Paediatric History Taking - PowerPoint Presentation

Slide1

Paediatric History Taking& Examinations

Slide2

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

Slide3

Paediatric Histories

Different

ball game

Collateral history

Comms

,

comms

,

comms

!

Red book

Slide4

New components

Feeding & Drinking

Wet/dirty nappies

Growth & Development

Pregnancy History

Birth History

Immunisation History

Slide5

Structure

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.

Slide6

What’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.

Slide7

What’s normal?

Slide8

Red 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

Slide9

Red 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

Slide10

Systems 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

Slide11

Previous 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

Slide12

Top 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”

Slide13

Presenting 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

Slide14

Breathless/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”

Slide15

Breathless/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)

Slide16

Vomiting

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

Slide17

Failure 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)

Slide18

Neonatal 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.

Slide19

Childhood 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

Slide20

Neurological Febrile convulsionSeizure (focal, generalised, absence)

Non-neurological

Vasovagal

syncope

Breath holding spells

Fit/Faint/Funny Turn

Slide21

Precocious 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

Slide22

ConstitutionalHypogonadotrophic 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

Slide23

SummaryCollateral historyRemember your red flags

Remember the paediatric-specific questions

M&M stuff can come up for you, so don’t neglect it.

Slide24

Questions so far…?

Slide25

Examining 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

Slide26

What could come up?

Cardiovascular exam

Respiratory exam

Abdominal exam

Neuro exam

MSK exam (hip, shoulder, knee)

?Specialties (ENT

etc

)

Slide27

signs

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

Slide28

signs

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

Slide29

Signs: 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)

Slide30

Examination 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

Slide31

To 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

Slide32

SummaryRelax and be friendlyMake it a game

You don’t have to finish to get good marks

M&M exams could show up

Slide33

Thank youAny Questions?