An Approach to Assessing Children

Question 1

Whats the best thing to help with diagnosing children?

Answer 1

Start with the age:

• Guides approach to history taking and examination
• Common pathologies differ
• Conditions manifest differently at different ages

Question 2

What is different in the paediatric history from the adult?

Answer 2

Anticipate what is different to adult consultations:

• Parents observers
• Play is essential and clinical helpful
• Specialised nursing staff
• Treatment differs by weight and age

Question 3

What are the key stages of the history?

Answer 3

• Introduction
  
  • Introduce yourself, identify patient and who is with them
  • Generate rapport
• Presenting complaint
• History of presenting complaint
  
  • Onset, progress, variation, effects, observations
  • Chronological stages (including GP, A and E, ward)
  • General/systems enquiry may be appropriate here
• Birth history
  
  • Details depends on age and presentation
• Past medical history
• Immunisations
  
  • Up to date, missed
• Development
  
  • What can they do
  • Basic enquiry essential (walking, words, support)
• Drugs and allergies
  
  • This illness, regular, previous
• Family and social history
  
  • Recent and related health issues
  • Parents/siblings (age and health)
  • Relationship dynamics
  • School and nursery
  • Parental social history – smoking, alcohol, drugs, occupation, stress
• Addressing concerns and closure
  
  • ICE
  • Summarise

Question 4

What does take an age appropriate apprach mean?

Answer 4

• Consider the age and developmental stage
• Consider language and intellectual skills
  
  • First engage in non-medical talk such as toys to get an idea
• Most questions directed to parents, but some for child

Question 5

What questions should be asked when exploring history of presenting complaint?

Answer 5

• Details depends on age and presentation

Question 6

What is asked about immunisations?

Answer 6

• Up to date, missed

Question 7

What should be asked about development?

Answer 7

• What can they do
• Basic enquiry essential (walking, words, support)

Question 8

What should be asked about drugs and allergies?

Answer 8

• This illness, regular, previous

Question 9

What should be asked about family and social history?

Answer 9

• Recent and related health issues
• Parents/siblings (age and health)
• Relationship dynamics
• School and nursery
• Parental social history – smoking, alcohol, drugs, occupation, stress

Question 10

What unit do we measure weight in?

Answer 10

kg and g, but parents often use lb and ounces

Question 11

What is:

• 1lb in kg
• 1 ounce in lb
• 1 ounce in g
• 1 stone in lb

Answer 11

• 1lb is 0.4536kg
• 1 ounce is 1/16 of 1 lb (28.35g)
• 1 stone is 14 lbs

Question 12

What is the normal weight gain of infants?

Answer 12

• About 150-200g/week from week 1 to 6 month
  
  • Which is an average of 20-30g per day
• Up to 10% loss in first few days common

Question 13

What do we measure feed volumes in?

Answer 13

ml, but parents often measure in ounces

Question 14

What is:

• 1 ounce in ml
• 1 ounce in pint
• 1 pint in ml

Answer 14

• 1 ounce is 28.4ml
• 1 ounce is 1/20^th of a pint (568ml)

Question 15

How much feed should a baby take if:

• well
• unwell

Answer 15

• Probably 140-180ml/kg/day
  
  • 100ml/kg/day if ill

Question 16

What should you ask about stool?

Answer 16

• Frequency
• Size, shape, appearance and consistency
• Difficulties passing
• Pain on passing
• Blood or mucus

Question 17

What are you trying to examine in paediatric examination?

Answer 17

• ABCDE and baseline observations/vital signs
• General conditions and peripheries
• Respiratory system
• Cardiovascular system
• Alimentary system
• Neurological and MSK systems
• ENT and skin
• Developmental skills
• Measurements and centile

Question 18

What are some tips for paediatric examination?

Answer 18

• Observe first
• Be friendly and smile
• Speak to the child (even if they are weeks old)
• Get down to their level
• Be careful moving them
• Show interest in their toys and play

Question 19

Describe the method for examination?

