For example, in the \200 Do you take time to look \201 rst? Communication \200 Can to identify the main concerns of the patient and family? Can you communicate informatio n to both the patient and parent, making sure both understand the diagnosis and treatment p lan, and do you give them the opportunity to ask questions? Can you write a discharge lette r for the family doctor? Can you write a full medical summary for the medical notes? Can Ca n you communicate effectively with other health care workers, including nurses and social w orkers, and explain the thought process that led to your diagnosis and treatment? you establish rapport with the patient and family? Are you able \200 \200 you present to colleagues a well-organized summary of your patient? Clinical problem solving \200 Can common clinical presentations? Can you use your knowledge of key signs and symptoms, an d the frequency and prevalence of diseases at different ages to develop a likely differenti al diagnosis? Can the results of commonly ordered laboratory tests, such as the full blood count, urinalysis, and serum electrolytes, and recognize that the normal values of some tes ts may vary with the age of the patient? you compile a problem list and differential diagnosis for each of the you make a management plan of investigations? Can you interpret 01_McClure_01.indd 4 11/14/2012 7:04:21 PM PROFESSIONAL SKILLS 5 Can and management of clinical problems? Can you critically appraise a topic (i.e. patient, intervention, outcome \200\224see b Chapter 2, p.16) and decide on best evidence for treat ment? you use the medical pediatric literature to research the diagnosis Practical procedures (b Chapter 7) \200 Do intravenous (IV) line, nasogastric (NG) tube, etc.)? Can you explain these procedures to parents and children? Specialist trainees in pediatrics should be able to perform the proc edures in the Boxes 1.1 and 1.2. you know when certain procedures are needed (e.g. lumbar puncture, \200 Box 1.1 Diagnostic procedures \200 \200 b p.203) Venepuncture and venous cannulation for blood sampling ( Collection of blood from central l ines and umbilical arterial lines (b pp.204 \200\223209) Capillary blood sampling ( Electro cardiogram (ECG) b p.220) Lumbar puncture (LP, Suprapubic aspiration of urine ( Non-invasiv e blood pressure (BP) measurement Urethral catheterization ( Urine analysis using standard bedside tests Blood sugar measurement using standard point-of-care glucometers \200 \200 \200 \200 \200 \200 \200 b p.202) b p.219) b p.218) Diagnostic procedures with supervision \200 \200 b p.205) Peripheral arterial cannulation ( Needle thoracentesis of pleural effusion for microbiology and cytology Box 1.2 Therapeutic procedures \200 \200 \200 \200 \200 \200 \200 b p.211) Bag, valve, and mask ventilation ( Placement of an oral airway ( External chest compression Tracheal intubation of term newborn babies ( Removal and replacement of a blocked tracheot omy tube Percutaneous long-line insertion ( Placement of NG tube b p.210) b p.212) b p.209) Therapeutic procedures with supervision \200 \200 \200 \200 \200 Injections: Insertion of an intraosseous (IO) needle Administer surfactant Tracheal intubat ion of preterm and older child Chest drain insertion for pneumothorax intradermal, subcutaneous (SC), intramuscular (IM), and IV 01_McClure_01.indd 5 11/14/2012 7:04:21 PM CHAPTER 1 Practicing pediatrics 6 Knowledge During your reading you should consider these questions as a starting point to th e knowledge that would be expected of a junior pediatrician. Growth (b Chapter 13) \200 \200 What are the intrauterine factors that affect growth of the fetus? Can you explain how grow th charts are used in the longitudinal evaluation of height, weight, and head circumference ? In particular, consider the following. \200 Can you recognize abnormalities of growth that warrant further evaluation? What is the sign i \201 cance of crossing centiles on a growth chart? What is the signi \201 cance of disc repancies between height, weight, and head circumference? What are: short stature; constitu tional delay; failure to thrive; obesity; microcephaly; and macrocephaly? \200 Development (b Chapters 15, 24, and 27) Why is following development important in clinical pediatrics? \200 What are the normal changes in re \202 exes, tone, and posture in the infant? What is the normal progression in motor milestones in the \201 rst year? What are the signs of cerebr al palsy? \200 Behavior (b Chapters 15, 16, and 21) What are the typical presentations of common behaviora l problems at