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.