Victoria Lack

 Mum says child has been unwell since yesterday. Off her milk, crying more, clingy, has a temp.  Hot since last night. Infant is sleeping longer, taking fewer feeds and less at each feed (bottle fed.) Irritable, won’t be put down, frequent waking last night and not consoled with bottle. Is distractible at times and have had few smiles today. Vomited x 1 today, runny poos x 2. Fewer wet nappies. No urti sx, no cough, no breathing problems, no rash.  PMH: Bronchiolitis aged 2/12. Observation in hospital overnight. Nil else.  Term. Normal delivery.  MedHx: no reg meds, no allergies. Had all primary imms.

Returning to work 2011……………………………………

 Assessment and initial management in children younger than 5 years.  Guidelines should be followed until a clinical diagnosis has been made.

Child with fever accessing health care Child < 5 years accessing healthcare Remote assessment Face to face assessment (non paediatric practitioner) Care and safety net at home Paediatric specialist assessment Further care

 ABCD  Check for presence/absence of symptoms and signs using the traffic light system.  Look for a source of the fever and check for the presence of signs and symptoms associated with specific diseases.

 Children with fever should be assessed using the traffic light system.  Children with green features can be managed at home.  If any amber features and no diagnosis has been reached HCPs should safety net OR refer to a paediatric specialist.  If any red features, refer child urgently to a paediatric specialist.  Oral antibiotics should not be prescribed to children with fever with no apparent source.

 < 4 weeks- electronic thermometer in axilla.  > 4 weeks electronic/chemical dot in axilla OR infra red tympanic thermometer.

 Temp  Heart rate  Respiratory rate  CRT

 Prolonged CRT  Abnormal skin turgor  Abnormal respiratory pattern  Weak pulse  Cool extremities  - if signs of circulatory compromise (hr/crt measure the child’s BP.)

 Mum is concerned that the child is vomiting more after feeds over the last couple of days. He also has a bit of a ‘cold.’  Breast fed baby; fine until 3/7 ago when caught cold from brother. Sniffly nose, cough, breathing more noisy and ? more rapid. Taking milk but feeding less often and more fussy. Posseting more of feed after every feed. Wet and dirty nappies as usual. Alert, during day but more cranky. Will only sleep upright last 2 nights. Mum awake all night holding him. Unable to put him down in Moses basket.  PMH: Term. Normal delivery, well up till 3/7 ago. Almost back to birth weight  SH: Mum at home with older brother (age 2) and baby. Live locally.

 T 37.2, HR 130, RR 70-80, CRT < 2 secs  Sleeping on arrival. Alert and wriggling when wakened. Not distressed during examination. Pink, warm extremities. No rash.  Fontanel not raised/depressed  ENT mucousy nose. Ears and throat nad.  Chest : slight chest in drawing noted. No intercostal recession. No added sounds.  Abdo nad skin turgor normal  Fed during consultation: able to suck, but fussing.

 Mum’s first child died in infancy

 Mum said Edwin was sent home from school with a temperature at lunchtime. Has been very lethargic since, very hot, thirsty- drinking lots of water. Not eating. Slept most of afternoon and early evening. Waking for a short time, upset and crying, drinking water then going back to sleep. Vomited x 1 this pm. No stools today. Has weed this afternoon. Putting hand over eyes to shield from light, no rash. Not c/o pain anywhere specific. Mum has given calpol.  Child was ok yesterday, was at school. A bit grumpy last night and had an unsettled night. Ok this am- still grumpy, but had breakfast.

 SH Started school several weeks ago. Only child. No recent travel. No one else unwell.  PMH None specific.  Medhx no meds, no allergies, had all imms including PSB.

 T 40, HR 150, RR 35, CRT < 2 secs  Sleeping in mums arms on arrival. Rousable but lethargic. Able to follow requests. Not talking or smiling. Falls back to sleep easily. Drinking water during consultation. Pale. Skin turgor normal. No rash. Warm extremities.  Ears TMs pink but no bulging and no loss of landmarks  Tongue moist. Throat red, tonsils red and enlarged, no exudate.  Cx LNs +++ and tender  Chest: no use accessory muscles. No added sounds

 Mum lives in a village 45 minutes by car from OOH centre.

 Mum and dad say that Jasmine has had a cold for several days. Last night she was unsettled. She kept waking up due to her cough. Her breathing sounded wheezy and was fast and shallow. Her temp was 38. This morning she is not herself. Wanting to be cuddled, few smiles. More crying. Taking normal amounts of formula but off solids. Wet and dirty nappies as usual. Vomited x 1 this am.

 SH At home with mum. One older brother aged 6. He has a cold.  PMH Term. Normal delivery. Well since.  Medhx. No meds. No allergies. Had all primary imms.

 T 38.5, HR 130, RR 40, CRT < 2 secs  Alert on entering the room. Reaching for things, few smiles. Pink, warm extremities, no rash.  Fontanel NAD.  ENT: mucousy nose, tongue moist, ears and throat NAD.  No cx LNs,  Chest, slight IC recession R side. No chest indrawing. ‘Noisy’ chest bilateral bases: fine crackles and wheezes.

 Advise:  Antipyretic interventions  Regular fluids (breastfeeding- continue as normal.)  Look for signs of dehydration (sunken fontanel, dry mouth, no tears, poor overall appearance.) and seek further advice if present.  How to identify non blanching rash.  Check child during the night.  Keep child away from school/nursery while fever and advise school/nursery of the illness.

 The child has a fit.  The child develops a non blanching rash.  Feel that the child is getting worse.  If they are more worried than when they last received advice.  The fever lasts > 5 days.  They are distressed or concerned they are unable to look after the child.

 Provide one or more of the following:  -verbal/written information on warning symptoms and how further care can be accessed.  -arrange follow up appointment at a certain time and place.  -liaise with other HCPs to ensure direct access if further assessment is required.

 Mum says child has been unwell since yesterday. Off her milk, crying more, clingy, has a temp.  Hot since last night. Infant is sleeping longer, taking fewer feeds and less at each feed (bottle fed.) Irritable, won’t be put down, frequent waking last night and not consoled with bottle. Is distractible at times and have had few smiles today. Vomited x 1 today, runny poos x 2. Fewer wet nappies. No urti sx, no cough, no breathing problems, no rash.  PMH: Bronchiolitis aged 2/12. Observation in hospital overnight. Nil else.  Term. Normal delivery.  MedHx: no reg meds, no allergies. Had all primary imms.

 T 39 HR 150 RR 40 CRT < 2 secs  Alert and responding. Miserable. Distressed during consultation. Pink colour, warm extremities. Fontanel nad, skin turgor normal. No rash  ENT NAD, tongue moist  No cx LNs  Chest: no use accessory muscles, no added sounds.  Abdo soft.

 The ‘amber’ ones without a diagnosis: to admit or not.  The ‘amber’ ones with a diagnosis.  The ‘red’ ones WITH a diagnosis.  The subjective assessments of clinical signs: ‘appears ill to a health care professional.’