amp Examinations Aims Top tips for paediatric histories Components of a paediatric history Common presenting complaints Red Flags Examining a child top tips OSCE tips on paediatric examination ID: 779465
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Slide1
Paediatric History Taking& Examinations
Slide2Aims:
Top tips for paediatric histories
Components of a paediatric history
Common presenting complaints
Red Flags
Examining a child: top tips
OSCE tips on paediatric examination
Paediatric Histories
Different
ball game
Collateral history
Comms
,
comms
,
comms
!
Red book
Slide4New components
Feeding & Drinking
Wet/dirty nappies
Growth & Development
Pregnancy History
Birth History
Immunisation History
Slide5Structure
Introduction
PC/HPC
+ feeding/drinking/nappies
ICE
PMH +
DH (allergies)
+ Immunisations
Pregnancy, birth history, growth, development.
FH – Genetics, family tree,
SH – Schools, pets, parents smoking, people at home.
Slide6What’s Normal?
Feeding – gain weight appropriately (first 2 weeks may lose some weight).
Breast feeding: on demand, every few hours, including during the night. Latching on. Rhythmic sucking. Breast softening.
Formula feeding: no exact amount, however average of 150-200ml/kg/24hr. (1 ounce is around 30ml)
Wet nappies: 6 per day
Dirty nappies: 2 per day. Green meconium first. Then soft, yellow stool.
Growth: should not cross deciles
Premature babies need to catch up.
Slide7What’s normal?
Slide8Red flags
Irritable, floppy, refusing feeds, dry nappies, increased work of breathing, stridor, cyanosis, “toxic” appearance, neck stiffness, unexplained bruising, non-blanching rash, jaundice <24h or >2wks postpartum, failure to pass meconium in 24h, bilious vomiting
Anxious parent.
Crossing deciles on growth charts.
Development:
No smile at 8 weeks
>18 months not walking
>24 months not talking
Loss/regression of skills
Early hand dominance
Slide9Red flags: Mini Quiz
Failure to pass meconium in 24h
Jaundice <24h or >2wks
Toxic child
Unexplained bruising
>18months not walking
>24months not talking
Stridor
Bilious vomiting
– CF,
Hirshsprung’s
– Haemolysis or biliary atresia
– Meningitis, epiglottitis, anaphylaxis, severe croup etc.
– NAI, ALL, clotting disorders, bleeding disorders
– Cerebral palsy, Duchenne’s MD
– Autism Spectrum Disorder
– Croup, epiglottitis, anaphylaxis, inhaled foreign object
– Malrotation, volvulus
Slide10Systems ScreenCardio: Cyanosis. Breathless. Collapse
Resp
: Increased work of breathing. Cough.
Gastro: feeding, vomiting, wet/dirty nappies, colicky baby
Neuro/MSK: Supporting weight, grip, crawling
etc
(motor milestones). Convulsions.
ENT: pulling on ears, discharge, redness.
Constitutional: Irritable, fever, weight loss
Slide11Previous stations
Child Psychiatry
Developmental delay
Self-harm
Behaviour
Allergic reaction
Convulsion
Acute Otitis Media
Cough
Conduct disorder
Pneumonia
Diarrhoea
Early puberty
Failure to Thrive
Non-accidental injury
Heart Failure
Jaundice
Pyloric Stenosis
Weight loss
IBD
Bruising
Headache
Slide12Top tipsDon’t ask the parent for their date of birth – easily done
Learn a good structure
Remember to include feeding, nappies, pregnancy/birth
hx
& immunisations
Good communication skills will get you through a difficult station:
“how are you coping?”
“you did the right thing by bringing him/her to see us”
“it’s not your fault”
Slide13Presenting complaintsBreathless/cough/sounds
Failure to thrive/faltering growth
Neonatal jaundice
Developmental delay (global, motor, language/social)
Childhood bruising
Fit/faint/funny turn
Precocious puberty
Delayed puberty
Slide14Breathless/Cough/Sounds
Viral infection
Bronchiolitis
Pneumonia
Asthma
Croup
Pertussis
Cough,
coryzal
symptoms, fever, wheeze (viral induced wheeze)
6 months -3 years, wheeze,
tachypnoeic
F
ever, wet cough, chest pain if older.
Night cough, wheeze, chest tightness, older children (not infants), atopy
Barking cough, viral
prodrome
Cough with inspiratory “whoop”
Slide15Breathless/Cough/Sounds
Wet
cough, faltering growth,
steatorrhoea
.
Acute setting,
with SOB and stridor.
Exposure
to allergen, rash, trouble breathing, swelling around
lips/tongue
Toxic child, excessive
drooling
Croup
with acute deterioration.
Cystic Fibrosis
Inhaled foreign object
Anaphylaxis
Epiglottitis
Bacterial
Tracheitis
Also consider congenital and cardiac
cause – cyanosis, sweating, faltering growth, tiredness)
Slide16Vomiting
A
fter
feeds, milk, common in
infants
C
oughing
followed by
vomiting
P
rojectile
vomiting, may have seen
peristalsis
F
ever
, tummy pain,
diarrhoea
B
ilious vomiting
R
ed-current
jelly stool, pale crying
infant, knees to chest
Blood in stools that is neither fresh nor true melenaDelayed passage of meconium, neonate.
Kids always vomit!
