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PAEDIATRICS

Richard Shaw

Paediatric History
Formalities
Wash Hands
Introduction - name, age, birth date, (gender),
consent, confidentiality
Establish relationship between child and other (e.g.
parent, grandparent, nanny, caretaker etc)
History of Presenting Complaint
Open Questioning SOCRATES and specific
differential questioning.
o Associated Symptoms
Mini-systems Review
o Eating, drinking, peeing, pooing, playing,
sleeping?
o Fevers? Crying? Other changes?
Risk Factor Questioning
Specific risk factors to help differential/provisional
Travel or particular contact? (Infectious diseases)
Antenatal History
Gravida/Para of mother + pregnancy outcomes
o Any complications?
USS, Vaccinations, Screening and/or other tests?
Length of pregnancy of this child, any
complications?
Any medications/illnesses during pregnancy?
Pregnancy symptoms? Normal/abnormal?
Maternal medical problems? DM, H/T, Epilepsy
Natural or assisted conception? Complications?
Blood group and rhesus status
GBS Status, Hep B, Hep C, HIV and syphilis serology
Birth History
Gestation and weight/length/HC at birth
How long was the labour? Intervention required?
Any indications of fetal distress?
Method of delivery (VD, AVD, Assisted/Planned CS)
Maternal fever or PROM?
APGARs at 1, 5, 10 minutes?
Neonatal History
Did the child have any neonatal problems
o jaundice, cyanosis, respiratory distress?
Was vitamin K given?
Was the child treated in NICU?
When did mother and child go home?
Breast fed/bottle fed? Weaning? Sleeping?
o Times a day? Duration/amount fed?

o Type of formula
Any other neonatal problems?

Developmental History
For Infants: milestones, primitive reflexes, postural
responses
Older children: milestones, educational (how are
they are school?), social difficulties.
Milestones? (Can compare to siblings)
o Gross Motor
o Fine Motor
o Social and Emotional
o Speech and Language
o Cognitive
How well has the child grown? Bluebook?
Have there been any concerns about
developmental milestones, vision or hearing?
Immunizations
Is the child up to date with their immunizations?
If not, why not? Which ones were missed?
Are you planning to immunize?
Past Medical/Surgical History
Illnesses/infections? Surgeries?
Asthma, diabetes, epilepsy?
Investigations/Test?
Medications and Allergies
Drugs
o Prescribed drugs?
o Over the counter drugs?
o Herbs/supplements?
Allergies/Drug Allergies
o Penicillin? Food? Latex?
o If yes, determine precise reaction and
causation
Family History
Ages of parents + any siblings? Their health?
Illnesses that run in the family?
o Seizures, cancer, asthma...
o DM, H/T, Hypercholesterolaemia
Contagious disease?
Consanguinity?
Any deaths in infancy/childhood?
Psychosocial History

PAEDIATRICS

Remember HEADSS for adolescents --> get to know


them e.g. starting with what school they go to.
Home Environment
o Who is living at home at the moment?
o Is there anyone at home to support you?
o Where do you live? What type of
accomodation is it?
o Normal childcare arrangements?
Parents and/or other carers
o Age, work, relationships
o Education/Employment/Financial -->
WHACS
o Drugs: smoking (incl. 2nd hand), alcohol,
recreational drugs
ADLs and other activities

Systems Review
Respiratory
breathing difficulties
cough
hoarseness
noisy breathing
possibility of foreign body inhalation
Cardiovascular
blue or white episodes
fainting
shortness of breath
palpitations
feeding difficulties and sweating (infants)
Gastrointestinal
appetite
nausea and vomiting
mouth ulcers
weight loss
diarrhoea and constipation
stools- colour, blood, mucus
Genitourinary
passing urine?
number of wet nappies in 24hrs (infant)
dysuria, nocturia, urine color
CNS
headaches and/or migraines
learning difficulties
hearing and vision
fits/seizures and clumsiness
Musculoskeletal

joint pain, swelling


Skin
rashes, hair, nails, mucosal symptoms
Haematological
bone pain
weight loss
infections
malaria
mouth ulcer
repeated infections

Richard Shaw

PAEDIATRICS

Richard Shaw

PAEDIATRICS

Richard Shaw

Examination (DJ/Jarred)

