Comprehensive Guide to Paediatric History & Examination

1. Paediatric History Taking& Examinations

2. Aims: • Top tips for paediatric histories • Components of a paediatric history • Common presenting complaints • Red Flags • Examining a child: top tips • OSCE tips on paediatric examination

3. Paediatric Histories • Different ball game • Collateral history • Comms, comms, comms! • Red book

4. New components • Feeding & Drinking • Wet/dirty nappies • Growth & Development • Pregnancy History • Birth History • Immunisation History

5. Structure • Introduction • PC/HPC + feeding/drinking/nappies • ICE • PMH + DH (allergies) + Immunisations • Pregnancy, birth history, growth, development. • FH – Genetics, family tree, • SH – Schools, pets, parents smoking, people at home.

6. What’s Normal? • Feeding – gain weight appropriately (first 2 weeks may lose some weight). • Breast feeding: on demand, every few hours, including during the night. Latching on. Rhythmic sucking. Breast softening. • Formula feeding: no exact amount, however average of 150-200ml/kg/24hr. (1 ounce is around 30ml) • Wet nappies: 6 per day • Dirty nappies: 2 per day. Green meconium first. Then soft, yellow stool. • Growth: should not cross deciles • Premature babies need to catch up.

7. What’s normal?

8. Red flags • Irritable, floppy, refusing feeds, dry nappies, increased work of breathing, stridor, cyanosis, “toxic” appearance, neck stiffness, unexplained bruising, non-blanching rash, jaundice <24h or >2wks postpartum, failure to pass meconium in 24h, bilious vomiting • Anxious parent. • Crossing deciles on growth charts. • Development: • No smile at 8 weeks • >18 months not walking • >24 months not talking • Loss/regression of skills • Early hand dominance

9. Red flags: Mini Quiz – CF, Hirshsprung’s – Haemolysis or biliary atresia – Meningitis, epiglottitis, anaphylaxis, severe croup etc. – NAI, ALL, clotting disorders, bleeding disorders – Cerebral palsy, Duchenne’s MD – Autism Spectrum Disorder – Croup, epiglottitis, anaphylaxis, inhaled foreign object – Malrotation, volvulus • Failure to pass meconium in 24h • Jaundice <24h or >2wks • Toxic child • Unexplained bruising • >18months not walking • >24months not talking • Stridor • Bilious vomiting

10. Systems Screen • Cardio: Cyanosis. Breathless. Collapse • Resp: Increased work of breathing. Cough. • Gastro: feeding, vomiting, wet/dirty nappies, colicky baby • Neuro/MSK: Supporting weight, grip, crawling etc (motor milestones). Convulsions. • ENT: pulling on ears, discharge, redness. • Constitutional: Irritable, fever, weight loss

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

12. Top tips • Don’t ask the parent for their date of birth – easily done • Learn a good structure • Remember to include feeding, nappies, pregnancy/birth hx & immunisations • Good communication skills will get you through a difficult station: • “how are you coping?” • “you did the right thing by bringing him/her to see us” • “it’s not your fault”

13. Presenting complaints • Breathless/cough/sounds • Failure to thrive/faltering growth • Neonatal jaundice • Developmental delay (global, motor, language/social) • Childhood bruising • Fit/faint/funny turn • Precocious puberty • Delayed puberty

14. Breathless/Cough/Sounds Cough, coryzal symptoms, fever, wheeze (viral induced wheeze) 6 months -3 years, wheeze, tachypnoeic Fever, wet cough, chest pain if older. Night cough, wheeze, chest tightness, older children (not infants), atopy Barking cough, viral prodrome Cough with inspiratory “whoop” • Viral infection • Bronchiolitis • Pneumonia • Asthma • Croup • Pertussis

15. Breathless/Cough/Sounds • Cystic Fibrosis • Inhaled foreign object • Anaphylaxis • Epiglottitis • Bacterial Tracheitis Also consider congenital and cardiac cause – cyanosis, sweating, faltering growth, tiredness) Wet cough, faltering growth, steatorrhoea. Acute setting, with SOB and stridor. Exposure to allergen, rash, trouble breathing, swelling around lips/tongue Toxic child, excessive drooling Croup with acute deterioration.

