Chapter 25: Children: Infancy through Adolescence

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Welcome back to The Deep Dive.

Today, we are tackling a subject that, you know, it's usually described with words like cute or precious.

But when you actually dig into the clinical reality of the word that comes to my mind is terrifyingly complex.

That is a very fair assessment.

Yeah.

Yeah.

We are diving into chapter 25 of Bates Guide to Physical Examination.

The title is Children, Infancy Through Adolescence.

Which sounds simple enough, right?

Until you realize that infancy through adolescence covers, I mean, it's the most radical biological transformation a human being ever goes through.

It is.

We are looking at a 60 page monster of a chapter.

It's a beast.

And honestly, it's the chapter that trips up the most medical students and even seasoned clinicians who don't work with kids very often.

Why do you think that is?

Because the trap, the big trap is thinking, oh, I know how to examine a patient.

A kid is just a small patient.

I'll just use a smaller cuff.

Right.

The tiny adult fallacy.

Exactly.

And if you take nothing else away from this deep dive, it's that children are not small adults.

They are.

They're entirely different organisms, effectively, depending on where they are on that timeline.

Anatomically, physiologically.

Everything.

Psychologically, a two month old has almost nothing in common with a 17 year old, other than the fact that, you know, they both have parents worrying about them.

Yeah.

I want to start with a stat from the intro that really, it knocked me back a bit.

The text mentions that within a few years, a child's weight increases 20 fold.

20 fold.

If that happened to me, I'd be the size of an office building.

I mean, that's just.

It really puts the metabolic demand in perspective, doesn't it?

Yeah.

We are observing an organism that is under massive, massive construction.

Right.

And our job effectively is building inspection.

We have to make sure the foundation is solid while the skyscraper is going up at like record speed.

So that's our mission for today's deep dive.

We're going to decode that inspection process.

We're going to follow the chapter structure exactly.

So general principles first, then we'll hit health promotion.

And then we are going to get into the trenches with the three distinct age groups, newborns and infants, then the preschool and school aged kids, and finally adolescents.

And the key,

really the whole point is that for each of those groups, the rules change.

The tools you use change.

Even the order of the exam itself changes completely.

Okay.

So let's start with what the book calls the laws of the road, the general principles of development.

Bates lists four of them.

These are the pillars.

Yeah.

If you don't get these, the rest of the exam is just, it's just noise.

Principle number one, development follows a predictable pathway.

Meaning it's not random.

There's an order to it.

Right.

It's hardwired by the maturation of the nervous system.

The text uses this fantastic phrase central to peripheral.

Okay.

Break that down for us.

What does central to peripheral mean in practice?

Think of the body like a map development starts at the center and moves out toward the edges.

So a baby learns to control their head or their neck first.

That's central.

Then the trunk, then the arms and the legs.

And then finally, the very last thing to come online is fine motor control in the fingers.

So you'll never see a baby who can, I don't know, write their name, but can't hold their head up.

Precisely.

It's a fixed sequence.

And that's incredibly helpful for us because if you see a child with great hand control,

but zero trunk control, something's wrong.

Something is wrong with the wiring.

It breaks the law.

Which leads right into principle two.

Yes.

We have a predictable order, but the timing,

that's a different story.

Wait.

Principle two is the range of normal is wide.

This is the one that saves parents from a lot of panic attack.

I can imagine.

Yeah.

Just because your neighbor's kid walked at 10 months and yours is 12 months and it's still scootin' around, it doesn't mean there's pathology.

They are very likely both well within that broad normal band.

But there are limits to that band, right?

There are, absolutely.

And that's where principle three comes in.

Various factors affect development.

The trajectory isn't occurring in a vacuum.

Chronic illness, obviously, can slow things down.

But the Toxt is very, very explicit about social determinants here.

Poverty, abuse, environmental stressors, these things chemically affect the developing brain.

So it's not just about genetics, it's about the context.

It's hugely about context.

