Paediatric History Taking & Examination STEPP Teaching, Dee Aswani, SpR

1. Paediatric History Taking & ExaminationSTEPP Teaching, Dee Aswani, SpR

2. Overview of Session • Principles of Paediatric History Taking • Practical Exercise • Examination Tips • Baby Checks

3. A smart mother makes often a better diagnosis than a poor doctor.August Bier (1861–1949)

4. Differences to adult practice & General Principles • Children are not small adults • LISTEN 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 otherwise • Useful to quote verbatim, but ask to define terms for eg - what does ‘diarrhoea’ actually mean? • Additional important features of the history • Always consider CHILD PROTECTION issues

5. 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

6. Inadequate History • Cough x 3 days • Off feeds x 2 days • Wheeze x 1 day • Temperature x 1 • Vomit x 2

7. 70% of paediatric diagnoses will be obtained by history alone

8. Peter, age 7 years, referred by GP “difficulty breathing”

9. History of presenting complaint • Coughing since started at school 2 years ago ‘always has a cough’ • Worse since last night teatime • Vomited x 1 last night, cough induced • No fever • Has been breathless • Breathing sounds noisy • Cough sounds productive • Complaining of tummy ache

10. 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

11. Past Medical History • One previous A&E attendance - was wheezy, had ‘steam medicine’ then went home • Frequent chest infections treated by GP with antibiotics • No operations or admissions • Has mild eczema

12. Birth History • Born at 34 weeks • Emergency Section , 4lb 8oz, foetal distress • Spontaneous labour and PROM • Pregnancy and scans fine • Was on SCBU for 3 weeks • Needed CPAP for 1 day and then some oxygen for a while • No oxygen when went home

13. Developmental History • Smiled at 10 weeks • Sat at 6 months • Never crawled • Walked at 13 months • Started talking around 18 months • No problems with hearing or vision • Average progress at school

14. Immunisation History • ‘up to date’ • didn’t have MMR - cousin with autism

15. Medication • Oilatum in bath for eczema • allergic to Penicillin • had it when 2 years and ‘was sick’ • Tixylix

16. Family History • Dad got eczema and hay fever • Maternal grandma has diabetes • Paternal Grandfather had TB • Mum and Dad separated • Younger 2 year old brother also has eczema • Mum works in retail. Suffers with depression • No consanguinuity

17. Social History • 2 Pet cats at home • Mum smokes “outside” • Dad also smokes • Goes to a childminders 3 times a week • Child spends every other weekend at Dad’s house

18. Examination

19. General Principles & Tips • Get down to their level • A lot of information can be gained by INSPECTION alone, before you lay an hand on the patient • Beware of asking the child’s permission • Know a conversation topic / latest craze / TV characters / films relating to different age groups • Examination needs to involve play and be opportunistic but thorough

20. Keep Mum close at hand and in child’s view or reach • Keep 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 position • Save the nasty things to the end so that you don’t lose trust (eg ENT)

22. Baby checks • To assess general condition • To establish normality • To detect major abnormalities • Useful in finding eye, hip and heart problems

23. Read Mum’s notes first • Pregnancy history • Paediatric Alerts • Delivery notes • Ask Mum if any concerns • Family History • Who does baby look like?

24. OBSERVATION • Appearance / Dysmorphia • Alert / Drowsy • Colour - anaemia / jaundice • Bruising • Posture • Birth Marks

25. HEAD • Shape of skull - moulding, sutures • OFC • Fontanelles • Eyes and ears • Mouth - look and feel for cleft • Range of neck movements

26. RESPIRATORY SYSTEM • Respiratory distress or increased work of breathing • CARDIOVASCULAR SYSTEM • Pulses including femorals • Heart sounds • Oxygen saturation - post-ductal

27. ABDOMEN • Shape • Palpation - masses • BO / BNO in first 24 hours • Genitalia / PU • HIPS • Barlow /Ortolani manouvres

28. LIMBS • Position - talipes • Movement • Palmar creases

29. NEUROLOGICAL SYSTEM • Tone • Posture • Primitive reflexes • Spine • EYES • Red reflexes

30. Hip Examination

31. Ortolani

32. Barlow

33. Primitive Reflexes

34. SUMMARY • Good Paediatric history taking needs to be through and takes practice • 70% of diagnoses can be made on the history alone • ALWAYS listen to the mother • Children are quite often unco-operative and examinations can be difficult • Be prepared to PLAY

35. Children will respond much better to you if you actually LIKE them