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Paediatric history taking

Taking a Paediatric History

Speak to both parent/ carer and child. Adapt history according to age and needs of child.

ICE throughout!!!

  1. Presenting Complaint
    1. Onset, duration, previous episodes, SOCRATES
    2. Has it affected the child/ family’s lifestyle
    3. What has the family done about it so far
  2. General Inquiry
    1. General health: how active and lively
    2. Normal growth for their age
    3. (Normal Pubertal development)
    4. Feeding/ drinking/ appetite
    5. Any changes in behaviour or personality
  3. Systems review
    1. General rashes, fever
    2. Respiratory: cough, wheeze, breathing difficulties
    3. ENT: throat infections, snoring, stridor
    4. Cardiovascular: murmur, cyanosis, exercise tolerance
    5. GI: D&V, nausea, constipation, abdominal pain
    6. GU: dysuria, frequency, wetting, toilet trained
    7. Neuro: seizures, headaches, abnormal movements
    8. MSK: gait, limb pain or swelling, functional abnormalities
  4. PMH incl Birth History
    1. Maternal obstetric problems & pregnancy
      1. Type of delivery, prolonged ruptured membranes, group B strep status, maternal pyrexia if neonate pyrexical
    2. Birthweight and gestation; place of birth
    3. Perinatal problems e.g. NICU, jaundice
    4. Feeding practice (breast or bottle, weight); weaning
      1. Type, method, interval, quantity (ml/ ounces)
    5. Immunisation
    6. Past illnesses, hospital admissions, operations, infections, accidents & injuries
  5. Medication
    1. Past & present medications
    2. Known allergies
  6. FHx:
    1. Anyone else ill/ similar problems/ serious conditions
    2. Any childhood/ neonatal deaths
    3. Family tree drawn if needed
  7. SHx
    1. School – missed school?
    2. Who’s in the family. Ages of siblings, deaths, miscarriages, still births
    3. Parental occupation, economic status, housing, relationships & marital stress, parental smoking
      1. Alcohol/ drug abuse
      2. Long term unemployment or poverty
  • Poor, damp, crowded housing
  1. Parental psychiatric disorders
  2. Unstable partnerships/ domestic abuse
  1. Child happy at home/ nursery/ school? Child’s leisure activities
  2. Social worker involved?
  3. Recent travel?
  1. Development (check in the Red Book)
    1. Parental worries: vision, hearing, development
    2. Check against development milestones
    3. Previous child health surveillance developmental checks
    4. Bladder and bowel control
    5. Child temperature, behaviour
    6. Sleeping problems
    7. Concerns and progress at nursery/ school

FAST review to complete the history: Family History, Adolescent screen, Safeguarding, and Travel

PRESENT USING “SBAR – Situation, Background, Assessment, Recommendations”

Systems Review

Respiratory review

  • SOB
  • Wheeze, Stridor?
  • Cough
  • Trigger? Sports, cold weather, pets
  • Sputum: children <5yo swallow sputum -> vomiting after coughing
  • Feeding difficulties
  • Unwell Relatives
  • Disturbed sleep

Examination findings to remember:

  • Respiratory distress: nasal flaring, accessory muscles, grunting, sternal recession
  • Pulsus paradoxicus – severe asthma
  • Petechiae +/- subconjunctival haemorrhage
  • Central/ peripheral cyanosis
  • Chest shape

DDx for Cough

ENT review

  • Pulling at ears?
  • Earache
  • Sore throat or Drooling more than usual (sore throat)
  • Corzyal
  • Fever?

Exam Findings

  • Pull pinna back in infants, back and up in older children
  • Parents to hold head and arms
  • Nose: discharge, polyps (CF, asthma), pale mucosa (allergic rhinitis)
  • Throat: “roar like a lion” visualise tonsils
    • Normal – pink and small
    • Acute inflammation: red, enlarged ± pustular exudates
    • Chronically hypertrophied: enlarged, pitted, not inflamed
  • Ear:
    • Normal: translucent light reflex
    • Acute otitis media: red, bulging, loss of light reflex
    • Glue ear (chronic OME): retracted, loss of light reflex, dull

Cardiovascular review

  • Cyanosis, blue, Tet spells
  • Tired, pale sweaty? (HF)
  • Difficulty feeding/ SIB
  • Plot growth
  • Recurrent chest infections?
  • Fainting or collapse?
  • FHx of congenital heart disease?