And finally, principle four, which is maybe the most practical one for us today, the developmental level dictates how you actually do the exam.

You have to shape shift.

You have to be a chameleon.

With an infant, you are a gentle, quiet observer.

With a toddler, you're basically a playmate with a stethoscope.

And with a teen, you're a confidant.

You're a non -judgmental third party.

Totally different roles.

Speaking of observing, the text uses this term surveillance of development.

It sounds a little bit like we're spies.

You kind of are.

You're watching for things the parents might not even notice because they see the child every single day.

Okay.

And we track five specific domains.

Physical is the obvious one.

You know, can they walk?

Can they run?

But we also track cognitive, language, and this big one, social -emotional.

And we can't just eyeball it.

The text seems pretty harsh on relying on clinical observation by itself.

Because we're biased.

We are human.

We want the kid to be okay.

The book says that clinical observation alone misses a lot of subtle delays.

So the American Academy of Pediatrics says, use the tools.

The standardized tools.

Standardized screening instruments like the ASQ, the ages and stages questionnaire.

It gives you objective data, not just a gut feeling.

And this is where we get into a little bit of math.

I saw a formula in there for the developmental quotient or DQ.

Yes.

The attempt to quantify potential.

It sounds complicated, but it's actually a pretty simple ratio.

It's DQ equals developmental age divided by chronologic age times 100.

Exactly.

So let's run a quick scenario just to make this concrete.

Let's say you have a child who's been alive for 20 months.

That's their chronologic age.

Okay.

20 months old.

But when you do the standardized testing, they're performing at the level of an average 15 month old.

That's their developmental age.

So you do 15 divided by 20.

That's 0 .75 times 100 is 75.

Right.

And the text gives us the cutoffs.

Anything over 85 is considered normal.

And below 70.

Below 70 is delayed.

That warrants a referral.

Between 70 and 85 is that gray zone, you know, watching, wait, maybe some early intervention.

So our kid with a 75, they're in that gray zone.

We aren't hitting the panic button yet, but we are definitely not ignoring it.

Okay.

That makes sense.

Before we jump into the specific age brackets, we have to touch on health promotion.

The chapter opens this section with a quote from Benjamin Franklin.

An ounce of prevention is worth a pound of cure.

A classic.

It's a cliche because it's so true, especially in pediatrics.

In adult medicine, a lot of what we do is damage control, treating the heart attack, managing the diabetes that's already there.

In pediatrics, the real goal is to stop those things from ever happening in the first place.

And the text brings up this really the core of the pediatric relationship.

It is.

It's basically time travel.

You are telling the parents what is going to happen next month before it happens.

Give me an example.

Hey, your baby is going to start rolling over any day now.

So you can't leave them on the sofa anymore, not even for a second.

Right.

They're going to start trying to put things in their mouth.

So we need to talk about choking hazards.

Yeah.

If you wait until the accident happens to give the advice, you've already failed.

It also mentions immunizations right at the top of the section.

It has to.

Bates calls it the most significant clinical achievement in public health.

Full stop.

It's the absolute bedrock of prevention.

And alongside that, you have screening, lots of screening,

vision, hearing, metabolic screenings right at birth.

Then we start checking BMI at age two and blood pressure at age three.

Okay.

Let's get into the weeds then.

The first major epoch, newborns and infants birth to one year.

The year of the explosion.

We start with the newborn visit, ideally in the first 24 hours.

The text describes the parents as elated, but exhausted and terrified.

Let's not forget terrified.

They have this fragile new life and they have no manual.

So your history taking here isn't just a checklist of questions.

It's a therapy session.

You are assessing the baby for sure, but you are also assessing the attachment,

the bonding.

Are the parents looking at the baby?

Are they holding it comfortably or are they holding it like it's a ticking bomb?

And physically the growth in this first year is just, it's bananas.

Birth weight triples in a year.

Triples.

Height goes up by 50%.

Imagine if you grew 50 % taller this year.

