Paediatrics: A clinical handbook

By Joe Esland, Anouska Lerner and Arif Khan

Paediatrics: a clinical handbook provides all the essential information required for a successful paediatrics rotation.
Written by two recently qualified junior doctors and a consultant paediatrician, the book offers an exam-centred, reader-friendly style backed up with concise clinical guidance.

Building on the success of the other ‘Clinical Handbook’ titles (Rheumatology and Psychiatry), Paediatrics: a clinical handbook provides reader-friendly coverage of the subject in an attractive full-colour design.

To help the reader get to grips with the subject quickly and easily, the book features a wide variety of learning aids including mnemonics, numerous clinical photos, OSCE tips, red flag boxes and rapid diagnosis boxes.

Paediatrics: a clinical handbook is ideal for medical students and junior doctors; like the other books in the series it will also appeal to medics who want a quick refresher of the subject.

Self-assessment tests, in the form of 20 Short Answer questions and 40 Single Best Answer Questions, are available at: www.scionpublishing.com/Paediatrics

• Language: English
• Publisher: Scion Publishing
• Release date: May 1, 2019
• ISBN: 9781911510413

Book preview

Chapter    

1

History taking

and examination

¹.¹ The paediatric history

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As the adage goes, ‘listen to your patient, they are telling you the diagnosis’. In this chapter, the foundations of the paediatric history are laid out with particular focus on the nuances that differentiate it from the adult counterpart.

It is assumed that the reader already has a good grasp of the general medical history, as well as the system-specific symptoms, before commencing their paediatric training. With this in mind, the below includes only questions that are asked in addition to those that one would usually ask in a normal adult history. Where a whole section of the history is new (see Table 1.1), all new questions are listed.

It is important to remember to introduce yourself to both the child and the people with them, usually addressing the child first. This early interaction is often a useful indicator of how able the child will be to provide a history. In reality, the history is often taken both from the child, as well as the collateral history.

Who is with the child? Do not assume that it is their mother and/or father.

What is the age of the child?

As in adults. Allow the patient or their carer to tell you the presenting symptoms, and explore the characteristics and qualities of these fullybefore moving on.

Next, screen for the other symptoms from the likely causal body system.

See Appendix A for a full list of the system-specific symptoms that should be asked.

As in adults, ask a few questions to screen for pathology of all the other systems.

This is of particular importance in infants and young children who commonly present with vague, non-specific symptoms.

Plus:

Dermatology:

Has the child developed any new rashes? Many childhood diseases are associated with a rash.

Neurology:

Is the child drowsy?

Any neck stiffness?

Photophobia/phonophobia? Especially in a febrile child, a high index of suspicion for meningitis is always needed – it is therefore good practice to ask about these as a matter of routine.

Features of dehydration:

Is the child still producing wet nappies?

Are they thirsty?

Do they produce tears when they cry?

As for adults.

If a patient has a previous medical condition it is useful to ask:

When was it diagnosed?

What treatment have they received?

Who are they under the care of (name of consultant) and at which hospital?

When is their next clinic appointment or have they been discharged from follow-up?

Drug history – ensure that you remember to ask about allergy status and when and what the reaction was.

Family history – some people find it useful to draw a family pedigree chart.

Who do they live with at home? Siblings?

Is there currently, or has there ever been, any social care involvement with this child or their siblings? This is an important question that should always be asked irrespective of the preconceptions you may have about the parents. Requiring a degree of sensitivity to ask, it is useful to fire a ‘warning shot’, such as this is a standard question we ask everyone.

Are they at school?

Are there any smokers in the home?

This aspect of the paediatric history is very important; it is essential to recognize that having an unwell child is a highly anxious time for the parents, who will often worry that their child has a serious illness. Addressing these ideas and concerns specifically will improve your rapport with the parents and increase their satisfaction with the consultation.

You may find the following questions useful:

Do you have any specific concerns about what the problem might be?

Are there any specific conditions that you’ve heard about and that are worrying you?

Were there any tests or treatments that you were expecting we would provide for your child today?

¹.² The paediatric examination

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Assessment of hydration status is a core part of the examination of children. Associated with some obvious aetiologies, such as illnesses causing diarrhoea and vomiting, many other non-specific illnesses can cause a child to stop feeding optimally. When protracted, this can lead to dehydration due to inadequate input and it is therefore not uncommonly seen in unwell children.

