Search This Blog

468x60.

728x90

 


and turning round; if so, comment warmly on this cooperation

and provide positive feedback on helpful behaviour. Children’s

social skills regress when they are unwell and some are very

apprehensive of strangers.

5+ years

The child may comply with a full adult-style examination. Although

children under 11 years are often not able to express themselves

well, those over 5 years are able to understand and comply with

requests such as finger-to-nose pointing, heel-to-toe walking, and

being asked to ‘sit forward’ and ‘take a deep breath in and hold it’.

The acutely unwell child

There are many non-specific signs that are common to a range

of conditions from a simple cold to meningitis. These include

a runny nose, fever, lethargy, vomiting, blanching rash and

irritability. However, some signs are serious, requiring immediate

investigation and management (Box 15.10).

Children become ill quickly. If a child has been unwell for less

than 24 hours and initial examination reveals only non-specific Male genital development Pubic hair MALE FEMALEBreast development

BI

Prepubertal

BII

Breast bud

BIII

Juvenile smooth

contour

BIV

Areola and papilla

project above breast

BV

Adult

PHI

Pre-adolescent

No sexual hair

PHIII

Dark, coarser, curlier

PHIV

Filling out towards

adult distribution

PHV

Adult in quantity and type

with spread to medial thighs

in male

GI

Pre-adolescent

GII

Lengthening

of penis

GIII

Further growth in length

and circumference

GIV

Development of glans penis,

darkening of scrotal skin

GV

Adult genitalia

PHII

Sparse, pigmented, long,

straight, mainly along

labia and at base of penis

Fig. 15.19 Stages of puberty in males and females. Pubertal changes according to the Tanner stages of puberty.

15.10 Serious signs requiring urgent attention

• Poor perfusion with reduced capillary refill and cool peripheries

(indicating shock)

• Listless, poorly responsive, whimpering child (suggesting sepsis)

• Petechial rash over the trunk (suggesting meningococcal sepsis)

• Headache with photophobia or neck stiffness (suggesting meningitis)

• Respiratory distress at rest (rapid rate and increased respiratory

effort, indicating loss of respiratory reserve due to pneumonia or

asthma)

Calibration checked

Head straight, eyes and ears level

Gentle upward traction on mastoid process

Knees straight

Heels touching back of board

Barefoot with feet flat on floor

Fig. 15.20 Stadiometer for measuring height accurately in children.

314 • Babies and children

Abnormal findings

Healthy tonsils and pharynx look pink; when inflamed, they are

crimson–red.

Inspecting the throat reveals the presence, but not the cause, of

the infection; pus on the tonsils and pharynx does not differentiate

a bacterial from a viral infection (p. 185).

Ears

Examination sequence

Ask the parent to:

Sit the child across their knees with the child’s ear

facing you.

Place one arm around the child’s shoulder and upper

arm that are facing you (to stop them pushing you

away, Fig. 15.22).

Place their other hand over the parietal area above

the child’s ear that is facing you (to keep the child’s

head still).

Use an otoscope with the largest speculum that will

comfortably fit the child’s external auditory meatus.

To straighten the ear canal and visualise the canal and

tympanic membrane, hold the pinna gently and pull it out

and down in a baby or toddler with no mastoid

development, or up and back in a child whose mastoid

process has formed.

Lymphadenopathy

Normal findings

Palpable neck and groin nodes are extremely common in children

under 5 years old. They are typically bilateral, less than 1 cm in

diameter, hard and mobile with no overlying redness, and can

persist for many weeks. In the absence of systemic symptoms

such as weight loss, fevers or night sweats, these are typically

a normal, healthy immune response to infection. Only rarely are

they due to malignancy (Box 15.12).

Vital signs

Normal ranges for vital signs vary according to age (Box 15.11).

Ears, nose and throat

The preschool child

Throat

Examination sequence

Ask the parent to:

Sit the child on their knees, both facing you.

Give an older child the opportunity to open their mouth

spontaneously (‘Roar like a lion!’). If this is not

successful, proceed as described here.

Place one arm over the child’s upper arms and chest

(to stop the child pushing you away, Fig. 15.21).

Hold the child’s forehead with their other hand (to stop

the child pulling their chin down to their chest).

Hold the torch in your non-dominant hand to illuminate the

child’s throat.

Slide a tongue depressor inside the child’s cheek with

your dominant hand. The child should open their clenched

teeth (perhaps with a shout), showing their tonsils and

pharynx.