Yeah.

The metabolic cost is just enormous.

So you walk into the room to examine this rapidly growing squirming, probably sleeping bundle.

How do you even begin?

First thing you do is you throw the head to toe rule right out the window.

Oh, interesting.

In adults, we are systematic head, neck, chest, abdomen, legs.

If you do that with a baby, you'll poke them in the eye or put a cold stethoscope on their chest.

They will start screaming and your exam is over.

You've lost.

Well, what's the strategy instead?

The strategy is quiet to distressing.

You do everything you possibly can while they are asleep or calm.

Like what?

Listen to the heart, listen to the lungs, feel the fontanels on the head, palpate the abdomen.

You save all the insults for the very end.

The insults being?

Looking in the ears.

That's an insult.

Opening the mouth, a huge insult.

And checking the hips.

Babies absolutely hate having their hips rotated.

You do that last right before you hand them back.

Let's talk about the specific checks.

We start right at birth, literally in the first minutes with the Apgar score.

The very first test you ever took in your life.

Yep.

Done at one minute and five minutes of life.

It's a triage tool, really.

It's not a predictor of long -term health.

Not really, no.

It's about how is this baby doing right now?

It looks at five things.

Heart rate, respiratory effort, muscle tone, reflex, irritability, and color.

And you score each one zero one or two.

Right.

So a perfect score is 10, but that's actually pretty rare because almost all newborns have blue hands and feet.

Which is called acrosynosis.

Exactly.

And it's totally normal.

It just means their peripheral circulation is a little sluggish getting started.

But, and this is a big but central sinosis, a blue lips, a blue tongue.

That's an emergency.

That is a five alarm fire.

That means the core of the body isn't getting oxygenated.

Now, when it comes to measuring them, the book says it involves some teamwork.

Yes, for somatic growth.

You can't measure a baby's height standing up because, well.

They can't stand.

They can't stand.

So you measure length.

And the text really emphasizes you need a proper measuring board and two people.

One person holds the head against the top board and the other person gently stretches out the legs to the footboard.

If you just try to mark the paper on the exam table with a pen, you're guessing and guessing isn't good enough.

And we are measuring the head too.

Head circumference.

Head circumference is a vital sign for the first two years.

Why is it so important?

Because the skull isn't fused yet.

It's made of plates that can move.

If the brain grows too fast, like in hydrocephalus, the head will expand to make room.

If the brain isn't growing, what we call microcephaly, the head stays small.

We are literally measuring brain growth with a tape measure.

Speaking of the skull not being fused, the fontanelles,

the soft spots.

Right.

We gently palpate them.

They tell you so much about the baby's fluid status.

If they are sunken or depressed, the baby is probably dehydrated.

And if they're bulging.

If they're bulging in chance, especially when the baby isn't crying, that suggests high pressure inside the brain.

It's a major warning sign.

I want to ask about vital signs.

The text has a very specific warning about counting the respiratory rate.

Yes.

And this is a tip for anyone new to pediatrics.

Do not cut corners here.

Okay.

In adults, we often count breaths for 15 seconds and multiply by four.

If you do that with an infant, you will almost certainly get the wrong number.

Why?

Because infants have what's called periodic breathing.

They'll breathe really fast for a bit, pant, pant, pant.

And then they'll just stop for five, sometimes 10 seconds.

It's normal.

Wow.

So if you happen to count during the stop, you think they're not breathing.

If you count during the panting part, you think they're in respiratory distress.

You have to watch and count for a full 60 seconds to get an accurate average.

That is a fantastic pro tip.

Let's move down to the skin and sensory organs.

We mentioned turgor earlier.

Turgor is your quick and dirty hydration check.

You gently pinch the skin on the belly.

If it snaps back instantly,

they're well hydrated.

If it tents...

What does that mean, tents?

It means it stays up in a little ridge for a second or two before it slowly settles down.

That means they're dry.

And for eyes and ears at this age, what are we really looking for?

