Taking a Paediatric History
Speak to both parent/ carer and child. Adapt history according to age and needs of child.
ICE throughout!!!
- Presenting Complaint
- Onset, duration, previous episodes, SOCRATES
- Has it affected the child/ family’s lifestyle
- What has the family done about it so far
- General Inquiry
- General health: how active and lively
- Normal growth for their age
- (Normal Pubertal development)
- Feeding/ drinking/ appetite
- Any changes in behaviour or personality
- Systems review
- General rashes, fever
- Respiratory: cough, wheeze, breathing difficulties
- ENT: throat infections, snoring, stridor
- Cardiovascular: murmur, cyanosis, exercise tolerance
- GI: D&V, nausea, constipation, abdominal pain
- GU: dysuria, frequency, wetting, toilet trained
- Neuro: seizures, headaches, abnormal movements
- MSK: gait, limb pain or swelling, functional abnormalities
- PMH incl Birth History
- Maternal obstetric problems & pregnancy
- Type of delivery, prolonged ruptured membranes, group B strep status, maternal pyrexia if neonate pyrexical
- Birthweight and gestation; place of birth
- Perinatal problems e.g. NICU, jaundice
- Feeding practice (breast or bottle, weight); weaning
- Type, method, interval, quantity (ml/ ounces)
- Immunisation
- Past illnesses, hospital admissions, operations, infections, accidents & injuries
- Maternal obstetric problems & pregnancy
- Medication
- Past & present medications
- Known allergies
- FHx:
- Anyone else ill/ similar problems/ serious conditions
- Any childhood/ neonatal deaths
- Family tree drawn if needed
- SHx
- School – missed school?
- Who’s in the family. Ages of siblings, deaths, miscarriages, still births
- Parental occupation, economic status, housing, relationships & marital stress, parental smoking
- Alcohol/ drug abuse
- Long term unemployment or poverty
- Poor, damp, crowded housing
- Parental psychiatric disorders
- Unstable partnerships/ domestic abuse
- Child happy at home/ nursery/ school? Child’s leisure activities
- Social worker involved?
- Recent travel?
- Development (check in the Red Book)
- Parental worries: vision, hearing, development
- Check against development milestones
- Previous child health surveillance developmental checks
- Bladder and bowel control
- Child temperature, behaviour
- Sleeping problems
- 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
- Squints beyond 6 weeks of age needs specialist assessment
- 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
- Shine torch between patient’s eyes to produce reflection in the cornea
- Reflected light should be at the same point on each eye
- If reflection in corneas is asymmetrical, a squint is likely
Cover test
- Encourage child to fix on a toy
- Cover one eye with a piece of cord
- 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