Neonatal Examination

Scope needs to be right up against


your eye
Scleral haemorrhages may be
normal after labour
o Cloudy cornea
Normal to 28 weeks
o Excessive tearing
o Movement
Rolling and cross eyed may be
normal in aneonate, but not if they
persist

General Appearance
o
o
o

Looks well
Spontaneous movements
Jaundice
Possibly pathological if in 1st 24
hours
Usually cephalo-rostral progression
Blanch the skin with a rubbing
motion on the abdomen, thighs and
legs to see if yellow
Erythema toxicum
Blotchy red spots with overlying
white or yellow papules or pustules

Ears and Nose

Hands

Inspect
o Palmar creases
o Phalanges (extra)
Palpate
o Grasping reflex
Stroke the inside of their palm and
see if they grab it

Head

Inspect
o Hair colour
o Pigment Defects
o Hair line
Palpate
Check the following havent fused:
o Anterior fontanelle
o Sagittal suture
o Posterior fontanelle
Other sutures

Eyes

Inspect
o Size
o Shape
o Position
o Reaction to light
Consistent after 32 weeks
o Red retinal reflex
Can do this from a distance

Inspect
o Size
o Shape
o Position
o Nasal patency

Mouth, Palate and Throat

Inspect
Cleft lift/palate
Benign cysts
Epstein pearls in midpalatal
raphe
Gingival cysts
Retro- or micrognathia (jaw)
Tongue
o Protrudes beyond lips
o Macroglossia
o Frenulum under tongue
connecting it to floor of mouth
Palpate
o Rooting and Sucking reflex
With a gloved finger stroke the
side of their mouth. The baby
should turn to that side and begin
sucking on your finger

Neck

Inspect
o Short/webbed neck
Turners
Noonans
o Clefts
o Cysts

PAEDIATRICS

o Urine stream
o Testes
o Hernia
Females
o Cliteromegaly
o Meatus
o Labia
o Vaginal opening
o Hernia
Patency of anus
o Check for passing of meconium in
first 48 hours (99% of neonates
do this)

o Masses
Thorax

Inspect
o Observe the work of breathing.
Respiratory distress indicated by:
RR
Grunting
Nasal Flaring
Intercostal/subcostal tug
Accessory muscle use
Palpate
o Palpate clavicles
Auscultate
o HR
Age
0-6months
612months
1-5years
6-10years
>10years

o
o

Respiratory
Rate
30-50
20-40

Heart
Rate
120-140
95-120

BP
80/55
90/60

20-30
18-25
12-25

90-110
80-100
60-100

100/65
110/70
120/75

Additional sounds
Murmurs

Abdomen

Inspect
o Look for distension
o Check umbilicus for:
Still present (falls off after 7-10
days)
3 vessels and skin
Dried out (it should be)
Signs of infection (erythema etc)
Palpate
o Liver tip below costal margin
o Spleen tip just below costal margin
o Palpate kidneys
Auscultate
o Auscultate bowel sounds

Genitourinary/Anus

Inspect
Check for micturition in first 48
hours (97% of neonates will do this)
Males
o Site of meatus

Richard Shaw

Spine
Inspect
o Cutaneous manifestations of
pathologies
Sacral dimple
May be normal if within 2cm of
anus and has no other
pathological manifestation
(tuft of hair etc)
If not, may be indicative of
meningomyelocele/spinda
bifida
o Dermal sinus tract (remnants of
incomplete NT closure)

Legs

Inspect
o See if the skin folds on the thigh are
symmetrical sign of asymmetric
thigh folds
Palpate
o Palpate femoral pulses
Coarctation of the aorta may
present >week (due to patent DA)
with inferior cyanosis on legs

Feet

Inspect
o Kicking?
o Phalanges
o Internally rotate feet and see if they
return to normal position
Talipes
Internally rotated feet

PAEDIATRICS

May be postural (movable) or


fixed

Palpate
o RFs are breech birth, and 1st degree
Fx
o DO ONE HIP AT A TIME
o First abduct the hip to check to see if
it is already dislocated
o Barlow manoeuvre adduction of
the hip, and then pressure on the
knee forcing femur backward to see
if it dislocates
o Ortolani manoeuvre flexion of the
hips and anterior pressure applied to
greater trochanters with the thumbs
abducting the hip. This is positive if
there is a click of the head back into
the acetabulum

