be identified on plain radiographs of the abdomen.
· No other radiographic evaluation is necessary. |
· No laboratory evaluation is necessary. Aquifer Case Study Developmental Evaluation and Screening |
Benign renal mass | · Hydronephrosis can be diagnosed with ultrasound.
· Voiding cystourethrogram will demonstrate any ureteral obstruction or vesicoureteral reflux. |
Aquifer Case Study Developmental Evaluation and Screening |
Aquifer Case Study – Developmental Evaluation and Screening
DIAGNOSIS
Aquifer Case Study Developmental Evaluation and Screening You review the results of Asia’s work-up with Dr. Clark: Aquifer Case Study Developmental Evaluation and Screening
Imaging studies
Bone marrow pathology
Bloodwork
Urinary catecholamine values
Because Asia has been diagnosed with neuroblastoma,she will need additional testing.
Dr. Clark explains that Asia has Neuroblastoma Stage 4S disease, which carries a favorable outcome. Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
It seems paradoxical for a cancer that has metastasized to be considered a favorable stage. However, in infants less than 1 year of age, these tumors may spontaneously regress. Aquifer Case Study Developmental Evaluation and Screening
This is due to the unique nature of this tumor derived from embryonal cell lines.
DEEP DIVE
Staging of Neuroblastoma
Stage | Description |
1 | Tumor localized to the area of origin. |
2 | Tumor extends beyond the area of origin, does not cross midline, may involve ipsilateral lymph nodes (Stage 2B). |
3 | Tumor extends beyond midline or has regional lymph node involvement. |
4 | Disseminated tumor to distant lymph nodes, bone, bone marrow, liver or other organs. |
4S | Localized primary tumor as in Stage I or II with dissemination limited to liver, skin or bone marrow. |
Aquifer Case Study – Developmental Evaluation and Screening
A family meeting is arranged to discuss Asia’s prognosis and treatment options. Present at this meeting in addition to Asia’s family are the oncologist, Dr. Clark, a nurse coordinator, a social worker, and yourself. This group of professionals will be very important in supporting Asia and her family through this difficult time. Aquifer Case Study Developmental Evaluation and Screening
Although Asia and her family will be seeing primarily the oncologist for the next few months, they will return to see you and Dr. Clark for Asia’s one-year visit. Aquifer Case Study Developmental Evaluation and Screening
DEEP DIVE
Stage | Treatment and Prognosis |
1 | · Surgical resection, chemotherapy if recurrence
· Disease-free survival rate of 90% Aquifer Case Study Developmental Evaluation and Screening |
2A | · Surgery and low-dose chemotherapy
· Radiation for those who fail to respond Aquifer Case Study Developmental Evaluation and Screening · 2-year survival rate of 85%. |
2B (infants) | · Surgery and low-dose chemotherapy
· Radiation for those who fail to respond · 2-year survival rate of 85% |
2B (children) | · Chemotherapy and/or irradiation
· Mean survival is 60-70% |
3 (infants) | · Surgery and low-dose chemotherapy
· Radiation for those who fail to respond · 2-year survival rate of 85% |
3 (children) | · Chemotherapy and/or irradiation Aquifer Case Study Developmental Evaluation and Screening
· Mean survival is 60-70% |
4 (infants) | · Chemotherapy and/or irradiation
· Mean survival is 60-70% |
4 (children) | · Chemotherapy, irradiation, and bone marrow transplantation
· Overall survival is < 15% Aquifer Case Study Developmental Evaluation and Screening |
4S | Infants older than 6 weeks:
· Can be observed for tumor progression · Chemotherapy or local irradiation are given for enlarging abdominal masses that are causing respiratory compromise · Mean survival is 86% Infants younger than 6 weeks of age who lack skin involvement: · Mean survival is 38% Aquifer Case Study Developmental Evaluation and Screening |
Important favorable prognostic factors include:
Aquifer Case Study – Developmental Evaluation and Screening
GENETIC RISK
Mrs. Foster asks, “I’ve read that some cancers can be passed down in families. Is neuroblastoma one of those?” Explaining some of the terms, the oncologist tells her the latest findings on the genetics of neuroblastoma (see below). Aquifer Case Study Developmental Evaluation and Screening
You wish Mrs. Foster and Asia well and let them know you are available for any concerns that may arise. The family leaves, apprehensive about the upcoming treatments, but very comfortable with the care proposed and the explanations given. Aquifer Case Study Developmental Evaluation and Screening
TEACHING POINT
Aquifer Case Study Developmental Evaluation and Screening Genetics of Neuroblastoma
Familial
According to the most recent studies, there are familial forms of neuroblastoma, but these account for only about 1% of cases. The familial form appears to be autosomal dominant, with low penetrance.
