General Approaches Flashcards
History, examination, investigations, recognising the sick child, prescribing, safeguarding (53 cards)
Paeds history taking
Relationship of adult
Speak to child when appropriate rather than just to adult, adolescent may want to speak alone
Find out what parent/child fear is-often from internet
Be clear with terms e.g. wheeze
SR: general health (active, normal self), growth, feeding/drinking, change in behaviour, normal SR
PMH: depends on age but maternal obstetric problems, birthweight + gestation, perinatal problems e.g. SCBU, immunisations, + normal PMH
DH: past + present inc OTC, known allergies
FH: as they share a home + genes
SH: parent occupation, housing, economic status, smoking at home, relationships, are they happy at home/school, impact of illness on child + family, SW involvement
Developmental: parental concerns, milestones, bladder + bowel control, sleeping, school/nursery issues
Paeds examinations
In younger children permission is from parents, explain to them what will do, distal/less upsetting parts first
Often opportunistic
Resp, CVS, GI, CNS, PNS
Important markers in resp exam?
Sputum rarely produced in children until older
Tachypnoea most sensitive marker
Chest recession most specific marker
Important things CVS exam?
Murmurs: likely significant if conducted all over chest or loud or have thrill or diastolic
Hepatomegaly is a sign of HF in infants
Always palpate femorals in neonates to exclude coarctation of the aorta
Signs of HF in neonates: faltering growth, sweating, tachypnoea, tachycardia, gallop rhythm, cardiomegaly, hepatomegaly
Hepatomegaly in children?
Causes-infection, haematological, liver (e.g. polycystic disease), malignancy (leukaemia, lymphoma, neuroblastoma, Wilms’ tumour), metabolic (glycogen/lipid storage disease), heart failure; or apparent (when chest hyper-expands due to bronchiolitis/asthma)
Splenomegaly in children?
Infection, haematological, malignancy (leukaemia/lymphoma), Still’s disease
Abdominal masses?
Wilms’ tumour - doesn’t cross the midline
Neuroblastoma - irregular firm mass, child usually unwell
Faecal masses - mobile, non-tender, indentable, often in LIF
Intussusception - acutely unwell, most in RUQ
How do you even do neuro exam in children?
Screening: watch play, language/social interactions; in infants may be indicated by posture/limb movements/head control/tone.
Most children don’t have issues so don’t need formal exam
CN: basically same as adult as much as they can do
Peripheral nerves: inspection, can prob do tone in toddlers, power mostly in children who can follow instructions, coordination depends on age, sensation with light touch as screening test, gait/movement if can walk, reflexes (do last, explain, demonstrate on parent/toy - brisk may be anxiety or pyramidal issue, absent may be NMJ/SC issue)
How to examine MSK?
Paediatric GALS rapid screen test: do they have pain/stiffness in joints or muscles or back, difficulty dressing/stairs, observe gait (inc tip toe, heel toe).
Arms- hold out, make fist, pinch index finger + thumb, touch tips of all fingers with thumb, squeeze MCP for tenderness, put hands palm to palm + back to back, reach up to sky, put hands behind neck
Legs - knee effusion, active movement knee, passive movement hip
TMJ
Neck + spine - touch shoulder with ear, bend forward to toes
What are the normal observations in children of varying ages?
<1y: RR 30-40, HR 110-160
1-2y: RR 25-35, HR 100-150
2-5y: RR 20-30, HR 95-140
5-12y: RR 15-20, HR 80-120
> 12y: RR 12-16, HR 60-100
What are the two types of growth charts used?
Age 2w to 4y: UK-WHO growth chart (standard-based)
Age 4-20y: 1990 UK growth chart (reference-based)
How should we measure growth?
Perpendicular measure thing for length + height (not tape measure!)
Head circumference: tape measure. Take the maximum occipital-frontal head circumference (if you can wiggle it up and down then you have the maximum). Take off and put on again 3 times
How often should a baby be weighed?
Routinely in 1st week to check not getting more than a 10% loss (which is normal)
Once a month in the first 6 months
Once every 2 months in 6-12 months
Thereafter every 3m (done routinely at the 12-13m vaccines)
Unless they have sx then don’t do it more often as regression to the mean means there are fluctuations (cause anxiety but normal)
Calculating age for growth chart
Use DOB for accuracy - e.g. if mother says they are 5 months that could mean almost 6 months or just turned 5 months
Preterm <37w: record the actual chronological age from birth, and draw an arrow line back for the number of weeks they are pre-term. E.g. for a 5w old who was 6w early, you’d plot the weight at 5w then arrow back for 6w
How to plot + interpret growth charts
SINGLE DOT
Arrow back for premature
Centile - distance between two of the centile lines. Lines are the blue lines not the grid
If they go across the lines you count the bandwidth (gaps) not the lines
Lines below the 0.4th centile-take bandwidth above to determine where it is
If point is within 1/4 of a space of a line above + below then they are on the centile, e.g. the 91st. If not they should be described as between the two e.g. between the 75th and the 91st. If in doubt go for the line-needs to be clearly in the middle to say it’s between
What is affected first by a new insult?
