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Paediatrics > An Approach to Assessing Children > Flashcards

An Approach to Assessing Children Flashcards

1
Q

do children see the world differentyl?

A

yes

Think back…

  • As a child what made you happy?
  • Triggered your imagination?
  • What was fun? (also what was not fun?)
  • Favourite toys?
  • Best things to play with?
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2
Q

An Approach to general paediatrics:

•Holistic multi-system approach essential - why?

A

More than one problem may exist

More than one system may be involved

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3
Q

An Approach to general paediatrics:

•Start with the age - why?

A

Guides approach to history taking and examination

Common pathologies differ

Conditions manifest differently at different ages

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4
Q

Consider common _________ for the presenting problem

A

differential

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5
Q

Anticipate what is different:

what is different in paediatrics?

A
  • Parent(s) will be there - Astute observers, Resident carers
  • Play is essential and clinically helpful (Play helpful for understanding pathologies and facilitates aspects of clinical examination)
  • Specialised nursing staff - Different ratios, Understandably protective, Experienced at recognising sick children
  • Treatments differ by weight and age
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6
Q

How can you Prepare for your encounter with a child?

A
  • Why have they come to see you or been referred to the hospital or clinic?
  • Do you know the child’s name age and sex?
  • Do you have an opportunity to observe the child before “starting” your assessment?
  • What is the likely differential diagnosis?
  • What conditions do you need to rule out?
  • What information have the nurses gathered?
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7
Q

Take a good history - how is it done and why is it important:

  • Key step to making the _______
  • Gather important __________
  • Potentially rule out significant _________
  • Helps examination be more ________
  • Be calm and ________
  • Show _______ in what the parents are saying
  • Facilitates dealing with concerns and ________
A

diagnosis

information

pathology

targeted

empathetic

interest

anxieties

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8
Q

Age appropriate approach - how is it done?

A
  • Consider the age and developmental stage
  • Consider language and intellectual skills
  • Typically most questions directed to parents
  • Some questions are appropriate for a child
  • Different perspectives may be gathered from both parents or from parent and child
  • Pre-verbal children communicate! (eye contact etc)
  • Older children can be quiet
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9
Q

History Taking Key Stages:

how is the introduction done?

A

Introduce yourself, identify the patient and who is with them (parents/ carers/ others)

Generate rapport with the child

Note your “examination” observations

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10
Q

History Taking Key Stages:

whats after the introduction?

A

Presenting complaint (what’s already known?)

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11
Q

History Taking Key Stages:

whats involved in the history of presenting complaint?

A

Onset, progress, variation, effects, observations

Chronological stages (Including GP/ A+E/ Ward)

General/systems enquiry may be appropriate here

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12
Q

Know your units….. (Weight)

what are they?

A
  • What units do we measure a child’s weight in?
  • What units do parents want the weight in?
  • What is a pound?
  • What is an ounce?
  • What is a stone? - 14 pounds (6.35kg)
  • How much weight should a baby gain?
  • ~150(100)- 200g/ week 1st 6 months
  • = 20-30g per day (need to average time intervals)
  • Up to 10% loss in first few days is common

•I once saw….

  • “Birth weight: 98.5”
  • “Birth weight: 2 pounds 7 ounces” (Term, 0NNU)
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13
Q

Know your units… (Feeding)

A

•How much feed should a baby take? - Probably 140-180 ml/kg/day (100ml/kg/day if ill)

  • Baby 1 (3m, Vomiting and unsettled): - “He weighs 11lbs, he usually takes a 7oz feed 6 times per day, he always seems hungry and unsettled after his feed. What should we do?”
  • Baby 2 (6m Bronchiolitis and feeding concerns): - “She weighs 151/2lbs, she usually takes a 10oz feed 5 times per day, she just been taking 4oz every 3 hours. What should we do?”
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14
Q

Be prepared to ask about pooh…

what things should you ask?

A
  • Children in nappies vs. independent toileting (parents less involved)
  • 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!
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15
Q

HIstory taking key stages:

what information do you want in regards to Birth History?

A

Detail depends on age and presentation

Some features may be very relevant years later

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16
Q

HIstory taking key stages:

what comes after birth history?

A
  • Past Medical History (Admissions/ Similar Problems)
  • Immunisations (Missed?/ Additional?)
17
Q

HIstory taking key stages:

what do you want to know about development?

A

What can they do? Any concerns?

Basic enquiry essential (Walking, Words, Support)

What age where they when they first walked, talked etc

18
Q

HIstory taking key stages:

what infromation do you need in regards to drugs and allergies?

A

This illness/Regular/Previous

May need to ask specifically about inhaler as people may not see that as drugs

19
Q

Family and Social History - what do you want to know?

A

•Key stage in assessing patients:

  • Recent and related health issues
  • Parents/siblings (age and health)
  • Relationship dynamics

•School and nursery:

  • Common source of infective contacts
  • Can give insight into developmental progress

•Parental social history impacts on child’s health

  • Smoking/alcohol/ drugs/occupation/stress
20
Q

Addressing concerns and closure - how should this be done?

A
  • What made them come to see you today?
  • What concerns do they have?
  • What were they looking to understand?
  • Discuss above questions (appropriate for stage)
  • Summarise key features
  • Check understanding and safety net
  • Document history and discussions
  • Note date, time, who was present/ gave history
21
Q

Examination:

  • Key step in working towards a _______
  • Already _______ during history taking
  • ___ appropriate techniques used
  • Be sensitive to what _______ children
A

diagnosis

started

Age

upsets

22
Q

What you are trying to examine?