You're just checking basic function.

Visual acuity is simply, can they fix their eyes on your face and track it as you move?

Okay.

And for hearing, we do the acoustic blink reflex.

You snap your fingers or ring a little bell near their ear.

They should blink or startle.

If they don't react at all, you start to worry about hearing loss.

Inside the mouth, the text mentions something called Epstein pearls.

These freak parents out all the time, but they are totally benign.

They're just tiny white cysts on the roof of the mouth.

They look like little teeth, but they're not.

They go away on their own.

But while you're in there...

While you're in there, you have to do something really important.

You have to put your gloved finger in and gently palpate the entire roof of the mouth, the hard and soft palate.

You're checking for a cleft palate.

Sometimes a cleft is hidden in the soft palate, so you can't just look.

You have to feel for it.

Let's talk about the heart exam, the point of maximal impulse, the PMI.

Right, the PMI.

In an adult, it's usually down at the fifth intercostal space, kind of mid -clavicular line.

But in an infant, the heart lies a bit more horizontally in the chest.

So the PMI is higher, usually around the fourth intercostal space.

And what about murmurs?

Very, very common in newborns.

You have to remember the whole circulatory system is rerouting itself after birth.

Shunts like the ductus arteriosus are closing off.

Sometimes that takes a few days, and you can hear a murmur as it happens.

The challenge is distinguishing those benign transitional flow murmurs from the pathologic ones.

Moving down to the abdomen.

You want to palpate the liver.

In infants, the liver is relatively large for their body size, so it's actually normal to feel the edge of it one to even three centimeters below the rib cage.

Is there a trick to getting them to relax their belly muscles so you can feel?

There is.

You flex their knees, just gently bring their knees up toward their chest.

It mechanically relaxes the abdominal wall so you can get a much better feel for what's going on inside.

Okay, now we're at a part of the infant exam that the book seems to highlight as a do not miss section.

The hips.

Because missing it is catastrophic.

It really is.

We're looking for developmental dysplasia of the hip or DDH.

So what is that exam?

It's basically when the ball of the femur isn't sitting snugly in the socket of the pelvis, the joint is unstable.

If you miss it, the child can end up with a permanent limp and debilitating arthritis by the time they're 30.

We have two key maneuvers here.

Ortolani and Barlow.

I have to admit, I always mix these two up.

Everyone does.

Here's how to remember it.

Think about what you are trying to do to the hip with each test.

The Ortolani test is trying to put a dislocated hip back in.

So you duck the legs, you open them up like a book.

If the hip was out, you'll feel a distinct clunk as the femoral head pops back into the socket.

O for Ortolani, O for out to in.

Out to in.

Okay, I like that.

So what's Barlow?

Barlow is a stress test.

You're seeing if you can push a stable hip out of the socket.

You would duck the legs, bring them back together and apply gentle posterior pressure.

If you feel it slip out, that hip is unstable.

So Ortolani is a test of reduction and Barlow is a test of dislocation.

Exactly.

Ortolani fixes it, Barlow.

No.

Barlow breaks it gently.

We do this at every single visit until they're walking.

There's also one more sign, the Goliath C sign.

What's that?

You lay the baby flat, you bend both knees and you put their feet flat on the table side by side.

Then you just look at the height of their knees.

If one knee is lower than the other, it usually means that femur is shorter.

Because the hip is dislocated.

Exactly.

It's pushed up and back.

It's really simple but effective screen.

Finally for infants, the neurologic exam, which the book says is all about primitive reflexes.

These are the automatisms.

There are these fascinating evolutionary leftovers controlled by the brain stem.

Like the palmar grass.

The palmar grass, yeah.

You put your finger in their palm, they lock onto it with incredible strength.

The rooting reflex, you stroke their cheek and they'll turn their head toward that side to feed.

And then there's the drop back just a tiny bit and they'll fling their arms out and then bring them back in like they're trying to grab a tree branch while falling.

