CASE 4

Concerns
1. Is Andrew ready to start school?
a. Here are a few developmental challenges that Andrew will face in the
transition to Kindergarten. Andrew has already participated in
Preschool therefore he has already interacted with other children and
has been separated from his parents and other caregivers.

History

Andrew and his family have just moved to Ft. Lewis from Virginia.
After having several ear infections in his second year of life
Andrew’s language development was delayed due to mild
conductive hearing loss that resolved without surgical treatment.
During that time he participated in an early intervention program
between ages 2 and 3 and then received supplemental speech
and language therapy in preschool until about a year ago. Now
that kindergarten is approaching, his parents want to make sure
he’s ready for school. Since they are new to the area, this is the
first healthcare visit Andrew has had at Madigan.

Developmental History
Andrew sat at 6 months, walked at 15 months, spoke single words
by 18 months and used two-word phrases a few months after he
turned two. His language, while initially delayed, improved with
early intervention and speech and language therapy, and by age 4
½ no delays were evident. He attended preschool and day care in
Virginia, and the family hopes to find an after-school program
here. He has been toilet trained during the day since he entered
preschool at age 3, but he still “wets the bed most nights.”

It affects one out of every four children at age five, one in five at
age seven years, and about one in twenty at age ten years. Boys
make up two-thirds of this group, and often there is a family
history of bedwetting(usually in the father). It may be related to
the time it takes different children to develop control over the
nervous, muscular, and nighttime full bladder sensation that
needs to be subconsciously suppressed. If your child wets at night,
here are some possible causes:
 Slow development to awaken when the bladder is full
 Constipation, which can cause extra pressure on the bladder from the
rectum
 An early sign of diabetes mellitus, a urinary tract infection, or emotional
distress caused by an upsetting event or unusual stress—but only if
wetting began suddenly after an extended dry period.

If your child continues to wet frequently, or if you notice any of the following
signals, talk with your pediatrician:

 Wet underpants, nightclothes, and bed linens, even when the child
 regularly uses the toilet
 Unusual straining during urination, a very small or narrow stream of
urine, or dribbling after urination
 Cloudy or pink urine, or bloodstains on underpants or nightclothes
 Redness or rash in the genital area
 Hiding underwear to conceal wetting
 Daytime as well as nighttime wetting

 Explain the problem to your child, emphasizing that you understand and
know it’s not his fault.
 Discourage him from drinking fluids during the two hours before bedtime.
 Reward dry nights, but don’t punish wet ones. This is very important,
since this is an emotional issue for both of you.

What can you tell me about alarm training versus medication as a

way to address it?”
Anticipatory guidance for Andrew

 Mental Health
o Continue family routines, assign chores,
o show affection/respect, model anger management/self discipline
o use discipline for teaching not punishing
o Solve conflict/anger by talking, going outside and playing or walking
away
 Nutrition and physical activity
o Eat breakfast and 5 servings of fruits/veggies per day
o limit candy/soda/high fat snacks
o @ least 2 cups low fat milk/day
o Play 60
o Limit TV to 2 hours/day
 Oral Health
o Help with brushing if needed
o Dentist 2 times/yr
o Brush twice daily/floss once
 Safety
o Safe street habits, wearing helmet and safety pads when riding
bike
o Booster seat in back seat
o Teach to swim/supervise around water
o Safety w/ adults
  no secrets b/t adults
 no interest in private parts
 no “helping” adults with their private parts
o Smoke detectors/CO detectors
o Remove guns or store unloaded and locked with ammunition
locked separately

CASE 5

Concerns
Mom is concerned about his school performance and he is concerned about his
height.

History:

Andrew was born 5 weeks early. Otherwise, he has

been fairly healthy, except for 4 or 5 ear infections in
his first two years of life. He used inhalers on several
occasions for a night-time cough 3 years ago, but
has not used them again since that time. He has had
no surgeries and no hospitalizations. 
Environment
Andrew is now 10 years old as mentioned previously. He lives with his mother
(army nurse), father (science teacher/admin), sister Lydia who is 13 and a 5 year
old sister who was adopted from Russia. He is planning on attending a 2 week music
camp in July for violin. He is also in preparation to move to Germany for his mothers
PCSing to Landstuhl in August.

Anticipatory Guidance
 School
o Ask teacher about help if there are concerns about school performance
o Create a quiet space for homework
o Get help from trusted adult/teacher in reference to bullying
 Development and Mental Health
o Promote independence, self responsibility, assign chores, provide
personal space @ home
o be a positive role model, discuss respect & anger management
o know your child’s friends and supervise activities with peers
o anticipate new adolescent behaviors
o Answer questions about puberty and sex
 Nutrition/Physical activity
o Encourage nutritious foods.
o Play 60
o Limit non academic screen time to two hours
 Oral Health
o Wear mouth guard with sports
o Dentist 2 times/yr
o Brush twice daily/floss once
 Safety
o back seat is the safest place
o use safety equiptment
o use sunscreen
o counsel about tobacco, alcohol and drugs
 1. What aspects of Andrew’s diet can you praise
him for?  
The fact that he eats a variety of foods and chooses to eat veggies. Also, he stays
away from candy.
 2. What aspects of Andrew’s diet could be
improved?   
He does not voluntarily eat fruit and he eats McDonalds every day after school.
 3. How will you prioritize your advice for Andrew,
and how will you educate him about his diet?   

In reference to his fast food eating, it is alright to eat at fast

food restaurant. A plain burger could have the same
nutritional value as something that is made at home. Also,
many of these restaurants have salads and eating a salad with
low calorie dressing and low fat cheeses helps to limit high
caloric food intake. Also, snacks are not bad but healthy
choices are best. Eating veggies and fruit rather than a
cheeseburger would be beneficial.
 4. How will you counsel him about his growth?
I would tell him to continue eating healthy, making sure that he is maintaining
adequate caloric intake. One method of calculating the Estimated Energy
Requirement is the following equation for 9-18 years of age:

EER = 135.3-30.8 * Age + Physical Activity Level * (10 * weight [kg] + 934 * height
[m] ) +25
He is not falling off of the growth curve and seems to be maintaining in the 10 th
percentile. I would be more concerned if he was falling off of the curve.

Does Andrew need a PPD placed today? 

Yes, seeing that he has had contact with some one who is suspected to have
tuberculosis with a positive TST and being treated empirically with anti-Tb
medication.

In reference to him not wanting to move to Germany. I would talk to him about how
he moved from VA to Ft. Lewis and was able to make new friends. I am sure that he
will be able to do the same in Germany. Also, he will be able to experience a different
culture, something most children and even adults never get to experience.