A
  • ABCDE and baseline observations/ vital signs
  • General condition and peripheries
  • Respiratory system
  • Cardiovascular system
  • Alimentary system
  • Neurological and musculoskeletal systems
  • ENT and skin
  • Developmental skills
  • Measurements and centile
23
Q

what are some Tips on getting started your examination?

A
  • Observe first (Watch at start so you can get to know what is happening with the child)
  • Be friendly and smile (Child will respond to a positive smiley face)
  • Speak to the child (even if they are weeks old)
  • Get down to their level (crouch down so not looking down onto them, to their eye level)
  • Be careful moving them- keep parents close (don’t want to upset them)
  • Gentle handling and gradual exposure
  • Show interest in their toys + play
24
Q

What is the method of examination?

A
  • It can be different every time!
  • Always start with good observation - Pre-assessment, During history
  • Think of each system
  • Think of each area (of the body)
  • Think of the method for that age
  • Rapport is essential - Key step is to get that good rapport to be able to keep the child distracted and keep the child and parent on side with you and can extent your examination time
25
Q

What do you observe for? (and don’t say sputum pots!)

A
  • General: Appearance, play, interaction, obs (sats probe, temp, HR)
  • Resp: Effort, noise, rate, recession (effort), O2, nebs
  • CVS: Colour, perfusion
  • GI: Feeding, vomit, abdo distension/ movement
  • Neuro: Alertness, interaction, play, posture
  • MSK: Mobility, limbs movements, posture, splints, mobility aids
  • Other: Rashes, bruises, infusions, tubes, lines
  • Other: Toys (clue of development stage), pictures, cards, games, caffeine, books
26
Q

Progress by area, think by system:

how do you examine hands and arms?

A

Warmth, cap refill, radial/brachial pulses (rate/ rhythm)

Clubbing, nail changes, hand skills, pen marks

27
Q

Progress by area, think by system:

how do you examine head and face

A

Eyes (jaundice), Lips (Colour, moisture), Tongue, Nose

Scalp changes, Bruises, Rashes, Fontanel

28
Q

Progress by area, think by system:

how do you examine the neck

A

Rashes and Nodes (easier from the front); size, shape, mobility, position, consistency, symmetry

Tracheal tug (Don’t push for carotid pulse or trachea)

29
Q

Progress by area, think by system:

how do you examine the chest and back?

A

Murmurs (Timing, pitch, quality, location, radiation)

Apex beat, thrills, chest expansion (limited if small)

Breath sounds (all areas, reduced, symmetry, added)

Percussion (limited in infants, not routine, commonly forgotten when dealing with pneumonia)

Resonance and fremitus? (most are pre-school!)

Rashes and skin marks (inc neuro-cutaneous)

Spine alignment, deformity, sacral dimples

30
Q

Progress by area, think by system:

how do you examine the abdomen and groin?

A

Tenderness- watch their face and movement

Masses (esp stool) and organomegaly (liver, spleen, kidneys). Thumb can be used to feel

Bowel sounds and bruits (v.rare)

Femoral pulses (essential in infants)

Hernias (and testis)

Genital/ anal appearance (routine in nappies but often not appropriate for older children)

DON’T DO A RECTAL EXAM! (Senior staff only)

31
Q

Progress by area, think by system:

how do you examine the legs and feet?

A

Mobility, changing posture, movements, tone

Reflexes (easy when v. young), plantars, clonus

Power, coordination, sensory assessment if older (Power and coordination most commonly assessed by observing normal play but can be more formally assessed when circumstances allow depending on what the child is presenting with)

Pulses, warmth, cap refill, colour, mottling,

Rashes, bruises, marks

Deformities and gait usually evident on inspection

32
Q

Exami nation can be a challenge…

Observation tells you more than __________

Be prepared to _____ your approach

Be opportunistic

A

auscultation

adapt

33
Q

Check ____ ears

And the throat

Measure and ____

The unorthodox can be appropriate but learn how to handle babies

It can get a bit stressful (and noisy)

It can be a bit confusing…

A

both

Plot

34
Q

Play and Examination - how should this be done?

A
  • A creative approach is often needed
  • Let the child continue to play as appropriate
  • Select age appropriate toys
  • Use play to illustrate
  • Use play as a distracter
  • Use play as a clinical tool
  • The aim is to gather useful clinical information
  • Appropriate sensitivity needed at times
35
Q

What works for me?

A
  • Smile and make positive eye contact
  • Engage with the child’s interests
  • Recognise common toys and characters
  • Develop your banter
  • Soothing words to babies (parents notice)
  • Nursery and school chat
  • Counting fingers
  • Activities and interests

•Always observe as much as you can

36
Q

what are some tips for success?

A
  • Use child friendly language
  • Recognise normality
  • Leave unpleasant things to the end
  • Be honest
  • Develop play skills
  • Document systematically
  • Practice (including adults)
37
Q

An Approach to Assessing Children?

  • Listen well
  • Learn what to ask and how to ask it
  • Build a rapport
  • Be creative, adaptive and opportunistic
  • Be systematic and thorough
  • Communicate well
A

Paediatrics (36 decks)

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