The clinical features of dehydration (see Fig. 1.1) can be categorized into two broad groups: initially, features of depletion of the interstitial fluid volume and, later, depletion of the intravascular fluid volume.

Fig. 1.1: Clinical signs of dehydration in an infant.

When assessing dehydration, it is important to assess the degree of severity. Clinical features are used to determine if it is mild, moderate or severe: each of these degrees represents the approximate percentage loss of body weight as water (see Table 1.2). This then allows you to prescribe the correct volume of fluid that will need replacing.

When you are sending a child home who is at risk of progression to hypovolaemic shock, it is important that you make parents aware of the clinical features that indicate that the child is moving towards that point. NICE (2009, CG84) recommends telling parents about the features marked with an asterisk (*) in Table 1.2. The clinical features of a child in hypovolaemic shock are, in addition to the above:

Pale/mottled skin

Cool extremities

Weak peripheral pulses

↑ capillary refill time

Hypotension.

In this section, we are referring to the observational assessment you will perform irrespective of the system that is being examined primarily.

Always begin with observing the child playing in the waiting room – this is a good general indicator of growth/nutrition, hygiene and illness severity.

Assess growth formally – height (>2 y/o) or length (<2 y/o), weight and head circumference (in infants). To do the latter, measure the largest circumference of the head (which is between the brow and the occiput) three times, and take the largest measurement.

Hands – cyanosis, clubbing and capillary refill time – either at the nail bed or press over the sternum.

Head – palpate the fontanelle in infants.

Face – Look for dysmorphic features, suggestive of chromosomal or syndromic conditions.

Skin – it is useful in children to expose the skin and look for new rashes.

Count the respiratory rate (see Table 1.3)

Drooling – a sign of a partially obstructed airway.

Chest:

Inspect for skin changes, scars, swelling or asymmetry

Listen for any additional airway sounds such as:

grunting: a sign of serious illness, produced by exhaling against a partially closed glottis. Localizes pathology to the lower respiratory tract.

stridor: a harsh breathing sound due to breathing through narrowed upper airway, so localizing pathology to this part of the tract. It may be both inspiratory and expiratory. In a relaxed child it may not be audible but will manifest if the child becomes distressed. Do not examine the child’s mouth or throat if you hear this sound, as it may cause laryngospasm.

wheeze: a high-pitched musical, whistling noise usually heard during expiration. Polyphonic wheeze usually represents asthma, whilst a monophonic wheeze (same pitched wheeze with each breath and the same across the chest) indicates a fixed narrowing – consider an inhaled foreign body.

Signs of acute respiratory distress:

nasal flaring

tracheal tug and intercostal recession

use of accessory muscles

Chronic changes:

barrel chest

Harrison’s sulcus (see Fig. 1.2).

Fig. 1.2: Harrison’s sulcus, seen in those with chronic respiratory conditions. Note the flaring of the costal margin with an inferior groove.

Trachea central?

Assess chest expansion as you would in adults. In children ≈≥5 years; 3–5cm is normal.

Tactile vocal fremitus can be assessed – older children will be able to say ‘99’ as in adults, but in younger children this won’t be possible. If they are crying, you can use this instead.

Do sensitively, but essentially the same as in adults – particularly in children of school age.

If you do not have a paediatric diaphragm on your stethoscope, it is best to use the bell for auscultation of the younger child’s chest.

Auscultate in the traditional way, listening for equality of air entry, vesicular vs. bronchial breath sounds and any added sounds (such as wheeze or crackles/rales).

It is common in children to hear ‘transmitted upper airway sounds’. These are sounds from the upper respiratory tract that are ‘transmitted’ into the chest so that you hear them on auscultation – these tend to be loud, inspiratory, coarse and are heard diffusely throughout the chest. They are usually a sign of an upper respiratory tract infection.

Inspect the abdomen for any skin changes, scars, swelling or asymmetry.

There are some normal variants in children:

A protuberant abdomen is normal in toddlers.

Umbilical hernias are not unusual, particularly in black infants.

Rectus divarication is sometimes seen and is normal (see Fig. 1.3).

Inspect the buttocks for any wasting – indicates recent weight loss.

Always check the hernial orifices.

Fig. 1.3: Rectus divarication.

