History Taking and Examination Skills for Paediatrics

D. HiltonDeborah.hilton@uhcw.nhs.uk

Welcome to the Department- GEH / Warwick / UHCW- Exams at UHCW- Ward Work- Clinics (inc teaching

clinics)- Emergency Dept / PAU- Educational meetings- Handovers- Bedside Teaching- Portfolios

End of block assessmentWritten Paper – Common Paediatric conditions (Bronchiolitis, meningitis, neonatal jaundice, asthma)- Development

Observed consultation- 20 minutes history and examination- Thorough paediatric history, systems based examination- 20 minutes thinking time- 20 minutes presentation, investigations, management

Marked according to Leicester Assessment PackageCompared to skills required of newly qualified F1

Leicester Assessment Package• Interviewing/history taking

– Introduces self to patients – Puts patients at ease – Allows patients to elaborate presenting problem fully – Listens attentively – Seeks clarification of words used by patients as appropriate – Phrases questions simply and clearly – Uses silence appropriately – Recognises patients' verbal and non-verbal cues – Identifies patients reasons for consultation – Elicits relevant and specific information from patient and/or their records to

help distinguish between working diagnoses – Considers physical, social and psychological factors as appropriate – Exhibits well organised approach to information-gathering

History Taking

• Organised approach – start with open questions and clarify appropriately

• Remember to include ALL subheadings from history• Try and assess medical significance of what parents

tell you (vomiting, fever, diarrhoea)• Show what you know about paediatrics

(development, immunisations etc)• ICE• Response to cues from parents and child

Leicester Assessment Package• Physical examination

– Performs examination and elicits physical signs correctly and sensitively

– Uses the instruments commonly used in family practice in a selective, competent and sensitive manner

– Generally systems based– Some general baby examinations– OBSERVE!!!!– Resp rate, Heart rate, machines, hydration status, interaction,

development, feeding– Top to toe, organised wherever possible

Leicester Assessment Package• Problem solving

– Generates appropriate working diagnoses or identifies problem(s) depending on circumstances

– Seeks relevant and discriminating physical signs to help confirm or refute working diagnoses

– Correctly interprets and applies information obtained from patient records, history, physical examination and investigations

– Is capable of applying knowledge of basic, behavioural and clinical sciences to the identification, management and solution of patients' problems

– Is capable of recognising the limits of personal competence and acting accordingly

Problem Solving

• PLEASE relate to the history and examination that you have performed

• Consider in relation to age of child• What treatment has the child has so far?• What investigations are you likely to need to

help you differentiate between them• Pathophysiology of the conditions and

response to treatment

Patient Management

• General Principles• Fluids• Analgesia• Team working & senior support• Potential complications

• Emergency Management (A, B, C, D, E)

Interaction with Patient- Involve child as much as

possible- INSPECTION &

OBSERVATION- Examiner will be aware of

efforts made to placate child- Leave with parent if required- Use parents / toys /

disctractions- Expose with respect and

considering child’s mood- Get on your knees!- If you arent sure you should

proceed, mention to examiners

Paediatric History Taking

• Presenting complaint• History of presenting complaint

(Clarification)• (Previous Episodes)• Past Medical History• Birth History• Medications• Allergies• Developmental History• Immunisations• Social History• Family History

Presenting Complaint

• Use your medical knowledge to interpret what you are being told by parents

• Associated symptoms• Clarify what parents mean – wheeze etc• Duration of symptoms• Systems review & overall impression of the

child

Past Medical History

• Birth (if relevant)• Preterm / Term• SCBU & Resuscitation• Previous illnesses & treatments• Associated illnesses (Atopy etc)• Other medical conditions• Other professionals involved (Physio, OT, SALT)

Development• Know milestones for ages• Consider school in older

children• Don’t rely solely on

parental reports

Social History & Family History

• Siblings• Parents / Step-parents• Smoking / Pets• Social Services• Health Visiting• Education• Physio / OT / SALT• Relevant illnesses in others

ICE

Examination

• Generally systems based • General baby examination

Examination

• Look around room• Look at the child• Hydration, Demeanour, Development, Pain,

DIB, Growth• Interact with child before examination• Inspect before approach

Respiratory Examination

• Observe – RR, DIB, Recession, Medical Adjuncts• Hands• Eyes & Mouth• Airway, Lymphadenopathy• Palpation – chest expansion• Percussion• Auscultation• TVF• Sats, PEFR, Growth

Cardiovascular Examination• Observe – HR, RR, DIB, Recession, Medical Adjuncts• Hands• Pulses• JVP• Eyes & Mouth• Palpation – heaves, thrills, apex• Auscultation (front & Back)• Liver edge• Oedema• BP, sats, growth

Abdominal Examination

• Observe – HR, RR, Medical Adjuncts, Hydration• Hands• Face• Inspection• Palpation- masses, tenderness, organomegaly• Percussion• Auscultation• Urine, Stool, Feeding charts, growth

Neurological Examination

• Observe – Medical Adjuncts, Hydration, dysmorphism, development, posture, neurocutaneous lesions

• Cranial • Peripheral – tone, power, reflexes, co-

ordination• Gait• Co-ordination

Baby Examination- Not newborn check (but should be

aware how to do)- Observe – medical adjuncts,

hydration, posture, DIB, demeanour, interaction, dysmorphism

- Often need to be opportunistic- Auscultation lungs & Heart sounds- Palpation abdomen – masses &

organomegaly- Genitalia & femorals- Growth

Common problems

• Inadequate inspection & observation• “Pouncing on the child”• Failure to respond to childs cues• Forgetting the details• Obvious inexperience

Advice

• Get experience• Practice being watched, presenting cases• Ask questions• Always make sure someone sees patients

with you