An approach to assessing children Flashcards
What can change depending on the age of the child?
Your own approach to history taking and examination
Common pathologies differ
Conditions manifest differently at different ages
What is important to do when preparing for a paediatric consultation?
Why the child has come to see you or been referred
Do you know the child’s name and sex?
Do you have an opportunity to observe child before “starting” assessment?
What is the likely differential diagnosis?
What conditions need to be ruled out?
What info have nurses gathered?
What is important to do while taking history?
Gather important information
Try to rule out significant pathology
Helps examination be more targeted
Be calm and empathetic
Show interest in what parents are saying
Facilitates dealing with concerns and anxieties
What’s important to consider regarding the age of the child?
Consider age and developmental stage
Consider language and intellectual skills
Typically most questions will be directed to parents
Some questions appropriate for child
Different perspectives may be gathered from both parent and child
Pre-verbal children still communicate
Older children can be quiet
What should be done in introduction in history?
Introduce yourself, identify patient and who is with them
Generate rapport with child
Note your “examination” observations
What’s important to find out in the history of presenting complaint?
Onset, progress, variations, effects, observations Chronological stages (including GP/A&E/Ward) General/systems enquiry
How much should a baby increase weight by in the first 6 months?
Around 150-200g per week for the first 6 months
What units can parents use to to weigh their child?
Grams
Stones
Pounds and ounces
How many grams are in 1 pound?
About 450 grams
How many grams are in an ounce?
About 28 grams
How many ounces are in a pound?
16
How many pounds are in a stone?
14
How many mls are in a fluid ounce?
About 28mls
How much feed should a baby take each day?
Around 140-180 ml/kg/day
How should you ask about a baby’s stool?
Distinguish between child in nappies vs independent toileting Frequency - per day, week, or even month Size, shape, appearance, and consistency Difficulties passing Pain on passing Blood or mucus seen Parents are sometimes surprised
What are the 7 stages of the bristol stool chart?
Type 1 - Seperate hard lumps like nuts - hard to pass
Type 2 - sausage shaped but lumpy
Type 3 - like a sausage but with cracks on the surface
Type 4 - Like a sausage or snake, smooth and soft
Type 5 - Soft blobs with clear cut edges
Type 6 - fluffy pieces with ragged edges, mushy stool
Type 7 - Entirely liquid
What should be asked about in the birth history?
Detail depends on age and presentation
Some features may be very relevant years later
What should be asked about in developmental history?
What can they do, any concerns?
Basic enquiry about walking, words, support
What are the key components of paediatric history?
Introduction Presenting complaint/history of presenting complaint Nutritional history Birth history Past medical history Immunisation history Developmental history Drugs and allergies Family and social history
What should be asked about in nutritional history?
Weight
Feeding
Stool
What is important to cover in family and social history?
Key stage in assessing patients - recent and related health issues, parents/siblings, relationship dynamics
School and nursery - common source of infective contacts, give insight into developmental process
Parental social history impacts on child’s health
How can the parental social history impact on the child’s health?
Smoking Alcohol Drugs Occupation Stress
How do you close a paediatric consultation?
Discuss why they came to see you, concerns, and what they’re looking to understand
Summarise key features
Check understanding and safety net
Document history and discussions
Note date, time, who was present/gave history
Is examination expected in year 3 OSCE?
No
What tells you the most in examination?
Observation
What should be examined in paediatrics?
ABCDE and vital signs General condition and peripheries Respiratory system CVS GI system Neuro and MSK ENT and skin Developmental skills Measurement and centile
How can you start an examination?
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 - keep parents close
Gentle handling and gradual exposure
Show interest in their toys and play
What general things are observed for?
Appearance
Play
Interaction
Obs
What respiratory features are observed for?
Effort Noise Rate Recession Nebulisers Are they on oxygen NOT SPUTUM POTS
What CVS features are observed for?
Colour of the child
Perfusion
What GI features are observed for?
Feeding
Vomit
Abdominal distension
Abdominal movement
What neuro features are examined for?
Alertness
Interaction
Play
Posture
What MSK features are observed for?
Mobility Limbs movements Posture Splints Mobility aids
What features are looked for over the skin?
Rashes Bruises Infusions Tubes Lines
What can you look for environmentally unrelated to medicine?
Toys Pictures Cards Games Books
What is examined in the hands?
Warmth Cap refill Radial/brachial pulses Clubbing Nail changes Hand skills Pen marks
What is examined in the head and face?
Eyes - jaundice Lips (colour, moisture) Tongue Nose Scalp changes Bruises Rashes Fontanel
What is examined in the neck?
Rashes and nodes (easier from the front); size, shape, mobility, position, consistency, symmetry
Tracheal tug
What should be examined for in the chest and back?
Heart murmurs Apex beat, thrills, chest expansion Breath sounds Percussion Resonance and fremitus Rashes and skin marks Spinal alignment, deformity, sacral dimples
What should be examined in the abdomen and groin?
Tenderness - watch face and movement
Masses (esp stool) and organomegaly - spleen, liver, kidneys
Bowel sounds and bruits
Femoral pulses - essential in infants
Hernias and testis
Genital/anal appearance (routine in nappies but often not appropriate for older children)
Do not do a rectal exam
What should be examined in the legs and feet?
Mobility, changing posture, movements, tone
Reflexes, clonus
Power, coordination, sensory assessment
Pulses, warmth, cap refill, colour, mottling
Rashes, bruises, marks
Deformities and gait
What can play be used for?
Illustrate something
A distracter
A clinical tool
How can you improve your paediatric history and examination?
Use child friendly language Recognise normality Leave unpleasant things to the end Be honest Develop play skills Document systematically Practice
