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1 PAEDIATRIC HISTORY TAKING By Dr Ciara Fitzgerald F4 (Paediatric locum doctor)Aims To develop an understanding of the principles of paediatric history taking. To gather relevant information in the paediatric history. To encourage a patient-centered approach in paediatric history taking Applying paediatric history taking to a case. 2Introduction Why is paediatric •Essential for diagnosis and management. •Variation in components of the history compared to adults. history important? •Child may be too young/unable to give history. Challenges •Reliance on caregivers for information. •Developmental milestones •Growth patterns Key differences •Immunization history •Feeding history •Social history 3Definitions Neonate = Infant = 1- Child = 1- <28 days 12 months 12 years Adolescent Term Preterm = >12 years >37weeks. <37weeks. 4 Presenting complaint Paediatric History overview History of presenting complaint Systems review Birth history Developmental history Growth history Immunization history Past medical/surgical history/previous admissions Medication history and allergies Family history Social history. ICE- ideas/concerns/expectationsPresenting complaint Presenting complaint •Why has the child been brought in? •Remember open questions. History of presenting complaint •Onset, duration, progression of symptoms. •SOCRATES for pain and can be adapted for other presenting complaints. •Key symptoms to consider: fever, rash, pain, cough, breathing difficulties, feeding, urine output, vomiting, diarrhoea. 6Systems review General: fever, lethargy, behaviour, activity level, rashes, growth, night sweats, weight loss, hydration and feeding. Cardiorespiratory: cough, difficulty breathing, wheeze, stridor, cyanosis, palpitations, chest pain. Gastrointestinal: abdominal pain, diarrhoea, vomiting (projectile? Bilious?), constipation, abdominal distension. Genitourinary: dysuria, haematuria, foul odour urine, frequency, loin pain/suprapubic pain, how many wet nappies/toilet trained. Neurological: headaches, seizures, abnormal movements, funny turns, syncope, photophobia, neck stiffness. ENT: sore throat, ear pain/discharge. 7Birth History •GDM), alcohol, drug use.ections/chronic conditions/conditions of pregnancy (e.g. Antenatal •Extra scans e.g. growth. Abnormalities on scans. •Mode of delivery: SVD, IOL, ElLSCS, EmLSCS, instrumental. •Birth weight (normal 2.5kg-4.5kg)term Birth •Birth complications: PROM/prolonged labour, birth injury, resuscitation required. •Feeding problems •Jaundice Neonatal •Infections •Admission to SCBU/NICU. 8Developmental history • Nursery progress and reports. • School progress and attendance. • Any parental concerns? 9Growth History ► Gaining weight appropriately? ► Any weight loss e.g. neonatal period check red book (used birth to 5years). ► Using growth charts/centiles to monitor weight/height/head circumference.Immunisation History 11Past medical/Surgical Previous surgical history Previous medical diagnoses Previous operations Any medical conditions Planned procedures Anything they see a doctor for regularly? Any upcoming appointments or referrals? Anything they take medication for? Any previous admissions? 12 Medication History and allergies Allergies Current medications? Medications Prescribed- dose/route/adherence/ compliance • What’s the reaction? OTC including vitamins. • Anaphylactic symptoms? Ever needed treatment for reaction? Food e.g. peanuts/CMPA 13 Family and Social History ► Anything relevant to HPC? ► Unwell contacts- parents/siblings/nursery/school ► Genetic conditions. ► Who lives at home? Parents/siblings/extended family ► Smokers in the family (inside or out) ► Any social services or safeguarding concerns ► Nursery/school attendance ► Recent foreign travel ► Pets 14Ideas Concerns Expectations Don’t forget****- OSCE stations like to see you ask this set of questions! Ideas: What does the patient think is going on? Concerns: What’s worrying them currently? Expectations: What are they hoping comes from this consultation e.g. advice/ reassurance/ referral to another specialty/ scans/ bloods etc. 15Example Case- Fever You’re the on call Paediatric F1 on rotation at the Student Brief local District General Hospital. Setting A+E 8week old baby girl called Sophie accompanied by Patient Details: her mum Sarah after being referred to paediatrics with history of fever and vomiting. Please take a focused collateral history from Sophie’s mum. The examiner will then stop you at 7minutes to ask you some questions relating to the case. 16Differential Diagnoses…. 