History Taking and Examination Skills for Paediatrics

1. History Taking and Examination Skills for Paediatrics D. Hilton Deborah.hilton@uhcw.nhs.uk

2. Welcome to the Department GEH / Warwick / UHCW Exams at UHCW Ward Work Clinics (inc teaching clinics) Emergency Dept / PAU Educational meetings Handovers Bedside Teaching Portfolios

3. End of block assessment Written Paper – Common Paediatric conditions (Bronchiolitis, meningitis, neonatal jaundice, asthma) Development Observed consultation 20 minutes history and examination Thorough paediatric history, systems based examination 20 minutes thinking time 20 minutes presentation, investigations, management Marked according to Leicester Assessment Package Compared to skills required of newly qualified F1

4. Leicester Assessment Package • Interviewing/history taking • Introduces self to patients • Puts patients at ease • Allows patients to elaborate presenting problem fully • Listens attentively • Seeks clarification of words used by patients as appropriate • Phrases questions simply and clearly • Uses silence appropriately • Recognises patients' verbal and non-verbal cues • Identifies patients reasons for consultation • Elicits relevant and specific information from patient and/or their records to help distinguish between working diagnoses • Considers physical, social and psychological factors as appropriate • Exhibits well organised approach to information-gathering

5. History Taking • Organised approach – start with open questions and clarify appropriately • Remember to include ALL subheadings from history • Try and assess medical significance of what parents tell you (vomiting, fever, diarrhoea) • Show what you know about paediatrics (development, immunisations etc) • ICE • Response to cues from parents and child

6. Leicester Assessment Package • Physical examination • Performs examination and elicits physical signs correctly and sensitively • Uses the instruments commonly used in family practice in a selective, competent and sensitive manner • Generally systems based • Some general baby examinations • OBSERVE!!!! • Resp rate, Heart rate, machines, hydration status, interaction, development, feeding • Top to toe, organised wherever possible

7. Leicester Assessment Package • Problem solving • Generates appropriate working diagnoses or identifies problem(s) depending on circumstances • Seeks relevant and discriminating physical signs to help confirm or refute working diagnoses • Correctly interprets and applies information obtained from patient records, history, physical examination and investigations • Is capable of applying knowledge of basic, behavioural and clinical sciences to the identification, management and solution of patients' problems • Is capable of recognising the limits of personal competence and acting accordingly

8. Problem Solving • PLEASE relate to the history and examination that you have performed • Consider in relation to age of child • What treatment has the child has so far? • What investigations are you likely to need to help you differentiate between them • Pathophysiology of the conditions and response to treatment

9. Patient Management • General Principles • Fluids • Analgesia • Team working & senior support • Potential complications • Emergency Management (A, B, C, D, E)

10. Interactionwith Patient Involve child as much as possible INSPECTION & OBSERVATION Examiner will be aware of efforts made to placate child Leave with parent if required Use parents / toys / disctractions Expose with respect and considering child’s mood Get on your knees! If you arent sure you should proceed, mention to examiners

12. Paediatric History Taking • Presenting complaint • History of presenting complaint (Clarification) • (Previous Episodes) • Past Medical History • Birth History • Medications • Allergies • Developmental History • Immunisations • Social History • Family History

13. Presenting Complaint • Use your medical knowledge to interpret what you are being told by parents • Associated symptoms • Clarify what parents mean – wheeze etc • Duration of symptoms • Systems review & overall impression of the child

14. Past Medical History • Birth (if relevant) • Preterm / Term • SCBU & Resuscitation • Previous illnesses & treatments • Associated illnesses (Atopy etc) • Other medical conditions • Other professionals involved (Physio, OT, SALT)

15. Development • Know milestones for ages • Consider school in older children • Don’t rely solely on parental reports

16. Social History & Family History • Siblings • Parents / Step-parents • Smoking / Pets • Social Services • Health Visiting • Education • Physio / OT / SALT • Relevant illnesses in others

17. ICE

18. Examination • Generally systems based • General baby examination

19. Examination • Look around room • Look at the child • Hydration, Demeanour, Development, Pain, DIB, Growth • Interact with child before examination • Inspect before approach

20. Respiratory Examination • Observe – RR, DIB, Recession, Medical Adjuncts • Hands • Eyes & Mouth • Airway, Lymphadenopathy • Palpation – chest expansion • Percussion • Auscultation • TVF • Sats, PEFR, Growth

21. Cardiovascular Examination • Observe – HR, RR, DIB, Recession, Medical Adjuncts • Hands • Pulses • JVP • Eyes & Mouth • Palpation – heaves, thrills, apex • Auscultation (front & Back) • Liver edge • Oedema • BP, sats, growth

22. Abdominal Examination • Observe – HR, RR, Medical Adjuncts, Hydration • Hands • Face • Inspection • Palpation- masses, tenderness, organomegaly • Percussion • Auscultation • Urine, Stool, Feeding charts, growth

23. Neurological Examination • Observe – Medical Adjuncts, Hydration, dysmorphism, development, posture, neurocutaneous lesions • Cranial • Peripheral – tone, power, reflexes, co-ordination • Gait • Co-ordination

24. Baby Examination Not newborn check (but should be aware how to do) Observe – medical adjuncts, hydration, posture, DIB, demeanour, interaction, dysmorphism Often need to be opportunistic Auscultation lungs & Heart sounds Palpation abdomen – masses & organomegaly Genitalia & femorals Growth

25. Common problems • Inadequate inspection & observation • “Pouncing on the child” • Failure to respond to childs cues • Forgetting the details • Obvious inexperience

26. Advice • Get experience • Practice being watched, presenting cases • Ask questions • Always make sure someone sees patients with you