Paediatric History Taking

1. Paediatric History Taking

2. A different ball game… • Some children (especially young ones) cannot tell you their symptoms and even older children may struggle to express them. • Often a collateral history from parents. • Children aren’t just mini-adults – it’s a bit more complicated than that • Some conditions are highly prevalent in children • There are some paediatric specific questions to remember.

3. Introduction • As with all histories, start by washing your hands and introducing yourself. (Remember in 4th year you are playing “doctors”) • Also remember in 4th year you can get history + explanation stations (but we will focus on histories today) • With the collateral history: confirm who you are speaking to and their relation to the child. (Parent/guardian). • Don’t ask the parents date of birth, just their name! • Confirm the child’s full name and date of birth. • Ask if they have brought the child’s red book, as there could be useful information in there to give you clues in your diagnosis. • Begin with a nice open question

4. History of Presenting Complaint • Explore symptoms as you normally would: onset, duration, severity, progression, precipitating/relieving factors, associated symptoms, previous episodes. KEY paediatric questions to ask about • Feeding – volume/frequency. Bottle/breast milk in infants. Introduction of new foods. • Vomiting – volume, timing, projectile/bilious/blood • Fever – feels hot? Thermometer at home? • Wet nappies? How many? • Stools – frequency, consistency, colour, blood?

5. History of Presenting Complaint (continued) • Behaviour – irritable • Weight changes (this is where the baby book is helpful) • Sleeping pattern • Localising symptoms (pulling at ear) • Others include: cough (wet/dry), rash (blanching/distribution/trigger), unwell contacts at home

6. ICE • Parents know their children and will often have ideas and worries about what is happening • ICE is particularly useful due to anxious parents. • Find out what they are hoping to achieve • Be aware of concerns in non-accidental injury

7. Past Medical History • Antenatal period – any problems? Infections? • Birth – type of delivery? Term? Any problems? • Neonatal period – NICU admission? • Medical conditions • Previous hospitalisation • Surgery • Accidents/injuries – be aware of signs of non-accidental injury. • Immunisations – Up to date? If not why?

8. Drug History • Regular medications • Over the counter • Allergies

9. Developmental History • Weight & Height • Developmental milestones • Red flags • No smile at 8 weeks • >18 months not walking • >24 months not talking • Loss/regression of skills • Early hand dominance • Remember that premature babies need a little longer to catch up.

10. Family History • Family history of any disease • Genetic disease • Family tree

11. Social History • Who is at home/takes care of children? Any other children? • Any pets? • Do parents smoke? • Depending on age – are they at school? Any issues? • Foreign travel • Parental occupation

12. To Recap Paediatric specific additions: • Always ask about feeding, bowels, urine, vomiting, cough, behaviour change, sleeping, rash, unwell contacts at home. • Antenatal, post-natal, neonatal and birth history • Immunisations up to date • Growth & development • Family history – genetic conditions and family tree • Social history: home situation, parental occupation, second-hand smoke exposure

13. Past stations • Child Psychiatry • Developmental delay • Self-harm • Behaviour • Allergic reaction • Convulsion • Acute Otitis Media • Bruising • Cough • Conduct disorder • Pneumonia • Diarrhoea • Early puberty • Failure to Thrive • Non-accidental injury • Headache • Heart Failure • Jaundice • Pyloric Stenosis • Weight loss • IBD

14. Breathless/Cough/Sounds • Viral infection – cough, coryzal symptoms, fever, wheeze (viral induced wheeze) • Bronchiolitis – 6 months -3 years, wheeze, tachypnoeic • Pneumonia – fever, wet cough, chest pain if older. • Asthma – Night cough, wheeze, chest tightness, older children (not infants), atopy • Croup – barking cough, viral prodrome • Pertussis (whooping cough) – cough with inspiratory • Cystic Fibrosis – Wet cough, faltering growth, steatorrhoea. • Inhaled foreign object - always consider in acute setting with SOB and stridor. • Anaphylaxis – exposure to allergen, rash, trouble breathing, swelling around lips/tongue • Epiglottitis – Toxic child, excessive drooling • Bacterial Tracheitis – Croup with acute deterioration. • Congenital defects (Laryngomalacia etc.) • (Consider cardiac cause – cyanosis, sweating, faltering growth, tiredness)