Answer 19

• Use method for that age
• Start with observation
  
  • General – appearance, play, interaction, obs
  • Resp – effort, noise, rate, recession, O2, nebs
  • CVS – colour, perfusion
  • GI – feeding, vomit, abdominal distension/movement
  • Neuro – alertness, interaction, play, posture
  • MSK – mobility, limb movements, posture, splints, mobility aids
  • Other – rashes, bruises, infusions, tubes, lines, toys, pictures, cards, games, caffeine, books
• Progress by area, think by system
  
  • Hands and arms
    
    • Warms, cap refill, radial.brachial pulses (rate/rhythm)
    • Clubbing, nail changes, hand skills, pen marks
  • Head and neck
    
    • Eyes (jaundice), lips (colour, moisture), tongue, nose
    • Scalp changes, bruises, rashes, frontanel
  • Neck
    
    • Rashes and nodes (easier from front) – size, shape, mobility, position, consistency, symmetry
    • Tracheal tug – don’t push for carotid pulse or trachea
  • Chest and back
    
    • Murmurs (timing, pitch, quality, location, radiation)
    • Apex beats, thrills, chest expansion
    • Breath sounds (all areas, reduced, symmetry, added)
    • Percussion (limited in infants, not routine)
    • Resonance and fremitus
    • Rashes and skin marks
    • Spine alignment, deformity, sacral dimples)
  • Abdomen and groin
    
    • Tenderness – watch face and movement
    • Masses and organomegaly (spleen, liver, kidneys)
    • Bowwel sounds and bruits
    • Femoral pulses
    • Hernias (and testis)
    • Genital/anal appearance (routine for children in nappies but not often appropriate for older children)
    • DON’T DO RECTAL EXAM
  • Legs and feet
    
    • Mobility, changing posture, movements, tone
    • Reflexes, plantars, clonus – babies have primitive reflexes
    • Power, coordination, sensory assessment
    • Pulses, warmth, capillary refill, colour, mottling
    • Rashes, bruises, marks
    • Deformities and gait

Question 20

What are you looking for in the initial examination?

Answer 20

• General – appearance, play, interaction, obs
• Resp – effort, noise, rate, recession, O2, nebs
• CVS – colour, perfusion
• GI – feeding, vomit, abdominal distension/movement
• Neuro – alertness, interaction, play, posture
• MSK – mobility, limb movements, posture, splints, mobility aids
• Other – rashes, bruises, infusions, tubes, lines, toys, pictures, cards, games, caffeine, books

Question 21

What are you looking for in the hands and arms?

Answer 21

• Warms, cap refill, radial.brachial pulses (rate/rhythm)
• Clubbing, nail changes, hand skills, pen marks

Question 22

What are you looking for in the head and neck?

Answer 22

• Head and neck
  
  • Eyes (jaundice), lips (colour, moisture), tongue, nose
  • Scalp changes, bruises, rashes, frontanel
• Neck
  
  • Rashes and nodes (easier from front) – size, shape, mobility, position, consistency, symmetry
  • Tracheal tug – don’t push for carotid pulse or trachea

Question 23

What are you looking for in the chest and back?

Answer 23

• Murmurs (timing, pitch, quality, location, radiation)
• Apex beats, thrills, chest expansion
• Breath sounds (all areas, reduced, symmetry, added)
• Percussion (limited in infants, not routine)
• Resonance and fremitus
• Rashes and skin marks
• Spine alignment, deformity, sacral dimples)

Question 24

What commens should be made about murmurs?

Answer 24

• Timing
• Pitch
• Quality
• Location
• Radiation

Question 25

What comments should be made about breath sounds?

Answer 25

* Reduced, symmetry, added

Question 26

What are you looking for in the abdomin and groin?

Answer 26

* Tenderness – watch face and movement * Masses and organomegaly (spleen, liver, kidneys) * Bowwel sounds and bruits * Femoral pulses * Hernias (and testis) * Genital/anal appearance (routine for children in nappies but not often appropriate for older children) * DON’T DO RECTAL EXAM

Question 27

What are you looking for in the legs and feet?

Answer 27

* Mobility, changing posture, movements, tone * Reflexes, plantars, clonus – babies have primitive reflexes * Power, coordination, sensory assessment * Pulses, warmth, capillary refill, colour, mottling * Rashes, bruises, marks * Deformities and gait

Question 28

Describe the reflexes of babies?

Answer 28

Primitive reflexes

Question 29

Why is play important?

Answer 29

Play and examination is important: * Creative approach needed * Let child continue to play as appropriate * Select age appropriate toys * Use play to illustrate, as a distractor and as a clinical tool

Question 30

Why is knowing your children's characters useful?

Answer 30

* Helps dialogue with child