Then there's the one that always looks so strange, the fencing reflex.

The asymmetric tonic neck reflex or AT &R.

If you turn the baby's head to the right, their right arm will extend straight out and their left arm will flex up.

They look just like they're holding a sword and are about to say, on guard.

What I find fascinating is that the disappearance of these reflexes seems to be just as important as their presence.

That's the key point.

These are brain stem reflexes.

As the cortex, the higher thinking part of the brain matures over the first few months, it starts to suppress them.

It takes over.

So if they stick around too long.

If a six month old still has a really strong moro reflex, that's a red flag.

It tells you the cortex isn't doing its job of taking over.

It can be an early sign of something like cerebral palsy.

Okay, we've somehow survived the first year.

The baby is walking, maybe saying a few words.

We are now entering section four, preschool and school age children, ages one to ten.

And the dynamic shifts completely.

The patient now has an opinion.

And usually that opinion is a very loud no.

The text calls this phase the art of medicine.

It is pure negotiation.

You can't force a toddler to have an exam unless you want to on wrestling match, which you will lose.

You have to be faster and smarter than they are.

So what are the strategies?

What's the art?

Okay.

Strategy number one, ignore the child.

Really?

Ignore them for the first minute.

Yes.

Walk in, smile at them, but then turn and talk to the parent first.

Let the child size you up from a safe distance.

If you just swoop in with a stethoscope right away, you look like a predator.

If you're just a friendly person chatting with mom, you're safe.

And then you use the teddy bear trick, I assume.

Always.

Oh, let's listen to bear's heart first as you have a strong heart.

It shows them the instrument isn't scary, that it doesn't hurt.

You gamify everything.

I'm going to look for Elmo in your ears, or can you blow out my light for me?

That's to get them to take a deep breath.

And the sequence of the exam changes too.

Oh, absolutely.

For toddlers,

keep them on the parent's lap.

That's their home base, their safe zone.

And you still do least distressing to most distressing.

But as they get to be school age, you know, five, six, seven years old,

modesty starts to kick in.

Right.

The text mentions using gowns at that point.

Yes.

They become aware of their bodies.

You have to respect that.

You offer a gown.

You respect their privacy.

You might ask the parents if they think their child would be more comfortable if they stayed or stepped out for a part of the exam.

Let's hit some of the specific exam techniques for this age group.

Blood pressure screening starts here.

Yep.

Routine screening starts at age three.

We use the appropriate small cuff, of course.

And it's important because hypertension does exist in kids.

It's often secondary to kidney issues, so we have to look for it.

The eye exam also gets more sophisticated.

Right.

We start checking conjugate gaze, making sure the eyes move together as a team.

We use the corneal light reflex.

Shine a light at their eyes and make sure the reflection is in the exact same spot on both pupils.

And the cover and cover test.

The cover You have them focus on something.

You cover one eye and then you quickly uncover it.

If that eye you just uncovered has to jump back into position to focus, it means it was drifting when it was covered.

And vision charts.

Visual acuity with a Snellen chart, the one with a big E at the top, usually starts around age three or four.

Okay.

There's a very specific technical shift in the ear exam here too.

The book points out that the anatomy actually changes.

This is a classic board exam question.

It's a detail, but an important one.

In an infant, the ear canal angles slightly downward.

So to straighten it out to see the eardrum, you gently pull the earlobe down and back.

Down and back for infants.

But as they grow into toddlers and young children,

the canal angles up.

So now you have to pull the auricle, the outer ear, up and back to see clearly.

Up and back for older kids.

And the book mentions using pneumatic otoscopy.

Yes.

This is the gold standard for diagnosing ear infections.

Otitis media.

You know that little rubber bulb on the otoscope?

It's not just for decoration.

Right.

You get a good seal in the ear canal and you give it a little squeeze.

It puffs a tiny bit of air against the eardrum.

And what are we looking for?

Movement.

We want to see the eardrum move.

