paediatric history taking & examination stepp teaching, dee aswani, spr
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Paediatric History Taking & Examination STEPP Teaching, Dee Aswani, SpR. Overview of Session. Principles of Paediatric History Taking Practical Exercise Examination Tips Baby Checks. A smart mother makes often a better diagnosis than a poor doctor. August Bier (1861–1949). - PowerPoint PPT PresentationTRANSCRIPT
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Paediatric History Taking & Examination
STEPP Teaching, Dee Aswani, SpR
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Overview of Session
Principles of Paediatric History TakingPractical ExerciseExamination TipsBaby Checks
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A smart mother makes often a better diagnosis than a poor doctor.
August Bier (1861–1949)
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Differences to adult practice & General
PrinciplesChildren are not small adultsLISTEN CAREFULLY to what the mother is telling you - she knows her child best and intuitively knows when something is wrong. She is RIGHT unless proven otherwiseUseful to quote verbatim, but ask to define terms for eg - what does ‘diarrhoea’ actually mean?Additional important features of the historyAlways consider CHILD PROTECTION issues
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Components of History
Presenting complaint
History of presenting complaint
Past medical history
Incl feeding history & growth
Birth History
Developmental History
Immunisation History
Drug History
Family History
Social History
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Inadequate History
Cough x 3 daysOff feeds x 2 daysWheeze x 1 dayTemperature x 1Vomit x 2
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70% of paediatric
diagnoses will be obtained by history alone
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Peter, age 7 years, referred by GP “difficulty
breathing”
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History of presenting complaintCoughing since started at school 2 years ago
‘always has a cough’Worse since last night teatimeVomited x 1 last night, cough inducedNo feverHas been breathlessBreathing sounds noisyCough sounds productiveComplaining of tummy ache
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Cough wakes him at night, often needs a glass of water to settle down
Coughs approx 5 nights out of 7
Tired and difficult to wake in the morning
Missing a lot of school
Difficulty keeping up with peers at PE
General lack of energy, prefers to sit and watch telly rather than playing outside with friends, complains that ‘chest hurts’
No history of choking or foreign body
Came back from holiday in Turkey a week ago
Still in same school trousers as in reception, one of the smallest in class
Good appetite
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One previous A&E attendance - was wheezy, had ‘steam medicine ’ then went homeFrequent chest infections treated by GP with antibioticsNo operations or admissionsHas mild eczema
Past Medical History
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Birth HistoryBorn at 34 weeksEmergency Section , 4lb 8oz, foetal distressSpontaneous labour and PROMPregnancy and scans fineWas on SCBU for 3 weeksNeeded CPAP for 1 day and then some oxygen for a whileNo oxygen when went home
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Developmental History
Smiled at 10 weeks Sat at 6 monthsNever crawledWalked at 13 monthsStarted talking around 18 monthsNo problems with hearing or visionAverage progress at school
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Immunisation History
‘up to date’didn’t have MMR - cousin with autism
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MedicationOilatum in bath for eczemaallergic to Penicillinhad it when 2 years and ‘was sick’Tixylix
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Family HistoryDad got eczema and hay feverMaternal grandma has diabetesPaternal Grandfather had TBMum and Dad separatedYounger 2 year old brother also has eczemaMum works in retail. Suffers with depressionNo consanguinuity
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Social History2 Pet cats at homeMum smokes “outside”Dad also smokesGoes to a childminders 3 times a weekChild spends every other weekend at Dad’s house
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Examination
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General Principles & TipsGet down to their level
A lot of information can be gained by INSPECTION alone, before you lay an hand on the patientBeware of asking the child’s permissionKnow a conversation topic / latest craze / TV characters / films relating to different age groupsExamination needs to involve play and be opportunistic but thorough
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Keep Mum close at hand and in child ’s view or reachKeep child in the position in which they are comfortable. No need to lie them down unless you have to - children are very vulnerable in this positionSave the nasty things to the end so that you don’t lose trust (eg ENT)
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Baby checksTo assess general conditionTo establish normalityTo detect major abnormalitiesUseful in finding eye, hip and heart problems
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Read Mum’s notes first
Pregnancy history
Paediatric Alerts
Delivery notes
Ask Mum if any concerns
Family History
Who does baby look like?
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OBSERVATION
Appearance / Dysmorphia
Alert / Drowsy
Colour - anaemia / jaundice
Bruising
Posture
Birth Marks
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HEAD
Shape of skull - moulding, sutures
OFC
Fontanelles
Eyes and ears
Mouth - look and feel for cleft
Range of neck movements
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RESPIRATORY SYSTEM
Respiratory distress or increased work of breathing
CARDIOVASCULAR SYSTEM
Pulses including femorals
Heart sounds
Oxygen saturation - post-ductal
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ABDOMEN
Shape
Palpation - masses
BO / BNO in first 24 hours
Genitalia / PU
HIPS
Barlow /Ortolani manouvres
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LIMBS
Position - talipes
Movement
Palmar creases
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NEUROLOGICAL SYSTEM
Tone
Posture
Primitive reflexes
Spine
EYES
Red reflexes
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Hip Examination
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Ortolani
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Barlow
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Primitive Reflexes
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SUMMARYGood Paediatric history taking needs to be through and takes practice70% of diagnoses can be made on the history aloneALWAYS listen to the motherChildren are quite often unco-operative and examinations can be difficultBe prepared to PLAY
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Children will respond much better to you if
you actually LIKE them