various developmental levels and ages? \200 \200 \200 What are temper tantrums? How may somatic complaints represent psychosocial problems? In wh at types of situations does pathology in the family contribute to childhood behavior proble ms? Nutrition (b Chapter 10) \200 What factors contribute to the development of failure to thrive in infancy? What factors co ntribute to the development of child obesity? What are the special dietary needs of childre n with chronic illness? What caloric intake is needed for normal growth in infants and smal l children? \200 \200 Also consider the following. \200 What are the major differences between human milk and commonly available formulas? What are the advantages of breastfeeding? 01_McClure_01.indd 6 11/14/2012 7:04:21 PM KNOWLEDGE 7 Newborns (b Chapter 6) \200 \200 What diseases are detected by neonatal blood screening? What important historical informati on, physical examination \201 ndings, and laboratory data are needed for the differential diagnosis of the following problems: \200 \200 \200 \200 \200 \200 \200 \200 \200 jitteriness or seizures; jaundice; lethargy or poor feeding; respiratory distress; cyanosis ; bilious vomiting; non-bilious vomiting; hypoglycaemia; sepsis? Genetics and congenital malformations (b Chapters 23 and 25) \200 \200 What are the effects of teratogenic agents such as alcohol and phenytoin? What are the \201 ndings and implications of the common chromosomal abnormalities: \200 trisomy 21; se x chromosome abnormalities (e.g. Turner \200\231s syndrome, fragile X \200 syndrome); oth er genetic disorders (cystic \201 brosis, sickle cell disease)? Common pediatric illnesses For each of the common \200\230presentations \200\231 and \200 \230conditions \200\231 in this handbook can you review: \200 \200 \200 \200 \200 \200 cause; pathophysiology; natural history; presenting signs and symptoms; initial laboratory test and/or imaging needed for diagnosis; plan for initial management? 01_McClure_01.indd 7 11/14/2012 7:04:22 PM This page intentionally left blank 9 Chapter 2 Epidemiology, evidence, and practice Introduction 10 Descriptions in populations 10 Summary of study designs 11 Levels of eviden ce 12 Basics of statistics 14 Training and special knowledge skills 16 Useful websites and resources 18 References 18 02_McClure_02.indd 9 11/14/2012 2:00:43 PM CHAPTER 2 Epidemiology, evidence, and practice 10 Introduction The aim of this chapter is to provide the epidemiological information that we \201 nd useful in supporting our every-day clinical practice. You may have read an articl e and need a quick reference. Alternatively, you may want to examine some data published in a report and apply it to your work. Asking questions is a skill that you, the clinician, s hould develop. It is important to ask questions that fall into two main categories: \200 Those that de \201 ne the burden of disease: when questions. Those that understand or sear ch for the cause of childhood disease : i.e. why, and how questions. i.e. what, who, where, and The answers to these questions will require the use of numerical reason- ing and statistics . In your professional development you should seek an understanding of: \200 Quantifying \200 Research design \200 Basic statistical tests \200 Clinical guidelines \200 Cri tical appraisal disease in populations. , methodology, and implementation. and their interpretation. , systematic reviews and meta-analyzes. of the literature. This chapter will highlight some of these areas. Other texts should be read for a fuller ac count of statistics and evidence-based medicine. Descriptions in populations Measurements \200 Prevalence: the proportion of a study population who have a disease at one instant, or peri od in time. This number includes both new and old cases. Incidence: a new condition or diag nosis. the proportion of people in a study population who develop Mortality rates \200 Still birth: an infant born after the 24th week of pregnancy who does not, at any time afte r being born, breathe or show any other sign of life. Perinatal mortality: Infant mortality : Post-neonatal mortality: Under 5-yr-old mortality: \200 \200 \200 still births plus deaths in \201 rst week of life. deaths from birth to 1yr. deaths from 4wks of age to 1yr. deaths from birth to under 5yrs. 02_McClure_02.indd 10 11/14/2012 2:00:43 PM SUMMARY OF STUDY DESIGNS 11 Summary of study designs Here are the common types of clinical study that you will read abo ut. Experimental study \200 Randomized controlled trial (RCT): intervention studies. These studies assign