Leave uncomfortable things until


last
Positioning
o Babies

Examination couch with


parents next to them
o Toddlers

In mothers lap/over
parents shoulder
o Preschool

Whilst playing
Exposure
o Ask the parent if the child would
mind exposing the area
o Examine in stages, redressing the
child after each stage
Inspection
o You must watch the child play
o

Hips

Paediatric
Examination

Tone and Reflexes

General Appearance

Pull to sit
o Pull them up by their arms and see if
their head lags
A little lag is normal, but there
should not be completely toneless
in the neck
Morrow reflex
o Hold head and neck in hand above
cot. Move downwards towards cot
rapidly and check if arms and hands
spread out as if to grasp something
to stop from falling.
Head tone
o Hold the baby prone an see if they
hold their head up, and if so, check if
it is midline.

Paediatric Examination
Examination Tips

General
o
o
o
o
o

Get down to the childs level


Go slowly
Engage parents and carers
Demonstrate on
teddy/doll/yourself
Clear and simple instructions

Richard Shaw

Good tips for examining a child


o Get to the childs level
o Go slowly
o Engage parents and carers
o Demonstrate on teddy/doll/yourself
o Clear and simple explanations
o Be fun but firm
o Leave uncomfortable things until
last
Its good to have someone the same
gender as the child with you when
you do the examination/Hx
Position
o Babies
Examination couch with parents
next to them
o Toddlers
In mothers lap/over parents
shoulder
o Preschool
Whilst playing
o Older children
Often concerned about privacy, so
have an appropriate chaperone
present

PAEDIATRICS
Be aware of cultural sensitivities
Exposure
o The area to be examined must be
inspected fully
Be sure to ask the parent if the child
would mind exposing the area
o Examine in stages, redressing the
child after each stage
ALWAYS:
o Use alcohol rub/wash your hands,
both BEFORE and AFTER
o WARM your
Hands
Stethoscope
Inspection
o THIS IS THE MOST IMPORTANT
PART OF A PAEDIATRIC
EXAMINATION
o Watch the child play. It will allow you
to assess:
Severity of illness
Growth and nutrition
Behaviour and social
responsiveness
Level of hygiene and care

Growth
1. Height/Length
a. Determine method of measurement
<24 months is length
24-36 months either
>36 months height
Note that supine length is usually
slightly longer than height
(about +2cm according to new
CDC graphs)
b. Measure the child
Length
1. Take the nappy off
2. Needs 2 people, with carer
holding the childs head
3. Ensure that:
Back, legs and head
are straight
Shoulders are
touching the board
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Richard Shaw

Crown of the head


touching the head
board
4. Move the footboard up so
they are touching the
heels
5. Read the measurement
Height
1. Take shoes off
2. Ensure:
a. Heels are right
against the wall
b. Back of head,
shoulder blades and
buttocks are against
wall
c. Child is looking
straight ahead
3. Use a flat object to place
on top of the top of the
childs head, and read
what their height is
c. Plot their height on the appropriate
growth chart (CDC in NSW) for
their:
Age
Gender
Adjust for prematurity if below
36 months
Note that these are for Caucasian
children, and therefore some
ethnicities might fall outside
normal values, but still be
healthy
d. If you have weight measurements
over a period of time, plot the
childs weight on the growth
velocity graph as well
o The following are categories for
height:
<3rd percentile in height for age
is short stature
<25th percentile in height
velocity is growth failure

PAEDIATRICS
Constitutional delay is short, but
with no growth failure OR
delayed bone maturity
o Height is an indication of long term
nutrition
2. Weight
a. Ensure the weighing machine is
properly calibrated
b. Weigh the child
Child should have bare
weight/minimum clothing on,
depending on the age of the child
In an uncooperative child, weight
the parent and the child together,
and then the parent, subtracting
the second value from the first
c. Plot the childs weight on the
appropriate growth chart (CDC in
NSW) for their:
Gender
Age
Adjust for prematurity if below
21 months
Note that these are for Caucasian
children, and therefore some
ethnicities might fall outside
normal values, but still be
healthy
Determine what percentile the
child is in
d. Determine the childs BMI
(assuming you previously did
height)
BMI = Weight (kgs) / (Height in
m)^2
Plot this on the correct graph
according to age
These have the following
abnormal categories:
o >95% is considered obese
o 85-95% is considered
overweight
o <5% is considered
underweight
o Failure to Thrive is:
a. Weight <3%
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Richard Shaw