Fig. 15.21 How to hold a child to examine the mouth and throat.

Fig. 15.22 How to hold a child to examine the ear.

15.11 Physiological measurements in

children of different ages

Age (years) Pulse (bpm)

Respiratory

rate (breaths

per minute)

Systolic blood

pressure (mmHg)

0–1 110–160 30–60 70–90

2–5 60–140 25–40 80–100

6–12 60–120 20–25 90–110

13–18 60–100 15–20 100–120

Child protection • 315

15

want to move, and if they are forced to do so, the neck remains

aligned with the trunk. With a young child, move a toy to catch

their attention and see if they move their head.

Spotting the sick child

It can be difficult to identify a child with severe illness. With

experience you will learn to identify whether a child is just miserable

or really ill. Early-warning scores (such as PEWS or COAST, Fig.

15.23) can help. Certain features correlate with severe illness

(Box 15.13).

Child protection

Children who experience neglect or physical and/or emotional

abuse are at increased risk of health problems. At-risk children

are often already known to other agencies but this information

may not be available to you in the acute setting. Injuries from

physical abuse can be detected visually. Consider non-accidental

injury if the history is not consistent with the injury, or the injury

is present in unusual places such as over the back. It may be

difficult to detect neglect during a brief encounter but consider

it if the child appears dirty or is wearing dirty or torn clothes

that are too small or large. The parent–child relationship gives

insight into neglect; the child is apparently scared of the parent

(‘frozen watchfulness’) or the parent is apparently oblivious to

the child’s attention (Box 15.14).

Cardiovascular examination

Feel the brachial pulse in the antecubital fossa in children below

2–3 years. Do not palpate the carotid or radial pulses in young

children. Measure blood pressure using a cuff sized two-thirds

the distance from elbow to shoulder tip. Repeat with a larger

cuff if the reading is elevated. If in doubt, use a larger cuff, as

smaller cuffs yield falsely high values.

Respiratory examination

Abnormal findings

The child under 3 years has a soft chest wall and relatively

small, stiff lungs. When the lungs are made stiffer (by infection

or fluid), the diaphragm must contract vigorously to draw air into

the lungs. This produces recession (ribs ‘sucking in’ – tracheal,

intercostal and subcostal) and paradoxical outward movement

of the abdomen (wrongly called ‘abdominal breathing’). These

important signs of increased work of breathing are often

noticed by parents. Older children may be able to articulate

the accompanying symptom of dyspnoea.

Children’s small, thin chests transmit noises readily, and

their smaller airways are more prone to turbulence and added

sounds. Auscultation may reveal a variety of sounds, including

expiratory polyphonic wheeze (occasionally inspiratory too), fine

end-expiratory crackles, coarse louder crackles transmitted from

the larger airways, and other sounds described as pops and

squeaks (typically in the chest of recovering patients with asthma).

Abdominal examination

In children aged 6 months to 3 years, examine the abdomen

with the child sitting upright on their parent’s knee. In the

young child, splenic enlargement extends towards the left iliac

fossa. In older children the enlarged spleen edge moves towards

the right iliac fossa. Faecal loading of the left iliac fossa is common

in constipation. Rectal examination is rarely indicated in children.

Neurological examination

Test power initially by watching the child demonstrate their

strength against gravity. Ask them to lift their arms above their

head, raise their leg from the bed while they are lying down,

and stand from a squatting position. If appropriate, test power

against your strength.

Neck stiffness in a child is usually apparent when you are

talking to them or their parents. A child with meningitis will not

15.12 Causes of lymph node enlargement

Cervical lymphadenopathy

• Tonsillitis, pharyngitis, sinusitis

• ‘Glandular fever’ (infectious mononucleosis/cytomegalovirus)

• Tuberculosis (uncommon in developed countries)

Generalised lymphadenopathy

• Febrile illness with a generalised rash

• ‘Glandular fever’

• Systemic juvenile chronic arthritis (Still’s disease)

• Acute lymphatic leukaemia

• Drug reaction

• Mucocutaneous lymph node syndrome (Kawasaki disease)

15.13 Clinical signs associated with severe

illness in children

• Fever >38°C

• Drowsiness

• Cold hands and feet

• Petechial rash

• Neck stiffness

• Shortness of breath at rest

• Tachycardia

• Hypotension (a late sign in shocked children where blood pressure

is initially maintained by tachycardia and increased peripheral

vascular resistance)