A healthy tympanic membrane.

It's flexible.

It's like a sail.

It flutters when the wind hits it.

But if the middle ear is full of pus or fluid from an infection, that drum is stiff and inflamed.

It won't move at all.

No motion equals an infection.

Let's talk about the mouth.

The text says dental caries are the most common health problem in children.

It's a silent epidemic.

It's a huge problem.

So you have to do the lift the lip exam.

Don't just glance in and look at the tongue.

You have to physically lift the child's upper lip and look at the gum line of the front teeth.

That's where the rot starts and it's easily missed.

The heart exam in this age group brings up some specific sounds we might hear.

Right.

You might hear a stills murmur.

It's this very characteristic musical or vibratory murmur that is completely benign.

It sounds a bit like a pluck string or a tuning fork.

You also very commonly hear sinus arrhythmia.

That sounds scary.

An arrhythmia.

The name sounds scary, but it's totally normal and healthy.

It just means the heart rate naturally speeds up when they breathe in and slows down when they breathe out.

It's a sign that their autonomic nervous system is responsive and working well.

Okay.

Musculoskeletal for this age group.

There's a specific sign mentioned for muscular dystrophy called the Gower sign.

This is a heartbreaking but absolute critical sign to recognize.

You ask the child to stand up from a sitting position on the floor.

A healthy kid just pops right up.

A child with proximal muscle weakness like the Duchenne muscular dystrophy can't do that.

Their leg muscles are too weak.

So they have to plant their hands on the floor, push their butt up into the air, and then walk their hands up their own legs to get themselves upright.

It is unmistakable once you've seen it.

And just generally you're watching them move around the room.

Always.

Watch their gait, have them walk on their heels, then on their toes.

You're also looking for things like nursemaid's elbow.

That's a subluxation, a partial dislocation of the radial head in the elbow.

It happens when parents swing their kids by their arms.

So note to parents, don't swing your kids by their arms.

Got it.

Finally, for this the neurologic exam.

You integrate it completely into play.

You don't sit them down and say, now I'm testing your coordination.

You say, hey, can you stack these blocks as high as you can?

Can you draw a circle for me?

Can you make a funny face just like me?

You're testing cranial nerves and motor skills without them even realizing it's an exam.

All right, moving into the final stretch.

Section five, adolescence, ages 11 to 20.

The transition to adulthood.

And this is where the changes.

Until now, the parent was your primary partner.

Now the adolescent needs to become your partner.

The text is very, very clear about the importance of the setting for this encounter.

It must be confidential.

You need a comfortable, nonjudgmental environment.

And frankly, for at least part of the visit, you need to get the parents out of the room.

That can be a tricky conversation to have with a parent.

It can be, but you explain it as a standard of care.

You say okay, at this point in the visit, it's my practice to spend a few minutes talking with all my teen patients alone.

We'll just be talking about some standard health topics.

I'll have you step out for a few minutes and bring you back in at the end.

And if you don't do that, you will not get an honest history.

Period.

No team is going to talk about substance use or sexual activity with their mom sitting right there.

And to guide that private history, we have the famous acronym,

HEADSS.

H -E -E -A -D -S -S.

It's the psychosocial review of systems.

And it's brilliant because it's structured to move from the least invasive questions to the most invasive.

Walk us through why that specific order.

So H is home.

Who lives with you?

Do you feel safe there?

It's an easy entry point.

The two E's are education and employment and eating.

How's school?

Are you working?

And then eating habits, body image.

Eating disorders often start here.

A is for activities, sports, friends, what do you do for fun?

So you're building rapport.

You're starting with the easy stuff.

You're warming them up.

Exactly.

Then you get to the hard stuff.

D is for drugs,

alcohol, tobacco, other substances.

The first S is for sexuality.

Are you sexually active?

Questions about consent, safety, identity.

The next S is for suicide and depression.

You have to ask about it directly.

And the final S is for safety.

