paediatric history taking & examination stepp teaching, dee aswani, spr

Paediatric History Taking & Examination

STEPP Teaching, Dee Aswani, SpR

Overview of Session

Principles of Paediatric History TakingPractical ExerciseExamination TipsBaby Checks

A smart mother makes often a better diagnosis than a poor doctor.

August Bier (1861–1949)

Differences to adult practice & General

PrinciplesChildren are not small adultsLISTEN CAREFULLY to what the mother is telling you - she knows her child best and intuitively knows when something is wrong. She is RIGHT unless proven otherwiseUseful to quote verbatim, but ask to define terms for eg - what does ‘diarrhoea’ actually mean?Additional important features of the historyAlways consider CHILD PROTECTION issues

Components of History

Presenting complaint

History of presenting complaint

Past medical history

Incl feeding history & growth

Birth History

Developmental History

Immunisation History

Drug History

Family History

Social History

Inadequate History

Cough x 3 daysOff feeds x 2 daysWheeze x 1 dayTemperature x 1Vomit x 2

70% of paediatric

diagnoses will be obtained by history alone

Peter, age 7 years, referred by GP “difficulty

breathing”

History of presenting complaintCoughing since started at school 2 years ago

‘always has a cough’Worse since last night teatimeVomited x 1 last night, cough inducedNo feverHas been breathlessBreathing sounds noisyCough sounds productiveComplaining of tummy ache

Cough wakes him at night, often needs a glass of water to settle down

Coughs approx 5 nights out of 7

Tired and difficult to wake in the morning

Missing a lot of school

Difficulty keeping up with peers at PE

General lack of energy, prefers to sit and watch telly rather than playing outside with friends, complains that ‘chest hurts’

No history of choking or foreign body

Came back from holiday in Turkey a week ago

Still in same school trousers as in reception, one of the smallest in class

Good appetite

One previous A&E attendance - was wheezy, had ‘steam medicine ’ then went homeFrequent chest infections treated by GP with antibioticsNo operations or admissionsHas mild eczema

Past Medical History

Birth HistoryBorn at 34 weeksEmergency Section , 4lb 8oz, foetal distressSpontaneous labour and PROMPregnancy and scans fineWas on SCBU for 3 weeksNeeded CPAP for 1 day and then some oxygen for a whileNo oxygen when went home

Developmental History

Smiled at 10 weeks Sat at 6 monthsNever crawledWalked at 13 monthsStarted talking around 18 monthsNo problems with hearing or visionAverage progress at school

Immunisation History

‘up to date’didn’t have MMR - cousin with autism

MedicationOilatum in bath for eczemaallergic to Penicillinhad it when 2 years and ‘was sick’Tixylix

Family HistoryDad got eczema and hay feverMaternal grandma has diabetesPaternal Grandfather had TBMum and Dad separatedYounger 2 year old brother also has eczemaMum works in retail. Suffers with depressionNo consanguinuity

Social History2 Pet cats at homeMum smokes “outside”Dad also smokesGoes to a childminders 3 times a weekChild spends every other weekend at Dad’s house

Examination

General Principles & TipsGet down to their level

A lot of information can be gained by INSPECTION alone, before you lay an hand on the patientBeware of asking the child’s permissionKnow a conversation topic / latest craze / TV characters / films relating to different age groupsExamination needs to involve play and be opportunistic but thorough

Keep Mum close at hand and in child ’s view or reachKeep child in the position in which they are comfortable. No need to lie them down unless you have to - children are very vulnerable in this positionSave the nasty things to the end so that you don’t lose trust (eg ENT)

Baby checksTo assess general conditionTo establish normalityTo detect major abnormalitiesUseful in finding eye, hip and heart problems

Read Mum’s notes first

Pregnancy history

Paediatric Alerts

Delivery notes

Ask Mum if any concerns

Family History

Who does baby look like?

OBSERVATION

Appearance / Dysmorphia

Alert / Drowsy

Colour - anaemia / jaundice

Bruising

Posture

Birth Marks

HEAD

Shape of skull - moulding, sutures

OFC

Fontanelles

Eyes and ears

Mouth - look and feel for cleft

Range of neck movements

RESPIRATORY SYSTEM

Respiratory distress or increased work of breathing

CARDIOVASCULAR SYSTEM

Pulses including femorals

Heart sounds

Oxygen saturation - post-ductal

ABDOMEN

Shape

Palpation - masses

BO / BNO in first 24 hours

Genitalia / PU

HIPS

Barlow /Ortolani manouvres

LIMBS

Position - talipes

Movement

Palmar creases

NEUROLOGICAL SYSTEM

Tone

Posture

Primitive reflexes

Spine

EYES

Red reflexes

Hip Examination

Ortolani

Barlow

Primitive Reflexes

SUMMARYGood Paediatric history taking needs to be through and takes practice70% of diagnoses can be made on the history aloneALWAYS listen to the motherChildren are quite often unco-operative and examinations can be difficultBe prepared to PLAY

Children will respond much better to you if

you actually LIKE them