subjects to r eceive treatment or no treatment. The RCT provides the best evidence for causation Quasi-ex perimental: measurement of an outcome this is the gold-standard of clinical other studies with an intervention and Observational study In populations These are descriptive studies and can, at best, provide an ecological correlation In individuals These studies can be descriptive, as in case series; or they can be analytic al, as in case-control, cohort, and cross-sectional studies. \200 Case-series (retrospective) review: of practice or uncontrolled treatment in a de \201 ned patient group. Case-control (retrospective) study: de \201 ned by their disease, and cont rols that do not have disease. Typically, cases are compared with controls, but there is co nsiderable potential for bias. This type of evidence for causation is weak. these studies o bserve, over time, the effect Cohort (prospective) study: of exposure to a risk factor or d isease in a study cohort and a suitable control group not exposed to the factor or disease. Population studies can be used to de \201 ne incidence and they provide stronger evidence of causation. Cross-sectional study: outcome or disease, and the presence of a risk factor . Cross-sectional studies can be used to de \201 ne prevalence. these studies are essentially reviews these studies have cases that are these studies examine, at the same time, an 02_McClure_02.indd 11 11/14/2012 2:00:43 PM CHAPTER 2 Epidemiology, evidence, and practice 12 Levels of evidence Evidence-based medicine is a method used for guiding clinical decision- making based on critically analyzed information. There are now standard texts for this disc ipline. These approaches, however, are now common- place and the clinician should be aware of the types of information that are available: Systematic reviews A systematic review is a summary of the medical literature that uses a s tandardized methodology for searching databases, appraising the content of individual studi es, and synthesizing all the data in a coherent and statisti- cally rigorous manner. When t his process involves quantitative data then it could be called a \200\230meta-analysis \200\231. Guidelines A clinical guideline is a series of systematically developed statements that are used to assist clinical decisions. Guidelines should provide a summary of the evidence (qu ality and level) on which the statements are based, and an instruction on applying the evid ence in practice. Expert opinions In areas where there is little in the way of systematic or high-quality dat a, one may have to resort to the advice of a panel of experts. The approach can be systemat ized with a technique called the \200\230Delphi \200\231 approach. In this iterative proce ss one brings together a panel of experts who each assign a score (0 \200\2239) to statemen ts about practice, management or care. The proc- ess continues with changes to statements u ntil consensus is achieved. Each step, for acceptance or rejection, has strict criteria. The GRADE (GRades of recommendation, Assessment, Development, and Evaluation) system for presenting \200\230Quality of Evidence \200\231 (Table 2.1): Table 2.1 The GRADE system for presenting \200\230Quality of Evidence \200\231 Quality rating Underlying methodology High Randomized controlled trials (RCT) yielding consistent and directly applicable results, or well-done observational studies yielding large effects Moderate RCT with important limitations, or well-done observational studies with yielding large effe cts Low Well-done observational studies, or RCTs with serious limitations Very low Poorly controlled observational studies and unsystematic clinical observations such as case series, or case reports 02_McClure_02.indd 12 11/14/2012 2:00:43 PM LEVELS OF EVIDENCE 13 02_McClure_02.indd 13 11/14/2012 2:00:44 PM CHAPTER 2 Epidemiology, evidence, and practice 14 Basics of statistics In the following section we describe the terms and tests that we often refer to when assessing as study. Commonly used term \200 ) level of a statistical test: often set at 5% (0.05), this is Signi \201 cance ( the probability of \201 nding a statistical association by chance alo ne when there really is no association. Power (1- \201 nding a statistical association wh en there is one. Sample size: achieve a suf \201 ciently high power and low , in order t o obtain a result that is of value clinically. P-value: alone. If the P-value is less than the preset , then the \201 nding is considered not due to chance. Con \201 dence inter val (CI): there is 