Presentation Transcript

1. Introduction to the Pediatric History & Physical Exam

   Talking with kids & their parents: Tips for making things go well ICMII Spring 2010
2. Goals of this Session To highlight the unique components of pediatric database Review some ways to interview children and parents Discuss ways of creating a therapeutic alliance with patients and their parents Hear practical tips from 4th-yr students
3. The Pediatric Database What is different in the history from that in adult patients? (review from ICMI) Birth history Diet history Growth and development Immunizations Contact history Social history
4. Birth History For infants, this is often their “PMH” This an important component for: Children < 1 years-old (infants) Any child whose presenting problem might be related to the prenatal or birth history
5. Components of the birth history Maternal: mother’s age, gravida, para, health problems and medications Pregnancy: complications; prenatal care/labs/tests Labor: duration of membrane rupture; complications Delivery: gestational age (at a minimum whether term or premature), mode (vaginal/c-section, forceps/vacuum), APGAR score Neonatal Course: duration of hospitalization and any events that occurred shortly after birth.
6. Example of the Birth History The pt was born at term via NSVD, weighing 3200 gms, to a 25 yr-old G1P1 mother who had routine prenatal care Prenatal labs: Blood type A+; GBS/HIV -; HepB and rubella immune There were no perinatal complications, and the infant was discharged home on day of 1 of life
7. Diet History Important to collect on all children Particularly important for: Infants Any child not growing well Any child with underlying medical problems
8. Examples of diet history This 4 month-old takes 4 oz of formula by bottle approx. every 4 hrs during the day. He wakes up once each night to feed. His parents are interested in starting her on some baby foods. This 2 year-old drinks 48 oz of whole milk a day, eats rice, pasta, and loves chicken nuggets.
9. Development Extremely important to know what is normal for a given age Helps when discussing injury prevention Helps you figure out how to interact with your patient Useful when assessing for psychosocial, neurological, and other organic problems
10. Developmental History Start with an open ended question, e.g. “Tell me what types of things your child is doing now?” Can be assessed with formal tools, e.g. the Denver developmental screening test (DDST) Development is categorized into four domains G gross motor A adaptive motor L language S social
11. Immunizations Children receive many immunizations during the first 2 years of life Important to be as specific as possible about the vaccinations that the child has received
12. Contact History Obtain history about: Ill contacts Child care situation Food allergies/intolerances Pets and other allergen exposures
13. Family History Explore diseases that run in the family Problems resembling the child’s problem Siblings and their states of health Childhood deaths Genetic illnesses
14. Social History Provides insight into the support system of the child Find out who is living in the home and who takes care of the child If school-aged: What school do they attend? What are their hobbies?
15. Environmental History Ask about Firearms Seatbelt/car seat use Hot water heaters Bike helmets Smokers in the home
16. Thinking about Pediatric Problems Age is an important “filter” when thinking about diagnostic possibilities Add congenital problems to your database/diff. diagnosis when trying to determine the causes of signs/symptoms in young children Ask focused questions based on age-specific diagnostic possibilities
17. Differential Dx of Wheezing Wheezing in a 2 month-old Wheezing in an Adolescent Asthma Psychogenic stridor/paradoxical vocal cord motion Endobronchial lesions Foreign body Tumor Respiratory infections/bronchiolitis Swallowing problems and/or GE-reflux leading to aspiration Congenital airway abnormalities Cystic Fibrosis Enlarged para-bronchial lymph nodes -- TB
18. The Triadic Approach-A fact of life in pediatrics Definition: the process of conferring about the patient’s problem with the patient and someone else at the same time. Examples: Eliciting symptoms of a 4 month-old in the ED Getting a two year old child’s immunizations up to date. Starting an 8 year-old on medication for asthma.
19. General principles of pediatric patient interviewing Establishing rapport (know the developmental level of your patient) Agenda setting Contextual sensitivity Verbal and non verbal clues Closure Self awareness/reflection (Insight)
20. This can be really Fun! You get to interact with children of all ages and different levels of maturity. It brings out the child in you! You get to work with more than one person You get to interact with the family and not just the patient.
21. Strategies for Interviewing Know the developmental level of your patient Less than 2 years-old Engage the patient Be aware of stranger anxiety 2 - 8 years-old Talk about things of interest to the patient Focus on establishing rapport (talk to the patient) In older children begin to engage them in relating symptoms and decision making
22. Strategies for Interviewing 8 year-old – young teenagers Ask them about their illness/presenting problems Parents may still be the primary information source for younger children, but include the child Older teenagers Primary source of information Ask for permission to obtain additional information from parents Be ready for differing opinions and agendas
23. Things that can help build rapport Know some developmental activities appropriate for that age group Games; Movies, books and TV shows Hobbies School Don’t push it. Don’t try to hard, and alter your approach if the first one isn’t working
24. Common Mistakes Rapport: talking only to one party Agenda setting: not meeting each of the party’s agenda Jargon: speaking at a level that only one person understands Closure: not making sure both the child and parents understand what’s going on
25. Creating a Therapeutic Alliance & Establishing Family Centered Care Include the parents/child in clinical decisions and treatment plans Listen to what they have to say Make sure they know where you stand but also that you are willing to adjust the plan based on what they think Work as a team with the patient and family
26. Summary Triadic Interviewing can be both fun and challenging Pediatric Database: many similarities to adults, but there are some unique differences Birth history, Diet History, Growth & Development, Immunizations Approach to Clinical Problems: The diff dx is often age-specific
27. Preview of the Pediatric Tutorial You will get to interact with actualpediatric patients at Seattle Children’s Hospital Information will be sent out in the Spring Can view the online video about the pediatric physical examination before your session
28. Pediatric Tutorial Be at Seattle Children’s Hospital at 9 am Sign in and badges are required (know your student ID number!) You will work with a pediatrician in small groups to interview parents/children and perform the physical examination
29. Panel DiscussionMS IVs Lili Peacock Hanna Smith Katie Newell Heather Henne