Regurgitation/GORD
Post
tussive
Pyloric stenosis
Gastroenteritis
Bowel obstruction
Intercusseption
Meckel’s Diverticulum
Meconium ileus
Remember psychological factors
Slide17Failure To Thrive/Faltering GrowthCystic Fibrosis
–
(
chest and bowel symptoms)
Coeliac Disease
– Diarrhoea, pale, associated autoimmunity
Inadequate intake
– Refusing
feeds,
difficulty
with latching (cleft palate)
Emotional/nutritional disorder
– parents/cares not giving child enough food.
Eating disorder
– older child,
low BMI, binging-purging, fear of fatness.
Chronic illnesses
Diabetes
-
polyuria/polydipsia/fatigue
Inflammatory
Bowel Disease
– blood/mucus in stool, change in bowel habits, ulcers, skin changes (pyoderma gangrenosum/erythema nodosum)
Slide18Neonatal Jaundice
Timeline:
<
24hours – haemolytic disease of
newborn
, G6PD
defiency
, maternal TORCH infections
24hours - 14
days – Physiological jaundice, breast milk protein, infection
>14 days - biliary atresia, Total Parenteral Nutrition, breast milk
protein
Remember:
Unconjugated can lead to kernicterus.
Conjugated causes dark urine and pale stool.
Slide19Childhood bruising
Accidental
Bony prominences
Fits with age or developmental milestones
Non-accidental
Unusual or covered places (safe triangle).
History does not match injury. Delayed presentation. Inconsistent story.
Systemic
Meningococcal disease – headache, neck stiffness, photophobia, lethargic, feverish.
Vasculitis (HSP) – non-blanching rash on legs, polyarthritis
ALL (+ other
leukaemias
) – Pale, acutely unwell, recurrent infections
Primary bleeding disorders (von-
willebrand
etc
)
ITP – bleeding, purpura, epistaxis, menorrhagia
Slide20Neurological Febrile convulsionSeizure (focal, generalised, absence)
Non-neurological
Vasovagal
syncope
Breath holding spells
Fit/Faint/Funny Turn
Slide21Precocious PubertyGonadotrophin dependent
Familial/idiopathic
CNS abnormalities – history of hydrocephalus, hypoxic brain injury etc.
Intracranial tumour - neurological symptoms
Gonadotrophin independent
Adrenal tumour hyperplasia – excessive pubic hair, penis/clitoris enlargement, weight gain
Ovarian/testicular tumour – O
varian
: bloating, pelvic pain, menorrhagia. Testicular: painless lump
Other differentials
Premature
thelarche
– breast development only
Premature
pubarche
– pubic hair growth only
External sex hormones
Slide22ConstitutionalHypogonadotrophic hypogonadismSystemic disease – symptoms of underlying disease (IBD, CF, anorexia)Hypothyroidism – delayed growth, fatigue, cold intolerance, dry skin, coarse hair
Hypergonadotrophic
hypogonadism
Klinefelters
– small testes, gynaecomastia, tall and thin
Turners – short stature, amenorrhea
PCOS – oligo/amenorrhoea, hirsutism, acne.
Delayed Puberty
Slide23SummaryCollateral historyRemember your red flags
Remember the paediatric-specific questions
M&M stuff can come up for you, so don’t neglect it.
Slide24Questions so far…?
Slide25Examining A child: The basicsComms
comms
comms
!
Friendly introduction
Get down to their level.
Children ages: 6-10yrs
Check you have
permission
to examine the child.
Have a bank of questions ready (What films do you like? Do you play any sports? Favourite colour?)
Make it a game!
Comment on everything you see or present at the end
Slide26What could come up?
Cardiovascular exam
Respiratory exam
Abdominal exam
Neuro exam
MSK exam (hip, shoulder, knee)
?Specialties (ENT
etc
)
Slide27signs
General
Dysmorphism
Colour – mottling
Alertness and interest in surrounds
Respiratory:
Tracheal tug, intercostal/subcostal recessions, grunting, stridor, nasal flaring.
Beware upper respiratory tract secretions that sound like pneumonias
Slide28signs
Cardiovascular:
Innocent murmur: soft, systolic, small (no radiation), single, short duration, sensitive (to movement/respiration)
PDA: machinery, continuous, pulmonary area.
VSD:
Pansystolic
, lower left sternal edge
CoA: radio-radial delay, systolic murmur under left scapula and/or
infraclavicular
area
Gastro
Constipation may be umbilical as well as LIF
Slide29Signs: Observations
Normal observations for school children.
HR: 80-120 beats per minute
RR: 20-25 breaths per minute
BP: 90-110 mmHg
(https://
patient.info/doctor/paediatric-examination)
Slide30Examination of Newborn
Head-to-toe
examination looking in particular for:
Congenital cataracts/retinoblastoma
- by ophthalmoscope examination
.
Congenital heart disease-
by examination of the cardiovascular system.
Undescended testes
-
by palpation of the scrotum and inguinal canals.
Developmental dysplasia of the hip
- by the Barlow and
Ortolani
tests and examination of the lower limbs for asymmetry or limited abduction
.
Screen: dysmorphic signs, fontanelles, skin, joints, spine, anus (patent?), primitive reflex's
Slide31To completes:Full history from appropriate source
Plot height/weight on a growth chart
Check nutritional status
Observations
General system exam: cardio, respiratory,
abdo
, ENT
Double check with a senior
Slide32SummaryRelax and be friendlyMake it a game
You don’t have to finish to get good marks
M&M exams could show up
Slide33Thank youAny Questions?