17What do you want to know? 18PC: Systems r/v • General: • Fever • No rashes • Vomiting • Paler colour • Irritable/unsettled • No weight loss. • Reduced feeding. • No night sweats HPC: • Resp: ► Highest temp: 39.4oC in the • No wheeze/stridor axilla. • No increased effort. • No cyanosis. ► Started 2/7 ago. • No cough or coryza. • Gastro: ► Giving calpol which was bringing • No diarrhoea. it down well initially but now • Bowels opening daily doesn’t seem to be. • Normal colour stools. ► 1/7 of vomiting, non bilious just • Renal: milk and no blood. Approx 6 • Reduced wet nappies-1 in last 12hours. episodes. Not projectile. • Urine quite concentrated. • No apparent foul odour. • No visible blood in urine. • Neuro: • More lethargic • Less interactive with smiling • Needs waking for feeds. 19 • No seizure activity. • MSK NAD • ENT NAD PMH: ► No medical conditions. Birth History: ► No prior admissions. • Maternal GDM diet controlled. ► No previous surgery • Born at 38weeks via NVD. • Born in good condition Medications and allergy • Birthweight 3.2kg ► Calpol whilst he’s been unwell. • No neonatal concerns. ► NKDA FH: Immunisations: • Not yet had- due 8/52 ones tomorrow ► Nil relevant Social History: Developmental and growth: ► Lives at home with mum/dad/3year old • Smiling and startles to loud noises. brother. th • Gaining weight and progressing along 50 ► Non smokers. centile. ► No recent travel ► 3y.o brother currently unwell with cough/cold symptoms, attends nursery. 20Further Investigations ► Bedside: ► Full systems examination: General inspection, CVS, Resp, GI, neuro, ENT ► Full observations Looks unwell- mottled skin, pallor, lethargic but rousable with stimulation. No rashes Sunken anterior fontanelle. CVS: HS 1+2+0 Chest: Clear with good air entry bilaterally. No increased WOB. Abdomen SNT. Normal bowel sounds. No distension. Temp 39oC, HR 170bpm, RR 45 breaths/min, SpO2 97% Air, CRT 3secs. 2122Management What traffic light colour would you assign to this baby? •Red •Amber •Green What condition are you most concerned about with this baby? •SEPSIS with possible shock. •Infection origin currently unknown What management do you want to commence immediately with this baby? •ABCDE assessment •Refer to senior paediatrician •Sepsis 6! Golden hour! •Blood cultures/Bloods/Blood gas •Urine output •Fluids IV •Antibiotics IV •Lactate •Oxygen (if needed) •Other investigations to try and get prior to antibiotics include urine MC+S/Lumbar Puncture 23 Observations and examination ► Looks unwell- mottled skin, pallor, lethargic but rousable with stimulation. ► No rashes ► Sunken anterior fontanelle. ► CVS: HS 1+2+0 ► Chest: Clear with good air entry bilaterally. No increased WOB. ► Abdomen SNT. Normal bowel sounds. No distension. ► Temp 39oC, HR 170bpm, RR 45 breaths/min, SpO2 97% Air, CRT 3secs. 24 Further Investigation: BBOXES Bedside: Bloods: Imaging: ECG Special tests: •Full systems •FBC •CXR (if respiratory • Lumbar puncture examination: •CRP signs present) • CSF culture General inspection, •U&Es •Abdominal US scan: • Serum CVS, Resp, GI, •LFT (baseline) e.g. if meningococcal/ neuro, ENT •Blood glucose UTI/appendicitis pneumococcal PCR •Full observations •Blood cultures •viral •Blood gas (venous or •CT scan if indicated (enterovirus/herpes •Urinalysis +/- urine capillary) simplex/varicella MC+S. zoster) PCR from •+/- viral swab CSF •+/- stool culture •+/- bacterial throat swab 25► Bloods: ► Hb 119 (94-130) ► WCC 21.0 (5.0-15.0) ► Neut 13 (1.0-5.0) ► CRP 95 ► Lactate 4.0 ► Cr 65 (13-34) ► Urine dip: ► Erythrocytes + ► Leucocytes –ve. ► Nitrites +ve ► Urine MC+S: E.Coli +ve. ► Lumbar Puncture ► Pressure: 10cm H20 (5-20) ► Colourless appearance ► Protein: 0.25g/L (0.18-0.45) ► Glucose: 3.0 (2.5-3.5) ► Gram stain Normal ► WCC <3 ► Blood culture: E.Coli +ve. 26 Diagnosis? =Urosepsis ‘Sepsis is a life threatening condition that happens when the body’s immune system has an extreme response to an infection, causing organ dysfunction.’ 