Taking a Paediatric History

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

ICE throughout!!!

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
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
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
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
Medication
1. Past & present medications
2. Known allergies
FHx:
1. Anyone else ill/ similar problems/ serious conditions
2. Any childhood/ neonatal deaths
3. Family tree drawn if needed
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

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)
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: 5^th 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
- 3^rd Heart sound
  - Normal
  - Rapid ventricular filling (increased LV stroke volume) e.g. AR, MR
  - Restricted ventricular filling e.g. constrictive pericarditis, restrictive cardiomyopathy
- 4^th 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

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

C.U.P.S.