15. Vomiting • Kids vomit with everything! – systemically unwell, DKA, meningitis etc. • Regurgitation/GORD (after feeds, milk, common in infants) • Post tussive (coughing followed by vomiting) • Pyloric stenosis (projectile vomiting, may have seen peristalsis) • Gastroenteritis (fever, tummy pain, diarrhoea) • Bowel obstruction (bilious vomiting) • Volvulus, Intersussception (red-current jelly stool, pale crying infant), Meckel’s diverticulum (blood in stools that is neither fresh nor true melena), necrotizing enterocolitis, meconium ileus • Psychological factors

16. Failure To Thrive/Faltering Growth • Cystic Fibrosis - (chest and bowel symptoms) • Coeliac Disease – Diarrhoea, pale, associated autoimmunity • Inadequate intake – Children refusing feeds, parents unsure as to quantity required, difficulty with latching (cleft palate) • Emotional/nutritional disorder – parents/cares not giving child enough food. • Eating disorder – older child, fear of fatness, very low BMI, purging with laxatives, vomiting, under-eating, distorted body image. • Chronic illnesses (asthma, congenital heart disease, diabetes (polyuria/polydipsia/fatigue) etc. particularly with steroids) • Inflammatory Bowel Disease – blood/mucus in stool, change in bowel habits, ulcers, skin changes (pyoderma gangrenosum/erythema nodosum)

17. Neonatal Jaundice • <24hours – haemolytic disease of newborn, G6PD defiency, maternal TORCH infections • 24hours-14 days – Physiological jaundice, breast milk protein, infection • >14 days - biliary atresia, Total Parenteral Nutrition, breast milk protein

18. Development Delay • Generalised/Global • Cerebral palsy (quadriplegic) • Chromosomal disorders • Maternal factors (smoking, drinking, TORCH infections). • Brain injury (bleeding, infection, hypoxia) • Motor • Muscular dystrophy – thick calves, Gower’s sign • Cerebral palsy (diplegic) • Hip dysplasia • Language/Social • Deafness/glue ear. • Autism – trouble with communication, struggle to make friends. May not speak. • ADHD – impulsive, hyperactive, poor concentration. Often good at making friends, but struggle to keep them

19. Childhood bruising • Accidental • Bony prominences • Fits with age or developmental milestones • Non-accidental • Unusual or covered places (safe triangle). • History does not match injury. Delayed presentation. Inconsistent story. • Systemic • Meningococcal disease – headache, neck stiffness, photophobia, lethargic, feverish. • Vasculitis (HSP) – non-blanching rash on legs, polyarthritis • ALL (+ other leukaemias) – Pale, acutely unwell, recurrent infections • Primary bleeding disorders (von-willebrand etc) • ITP – bleeding, purpura, epistaxis, menorrhagia

20. Fit/Faint/Funny Turn • Neurological • Febrile convulsion • Seizure (absence, focal, generalised) • Reflex anoxic seizure • Non-neurological • Vasovagal syncrope • Breath holding spells

21. Precocious Puberty • Gonadotrophin dependent • Familial/idiopathic • CNS abnormalities – history of hydrocephalus, hypoxic brain injury etc. • Intracranial tumour - neurological symptoms • Gonadotrophin independent • Adrenal tumour hyperplasia – excessive pubic hair, penis/clitoris enlargement, weight gain • Ovarian/testicular tumour – ovarian: bloating, pelvic pain, menorrhagia. Testicular: painless lump • Other differentials • Premature thelarche – breast development only • Premature pubarche – pubic hair growth only • External sex hormones

22. Delayed Puberty • Constitutional • Hypogonadotrophic hypogonadism • Systemic disease – symptoms of underlying disease (IBD, CF, anorexia) • Hypothyroidism – delayed growth, fatigue, cold intolerance, dry skin, coarse hair • Hypergonadotrophic hypogonadism • Klinefelters – small testes, gynaecomastia, tall and thin • Turners – short stature, amenorrhea • PCOS – oligo/amenorrhoea, hirsutism, acne.

23. Others • Cyanosis • Polydipsia/polyuria • Irritability/inconsolable crying • Lumps/bumps • Tiredness • Delayed meconium passage (CF, Hirsprungs etc.) • Ear pain/tugging at ear

24. ANY QUESTIONS?