15.14 Signs that may suggest child neglect or abuse

Behavioural signs

• ‘Frozen watchfulness’

• Passivity

• Over-friendliness

• Sexualised behaviour

• Inappropriate dress

• Hunger, stealing food

Physical signs

• Identifiable bruises, e.g. fingertips, handprints, belt buckle, bites

• Circular (cigarette) burns or submersion burns with no splash marks

• Injuries of differing ages

• Eye or mouth injuries

• Long-bone fractures or bruises in non-mobile infants

• Posterior rib fracture

• Subconjunctival or retinal haemorrhage

• Dirty, smelly, unkempt child

• Bad nappy rash

316 • Babies and children

Date

Time

40

Doctor/Nurse/Family Concern?

39

38 Temperature

(°C)

Heart Rate

(bpm)

Resp Rate

(bpm)

Heart Rate (number)

Resp Rate (number)

GCS*

Pain Score*

Continue normal observations.

Nurse in Charge review. Hourly observations.

Nurse in Charge & Doctor to review patient. Half-hourly observations.

Nurse in Charge & SpR to review patient. Consider informing Consultant.

*nb: BP, GCS and Pain Score values do not contribute to the overall COAST score.

Nurse in Charge & Senior Doctor to see immediately.

If airway compromise, call ITU Registrar immediately.

Receiving O2 (L/min)

Resp. Mod/Severe

Distress None/Mild

Distress None/Mild

Level Decreased

TOTAL COAST SCORE

Number of shaded boxes

NB: Scores 3 should

be recorded overleaf

Observer’s initials

ACTIONS

O2 saturations (%)

Blood Pressure

(mmHg)*

*nb BP does not score

in COAST Scoring

(over 1 minute)

and

37

36

35

34

220

210

200

190

180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

70

60

50

40

30

20

10

0–1

2

3

4

5–6

Patient details

Name

DOB

Hosp No

PRESCHOOL (1–4 years)

COAST: CHILDREN’S UNIT

CHILDREN’S OBSERVATION AND SEVERITY TOOL

CHILDREN’S

UNIT

SOUTH COAST CHILDREN’S EARLY WARNING SCORE: CHILDREN’S UNIT

Fig. 15.23 Rapid cardiopulmonary evaluation. BP, blood pressure; bpm, beats/breaths per minute; GCS, Glasgow coma scale score; ITU, intensive

treatment unit; SpR, specialist registrar. Courtesy Dr Sandell.

Child protection • 317

15

OSCE example case 1: Cyanotic episodes

Charlie, 4 months old, is brought in to see you by his mother Helen. She is anxious, as he has ‘turned blue’ on three occasions since discharge from

hospital. Two of the episodes have been during breastfeeding, when he has become agitated and breathless.

Please perform a newborn examination, focusing on the cardiovascular system

• Introduce yourself to the parent and clean your hands

• Carry out a general inspection: are there any signs of congenital heart disease?

• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).

• Check for scars on the chest.

• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).

• Look for signs of dysmorphic features that might indicate an associated chromosomal abnormality.

• Look for signs of poor weight gain.

• Palpate: is the infant warm and well perfused? Are there any palpable cardiac abnormalities?

• Check central capillary refill. Feel the temperature.

• Palpate peripheral pulses (brachial, femoral).

• Palpate the precordium for palpable murmurs (thrills), ventricular heave or abnormal position of the apex.

• Assess whether there is palpable hepatomegaly or finger clubbing.

• Auscultate: is there a murmur?

• Auscultate the heart in a systematic fashion.

• Describe any murmur by documenting timing, grade (1–6), character, location, radiation, and variation with position and respiration.

• Auscultate the back to check whether the murmur radiates.

• Clean your hands and thank the parent.

Suggest a diagnosis

Congenital heart disease is possible with this presentation. There are many possible types and further investigation is needed for diagnosis. Tetralogy

of Fallot consists of four features: ventricular septal defect, right ventricular outflow obstruction, right ventricular hypertrophy and an overriding aorta. It

requires surgical correction. Children with tetralogy of Fallot are more likely to have chromosome disorders (Down’s syndrome or Di George syndrome).

Finger clubbing is not usually present in young infants.

Suggest investigations

Pulse oximetry, echocardiogram, electrocardiogram, chest X-ray.