Weight is usually first thing to drop, then height, then HC last (most protected) so be vigilant
Concerning features on growth charts?
Someone staying below the 0.4th centile-even if following a trend must exclude pathology as is only normal in <0.4% of healthy babies
> 10% weight lost (only occurs in <5% of healthy babies)
> 10% weight lost still at 2w (only in <2% of healthy babies)
More than 2 centiles are crossed over time
How should you approach the CXR in children?
Use rib ends to assess rotation as clavicle ends hard to see
Good inspiration is when the 8-9th posterior rib is visible or 6th anterior rib (posterior only in young children)
Unilateral hyperinflation (Ball-valve effect)
Systematic approach as for adult - deets, ABCDE. Remember hidden spaces like behind the heart/sternum + below diaphragm
How might important abnormalities appear on a CXR?
Neonatal RDS: diffuse ground glass lungs, usually b/l + symmetrical, may have air bronchograms, severe-whiteout. Hyperinflation excludes it if they aren’t ventilated. Surfactant + oxygen to treat
Hyperinflation: flattened hemidiaphragm, >6 ant/>9 posterior ribs above diaphragm, hyper lucent. E.g. asthma, CF, bronchiectasis, bronchiolitis
Consolidation: air in alveoli replaced with pus/transudate/blood/cells. Homogenous opacity, Silhouette sign (loss of lung/soft tissue interface), air bronchogram, no volume loss. May be lobar, diffuse or multi-focal
Collapse: not same as atelectasis is ‘incomplete expansion’. Lobes may collapse when bronchus supplying it is obstructed e.g. aspirated FB, mucus plugging, or compression by an external mass. See displacement of a fissure towards collapsing lobe, air space opacification if lots of volume loss, elevation of ipsilateral hemidiaphragm, mediastinum shifts to affected side
Effusion: transudate or exudate. Lateral decubitus most sensitive. Blunting of costophrenic/cardiophrenic angle, fluid in horizontal/oblique fissure, may see a meniscus, if large may get mediastinal shift away
Possible AXR abnormalities?
Perforation:
- Erect CXR sees even small amount of gas in peritoneal cavity as a crescent under diaphragm
- AXR: pneumoperitoneum (Rigler sign-double wall sign, air on both sides of intestine; can get false double wall sign from two loops of bowel touching)
Obstruction:
- SBO: dilated loops of SB proximal to obstruction (mostly central, valvular conniventes), may have string of beads sign, SB should be <3cm and caecum <9cm
- 3-6-9 rule
- LBO: LB should be <6cm, colonic distention proximal to obstruction + collapse distally, SB may be dilated (if ileocaecal valve is incompetent), may have intramural gas (pneumostasis coli)
Acid-base abnormalities?
Look at patient for context e.g. normal PaO2 when on high flow oxygen (abnormal), normal PaCO2 in asthmatic attack (abnormal-tiring), v low o2 if pt looks very normal and has normal sats (venous sample)
Look at O2: hypoxia kills first. If on O2 therapy then PaO2 should be around 10kPa less than % inspired conc. Hypoxaemic <10, RF when <8, T1RF if just O2 and T2 RF if CO2 also high
Look at pH: is it normal, acidosis or alkalosis?
Abnormality respiratory if abnormal CO2 or metabolic if abnormal HCO3
Resp acidosis: high CO2, normal HCO3 (or raised if less acute due to compensation)
Resp alkalosis: low CO2, normal HCO3 (or low if compensation)
Metabolic acidosis: low HCO3, normal CO2 (or low if resp compensation)
Metabolic alkalosis: high HCO3, normal CO2 (or high if resp compensation)
Anion gap for metabolic acidosis:
- Increased means more acid: DKA, lactic acidosis, aspirin OD
- Decreased means less acid excreted or more HCO3 lost: diarrhoea/ileostomy/Addison’s (retain H+)
Base excess for metabolic issues:
- High (>+2) means metabolic alkalosis or compensated resp acidosis (means high HCO3 in blood)
- Low (
Pyloric stenosis biochemistry?
Hypochloraemic, hypokalaemic alkalosis (due to persistent vomiting)
Dehydration biochemistry
Monitor U+Es and glucose
Metabolic acidosis possible from diarrhoea/ileostomy losses from loss of HCO3
Metabolic alkalosis possible from GI losses of H+ diarrhoea/vomiting
Hypernatraemic dehydration: more water lost than electrolytes, usually due to high insensible losses in fever. ECG becomes hypertonic - fluid shifts to ICF - don’t get signs like reduced skin turgor until later - more dangerous. Replace slowly to avoid cerebral oedema
DKA biochemistry
High glucose Low pH <7.3 Low bicarb <15 Ketones >3 (or ++ on dipstick) Raised anion gap