27UTI ⮚ Definition: ⮚ Urinary tract infection (UTI) is an illness caused by microorganisms in the urinary tract. ⮚ Lower UTI (cystitis) = bladder and urethra. ⮚ Upper UTI (acute pyelonephritis) = renal pelvis and kidneys. ⮚ Asymptomatic bacteriuria is the presence of bacteria in urine collected from a person without the signs and symptoms of UTI. ⮚ Main bacterial cause: Dipstick result 3m-3yr >3yr Leuc +ve/nit +ve. Assume UTI = Abx Assume UTI = Abx Urine MC+S Med-high risk serious illness then urine MC+S. Leuc –ve/nit +ve. Treat as UTI* = Abx Treat as UTI* = Abx Urine MC+S Urine MC+S Leuc +ve/nit –ve. Treat as UTI = Abx Abx ONLY if good clinical evidence Urine MC+S of UTI Urine MC+S Leuc –ve/nit –ve. Assume NO UTI Assume NO UTI Consider DDx Consider DDx 28 No MC+S unless indicated** No MC+S unless indicated.** <3months >3months Upper UTI >3months Lower UTI • Refer urgently • Urine dipstick • Urine dipstick st • Send Urine MC+S • Consider referral secondary care • Oral antibiotics 1 line • Parenteral antibiotics • Oral antibiotics • Trimethoprim • Cefalexin • Nitrofurantoin • Co-amoxiclav* • 2nd line antibiotics • Reassess if symptoms worsen/don’t • Nitrofurantoin** improve within 48hours of • Amoxicillin* treatment. • Cefalexin • Reassess if symptoms worsen/ don’t improve with 48hours of treatment. Atypical UTI criteria: US imaging renal tract indicated: • During acute infection in all children with atypical infection • Poor urine flow • Within 6weeks if • Abdominal or bladder mass st • <6month olds with 1 time UTI responded to treatment • Raised creatinine • Babies/children with non-E.Coli UTI responded to treatment with no other atypical features. • Sepsis • Failure to respond to • If imaging abnormal refer to paediatric specialist . treatment with suitable antibiotics within 48hours. • Infection with non-E.Coli 29 organisms. Causes of Fever Bacterial Viral Inflammatory Other Meningitis Meningitis Kawasaki disease Leukaemia Pneumonia Encephalitis JIA Lymphoma UTI URTI/LRTI SLE Malaria Appendicitis Gastroenteritis IBD Toxoplasmosis Bacterial enteritis Influenza Vaccine induced Infective endocarditis Covid Septic Arthritis RSV Osteomyelitis Rotavirus Cellulitis Measles Tonsilitis/Scarlet fever Croup Otitis Media Whooping cough 3031Other Paediatric Presentations to consider: Geeky medics and OSCE stop have some good examples for further information. 32References ► https://oscestop.education/learning/paediatric-history/ ► Paediatric History Taking | OSCE Guide | Geeky Medics ► https://www.gov.uk/government/publications/the-complete-routine-immunisation-schedule ► https://cks.nice.org.uk/topics/feverish-children-risk-assessment-management/ ► Recommendations | Fever in under 5s: assessment and initial management | Guidance | NICE ► https://pmc.ncbi.nlm.nih.gov/articles/PMC3849992/ ► https://www.ebmedicine.net/topics/infectious-disease/pediatric-emergency-medicine-fever-3-to-36-months ► https://www.who.int/news-room/fact-sheets/detail/sepsis ► Definition | Background information | Urinary tract infection - children | CKS | NICE ► Causes | Background information | Urinary tract infection - children | CKS | NICE ► Diagnosing a urinary tract infection | Diagnosis | Urinary tract infection - children | CKS | NICE ► Scenario: UTI in children | Management | Urinary tract infection - children | CKS | NICE ► https://litfl.com/csf-analysis/ ► https://www.nbt.nhs.uk/sites/default/files/Childrens%20FBC%20Reference%20Ranges.pdf ► Clinical chemistry reference ranges- Sheffield Children’s Hospital. ► https://bestpractice.bmj.com/topics/en-gb/3000104 ► https://geekymedics.com/common-ed-presentations-paediatrics/ ► https://oscestop.education/learning/common-paediatric-histories/ 33