History Taking and Examination Skills for Paediatrics D. Hilton

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 assessment Written 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 Package Compared 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