Objectives Present general advise & tips on Paediatric clinical examination/approach Present general advise on how to provide information to Paediatric patients
General points The cornerstone of clinical practice continues to be history- taking and clinical examination. Good doctors will continue to be admired:1) For their ability to distil important facts and information from the history and ,2) For their clinical skills3) For their attitude towards the patient4) For their knowledge of diseases, disorders and behavioural problems
General points In approaching clinical history and examination of children visualise common scenarios:a)Acute illness, e.g. ?? Respiratory tract infection, appendicitisb) Chronic problems e.g. ??Failure to thrive, chronic coughc) A newborn infant with congenital malformation, e.g. ??Down’s syndrome , congenital malformationd) Suspected delay in development, e.g. ??Slow to walk or talke) Behaviour problems, e.g. ??Hyperactivity, eating disorders
General points The aims and objectives should be: HELP!!!H=historyE=examinationL=logical deductionP=plan of management
General examination Each doctor might vary in style and favourite tricks. However I present a few tips for the paediatric physical exam to improve your interaction and comfort level....
Key points Childs age, e.g.??Nature and presentation of illnessWay history is conductedWay subsequent management is organised Parents are astute observers, listen to what they say....
Taking history Read referral letter and notes before interview, Observe the child at play, may provide clues, Know/ask for the patients name when you welcome the family and the patient. Ask how he prefers to be addressed, Determine the relationship between the adult and child, Infants are most secure in parents lap or arms. Older children might need some time to get to know you... DONT RUSH!
Taking history Avoid having beds and desks between you and family, Have toys available..... Or a play specialist at hand. Observe how he plays and interacts, Dont forget to address questions to the patient when appropriate
Taking history Make sure you adapt the history-taking to child’s age....The age when a child first walks is relevant for a toddler but is it relevant for a teenager with headaches??... ...“LOL”
Approach to examining childrenObtaining childs cooperation Make friends with the child, Be confident and gentle, Avoid dominating, Short mock examinations,e.g. Auscultating a teddy or mothers hand, ask help to play specialist,parent or nurse Start exam on non-threatening area (hand or knee),
Approach to examining childrenObtaining childs cooperation Explain what you are about to do, and what you want the child to do, Examination is essential . Dont ask his permission!...LOL Smile and talk, Leave unpleasant procedures last.
Approach to examining childrenAdapting to childs age Babies in first months best examined on examination couch with parent next to them, A toddler is best initially examined on mothers lap , or over parents shoulder , Preschool children may be examined while playing, Older children and teenagers, concerned about privacy. Teenager girls in presence of mother, nurse or chaperone. Be aware of sensitivities in ethnic groups.
Approach to examining childrenWarm clean hands Hands must be washed before and after examining the child, “Warm smile, warm hands”, ..warm stethoscope also helps.
Approach to examining childrenUndressing children Be sensitive to childrens modesty. The area to be examined must be inspected fully, Do it in stages and re-dress in stages, Its easiest to ask parent or child to do the undressing.
Approach to examining childrenDevelopmental skills Watch the child play to asses development, A few simple toys and bricks , a car , pencil and paper is all that is required. If developmental assessment focus of examination asses this before physical examination.........As cooperation may be lost....
Communicating with childrenImparting information
Communicating with childrenImparting informationAge Who needs info and preparing? Resources?0-3 Parents; older siblings Photos, body maps, diagrams.3-6 Children; parents; older siblings Storybooks, photos, dolls.7-11 Children, parents; siblings Dolls and models, photos, conversation and planning before procedures.12+ Children, parents; siblings Body maps, photos, diagrams, peer support and conversation and planning around worries and procedures.
Communicating with childrenLanguage when imparting informationA child Child might think.. Improved method ofhears .. communicationPut you to Like my cat was put to sleep ? It “Medicine called anaesthesia helpssleep never came back!! you sleep during your operation, so you wont feel anything!” .. “Its a special sleep!!”Flush your Flush it where? Down the toilet? “To put some water down your IVIV tube, so that continues to work and says clean”Intravenous ???? “Medicine that works best when it/IV goes right into your vein”....”usually in a tube”
Communicating with childrenLanguage when imparting informationA child Child might think.. Improved method ofhears .. communicationThis part will Which part? Big ? How painful? How “This part of your body may feelhurt long? sore, scratchy, or achey for this long”Medicine How bad? As bad a dirt or liver? “The medicine may taste different towill taste anything you taste before. Let mebad know how is it for you after taking it ,ok? ”Cut What!!!!!!! “The doctor will make a smallopen/open opening , the size of you little fingeryou to make you feel better”
Summarising Always wash your hands when evaluating a child, before and after, In general, when evaluating any child, observation is the best initial diagnostic tool, Talk to the child as well as the parents, For older children, introduce yourself to them first before the parents and sit down on the bed or chair as to not tower over them.
Summarising While doing physical exam, try use the parent’s lap as much as possible as child is most comfortable there, Consider having something fun in your pocket such as stickers or a bubble-blowing...or a play specialist at hand, Distract and calm them, consider telling them a story throughout the exam, Try to make the physical exam a game.
Summarising The last thing in physical exam should always be those things that are most threatening to the child, including looking in the ears and mouth. Remember if else fails... Ask for help! To a superior, colleague , parent , nurse or play specialist.
SummarisingPlay specialist teams are common practice in the UK and aid doctors and nurses alike ....Good news is your hospital has a one!
References Rudolf M, Lee T, Levene M. Paediatrics and Child Health. Wiley Blackwell, 2001; 3rd ed. Lissauer T, Clayden G. Illustrated textbook of Paediatrics. UK: Mosby Elsevier, 2007; 3rd ed. Tasker R, McClure R, Acerini C. Oxford handbook of Paediatrics. Oxford: Oxford University press, 2008.