General paediatric

Question 1

What should be done whilst examining?

Answer 1

Avoid waking sleeping children

Approach the child at their level; if necessary kneel on the floor

Observe before examining as may provoke crying

Start examining peripherally (hands and feet), as this is less threatening

Make the examination fun to help with their anxiety - toy. even a pen torch or an ear speculum rattling in a urine container

Make sure the child is comfortable, and that your hands, stethoscope and other instruments are warm

Ask parents to assist with dressing or undressing children and be aware of sensitivities about this

Wherever possible avoid unpleasant procedures (ie rectal examination)

Question 2

What is key in observations?

Answer 2

Observe the child’s behaviour and level of awareness and take these into account with the parent’s or parents’ own reports

Consider if the child’s appearance is unusual at all and in what way

Note the shape of the head, mould of ears, position of eyes, body proportions, posture

Note whether the child looks like the parent/s

Establish whether there any recognisable major or minor anomalies

Record the nature and distribution of skin lesions and rashes

Note the colouring, shape and positions of bruises - -f they have suspicious appearance, consider the possibility of non-accidental injury

Question 3

What is different about the cardiac examination?

Answer 3

Nothing ?

Question 4

What is different about the respiratory examination?

Answer 4

Crepitations can occur in apparently normal babies - persistent bilateral creps in a distressed toddler usually suggests bronchiolitis (or L heart failure)

Rales (intermittent, insp/exp noises) - liquid debris in larger airways

Rhonchi (persistent harsh added sounds) - less common; more persistent obstruction

Bronchial breathing - heard over baby upper back usually transmitted from main airway

Stridor - harsh inspiratory noise, often in croup

Question 5

What is different about an ENT examination?

Answer 5

To examine ears - best to sit child sideways on parents lap with one parents hand holding both the child’s hands and the other holding the top of the head

To view the throat in a defiant toddler - insert tongue depressor into the gap between clamped teeth and cheek and teeth may briefly open allowing you to insert tongue depressor

Question 6

What is different about the GI examination?

Answer 6

Enquire about tenderness - if present and child is systemically unwell, ask child to puff up their stomach like a balloon - may elicit rebound tenderness without you having to touch them

Assessing dehydration - in young babies the fontanelle may be depressed

Question 7

What is different about the MSK examination?

Answer 7

Small babies - pay particular attention to sacrum - hairy naevi or sinus present

Be aware of normal variation - ‘in-toeing’, femoral anteversion, genu valgus, genu varus, etc

Question 8

What is different about the CNS examination?

Answer 8

Normal development in motor/speech/language/social? Parental concerns?

Always examine the fontanelle by palpation (up to 2.5yrs) - note pulsation and if its normal

Although rarely useful, you may be able to elicit reflexes with a finger rather than a hammer