Approach to Assessing Children

Question 1

How can we approach general paeds?

Answer 1

• Holistic multi-system approach essential
  
  • More than one problem may exist
  • More than one system may be involved
• Start with the age
  
  • Guides approach to history taking and examination
  • Common pathologies differ
  • Conditions manifest differently at different ages
• Consider common differential for the presenting problem

Question 2

What is likely to be different in paediatrics?

Answer 2

• parents will be present
  
  • they are astute observers
  • resident carers
• Play is essential and clinical helpful
• Specialised nursing staff
• Treatments differ by age and weight

Question 3

What can we do to prepare for clinical encounter?

Answer 3

• Why are they coming to see me?
• Name, sex and age of child
• Do we have opportunity to observe child first?
• What are likely DDx?
• What conditions need ruled out?
• What info have the nurses already gathered?

Question 4

How can we take a good paeds history?

Answer 4

• Be calm and empathetic
• Show interest in what the parents are saying
• Facilitates dealing with concerns and anxietiesa

Question 5

How can we use an age appropriate approach?

Answer 5

• Consider the age and developmental stage
• Consider language and intellectual skills
• Typically most questions directed to parents
• Some questions are appropriate for a child
• Different perspectives may be gathered from both parents or from parent and child
• Pre-verbal children communicate!
• Older children can be quiet

Question 6

Paeds history

What do we cover in introduction?

Answer 6

• Introduce yourself, identify the patient and who is with them (parents/ carers/ others)
• Generate rapport with the child
• Note your “examination” observations

Question 7

Knowing your units

What do we normally weigh babies in?

Answer 7

Pounds and ounces

9lb = 4kg

Question 8

•How much weight should a baby gain?

Answer 8

• ~150(100)- 200g/ week 1st 6 months
• = 20-30g per day (need to average time intervals)
• Up to 10% loss in first few days is common

Question 9

•How much feed should a baby take?

Answer 9

• Probably 140-180 ml/kg/day (100ml/kg/day if ill)

Question 10

What questions need covered about jobbies?

Answer 10

• Children in nappies vs. independent toileting
• Frequency (per day, week or even month)
• Size, shape, appearance and consistency
• Difficulties passing
• Pain on passing
• Blood or mucus seen

Question 11

Paeds history

What needs covered in birth history?

Answer 11

• Detail depends on age and presentation
• Some features may be very relevant years later

Question 12

Paeds history

What needs covered in immunisations?

Answer 12

• Have they missed any
• Had any additional

Question 13

Paeds history

What needs covered in development?

Answer 13

• What can they do? Any concerns?
• Basic enquiry essential (Walking, Words, Support)

Question 14

Paeds history

What needs covered in FH/SH?

Answer 14

• Key stage in assessing patients
  
  • Recent and related health issues
  • Parents/ siblings (age and health)
  • Relationship dynamics
• School and nursery
  
  • Common source of infective contacts
  • Can give insight into developmental progress
• Parental social history impacts on child’s health
  
  • Smoking/ alcohol/ drugs/ occupation/ stress

Question 15

What are some questions we can use to address the parents concerns?

Answer 15

• What made them come to see you today?
• What concerns do they have?
• What were they looking to understand?

Question 16

How can we close the paeds history?

Answer 16

• Summarise key features
• Check understanding and safety net
• Document history and discussions
• Note date, time, who was present/ gave history

Question 17

Can we be expected to know paeds examination in year 3 osce?

Answer 17

Nope

Question 18

How do we start paeds examination?

Answer 18

• Observe first
• Smile
• Speak to the child (even if they are weeks old)
• Get down to their level
• Be careful moving them- keep parents close
• Gentle handling and gradual exposure
• Show interest in their toys + play

Question 19

What do we observe for in paeds examination?

Answer 19

• General: Appearance, play, interaction, obs
• Resp: Effort, noise, rate, recession, O2, nebs
• CVS: Colour, perfusion
• GI: Feeding, vomit, abdo distension/ movement
• Neuro: Alertness, interaction, play, posture
• MSK: Mobility, limbs movements, posture, splints, mobility aids
• Other: Rashes, bruises, infusions, tubes, lines
• Other: Toys, pictures, cards, games, caffeine, books

Question 20

What do we examine for on hands and arms?

Answer 20

• Warmth, cap refill, radial/brachial pulses (rate/ rhythm)
• Clubbing, nail changes, hand skills, pen marks

Question 21

What do we look for head and face?

Answer 21

• Eyes (jaundice), Lips (Colour, moisture), Tongue, Nose
• Scalp changes, Bruises, Rashes, Fontanel

Question 22

What do we examine for on the neck?

Answer 22

• Rashes and Nodes (easier from the front); size, shape, mobility, position, consistency, symmetry
• Tracheal tug (Don’t push for carotid pulse or trachea)

Question 23

What do we observe for chest and back?

Answer 23

• Murmurs (Timing, pitch, quality, location, radiation)
• Apex beat, thrills, chest expansion (limited if wee)
• Breath sounds (all areas, reduced, symmetry, added)
• Percussion (limited in infants, not routine, commonly forgotten when dealing with pneumonia)
• Resonance and fremitus? (most are pre-school!)
• Rashes and skin marks (inc neuro-cutaneous)
• Spine alignment, deformity, sacral dimples

Question 24

What do we observe for abdo and groin?

Answer 24

• Tenderness- watch their face and movement
• Masses (esp stool) and organomegaly (liver, spleen, kidneys). Thumb can be used 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 A RECTAL EXAM! (Senior staff only)

Question 25

What do we observe for in legs and feet?

Answer 25

• Mobility, changing posture, movements, tone
• Reflexes (easy when v. young), plantars, clonus
• Power, coordination, sensory assessment if older
• Pulses, warmth, cap refill, colour, mottling,
• Rashes, bruises, marks
• Deformities and gait usually evident on inspection

Question 26

How can we use play for examination?

Answer 26

• Let the child continue to play as appropriate
• Select age appropriate toys
  
  • Use play to illustrate
  • Use play as a distracter
  • Use play as a clinical tool
• The aim is to gather useful clinical information
• Appropriate sensitivity needed at times

Question 27

What are Revolta’s top tips?

Answer 27

• Smile and make positive eye contact
• Engage with the child’s interests
• Recognise common toys and characters
• Develop your banter
  
  • Soothing words to babies (parents notice)
  • Nursery and school chat
  • Counting fingers
  • Activities and interests
• Always observe as much as you can