Approach to Assessing Children Flashcards
What is the approach to general paediatrics?
Holistic multi-system approach essential
- More than one problem may exist
- More than one system may be involved
Start with the age
- Guides approach to history and examination
- Common pathologies differ
- Conditions manifest differently at different ages - viral infection in infant may make them very septic/unwell but same infection may give a bronchiolitis presentation in an older baby
Consider common differentials for the presenting problem
What do you need to consider when preparing for an encounter in paediatrics?
Why have they come to see you or been referred to the hospital or clinic? Clinic letter, A&E letter
Do you know the child’s name, age and sex?
Do you have any 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?
Why is taking a good history important in paediatrics?
Key to making the diagnosis
Gather important information
Potentially rule out significant pathology
Helps examination be more targeted
Be calm and empathetic
Show interest in what the parents are saying - what are you most worried about, is there anything in particular you want to know about etc.
Facilitates dealing with concerns and anxieties
What should you consider in an age-appropriate approach?
Consider age and developmental stage - infants with nappies; parents will be best people to ask e.g. GI problems, older children without nappies can be asked directly
Consider language and intellectual skills
Typically most questions directed to parents
Some questions are appropriate for the child
Different perspectives may be gathered from both parents or from parent and child
Pre-verbal children communicate
Older children can be quiet
What should you do in your introduction when taking a paediatric history?
Introduce yourself, identify the patient and who is with them - parents, carers, others
Generate rapport with the child
Note your examination observations
What do you want to know about presenting complaint and HPC in a paediatric history?
Onset, progress, variation, effects, observations
Chronological stages - including GP/A&E/ward
General/systematic enquiry may be appropriate here
Why is it important to know your units in paediatrics?
Parents may use a measurement that you are not familiar with
We measure a child’s weight in kg and g, and feed volumes in millilitres, whereas parents often measure weight in pounds and ounces and feed volumes in fluid ounces
How much weight should a baby gain in the first 6 months of life?
Around 150-200g/week (20-30g/day)
How much weight loss in the first few days of life is common?
10%
What is the typical volume of feed that babies take?
140-180ml/kg/day
100ml/kg/day if ill
What do you need to ask about stools in paediatrics?
Frequency - per day, week or even mouth Size, shape, appearance and consistency Difficulties passing Pain on passing Blood or mucus seen
Need to decide whether to ask parents e.g. children in nappies or ask the child directly i.e. independent toiling
What are the other key features of paediatric history?
Birth history
PMH - admissions, similar problems
Immunisations - missed/additional
Development - what they can do, any concerns, basic enquiry essential i.e. walking, talking, support
Drugs and allergies - this illness, regular and previous
What are the key features of family and social history in paediatrics?
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
How do you address concerns and give closure in a paediatric consultation?
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
What are the key differences in assessing children?
Parents will be there
- Astute observers
- Resident carers
Play is essential and clinically helpful
Specialised nursing staff
- Different ratios
- Understandably protective
- Experienced at recognising sick children
Treatments differ by weight and age - calculations all done by weight and age
What do you need to be aware of when carrying out a paediatric examination?
Key step in working towards a diagnosis Already started during history Age appropriate techniques used Be sensitive to what upsets children Difficult for undergraduates and postgraduates Observation tells you more than auscultation Be prepared to adapt your approach Be opportunistic
What are you trying examine during a paediatric examination?
ABCDE and baseline observations/vital signs General condition and peripheries - colour of fingers and toes Respiratory system Cardiovascular system Alimentary system Neurological and musculoskeletal systems ENT and skin Developmental skills Measurements and centile
What are the important things to do/consider when getting started with a paediatric 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, don’t take a settled child off of the parents in order to examine on the bed
Gentle handling and gradual exposure
Show interest in their toys and play
What is the method for doing a paediatric examination?
Can be different every time
Always start with good observation
- Pre-assessment
- During history
Think of each system
Think of each of area
Think of the method for that age
Rapport is essential
What do you observe for in paediatrics (observations before examination)?
General - appearance, play, interaction, observations
Respiratory - effort, noise, rate, recession, O2, nebulisers
CVS - colour, perfusion
GI - feeding, vomit, abdominal distension/movement
Neurology - alertness, interaction, play, posture
MSK - mobility, limb movements, posture, splints, mobility aids
Other - rashes, bruises, infusions, tubes, lines, toys, pictures, cards, games, caffeine, books
What would you be examining for in an examination of the hands and arms?
Warmth, capillary refill, radial/brachial pulses (rate and rhythm)
Clubbing, nail changes, hand skills, pen marks
What would you be examining for in an examination of the head and face?
Eyes - jaundice Lips - colour, moisture Tongue Nose Scalp changes, bruises, rashes, fontanel
What would you be examining for in an examination of the neck?
Rashes and nodules (easier from the front) - size, shape, mobility, position, consistency, symmetry
Tracheal tug
What would you be examining for in an examination of the chest and back?
Murmurs (timing, pitch, quality, location, radiation)
Apex beats, thrills, chest expansion (limited if very 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 (including neuro-cutaneous)
Spine alignment, deformity, sacral dimples
What would you be examining for in an examination of the abdomen and groin?
Tenderness - watch face and movement
Masses (especially stool) and organomegally (liver, spleen, kidneys), thumb can be used to feel
Bowel sounds and bruits (very rare)
Femoral pulses (essential in infants)
Hernias, testis
Genital/anal appearance (routine in nappies but often not appropriate for older children)
Do not do rectal exam - senior staff only with limited indications
What would you be examining for in an examination of the legs and feet?
Mobility, changing posture, movements, tone
Reflexes (easy when very young), plantars, clonus
Power, coordination, sensory assessment if older
Pulses, warmth, capillary refill, colour, mottling
Rashes, bruises, marks
Deformities and gait usually evident on inspection
How can you use play in examination?
Creative approach 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