b. Crossing 2 major
centile lines over time
c. If chronic, weight may
be affected, but HC
usually preserved if
not severe
e. Expected weight growth in children
are as follows:
Average birth weight: 3.5kgs
Some weight loss in first 5-7
days, regained by 10-14 days
Weight triples in first 12 months
Gain of 2.5kg in 2nd year
o Weight is an indication of short
term nutrition
3. Head Circumference
a. Find 0 on a non-stretch measuring
tape
b. Take a length
c. Put it around their head and find
the occiput
d. Wrap it around so that the tape
goes over the supraorbital ridges
(thus taking the largest head
circumference)
e. Pull it tight
f. Do this three times until a
consistent measurement is
achieved
g. Plot the childs weight on the
appropriate growth chart (CDC in
NSW) for their:
Gender
Age
Adjust for prematurity if below
18 months
Note that these are for Caucasian
children, and therefore some
ethnicities might fall outside
normal values, but still be
healthy
o This is useful in infants >2 years;
over 2 it slows and is not as useful
o Other methods of measuring growth
may include:

PAEDIATRICS
o

o
o

Mid upper arm circumference


(MUAC)
Useful in patients with
oedema/liver
disease/abdominal tumours
Knee height
Useful in CP patients with
contractures where height is
hard to measure
Skinfold thickness
Bone density and age

Growth Charts

Plotting on growth charts


o Ensure you have the right:
Gender
Age
o Determine if they were premature
(<37 weeks) so measurements can
be adjusted
For every week premature they are,
one month must be taken off their
age on the growth chart (even if
this means this makes them a fetus
on the chart)
This is done until:
18 months for HC
21 months for weight
36 months for length
One off measurements do not give a
complete picture of the child growth,
with serial measurements being
required to see changes in growth over
time

The Acutely Ill Child


General Appearance and
Airway

Inspection
o Do they look generally unwell/do
parents think they look wrong?
Well/Unwell
Toxic/Non-toxic
o Do they have spontaneous
movement, or are they limp and
lethargic

Richard Shaw

Mobility
Trauma
Tumour
Osteomyelitis/septic arthritis
Reactive arthritis
o Alertness
Interactiveness wit h environment
Children usually hypervigilant in
new environment
Consolability
If parents cannot settle child,
you should be worried
o Vocalisation
Strength of cry
Speech
Both quantity and quality
Palpate
o Vital signs
Temperature
Hypo- or Hyperthermic/Febrile
Importance on not how high the
fever is, but what is causing it
BP
Late to change
RR
HR
Late to change
Alertness
o

Breathing

Inspect
o Airway noises
Stridor
This sounds like an inspiratory
gasp
Can be very soft
Indicates URT obstruction
Grunting
Caused by a closed glottis
providing positive pressure to
prevent atelectasis of alveoli
Can be a sign of pain which may
not always be respiratory
related (gut etc).
May be a squeaking noise in
neonates
Wheezing

PAEDIATRICS

These are musical expiratory


noises
Snoring
Position
Sniffing position
Head held up and slightly
extended to hold airway open
Tripod position
Leaning forward to stabilise
accessory muscles to improve
their action
Increased work of breathing
Accessory muscles
Abdominal movements
Stomach usually goes out during
inspiration
Paradoxical breathing may occur
in respiratory distress due to
huge negative pressure
generation
Speech
Only able to say single words
indicates respiratory distress
Cyanosis

Circulation

10

Inspect
o Cyanosis
o Mottled appearance
o Fluid in/out
Urine

Richard Shaw

How many times do you need to


change the child each day
normally and how wet are the
diapers
How many times have you
needed to change the child
recently and how wet are the
diapers
Should admit if urine output is
<50% of normal
Weight change over the day
Palpation
o Perfusion
Press on sternal skin, capillary refill
should return in 2-3 seconds

Dextrose

Investigate
o BSL

DO IT ALL AGAIN
(Regular reassessment)