A 12-month-old girl is brought to her pediatrician for a checkup and vaccines. The patient’s mother wants to send her to daycare but is worried about exposure to unvaccinated children and other potential sources of infection. The toddler was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines. She does not walk yet but stands in place and can say a few words. The toddler drinks formula and eats a mixture of soft vegetables and pureed meals. She has no current medications. On physical exam, the vital signs include: temperature 37.0°C (98.6°F), blood pressure 95/50 mm Hg, pulse 130/min, and respiratory rate 28/min. The patient is alert and responsive. The remainder of the exam is unremarkable. Which of the following is most appropriate for this patient at this visit?

Gross motor workup and evaluation

A 4-year-old boy is brought to a pediatrician by his parents for a consultation after his teacher complained about his inability to focus or make friends at school. They mention that the boy does not interact well with others at home, school, or daycare. On physical examination, his vital signs are stable with normal weight, height, and head circumference for his age and sex. His general examination and neurologic examination are completely normal. A recent audiological evaluation shows normal hearing, and intellectual disability has been ruled out by a clinical psychologist. Which of the following investigations is indicated as part of his diagnostic evaluation at present?

Autism spectrum disorder screening and developmental assessment

Magnetic resonance imaging (MRI) of brain

Positron Emission Tomography (PET) scanning of head

A 28-year-old asymptomatic pregnant woman at 12 weeks gestation presents for prenatal care. She has no personal or family history of diabetes. Her BMI is 32 kg/m². She had a random glucose of 118 mg/dL at her first visit. She asks about gestational diabetes screening. Considering her risk factors and current pregnancy, what is the most appropriate screening approach?

Perform fasting glucose and hemoglobin A1c now to assess for preexisting diabetes

Perform 3-hour oral glucose tolerance test at 16 weeks

Diagnose gestational diabetes based on random glucose and begin treatment

Perform 1-hour glucose challenge test now

Defer screening until 24-28 weeks gestation per routine protocol

A 66-year-old man underwent screening colonoscopy which revealed a 1.2 cm tubular adenoma with low-grade dysplasia in the sigmoid colon that was completely removed. He has no family history of colorectal cancer. His colonoscopy 8 years ago was normal. He asks about surveillance recommendations. Considering current guidelines and competing risks, what is the most appropriate surveillance interval?

Repeat colonoscopy in 5-10 years

Annual fecal immunochemical testing

A 32-year-old woman presents for preconception counseling. She is healthy with no medical problems. Her mother and maternal aunt both had breast cancer diagnosed at ages 38 and 42, respectively. Her maternal grandmother died of ovarian cancer at age 52. The patient tested negative for BRCA1 and BRCA2 mutations 2 years ago through a commercial genetic testing panel. She asks about breast cancer screening recommendations. What is the most appropriate evaluation and management?

Refer for genetic counseling and consider expanded testing with breast MRI screening

Begin mammography at age 35 and annually thereafter

Recommend clinical breast exam every 6 months only

Reassure that negative BRCA testing indicates average risk

A 45-year-old woman presents requesting colorectal cancer screening after her sister was recently diagnosed with colon cancer at age 48. Further history reveals her sister's cancer was found to have microsatellite instability-high (MSI-H) features. The patient has no personal history of polyps or cancer and no gastrointestinal symptoms. Her sister is undergoing genetic testing for Lynch syndrome. What is the most appropriate next step in screening for this patient?

Refer for genetic counseling and consider colonoscopy

Begin colonoscopy screening at age 50 per routine guidelines

Defer screening until sister's genetic testing results are available

Begin colonoscopy screening now and repeat in 10 years if normal

A 72-year-old woman with well-controlled hypertension and hyperlipidemia presents for follow-up. She has been getting annual mammograms since age 40. Her most recent mammogram 10 months ago was normal. She has no family history of breast cancer and has never had an abnormal mammogram. She asks if she should continue screening. Her life expectancy is estimated at 12 years based on comorbidity indices. What is the most appropriate recommendation?

Continue mammography with shared decision-making about life expectancy

Perform breast MRI instead of mammography

Discontinue mammography screening

Continue annual mammography indefinitely

Developmental screening in pediatrics — USMLE Lesson

Developmental Screening - Spotting Delays Early

Universal Screening: AAP recommends standardized screening for all children at 9, 18, and 30-month visits.
Autism-Specific Screening: Done at 18 and 24-month visits using tools like the M-CHAT-R™.
Common Tools: Ages & Stages Questionnaires (ASQ), Parents' Evaluation of Developmental Status (PEDS).
Surveillance: Continuous monitoring of milestones at every well-child visit.

⭐ High-Yield: The M-CHAT-R (Modified Checklist for Autism in Toddlers, Revised) is the most validated tool for autism screening at 18 and 24 months. A positive screen requires a follow-up interview.

Screening Toolkit - Checklists & Questionnaires

Standardized, validated tools are used to identify children at risk for developmental delays. These are typically parent-completed questionnaires.

Ages & Stages Questionnaires (ASQ-3):
- Broad tool assessing communication, gross motor, fine motor, problem-solving, and personal-social domains.
- Used from age 1 month to 5.5 years.
Parents' Evaluation of Developmental Status (PEDS):
- Elicits and structures parental concerns about development, behavior, and learning.
- Used for birth to 8 years.
Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R/F):
- Specific screen for Autism Spectrum Disorder (ASD).
- Routinely done at 18 and 24-month visits.

M-CHAT-R/F Score Interpretation & Next Steps

⭐ The M-CHAT-R/F has a high false-positive rate. A positive initial screen must be clarified with the Follow-Up (the "F" in M-CHAT-R/F) interview before referral to a specialist.

Screening Schedule - Well-Child Checkpoints

General Developmental Screening: Standardized tools (e.g., Ages and Stages Questionnaires, ASQ-3; Parents' Evaluation of Developmental Status, PEDS) are mandated at 9, 18, and 30-month visits.
Autism-Specific Screening: The Modified Checklist for Autism in Toddlers (M-CHAT-R) is administered to all children at their 18 and 24-month visits, regardless of risk factors.

⭐ A positive M-CHAT-R screen is not diagnostic. It prompts a structured follow-up interview (M-CHAT-R/F) to clarify responses and reduce false positives before referring for a formal developmental evaluation.

The AAP recommends universal developmental screening at 9, 18, and 30 months.

Autism-specific screening with tools like the M-CHAT is crucial at 18 and 24 months.

Developmental surveillance should be performed at every well-child visit, not just at specific screening intervals.

Validated tools include the Ages and Stages Questionnaires (ASQ) and PEDS.

A positive screen is not a diagnosis; it mandates a referral for comprehensive evaluation.

Parental concerns are a valid screening component and should always be taken seriously.

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