Are you wearing a seatbelt?

Are you around violence or weapons?

It's an intense list of questions.

It is.

But you have to remember, most of the morbidity and mortality in teenagers isn't from cancer or heart disease.

It's from behaviors.

It's from accidents, suicide, homicide, STIs, unplanned pregnancy.

The EEPSS assessment is the most important part of the adolescent physical exam.

If you just check their throat and listen to their lungs, you have completely missed the developmental stages, which I found helpful for understanding their mindset.

Yeah, that's key.

Early adolescence is about 10 to 14.

They are very concrete thinkers.

Their body is changing in all these weird ways and they are freaking out.

Their main overwhelming question is, am I normal?

Then comes middle adolescence around 15 to 16.

This is the peak of peer pressure and risk taking.

Abstract thinking starts, but they also feel invincible.

Their question is, who am I?

They are testing limits, figuring out their identities separate from their family.

And finally, late adolescence, 17 to 20.

Things start to calm down.

They become more future oriented.

They start to see themselves as adults in the wider world, thinking about careers and long -term relationships.

Physically though, the big thing we're tracking is puberty.

Canter staging, yeah.

We use a standardized scale from one to five to rate the development of pubic hair and breasts in females or pubic hair and genitals in males.

It's a clinical and objective way to track if puberty is happening on time or if it's delayed or precocious.

And there is a specific skeletal check that becomes important here.

Scoliosis.

The Adams forward bend test.

This is the classic school nurse exam.

You have the teens stand straight, then bend forward at the waist as if they're going to touch their toes, letting their arms hang free.

And you're looking from behind them.

Exactly.

You look along the horizon of their spine.

If one side of the rib cage is higher than the other, what we call a rib hump, that's a positive screen for curvature.

It's a sign that the spine isn't just curving, it's rotating.

Finally, sports physicals.

This is a huge part of adolescent care.

A huge part.

And it is not just a rubber stamp to let a kid play football.

It is a critical safety screen.

What are we primarily looking for?

Our number one goal is to screen for risk of sudden cardiac death,

usually from an undiagnosed condition like hypertrophic cardiomyopathy.

So what are key questions?

You have to ask, have you ever fainted or passed out while exercising?

Does your heart ever race or skip beats?

And crucially, has any one of your family died suddenly and unexpectedly before the age of 50?

A yes to any of those means that kid does not step on the field until they see a cardiologist.

And there's a quick orthopedic screen mentioned as well.

The two minute orthopedic exam.

It's a rapid fire checklist to screen the major joints, have them duck walk four steps that test the hips, knees and ankles,

have them shrug their shoulders against your resistance, rotate their arms, stand on one leg.

It's a quick way to make sure all the major joints work before they go out and tackle someone.

We've really covered the whole roadmap from the fontanels of the newborn to the HESS assessment of a teenager.

It's a long and winding journey.

So how do we wrap this all up?

The chapter ends on recording findings and health promotion.

The documentation itself is pretty standard.

You'll use a SOAP note format, subjective objective assessment plan.

But the key is not to forget to record those growth percentiles and the Tanner stage at every visit.

That's your baseline.

That's how you track their trajectory.

And for health promotion,

the focus just shifts as they grow.

In babies, it's all about safety nutrition.

In teens, it's about establishing healthy habits, preventing obesity, managing screen time, mental health awareness.

We are literally setting the stage for their entire adult life.

Bates ends with a really nice sentiment about the privilege of working in this field.

It is a unique privilege.

In most other fields of medicine, you're just fixing a broken part.

Here you are watching a person become themselves.

You might see them at two days old and then you see them again when they're 18 and heading off to college.

There's no other field with that kind of narrative arc.

A massive chapter, but I think we wrestled it into submission.

I think we did.

Just remember, central to peripheral,

quiet to distressing, and always, always check the hips.

Words to live by.

Thanks for listening to this deep dive.

This has been the last minute lecture team signing off.

Take care, everyone.