95% chance of \201 nding the true value. Relative risk: people with a risk factor to the incidence of disease among people without the risk factor. Odds ratio: r isk factor in people with disease to odds of having the risk factor in people without the d isease. ) of a statistical test: often 80% (0.80), the probability of the number of subjects needed in a clinical study to this value quanti \201 es the probability of a \201 nding by chance often set at 95% probability: the interval where this value is the ratio of incidence of disease among in case-control studies, the ratio of odds of having the The hypothesis test for the difference between two proportions There will be instances wher e you want to re-analyze some data that have been presented (see Table 2.2) Table 2.2 Frequency table to display data Feature Group 1 Group 2 Total Present A B A+B Absent C A+C = n1 D B+D = n2 C+D A+B+C+D= n1 + n2 Total patients When a comparison is being made, you need: \200 An estimate of the 95% CI in each group: should consult standard tables. When the proportion is zero (i.e. 0/n), where n (cid:1) 100 , use the \200\230rule-of-3 \200\231 to calculate the upper limit of the 95% CI, i.e. uppe r limit = 3/n. Then draw a 2 x 2 frequency table to display the data The observed differenc e between groups 1 and 2: OD = A/n1 \200\223 B/n2. The proportion (p) in both groups combi ned: p = (A + B)/(n The standard error (SE) of the difference is: SE = p( )p ( )p ( / )p ( in small series (n (cid:1) 100) you \200 (see Table 2.2). (OD) in the proportions with the feature, \200 1 + n2). between the two proportions 2/n+n( / / 11 )n . 02_McClure_02.indd 14 11/14/2012 2:00:44 PM BASICS OF STATISTICS 15 \200 Difference in sample proportions will be normally distributed with mean 0. To calculate the observed difference in SE units away from hypothesized difference of zero: OD/SE. Exact le vel of signi \201 cance can be read from the table of the normal distribution. Assessing the validity of an RCT Calculate the number of patients that you need to treat (N NT) with the experimental therapy in order to prevent one additional bad outcome, as follow s: \200 RRR = (CER \200\223 EER)/CER, where CER is Relative risk reduction (RRR): the control event rate, and EER is the experimental event ra te. Absolute risk reduction (ARR): ARR = CER \200\223 EER. Number needed to treat: NNT = 1 /ARR The 95% CI on a NNT (1 \200\223 CER)/n1 + EER \227 (1 \200\223 EER)/n2 where n1 is the number of controls and n2 the number treated. \200 \200 \200\223 1/limits on the CI of its ARR: 1.96/CER \227 Measurements for evaluating a clinical test When you want to know whether a test will affec t management, assess the importance of the study in diagnostic terms (see Table 2.3). Table 2.3 Assessing the importance of a study in diagnostic terms Disease status Test result Positive Negative Positive A (true positive) B (false positive) Negative C (false negative) D (true negative) Sensitivity: (use Table 2.3) = A/(A + C). Speci \201 city: test = D/(B + D). Positive pred ictive value: truly have disease = A/(A + B). Negative predictive value: truly do not have disease = D/(C + D). Likelihood ratio (LR) positive: disease status = Sensitivity/(1-speci \201 city). LR negative: Speci \201 city/(1-sensitivity). Pre-test probability Pre-test-o dds Post-test odds Post-test probability the proportion of all diseased who have positive (+ve) test proportion of all non-diseased who have a negative ( \200\223ve) proportion of all those with +ve tests who proportion of all those with \200\223ve tests who ability of a +ve test result to con \201 rm ability of a \200\223ve test result to con \201 rm non-diseased status = \200 \200 \200 or prevalence = (A + C)/(A + B + C + D). = prevalence/(1-prevalence). = Pre-test odds \227 LR. = Post-test odds/(Post-test odds + 1). Having analyzed the data, ask \200\230Will the change from pre-test probability (prevalenc e) to post-test probability make a difference? \200\231 02_McClure_02.indd 15 11/14/2012 2:00:44 PM CHAPTER 2 Epidemiology, evidence, and practice 16 Training and special knowledge skills During clinical practice, as a postgraduate trainee o r an undergraduate medical student, there are many opportunities to demonstrate your abilit y and skills at approaching common questions at the core of pediatrics and child health. We suggest that writing a report will often help to clarify your thoughts. The format should follow this sequence: \200 \200 \200 Identify the problem you want to address. De \201 ne a structured question. Find the best