16. Vomiting Kids always vomit! • Regurgitation/GORD • Post tussive • Pyloric stenosis • Gastroenteritis • Bowel obstruction • Intercusseption • Meckel’s Diverticulum • Meconium ileus Remember psychological factors After feeds, milk, common in infants Coughing followed by vomiting Projectile vomiting, may have seen peristalsis Fever, tummy pain, diarrhoea Bilious vomiting • Red-current jelly stool, pale crying infant, knees to chest • Blood in stools that is neither fresh nor true melena • Delayed passage of meconium, neonate.

17. Failure To Thrive/Faltering Growth • Cystic Fibrosis –(chest and bowel symptoms) • Coeliac Disease – Diarrhoea, pale, associated autoimmunity • Inadequate intake – Refusing feeds, difficulty with latching (cleft palate) • Emotional/nutritional disorder – parents/cares not giving child enough food. • Eating disorder – older child, low BMI, binging-purging, fear of fatness. • Chronic illnesses • Diabetes - polyuria/polydipsia/fatigue • Inflammatory Bowel Disease – blood/mucus in stool, change in bowel habits, ulcers, skin changes (pyoderma gangrenosum/erythema nodosum)

18. Neonatal Jaundice Timeline: • <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 Remember: • Unconjugated can lead to kernicterus. • Conjugated causes dark urine and pale stool.

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-willebrandetc) • ITP – bleeding, purpura, epistaxis, menorrhagia

20. Fit/Faint/Funny Turn • Neurological • Febrile convulsion • Seizure (focal, generalised, absence) • Non-neurological • Vasovagal syncope • 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. Summary • Collateral history • Remember your red flags • Remember the paediatric-specific questions • M&M stuff can come up for you, so don’t neglect it.

24. Questions so far…?

25. Examining A child: The basics • Commscommscomms! • Friendly introduction • Get down to their level. • Children ages: 6-10yrs • Check you have permission to examine the child. • Have a bank of questions ready (What films do you like? Do you play any sports? Favourite colour?) • Make it a game! • Comment on everything you see or present at the end

26. What could come up? • Cardiovascular exam • Respiratory exam • Abdominal exam • Neuro exam • MSK exam (hip, shoulder, knee) • ?Specialties (ENT etc)

27. signs • General • Dysmorphism • Colour – mottling • Alertness and interest in surrounds • Respiratory: • Tracheal tug, intercostal/subcostal recessions, grunting, stridor, nasal flaring. • Beware upper respiratory tract secretions that sound like pneumonias

28. signs • Cardiovascular: • Innocent murmur: soft, systolic, small (no radiation), single, short duration, sensitive (to movement/respiration) • PDA: machinery, continuous, pulmonary area. • VSD: Pansystolic, lower left sternal edge • CoA: radio-radial delay, systolic murmur under left scapula and/or infraclavicular area • Gastro • Constipation may be umbilical as well as LIF

29. Signs: Observations Normal observations for school children. • HR: 80-120 beats per minute • RR: 20-25 breaths per minute • BP: 90-110 mmHg (https://patient.info/doctor/paediatric-examination)

30. Examination of Newborn Head-to-toe examination looking in particular for: • Congenital cataracts/retinoblastoma- by ophthalmoscope examination. • Congenital heart disease- by examination of the cardiovascular system. • Undescended testes - by palpation of the scrotum and inguinal canals. • Developmental dysplasia of the hip - by the Barlow and Ortolani tests and examination of the lower limbs for asymmetry or limited abduction. • Screen: dysmorphic signs, fontanelles, skin, joints, spine, anus (patent?), primitive reflex's

31. To completes: • Full history from appropriate source • Plot height/weight on a growth chart • Check nutritional status • Observations • General system exam: cardio, respiratory, abdo, ENT • Double check with a senior

32. Summary • Relax and be friendly • Make it a game • You don’t have to finish to get good marks • M&M exams could show up

33. Thank you Any Questions?