WCS37 Paediatric History Taking

Question 1

3 Hand signs

Answer 1

1. Hand gun sign: **History taking
   - vertical axis: **symptoms
   - horizontal axis: ***time
   - onset as zero time point
   - get most useful 3-4 symptoms
   - list attributes of the symptoms along timeline (see evolution of symptoms)
2. 3D hand sign
   - 中指: **site of disease
   - 食指: **causes of disease / pathophysiology, differentiating signs, defining features
   - Thumb: ***context of that patient e.g. socioeconomic situation
3. OK hand sign
   - 3 fingers: **Situation (i.e. complaint), **Background of patient, **Assessment of whole situation with PE / tests
   - Circle: **Recommendation for child / family (need to have consensus, discuss whole situation, recommendation)
   - ***SBAR: Situation, Background, Assessment, Recommendation

Question 2

RIDER

Answer 2

1. Reporting
2. Interpret
3. Differentiate
4. Evaluate
5. Recommendation

Question 3

ASK

Answer 3

1. Attitude
   - listen (mother + child)
   - respect individuality (uses the child’s name)
   - be sensitive, beware of hidden agenda
   - let child speak
   —> possible at any age
   —> use age-appropriate strategy and words
   —> gadgets to gain trust
   —> drawing can help communicating
   —> aware of maturing mind of child in understanding health issues, deliberating the tissues, having formed his values
   —> make medical decision, need to balance the child’s and parents’ wish in the context of best interest for the child
   - diaphragm can be cold!
   - establish good eye contact and rapport with the child
   - don’t handle children roughly
2. Skills
   - adequate medical, developmental, social and behavioural history taking
   - good communication skills
   - sufficient skill to do full PE of newborn infant, toddler, child, adolescent
   - formulation of problem lists, DDx, management plan
3. Knowledge
   - growth and development of normal and sick child
   - basic knowledge of child health and illness
   - genetic and environmental factors in illness

Question 4

Family interview during history taking

Answer 4

Objectives

1. Precise sequential description of unfolding a child’s illness
2. Therapeutic as well as Diagnostic

Key priorities:

• all parties ***seated for the interview —> I have time for you
• use ***lay terms —> I can listen actively and talk clearly
• focus on illness (***patient’s concern) as much as disease (physician’s concern) —> I am supportive and empathetic

Interview setting

• dress code
• physical setting
• occupying child with toys
• both parents, other carers
• nurse

Interviewing skills

• establish warm atmosphere
• maintain privacy
• sustain eye contact
• listen carefully
• continue a logical flow of content
• sprinkle empathetic and supportive comments

Question 5

Parents of ill children broadly seek ***4 degrees of information

Answer 5

1. What is it? What is wrong?
2. Cause? How it happen?
3. Outcome
4. Will it happen again?

Question 6

Key paediatric points

Answer 6

1. Listen to mother and their concerns
2. Preverbal children’s ability to communicate is limited
   —> appropriate ***“Body language” and observation
3. Conclude by asking any points not clearly understood / any further questions they may have forgotten to ask

Question 7

Breaking bad news to parents

Answer 7

1. Speak slowly and simply
2. Avoid medical terms
3. Clear and concise
4. Not give too much information at a time
5. Ask for questions
6. Always have a nurse present
7. Express sympathy

Question 8

History taking format

Answer 8

1. Present illness, Precise sequential description!!!
2. System review
3. Prior history, Prenatal birth, Neonatal feeding, Growth and development, Immunisation, Previous illness
   - **Birth history: Gestation, Mode of delivery, Birth weight
   - **Feeding history: Breast-fed, Formula-fed, Onset of solid food, Amount
   - **Developmental history: Cognitive, Social / Emotional, Speech / Language, Fine / Gross Motor
   - **Immunisation history
4. Family
   - Family tree, Consanguinity
   - Family history of illness
   - Family dynamics
5. Psychosocial
   - Occupational history of parent
   - Household, moves
   - Support system
   - Financial problems
   - Major life events (birth of another child, changing school)
   - Psychiatric illness
   - Marital stability
   - Substance abuse

Question 9

Counselling

Answer 9

• Strong doctor-parent-child relation
• Discussion
• Not to cover too much at each visit
• Not overly dogmatic
• “Natural” counselling moments
• ***Important information repeated several times during visit
• Positive reinforcement

Question 10

***Always serious symptoms in infancy

Answer 10

1. High-pitched screaming / crying (Not consolable)
2. Alternating drowsiness, irritability
3. Convulsion
4. Refusal to feed (***>=2 consecutive feeds)
5. Repeated vomiting
6. Rapid, laboured breathing, with / without grunting
7. Episodes of unusual blueness / paleness
8. Spreading ***purpuric spots >2 mm in diameter

Question 11

***Usually serious symptoms in infancy

Answer 11

1. Repeated diarrhoea
2. Prolonged crying
3. ***Croup (stridor, hoarseness, barking cough)
4. ***High fever (40oC / 104oF)
5. Persistent crankiness / irritable

Question 12

History on respiratory system

Answer 12

• Cough
• Wheeze
• Stridor
• Croup
• Poor feeding (document volume of feed)
• Fever
• Rapid respiration
• Grunting + Cyanosis

Normal RR at rest (Rapid RR)
Newborn: 30-50 (>60)
Infant: 20-30 (>50)
Toddler: 20-30 (>40)
Child: 15-20 (>30)

Question 13

History on CVS system

Answer 13

• Tachypnea (RR > 50-60 at rest)
• Dyspnea at rest / following a feed
• Sweating
• Inability to finish a feed
• Tachycardia
• Exercise tolerance

Normal HR at rest (upper limit)
0-6 months: 140 (160)
6-12 months: 130 (150)
1-2 years: 110 (130)
2-6 years: 100 (120)
6-10 years: 95 (110)
10-14 years: 85 (100)

Temperature and HR/RR
1oC —> ↑ HR: **10 beats/min
1oC —> ↑ RR: **4 breaths/min