evidence using original primary studies or evidence summaries. Ask yourself \200\230how va lid is the evidence? \200\231 Summarize the results. Then ask, \200\230how should I apply the results to patient care? \200\231 \200 \200 The following format for critically appraising a topic can be used as a guide \200\224the w ord lengths are approximate: Clinical setting (7150 words) Give a description of the clinic al setting that gave rise to your question for critical appraisal (e.g. where you saw the p atient, what interested you?). A structured question (a sentence) Your question should demonstrate that you have thought a bout speci \201 c knowledge which relates to managing patients. It will have four essentia l components: \200 \200 \200 \200 A [patient] or [problem]. An [intervention]. A comparison [ A clinical [ intervention] if relevant. outcome]. For example, in a wheezing child, admitted to hospital with bronchiolitis [patient], treatm ent with nebulized salbutamol [intervention] reduces the duration of oxygen therapy and hos pital admission [outcomes]. A brief report of search methods (3 sentences) List in order the sources of information you have used: \200 \200 \200 \200 Secondary sources. Systematic reviews (Cochrane Library see Primary research (PubMed query using MeSH \200\230subject headings \200\231). Search results: question. b p.18). have you identi \201 ed any papers as being relevant to your 02_McClure_02.indd 16 11/14/2012 2:00:44 PM TRAINING AND SPECIAL KNOWLEDGE SKILLS 17 A structured summary of search results (use a table) Using the information you have gained from reading the papers you identi- \201 ed construct a table listing: \200 \200 \200 \200 \200 The citation. The type of study. The outcome or endpoint of the study. The key result. Your personal comments. Commentary on the papers listed in your table (300 words) Write two paragraphs that draw to gether your knowledge and insights on the subject. Your clinical message or bottom line (50 words) Have an answer to your question and what yo u will do in your practice. Also, set a review date when you we review this topic. References Incorporate a list of all of the references. The \201 nal length of your written report should be 500 \200\223600 words. Some medical journals will accept these items for publication. Practice point You will \201 nd it helpful to present the results of your appraised topic to your collea gues. We suggest that you do this with no more than 10 presentation slides (see Table 2.4). Table 2.4 Suggested presentation slides Slide Content 1 The clinical setting 2 Your structured question 3 The search strategy 4, 5, and 6 Your \201 ndings and results 7 A summary 8 and 9 How this evidence applies to your patient or problem 10 The clinical bottom line 02_McClure_02.indd 17 11/14/2012 2:00:44 PM CHAPTER 2 Epidemiology, evidence, and practice 18 Useful websites and resources Useful synopses and syntheses of the medical literature: \200 Cochrane Database of Systematic Reviews: disciplines examining therapy and prevention. Avai lable at: M http:// www.cochrane.org/index.htm Database of Abstracts of Reviews of Effects (DARE): and concentrates on therapy and prevention. Available at: M http:// www.york.ac.uk/ inst/crd/crddatabases.htm Bandolier: medicine.ox.ac.uk/bandolier covers a broad range of covers all disciplines useful for primary care. Available at: M http://www. Primary sources of the medical literature that give access to reports of studies: \200 MEDLINE has lots of primary studies across all disciplines and areas of research which is f ree through PubMed. Available at: M http://www. ncbi.nlm.nih.gov/pubmed GOOGLE Scholar: sea rch term to use or the type of study \200\224the fastest way to \201 nd high- impact stud ies that have recently made the headlines. Available at: M http://scholar.google.com when all else fails \200\224you can \200\231t remember the right References Guyatt G, Rennie D. (2002). Users guide to the medical literature: a manual for evidence-ba sed clinical practice. Chicago: American Medical Association. Sackett, DL, Straus, SE, Richardson, WS, et al. (2000). Evidence-based medicine. How to pra ctice and teach EBM, 2nd edn. Edinburgh: Churchill Livingstone. 