assessing children Flashcards
• Understand the components of a paediatric history • Recognise the key differences in assessing children • Develop a multisystem approach to children • Describe the range of techniques used to facilitate examination • Be able to make a basic assessment of each system
what type of approach to take when assessing children
holistic multi-system approach
there may be more than one problem and more than one system may be involved
what to start with when assessing children
age
guides approach to hx and exam
common pathologies differ
conditions manifest differently at different ages
what is an age appropriate approach to taking a history
consider the age and developmental stage
consider language and intellectual skills - start w/ non-medical Qs
typically most questions are directed towards parents; some questions are appropriate for child
pre-verbal children communicate; older children can be quiet
key stages of paeds hx
intro
PC
HPC
birth hx
PMH
immunisations
development
D+A
FHx, SHx
ICE and closure
paeds hx - intro
introduce yourself
identify the patient and who is with them (parents, carers, siblings etc)
generate rapport w/ child
note your ‘examination’ observations
paeds hx - HPC
onset, progress, variation, effects, observations
chronological stages (incl GP, A+E, ward)
general/systems enquiry may be appropriate here
what units do we measure child’s weight in
kg/g
parents typically want it in lbs/oz
lb = 453.6g oz = 1/16th of a lb (28.35g) st = 14lbs (6/35kg)
how much weight should a baby gain
~150-200g /wk for 1st 6mths
~20-30g/day
up to 10% loss in first few days is common
what do we measure feed volumes in
ml
parents often measure in fl. oz
oz = ~30ml
1/20th of a pint (568ml)
how much feed should a baby take
~140-180ml/kg/day
100ml/kg/day if unwell
asking about stools/bowel function
children in nappies vs independent toileting
frequency ( per week/day/month)
size, shape, appearance, consistency
difficulties passing
pain on passing
blood/mucus seen
use bristol stool chart and ask child/parents to compare
paeds hx - birth hx
detail needed depends on age and presentation
some features may be very relevant yrs later
gestation, birth weight, health during pregnancy, delivery, child’s well being after delivery
paeds hx - PMH
admissions
similar problems
previous health issues etc
paeds hx - immunisations
missed - if so why
additional
paeds hx - development
what can they do
any concerns
basic enquiry essential - smiling, sitting, walking, words, support (age appropriate)
paeds hx - D+A
regular medication
OTC
prescribed
things for this illness
previous medications
name, dose, frequency, route, preparation
paeds hx - FHx and SHx
recent and related health issues
parents/siblings (age and health)
who does the child live with
realtionship dynamics
school and nursery
- common source of infective contacts
- can give insight into developmental process
parental SHx impacts on child’s health
- smoking, alcohol, drugs, occupation, stress
paeds hx - addressing concerns and closure
what made them come to see you today
what concerns do they have
what were they looking to understand
summarise key features
check understanding and safety net
document hx and discussions
note date, time, who was present/gave hx
approach to examining a child
observations started during hx
age appropriate techniques
be sensitive to what will upset the child
what are you trying to examine in a child
OBSERVATIONS!
ABCDE, baseline obs/vital signs
general condition and peripheries
resp CVS GI neuro MSK ENT skin developmental skills measurements and centile
process of examination for a child
be flexible
ALWAYS start w/ observations
- pre assessment, during hx
think of each system
think of each area
age appropriate approach
generate rapport
what to look for during observations
general: appearance, play, interaction, obs
resp: effort, noise, rate, recession, O2, nebs
CVS: colour, perfusion, posture
GI: feeding, vomiting, abdo distension/movement
neuro: alertness, interaction, play, posture, gait
MSK: mobility, limb movements, posture, splints, strength, mobility aids
other: rashes, bruises, infusions, tubes, lines; toys, pictures, cards, games etc
what to look for in hands and arms
warmth, cap refill, radial/brachial pulses (rate/rhythm)
clubbing, nail changes, hand skills, pen marks (developmental stage)
what to look for in the head and face
eyes - jaundice
lips - colour, moisture
tongue
nose - congestion
scalp changes, bruises, rashes, fontanel (depression, enlargement)
what to look for in the neck
rashes and nodes - size, shape, mobility, position, consistency, symmetry
tracheal tug
carotid pulse and trachea can be uncomfortable so not always necessary
examine from the front
what to look for and examine in the chest and back
murmurs - timing, pitch, quality, location, radiation
apex beat, thrills, chest expansion (limited in small children)
breath sounds - all areas, reduced/added sounds, symmetry
percussion - limited in infants and not routine BUT commonly forgotten in pneumonia
resonance and fremitus - difficult in young children
rashes and skin marks incl neuro-cutaneous
spine alignment, deformity, sacral dimples
what to look for and examine in the abdomen and groin
tenderness - watch face and movement, light and deep palpation (can be challenging)
masses (esp stool) and organomegaly (can use thumb 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 PR (senior staf only)
what to look for and examine in the legs and feet
mobility, changing posture, movements, tone
reflexes (easy when v. young), plantars, clonus
power, co-ordination, sensory assessment if older
pulses, warmth, CR, colour, mottling
rashes, bruises, markes
deformities and gait usually evident on inspection
primitive reflexes in babies
plantar - extensor plantar responses
grasp reflex on foot when pressing and hold
how to measure head circumference
front of head round occiput
repeat 2-3x to check
remove any hats etc
play and examination
let the child continue to play as appropaite
age appropriate toys - use to illustrate, distract and as clinical tool
