General tips on the clinical approach to Paediatric patients

2. Objectives
 Present general advise & tips on
Paediatric clinical
examination/approach
 Present general advise on how to
provide information to Paediatric
patients

3. 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 skills
3) For their attitude towards the patient
4) For their knowledge of diseases, disorders and behavioural
problems

4. General points
 In approaching clinical history and examination of children
visualise common scenarios:
a)Acute illness, e.g. ??
Respiratory tract infection, appendicitis
b) Chronic problems e.g. ??
Failure to thrive, chronic cough
c) A newborn infant with congenital malformation, e.g. ??
Down’s syndrome , congenital malformation
d) Suspected delay in development, e.g. ??
Slow to walk or talk
e) Behaviour problems, e.g. ??
Hyperactivity, eating disorders

5. General points
 The aims and objectives should be:
HELP!!!
H=history
E=examination
L=logical deduction
P=plan of management

6. 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....

7. Key points
 Childs age, e.g.??
Nature and presentation of illness
Way history is conducted
Way subsequent management is organised
 Parents are astute observers, listen to
what they say....

8. 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!

9. 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,
 Don't forget to address questions to the patient when
appropriate

10. 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”

11. Approach to examining children
Obtaining child's 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),

12. Approach to examining children
Obtaining child's cooperation
 Explain what you are about to do,
 and what you want the child to do,
 Examination is essential . Don't ask his permission!
...LOL
 Smile and talk,
 Leave unpleasant procedures last.

13. Approach to examining children
Adapting to child's 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.

14. Approach to examining children
Warm clean hands
 Hands must be washed before and after examining
the child,
 “Warm smile, warm hands”,
 ..warm stethoscope also helps.

15. Approach to examining children
Undressing children
 Be sensitive to children's 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.

16. Approach to examining children
Developmental 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....

17. Approach to examining children
System specific

18. Approach to examining children
System specific

19. Approach to examining children
System specific

20. Communicating with children
Imparting information

21. Communicating with children
Imparting information
Age 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.

22. Communicating with children
Language when imparting information
A child Child might think.. Improved method of
hears .. communication
Put you to Like my cat was put to sleep ? It “Medicine called anaesthesia helps
sleep 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 IV
IV 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”

23. Communicating with children
Language when imparting information
A child Child might think.. Improved method of
hears .. communication
This part will Which part? Big ? How painful? How “This part of your body may feel
hurt long? sore, scratchy, or achey for this
long”
Medicine How bad? As bad a dirt or liver? “The medicine may taste different to
will taste anything you taste before. Let me
bad know how is it for you after taking it
,ok? ”
Cut What!!!!!!! “The doctor will make a small
open/open opening , the size of you little finger
you to make you feel better”

24. 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.

25. 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.

26. 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.

27. Summarising
Play specialist teams are common
practice in the UK and aid
doctors and nurses alike ....
Good news is your
hospital has a one!

28. 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.

29. The end