02_McClure_02.indd 18 11/14/2012 2:00:45 PM 19 Chapter 3 Clinical assessment Communication skills 20 Taking a pediatric history: introduction 21 The presenting complain t 22 History of present illness 24 Past health history 25 Symptom review 26 Family history 28 Examining a child: introduction 28 General condition 29 Vital signs 30 Respiratory syste m 31 Cardiovascular system 32 Gastrointestinal system 33 Genitourinary system 34 Musculoske letal system 34 03_McClure_03.indd 19 11/14/2012 7:04:53 PM CHAPTER 3 Clinical assessment 20 Communication skills Skill at communication is central to pediatric medical practice. In ti me you will develop the following abilities and traits. Personal \200 Courtesy team. Patience families. Empathy dif \201 culty and distress. Ins ight managing sensitive and complex situations. to families, colleagues, and members of the multidisciplinary and sensitivity in your communication with children and their with children, young people, and their families experiencing into personal limitations and when help should be sought in Professional See also b pp.575 \200\223576, 794, 1005, 1034 \200\2231035. \200 Understand how to manage consultations with babies, young children, adolescents, and their families effectively. Learn how to listen to children and young people, i.e. hear their nee ds, respect their views, and respond in an age-appropriate manner where the child is feelin g vulnerable. Develop an effective way of communicating information about a diagnosis, prog nosis, or emotional issue to children, young people, families. Know when and what assistanc e is required when communicating with children and families who unable to speak or understa nd English. Learn what information is appropriate to share with children based on their phy sical and mental maturity. 03_McClure_03.indd 20 11/14/2012 7:04:54 PM TAKING A pediatric HISTORY: INTRODUCTION 21 Taking a pediatric history: introduction This section provides a system for reviewing the f ull pediatric medical history and examination. With experience, there are short-cuts, but i t is wise for newcomers to the \201 eld to be thorough. As you become more adept, develop your own style and process \200\224the key point is do not miss important information. Whe n you write-up notes, record the important +ve and \200\223ve \201 ndings and observatio ns. Remember, these are a form of communication \200\224between you and your colleagues, or for you at a later date \200\224they should be legible, clear, and logical, and written in black ink. Practice point Always record: \200 \200 \200 Date and time when you undertook the consultation Who was present Who gave the history 03_McClure_03.indd 21 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 22 The presenting complaint There are over 100 ways in which the human body can respond to ill ness or disease. To the clinician, the presenting complaint may be a symptom, a sign, a \201 nding, or a laboratory abnormality. If it is not clear to you what the problem is then ask yourself or the patient/carer \200\230Why has this child, and their family, sought me dical attention now? \200\231 Record the patient or parent \200\231s description of the pro blem. Box 3.1 lists, in alphabetical order, a selection of common pediatric symptoms and problems . A more detailed account of these complaints can be found in the chapters indexed, and the reader should refer to these sections (see Box 3.1). 03_McClure_03.indd 22 11/14/2012 7:04:54 PM THE PRESENTING COMPLAINT 23 Box 3.1 Common pediatric symptoms and problems \200 b pp.310, 351, 668, 845 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Abdominal mass and abdominal pain, b pp.192, 610 \200\223629 Anemia, b p.64 Anaphylaxis, An tisocial behavior, Apnoea, Ataxia, Attention de \201 cit and hyperkinesis, Bleeding, bruis ing, or purpura, b p.258 Breathlessness, Coma and head injury, Constipation, Cough (acute, chronic), b pp.60 \200\22363, 226 Cyanosis, b p.90 Dehydration, Developmental delay, Diarrh ea (acute, chronic), Ear pain or discharge, Electrolyte disturbance, Failure to thrive, Fat igue (chronic), Fever and febrile neutropenia, Headache, Hypotonia, Joint pain, limp, Lymph adenopathy, b pp.138, 226 Oedema, Polyuria and urinary frequency, Rash, b p.890 Red eye, Sc hool performance (poor), Seizures and status epilepticus, b pp.54 \200\22358, 65 Shock, Sle ep disturbance, b p.282 Sore throat, Stature (short, tall), Stridor, b p.300 Vomiting, Walk ing (delayed), b p.255 Wheeze, White blood cell count (abnormal), b p.598 b p.48 b p.524 b p.600 b p.632 b pp.72 \200\22379 b pp.304, 306 b p.257 b p.564 b pp.302 \200\223305 b p.900 \200\223901 b p.89 \200\22393 b p.308 b p.990 b pp.682 \200\223683, 696 \200\223702 b pp.516 \200\223518 b pp.136, 538 b pp.734 \200\223737 b p.654 b p.350 b p.806 b pp.986, 991 b pp.80, 134, 505 b p.279 b pp.466, 474 b p.256 b p.564 b pp.608, 626, 656 \200\223659, 724 03_McClure_03.indd 23 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 24 History of present illness Once you have established the presenting problem you will need t o answer the following questions: \200 \200 \200 When did the current problem start. What was it like? Has the problem changed at all? If so , when and in what way? Has the patient sought medical attention before now? If so, what in vestigations have been done so far? What treatments have been tried? Ask speci \201 cally about current state: eating, drinking, passing urine, stool, acting their normal self, and vomiting. 