A mother has brought in her 4-month-old infant for a scheduled
health maintenance visit.
Vital Signs:
Temperature 98.6°F
Blood pressure 105/60 mmHg
Respiratory rate 24 breaths per minute
Heart rate 100 beats per minute.HISTORY—Include significant positives and negatives from the history
of present illness, past medical history, review of systems, and social
and family history.
The mother of a 4-month-old is bringing in her infant for a scheduled
health maintenance examination. The infant had no prenatal infections and his was an uncomplicated, normal, spontaneous vaginal
delivery. His birth weight was 7 pounds, 6 ounces. Little Johnny Wilson
has been healthy since birth. He is eating well and wakes once a night
to feed. Other than the one feeding, he sleeps through the night. She
plans to continue breast-feeding until he is 1 year old. The mother
feels that the infant hears well, since he turns his head toward sounds
and voices. He follows people with his eyes, so the mother feels he
is able to see well. He coos and laughs and seems to be developing
his language skills. The mother states that he last received immunizations at 2 months of age. He has not been ill. She always puts him
in the appropriate child seat when in the car.
256 MASTERING THE USMLE STEP 2 CS
DIFFERENTIAL DIAGNOSIS
In order of likelihood, write no
more than five differential diagnoses for this patient’s current
problems.
1. normal health maintenance
visit
2. normal growth and
development
3.
4.
5.
DIAGNOSTIC WORKUP
Immediate plans for no more
than five diagnostic studies.
1. weight
2. height
3. head circumference
4. thorough physical
examination
5.
LEARNING OBJECTIVE FOR JOHNNY WILSON
MONITOR GROWTH AND DEVELOPMENT IN A CHILD
Health maintenance visits for children are scheduled at regular intervals. In the first 2 years of life, the child should be seen by the pediatrician at 1, 2, 4, 6, 12, 15, 18, and 24 months of age. Laboratory testing and immunizations are performed at the appropriate intervals.
Growth and development is followed at each visit by checking the child’s
weight, height, and head circumference. The physician should inquire
about the child’s pattern of sleep and diet (solid food may be started
at 6 months of age). Monitoring the developmental progress of the
child includes a careful assessment of the child’s behavior, language,
and motor skills.
The physical examination during health maintenance visits should
be thorough and complete. Heart rate and blood pressure should be
taken and the skin examined for lesions. Examination of the fontanelles
should reveal closure by 18 months of age (the posterior fontanelle
is usually closed by 8 weeks of age). The eyes should be examined for
cataracts or infection. The ears should be investigated for otitis media.
Anterior and posterior auscultation of the heart and lungs is necessary
to elicit murmurs and assess for bilateral breath sounds. The abdomen
should be palpated for masses and organomegaly. An examination of
the extremities, with special attention to the hips, and a neurologic
assessment—including the examination of cranial nerves, reflexes,
and motor and sensory systems—are included in every health maintenance visit.
Health maintenance visits give the parents and the physician a
chance to develop a relationship that will be helpful and educational
to the parents (anticipatory guidance) and rewarding to the physician.
The pediatrician should solicit questions and concerns from the parents and offer positive reinforcement, support, and reassurance when
appropriate. A physician should assist parents to provide a safe and
comfortable environment for children. Discussions about nutrition,
exercise, dental care, and discipline should be part of the routine
health maintenance visit.
History-Taking Pearl: Know the landmarks for normal development:
1 month: smiles, turns head, watches a person, holds chin up
2 months: recognizes parents, smiles on social contact, listens to
voice, coos
3 months: laughs, listens to music, recognizes objects, reaches for
objects and brings them to mouth
5 months: babbles, rolls over, prefers mother, lifts head
8 months: single words
10 months: sits up alone, plays peek-a-boo, waves bye-bye, grasps
objects with thumb and forefinger, points to a desired object
CASE 30 257
12 months: two-word sentences, walks with one hand held, releases
object to other person on request, plays simple ball game
17 months: conversational
Patient Note Pearl: Be able to discuss the immunization schedule with
a new parent.
At birth: hepatitis B virus (HBV) [if mother’s hepatitis B surface antigen (HBsAg) status is positive or unknown]
1 month: HBV
2 months: diphtheria, tetanus and pertussis vaccine (DTP), H. influenzae b conjugate vaccine (HbCV), and oral polio vaccine (OPV)
4 months: DTP, HbCV, and OPV
6 months: DTP, HBV, and HbCV
15 months: measles, mumps, rubella (MMR), HbCV, DTP, and OPV
4 years old: DTP, OPV, and MMR
11 years old: MMR
14 years old: tetanus, diphtheria toxoid vaccine (Td)
HBV schedule varies, depending on HBsAg status of mother; if mother’s
status is negative, then vaccination of HBV may be given: anytime
from birth–3 months followed by second HBV 1 month after the first
and a third HBV vaccine anytime between 6 and 18 months of age. case studies S.O.A.P Charting