OSCE example 2: Asthma

John, 8 years old, who has been diagnosed with asthma, is brought to see you by his parent. He has had more frequent episodes of wheeze and

night-time cough over the last 3 months, each lasting longer and responding less well to regular doses of bronchodilator.

Please perform a chest examination, focusing on the respiratory system

• Introduce yourself to the parent and patient, and clean your hands.

• Carry out a general inspection: are there any signs of acute or chronic respiratory distress?

• Look for chest wall deformity (pectus excavatum, Harrison’s sulcus).

• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).

• Count the respiratory rate over 1 minute.

• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).

• Look for finger clubbing and poor weight gain.

• Palpate: consider palpation if there are chest-wall abnormalities or differential chest expansion on inspection, to look for differential chest-wall

movement.

• Auscultate: warm the stethoscope.

• Auscultate the respiratory system in all lung regions, anteriorly and posteriorly, with the chest fully exposed.

• Wheeze is auscultated in all lung regions. No crepitations are heard. Air entry is reduced to all lung regions. The respiratory rate is raised at 40

breaths per minute.

• Heart sounds are normal with no murmur.

• Clean your hands and thank the parent and patient.

Summarise your findings

This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.

Suggest a diagnosis

Acute asthma attack on the background of unstable asthma is the likely diagnosis with these symptoms and signs. This requires treatment of the acute

episode with bronchodilator and oral glucocorticoids, and consideration of how to improve background control. Stabilising background control includes

an assessment of adherence and technique for current therapies, consideration of new triggers and how exposure may be reduced (by history and/or

skin-prick testing) and, if required, a trial of a stepwise increase in baseline asthma therapy.

Suggest initial investigations

Peak expiratory flow or spirometry, and oxygen saturation.

318 • Babies and children

Integrated examination sequence for the newborn child

• Perform a general examination:

• Looks well and is well grown? Dysmorphic features? Posture and behaviour? Does the cry sound normal?

• Skin: note cuts, bruising, naevi (haemangiomas or melanocytic), blisters or bullae.

• Head: check shape, swellings, anterior fontanelle, cranial sutures.

• Eyes: check for jaundice, ocular movements and vestibular function; perform ophthalmoscopy.

• Nose: check patency.

• Mouth: check mucosa, tongue, palate, jaw and any teeth.

• Ears: note size, shape and position; check the external auditory meatus.

• Neck: inspect and palpate for asymmetry, sinuses and swellings.

• Examine the cardiovascular system:

• Inspect: pallor, cyanosis and sweating.

• Palpate: apex, check for heave or thrill, count heart rate, femoral pulses, feel for hepatomegaly.

• Auscultate: heart sounds I and II, any additional heart sounds or murmurs.

• Examine the respiratory system:

• Inspect: chest shape, symmetry of movement, respiratory rate, respiratory distress: tachypnoea, suprasternal, intercostal and subcostal recession,

flaring of nostrils.

• Auscultate anteriorly, laterally and posteriorly, comparing sides.

• Examine the abdomen:

• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.

• Palpate: superficial, then deeper structures. Spleen, then liver.

• Examine the perineum:

• Both sexes: check normal anatomy.

• Male: assess the penis, noting shape; check the urethral meatus is at the tip. Do not retract the foreskin. Palpate the testes, and the inguinal

canal if the testes are not in the scrotum. Transilluminate scrotal swellings.

• Examine the spine and sacrum:

• With the infant in the prone position, inspect and palpate the entire spine for neural tube defects.

• Examine the neurological system:

• Inspect: asymmetry in posture and movement, any muscle wasting.

• Pick the baby up to note any stiff or floppy tone.

• Sensation: does the baby withdraw from gentle stimuli?

• In dim light, the eyes should open; in bright light, babies screw up their eyes.

• Check the primitive reflexes:

• Check grasp responses, ventral suspension/pelvic response to back stimulation, place-and-step reflexes, Moro reflex, root-and-suck responses.

• Inspect the limbs:

• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.

• Check hips for developmental dysplasia/dislocation.

• Weigh and measure:

• Weigh the infant to the nearest 5 g.

• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).

• Record on a centile chart.

16

The patient with

mental disorder

Stephen Potts

The history 320

General approach 320

Sensitive topics 320

The uncooperative patient 320

The mental state examination 320

No comments:

Post a Comment

اكتب تعليق حول الموضوع

mcq general

 

Search This Blog