Examination Findings:

  • Increases ~10bpm with every 1°C rise in temperature
  • HR increases with excitement
  • Sinus arrhythmias is common
  • Check FEMORALS!!!
  • Apex beat: 5th LIC MCL,
    • diffuse/forceful/ displaced = LVH;
    • impalpable = dextrocardia or pericardial effusion
  • Hepatomegaly (CCF: L->R shunting)
    • 5cm below right costal margin in newborns; 2cm in older children
  • Heart sounds:
    • M1T1 (S1) = systole; A2P2(S2) = diastole
    • A2P2 split common in children
      • Soft P2 = PS
      • Loud P2 = pulmonary HTn
      • Wide fixed splitting = ASD
    • 3rd Heart sound
      • Normal
      • Rapid ventricular filling (increased LV stroke volume) e.g. AR, MR
      • Restricted ventricular filling e.g. constrictive pericarditis, restrictive cardiomyopathy
    • 4th HS: Forceful atrial contraction e.g. HOCM, severe HTN

Murmurs Ddx:

Innocent: Patient asymptomatic, systolic, no radiation, no thrill

Pathological: ASD, VSD, CoA, PDA:

ASD = soft ejection systolic murmur, LSE

VSD= pansystolic, lower LSE, with/out signs of heart failure

CoA= ejection systolic, between shoulder blades

PDA= a continuous ‘machiner’ murmur below the left clavicle

 

Cyanotic vs acyanotic

Cyanotic:

Decreased pulmonary flow (TOF, tricuspid atresia)

Increased pulmonary flow: Transposition of the great arteries, total anomalous pulmonary venous return

Acyanotic:

A left to right shunt: VSD/ASD/AVSD; a PDA

Obstructive lesions: AS, pulmonary valve atresia, coarctation of the aorta

 

Duct Dependent Lesions

Systemic circulation: hypoplastic left heart syndrome, Critical aortic stenosis , coarctation of the aorta, Interrupted aortic arch

Pulmonary circulation: TOF with PS; pulmonary atresia (with intact IV septum), critical pulmonary stenosis, severe ebstein anomaly, Complete transposition of the great arteries (with an intact IV septum)

Surgical Scars

 

GI review

  • Plot growth chart (height and weight)
  • Vomiting:
    • Forceful? Effortless?
    • A/w feeds?
    • Green? Coffee-grounds? Frank Blood?
  • Abdominal Pain
    • Bloating
    • LUTS/dysuria
    • Bowel habit?
    • Offensive loose stools (malabsorption)
  • FHx of Coeliac, IBD

Examination Findings

  • Peristalsis during test feed – Pyloric stenosis
  • Wasted buttocks – Coeliac
  • Periorbital oedema – nephrotic syndrome
  • Distension: Fat, fluid, flatus, faeces, organomegaly, muscle hypotonia, exaggerated lordosis common in young children
  • Peritoneal inflammation: “make your belly as big/ thing as possible” “Cough for me” – no pain while doing it = no inflammation
  • Spleen 1-2cm below costal margin in infancy
  • Liver 1-2cm below costal margin normal until 3yrs

 

Nervous system review

  • Birth, perinatal Hx – any drugs and illnesses?
  • Developmental milestones – behind? any regression?
  • Hearing or visual concerns? Newborn Hearing Screen results
  • Change in school performance or personality/behavious?
  • Headache, vomiting, photophobia – ?meningism, raised ICP
  • FHx: learning difficulties, genetic conditions

Examination

  • Fontanelles (don’t assess when crying!)
    • Bulging – raised ICP
    • Sunken – dehydration
    • Pulsatile – normal
  • Squint/ strabismus
    • Squints beyond 6 weeks of age needs specialist assessment
      • Untreated -> cortical blindness
    • Latent squints may only be apparent when child is tired
  • Reflexes: upgoing plantars is normal until 8mths; primitive reflexes beyond 6mths is abnormal – think UMN lesion e.g. cerebral palsy

How to assess squints

Corneal light reflection test

  1. Shine torch between patient’s eyes to produce reflection in the cornea
  2. Reflected light should be at the same point on each eye
  3. If reflection in corneas is asymmetrical, a squint is likely

Cover test

  1. Encourage child to fix on a toy
  2. Cover one eye with a piece of cord
  3. If the normal/ fixing eye is covered, the squinting eye will move to take up fixation

Reflexes – should all be gone by 6mths

Rooting- pressure applied to check causes head turning

stepping- hold infant upright on a surface, the legs will move in a stepping fashion- 2 months

palmar grasp- fingers close to hold an object placed in the hand- 2-4 months

moro- 4-5 months

asymmetric tonic neck reflex- 6 months

 

DDx for Clubbing

Resp: CF, malignancy

Cardiac: cyanotic heart disease, endocarditis

Gastrointestinal: IBD, coeliac disease, cirrhosis

Other: familial, idiopathic, congenital

Developmental Assessment

  • Delay in all four areas – abnormal
    • Delay in one area may not necessarily be abnormal
  • Regression is always abnormal
  • Smiling before 6 weeks is abnormal
  • Hand preference before 18mths is abnormal

Warning signs

8 weeks- no smiling

6 months -persistant primitive reflexes

12 months- no sitting, pincer grip, or double babble

18 months- no walking or words

4 years -no words

 

Alisha Burman 

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