These pedigrees show examples of the autosomal dominant inheritance with complete and low penetrance:
Examples of the autosomal dominant inheritance with complete and low penetrance
Non-Familial
Most cases of neuroblastoma are due to somatic mutations. That is, these mutations arise in cells other than the gametes. Somatic mutations are not passed to the next generation. Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study Developmental Evaluation and Screening References
Shojaei-Brosseau T, Chompret A, Abel A, de Vathaire F, Raquin MA, Brugieres L, Feunteun J, Hartmann O, Bonaiti-Pellie C. Genetic epidemiology of neuroblastoma: a study of 426 cases at the Institut Gustave-Roussy in France. Pediatr Blood Cancer. 2004 Jan;42(1):99-105. Aquifer Case Study Developmental Evaluation and Screening
Neuroblastoma-Childhood Guide, American Society of Clinical Oncology Cancer.Net https://www.cancer.net/cancer-types/neuroblastoma-childhood/introduction
https://www.cancer.net/cancer-types/neuroblastoma-childhood/introduction
TWELVE-MONTH VISIT
When Asia comes back to see you for her 12-month checkup, you read the consultant notes from the pediatric hematology-oncology specialist: Aquifer Case Study Developmental Evaluation and Screening
Tumor was confirmed to be Stage 4S and lower-risk: She did not have the MYC-N gene amplification and had favorable histology.
The family and oncologist decided together that because the primary tumor was large, resection was a better option than observation for resolution. Of course, Asia will be observed closely for the next several years to make sure that the metastatic lesions resolve and that the primary tumor does not recur. Aquifer Case Study Developmental Evaluation and Screening
This is the final page of the case. We value your perspective on the learning experience. After completing three required feedback ratings you can finish the case and access the case summary. Aquifer Case Study Developmental Evaluation and Screening
You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. Aquifer Case Study Developmental Evaluation and Screening
He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? Aquifer Case Study Developmental Evaluation and Screening
The best option is indicated below. Your selections are indicated by the shaded boxes. Aquifer Case Study Developmental Evaluation and Screening
SUBMIT
Aquifer Case Study – Developmental Evaluation and Screening
Answer Comment
> The correct answer is C.
Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy’s age to be based upon his developmental milestones? Aquifer Case Study Developmental Evaluation and Screening
The best option is indicated below. Your selections are indicated by the shaded boxes. Aquifer Case Study Developmental Evaluation and Screening
SUBMIT
Aquifer Case Study – Developmental Evaluation and Screening
Answer Comment
> The correcgt answer is C.
Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. Aquifer Case Study Developmental Evaluation and Screening
He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? Aquifer Case Study Developmental Evaluation and Screening
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answer is A.
Aquifer Case Study – Developmental Evaluation and Screening
An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child?
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
> The correct answer is E.
QUESTION #5
A 9-month old baby boy comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today’s visit? Aquifer Case Study Developmental Evaluation and Screening
The best option is indicated below. Your selections are indicated by the shaded boxes. Aquifer Case Study Developmental Evaluation and Screening
Aquifer Case Study – Developmental Evaluation and Screening
SUBMIT
Answer Comment
> The correct answer ic C.
QUESTION #6
A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is perfo rmed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? Aquifer Case Study Developmental Evaluation and Screening
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Aquifer Case Study – Developmental Evaluation and Screening
Answer Comment
> The correct answer is B.
Thank you for completing Pediatrics 02: Infant well-child visits (2, 6, and 9 months).
DIAGNOSES
FINDINGS
NOTES
BOOKMARKS
Diagnoses
New Diagnosis…
Aquifer Case Study Developmental Evaluation and Screening