Well-Child Checkups (and Beyond)

MS3: It looks like our first patient this afternoon will be another well-child checkup (WCC).

Dr S: Yes, she is a 9-month-old girl. We did a couple WCCs this morning together. Are you starting to feel comfortable doing them?

MS3: Kind of. I did some on my peds rotation, too. But they’re still confusing because there’s so much to keep straight, and I’m never quite sure of what gets done at each age’s visit.

Dr S: Hey, I hear you. To me, it felt like a ton of issues to memorize and check until I figured out an overall approach to the WCC. If you’d like, we can talk about it now and help you be prepared for this next one.

MS3: That would be great.

Dr S: Let’s start by looking at the list for our morning schedule. Most of these patients came in with the reason for the visit. This man was here for “shoulder pain.” And that mom brought in her toddler for “fever and earache.” What’s your game plan for visits like those?

MS3: Chief complaint, history of present illness, pertinent background history, focused physical exam, come up with possible diagnoses, and propose a plan.

Dr S: Excellent. That is the agenda for a common kind of visit, the acute problem visit. For those visits, the patient brings the agenda wrapped up within the chief complaint. But there are a couple of visits we did this morning where folks came without this kind of agenda—the WCCs. Mom and dad brought in their kids because they believe that if they bring their children to the doctor for regular checkups, we’re going to do good things for their health. They’re counting on us to have an agenda of good things to do. So we have to come up with that agenda. What good things do you think we should do at a WCC?

MS3: Well, I’ve never thought of it that way. I’m not really sure.

Dr S: How about if I help you get started? What are some of the things we did this morning at our WCCs?

MS3: For the 4 month old, we measured height, weight, and head circumference.

Dr S: Right. Why did we do that?

MS3: We could have found failure to thrive or a growth abnormality.

Dr S: Which would have suggested that there is a problem, perhaps a disease. What else did we do?

MS3: For the newborn, we listened to the heart, and we checked the red reflex.

Dr S: Right again. Why did we do those?

MS3: We were trying to find a murmur or cataract.

Dr S: Exactly. Also, an abnormal red reflex can reveal a rare disease: retinoblastoma. What else did we do?

MS3: We asked about development, like rolling over and talking.

Dr S: Why?

MS3: If there was developmental delay, it would suggest a disease that we could work on.

Dr S: Precisely. All the stuff you’ve named so far fit into the first category of stuff that we do at WCCs—screening for disease. At different ages, we check for different diseases with history questions, exam findings, and even labs like a hemoglobin or a lead level. But that’s just one category of three worthwhile things on the WCC agenda. What else do we do?

MS3: Hmmm. Oh, how could I forget? I gave shots!

Dr S: Did you enjoy doing that with my nurse?

MS3: Yeah, I had never gotten to do that before.

Dr S: Well, then, you personally accomplished the entire second category of worthwhile things on the WCC agenda—preventive measures. Some docs call this category “chemoprophylaxis.” We could just call it “shots” because most of it is immunizations. But let’s not forget that there are some other preventive things we prescribe, such as fluoride for our rural patients with well water to prevent dental cavities.

MS3: So we’ve got screening for disease and preventive measures. You said there’s a third category?

Dr S: We did history, physical, and labs screening for disease; we gave shots; and we talked. Take that mom and 4 month old we saw. I take care of mom, and I delivered this baby, so we certainly did chat socially. But we also did some medical talk. What did we talk about?

MS3: You gave advice on breast- and bottle-feeding as mom prepares to head back to work. And you mentioned the risks of walkers. And you asked about the baby’s car seat. And I even answered some questions about first solid foods for the baby.

Dr S: Exactly. There are medical advice things we talk about to promote the health of children. I’d group these into the category of advice, patient education, and anticipatory guidance. Now, this talk stuff about diet, safety, and second-hand smoke could seem fluffy and not squarely medical. But let me pose a little question. What’s the number one thing that kills children in this country?

MS3: We learned that on peds. Accidents.

Dr S: Right. So if we’re doing a visit focused on maintaining the health of children, it could be pretty high yield to prevent the biggest problem: accidents. We do it by asking questions and giving advice about infant car safety seats, bike helmets, and smoke detectors. If you think about it, it’s really rare that we find a disease by examining the lungs and abdomen of a healthy 5 year old, so sometimes the highest yield things we do for a child’s health at a WCC are advising and educating about safety issues, diet issues, development issues, and the like. And think about a teen. The biggest health risks for a teen are probably not in undiagnosed diseases of the chest, but rather in the smoking, the alcohol, the relationships, and the sex that they may or may not engage in. We have a modest but real opportunity to influence how those health things work out through our advice/patient-education category. I’m only pointing this out because it’s easy to see the other categories as medical and the advice category as nonmedical, but they are each equally important contributors to maintaining the health of children.

MS3: So the agenda for the WCC is screening for disease, preventive measures, and advice/patient education.

Dr S: Let me ask you one more question, which I can’t resist as a doctor who takes care of folks both young and old. If the agenda for a visit to maintain the health of a child is screening for disease, preventive measures, and advice/patient education, what do you think the agenda for a well 24-year old woman is or a well 74-year-old woman is?

MS3: Um, well, I guess it might be screening for disease, preventive measures, and advice/patient education?

Dr S: Bingo! The issues at different ages are a bit different, like screening for STDs (sexually transmitted diseases), hypertension, and cervical cancer in a 24 year old, osteoporosis and breast cancer in the 74 year old. The anticipatory guidance might include family planning for the young woman and advanced directives for the elderly woman. A tetanus booster might be chemoprophylaxis for the 24 year old, pneumovax and a daily baby aspirin is for the aging patient. And what if I asked you the agenda for a prenatal visit, which would be a woman’s visit to maintain and promote the health of her pregnancy?

MS3: I guess it really is the same agenda: screening for disease, advice/guidance, and preventive measures.

Dr S: Right, it’s just that the issues are different. We screen for preeclampsia with blood pressure. We screen for fetal growth restriction and macrosomia with fundal heights. We give RhoGam to our Rh-negative patients as chemoprophylaxis. And we give plenty of anticipatory guidance throughout pregnancy.

MS3: So I got it, the agenda for all well visits is screening for disease, advice/patient education, and chemoprophylaxis.

Dr S: Great, because we’ve got this WCC and then two adult annual physicals and a prenatal visit on our afternoon schedule. The more you do, the more you’ll see how these visits are so similar.

MS3: I can’t wait!

Joshua Steinberg, MD, University of Cincinnati, Author
Alec Chessman, MD, Medical University of South Carolina, Editor

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