It is imperative that the abdomen is relaxed – you may find the child more compliant if you have them stand up, although lying down is optimal.

Palpate the nine regions of the abdomen for tenderness or masses.

Is the mass indentable? If so, this is usually just faeces, particularly if it is found in the left iliac fossa.

Liver:

As in an adult, moving from the right iliac fossa to the right hypochondrium. It is usually palpable 1–2cm below the right costal margin ≤2 years old.

Spleen:

As with adults, starting in the right iliac fossa and moving to the left hypochondrium. It is sometimes palpable in infants, protruding 1–2cm below the left costal margin. Characteristically, spleens move with respiration, have a notched lateral border and you cannot get above them.

Kidney:

Ballot as normal.

Bladder:

Is palpable in neonates and infants. This is normal.

Percuss for the liver and spleen as normal.

Ascites:

Shifting dullness is of far higher utility than fluid thrill. To do this, percuss from the midline to the flank, stopping as soon as you hear a dull percussion note. Keeping your finger in the same place, roll the child onto their opposite side and leave them there for ≥30 seconds. Percuss in this spot again – if it was ascitic fluid, the percussion note will now be resonant rather than dull.

Listen for bowel sounds and bruit.

Sweatiness/clamminess – may be a sign of cardiac failure.

Jugular venous pressure – not usually visible in children.

Inspect the chest for:

Any skin changes, scars, swelling or asymmetry

Ventricular impulse – seen in thin children commonly, but may represent ventricular enlargement.

Pulse rate – usually done at the brachial artery. This is most easily elicited by having the arm fully extended and palpating medial to the insertion of the biceps brachii.

Brachio-femoral/radio-femoral delay – signs of coarctation of the aorta.

Apex beat, heaves and thrills as in an adult.

Right ventricular enlargement – a parasternal heave is felt. Place the fingertips along the left sternal edge (approx. 2nd to 4th intercostal spaces) to elicit.

Nil.

Use the bell in younger children.

Particularly with young children, it can be difficult to ascertain where a murmur is in the cardiac cycle due to their fast heart rates. You may find palpating the brachial pulse useful.

As with adults.

Heart sounds: S2 may be physiologically split in children and a third heart sound (S3) is not always pathological.

Murmurs: if a murmur is heard, it is best to then listen in all areas with both the diaphragm and the bell. The difficulty lies in distinguishing if this is an ‘innocent’ (aka ‘flow’) murmur – heard in ≤50% of children – or pathological. Their distinguishing features are described in the box above.

The severity of murmurs is graded with the Levine scale – see Table 1.4.

Neurological examination of the infant is technically challenging and probably beyond the scope of a FY1’s competence. Once into early childhood, when the child is able to follow basic instruction, you will be able to perform the examination as you would on an adult. We therefore only lay out what is required in addition to the ‘full’ neurological examination, as well as some additional examination techniques in the infant.

Dysmorphic features and abnormal facies.

Movement – do they move spontaneously? Are there any abnormal movements? Tremor?

Walking:

How do they stand up? Is the Gower sign (Fig. 1.4) present (the patient uses their hands to ‘walk’ up their legs to push them into the standing position – seen in Duchenne muscular dystrophy (DMD))?

Stiffness?

Waddling (‘Trendelenburg’) gait? – seen in spastic diplegia (a form of cerebral palsy), DMD and developmental dysplasia of the hip.

Ataxia?

Muscle wasting?

Posture?

Fig. 1.4: Gower sign.

Fig. 1.5: A hypotonic infant with excessive/delayed head lag and floppiness in ventral suspension.

Position – hypotonic in the ‘frog’ position, with hips abducted and arms extended? Hypertonic with extended legs that are crossed (‘scissoring’)?

Hold their arms and pull them into the sitting position – is there head lag beyond 4/12 age (hypotonic)?

Ventral suspension – now pick the infant up with your hand on the child’s abdomen. Do they droop over your hand (hypotonic)? Are they stiff (hypertonic)?

Next, put one of your hands in each of the child’s axillae and pick them up – do they feel like they’re floppy and going to slip through your hands (hypotonic)?

You can also assess tone as you would in an adult.

Most of your information will come from observation – are they moving spontaneously? Are they performing anti-gravity movements (i.e. lifting head up or raising arms/legs from the bed)?