Paediatric History Taking

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Paediatric History Taking ExaminationSTEPP
Teaching, Dee Aswani, SpR
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Overview of Session

• Principles of Paediatric History Taking
• Practical Exercise
• Examination Tips
• Baby Checks

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A smart mother makes often a better diagnosis
than a poor doctor.August Bier (18611949)
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Differences to adult practice General Principles

• Children are not small adults
• LISTEN 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 otherwise
• Useful to quote verbatim, but ask to define terms
  for eg - what does diarrhoea actually mean?
• Additional important features of the history
• Always 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 days
• Off feeds x 2 days
• Wheeze x 1 day
• Temperature x 1
• Vomit 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 complaint

• Coughing since started at school 2 years ago
  always has a cough
• Worse since last night teatime
• Vomited x 1 last night, cough induced
• No fever
• Has been breathless
• Breathing sounds noisy
• Cough sounds productive
• Complaining 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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Past Medical History

• One previous AE attendance - was wheezy, had
  steam medicine then went home
• Frequent chest infections treated by GP with
  antibiotics
• No operations or admissions
• Has mild eczema

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Birth History

• Born at 34 weeks
• Emergency Section , 4lb 8oz, foetal distress
• Spontaneous labour and PROM
• Pregnancy and scans fine
• Was on SCBU for 3 weeks
• Needed CPAP for 1 day and then some oxygen for a
  while
• No oxygen when went home

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Developmental History

• Smiled at 10 weeks
• Sat at 6 months
• Never crawled
• Walked at 13 months
• Started talking around 18 months
• No problems with hearing or vision
• Average progress at school

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Immunisation History

• up to date
• didnt have MMR - cousin with autism

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Medication

• Oilatum in bath for eczema
• allergic to Penicillin
• had it when 2 years and was sick
• Tixylix

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Family History

• Dad got eczema and hay fever
• Maternal grandma has diabetes
• Paternal Grandfather had TB
• Mum and Dad separated
• Younger 2 year old brother also has eczema
• Mum works in retail. Suffers with depression
• No consanguinuity

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Social History

• 2 Pet cats at home
• Mum smokes outside
• Dad also smokes
• Goes to a childminders 3 times a week
• Child spends every other weekend at Dads house

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Examination
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General Principles Tips

• Get down to their level
• A lot of information can be gained by INSPECTION
  alone, before you lay an hand on the patient
• Beware of asking the childs permission
• Know a conversation topic / latest craze / TV
  characters / films relating to different age
  groups
• Examination needs to involve play and be
  opportunistic but thorough

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• Keep Mum close at hand and in childs view or
  reach
• Keep 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
  position
• Save the nasty things to the end so that you
  dont lose trust (eg ENT)

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Baby checks

• To assess general condition
• To establish normality
• To detect major abnormalities
• Useful in finding eye, hip and heart problems

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• Read Mums 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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SUMMARY

• Good Paediatric history taking needs to be
  through and takes practice
• 70 of diagnoses can be made on the history alone
• ALWAYS listen to the mother
• Children are quite often unco-operative and
  examinations can be difficult
• Be prepared to PLAY

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• Children will respond much better to you if you
  actually LIKE them