03_McClure_03.indd 24 11/14/2012 7:04:54 PM PAST HEALTH HISTORY 25 Past health history On reviewing the child \200\231s past health history there are \201 v e areas that should be covered by your questioning. It is important to consider and record at least those that relate to the current health problem. Prenatal history \200 \200 \200 How many pregnancies has mother had; what were the outcomes? What was the length of the pre gnancy with this child? Were there any complications during the pregnancy, such as abnormal bleeding, illness, or infection? Did the mother take any medication during pregnancy? Birth history \200 \200 \200 \200 What was this child \200\231s gestation at birth and what was the weight? How long was labo r? Was there maternal fever or premature rupture of membranes? Was any intervention require d at delivery? Neonatal period \200 Did the child have any neonatal problems, e.g. jaundice, cyanosis, or respiratory distress? Was vitamin K given? Was the baby treated on the special care baby unit? When did the baby and mother go home? \200 \200 Child development \200 When did the baby achieve key developmental milestones, e.g. smiling, rolling over, sitting unaided, standing, speaking, and toileting skills? How well has the child grown in weight and length/height? Have there been any concerns about development, vision, hearing? \200 Immunization What immunizations has the child had? Start from birth and review the date whe n each was given, as well as what was given. If any immuniza- tions have been missed or omi tted, identify any reasons, e.g. was the child unwell? Past medical history In this part of the history you will need to \201 nd out about past visits to the doctor and any admissions to hospital that the child has had. \200 Childhood illness and infections: child had? Does the child have asthma, diabetes, epilepsy ? Is the child on any medication Surgical procedures and investigations: in the past? Is th e child seeing another clinician? What infections and illnesses has the \200 ? Why? Are there any allergies? Which? What, if anything, has been done What for? 03_McClure_03.indd 25 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 26 Symptom review If you haven \200\231t done so already, you need to \201 nd out about the child \200\231s general condition. Do they feel unwell, tired, or fatigued? The following l ist of questions can be used for further review, although it is not exhaus- tive. Some of t hese questions will have been covered in your assessment of the presenting problem, so ther e is no point repeating them. However, it is important that you tailor this part of the his tory to issues you think relevant to the child \200\231s condition \200\224particularly whe n you suspect multisys- tem disease. Head Is there a history of injury, headaches, or infection? Eyes \200 \200 How good is visual acuity \200\224are glasses needed? Is there a history of infection, inju ry, or surgery? Ear, nose, and throat \200 \200 \200 \200 \200 \200 Is there a problem with hearing or balance? Is there a history of ear infection or discharg e? Is there any dif \201 culty with breathing? Is there a history of nasal discharge, snor ing, or bleeding? Are there any enlarged lumps or glands? Is there a history of sore throat , dental problems, or mouth ulcers? Chest \200 \200 \200 \200 \200 \200 Is there any limitation to exercise? Is there a history of cough, wheeze, chest pain, or ha emoptysis? Has there been any exposure to tuberculosis? Has the child ever had a chest X-ra y (CXR)? Are there any smokers in the family? Are there any smoke-free zones in the family accommodation? Heart \200 Is there a history of heart murmur or rheumatic fever in the patient or family? Is there a history of dyspnoea, orthopnoea, chest pain, or cyanosis? Gastrointestinal \200 \200 How good is the child \200\231s appetite? Have there been any recent changes in weight, foo d tolerance, or bowel movements? Has there been any rectal bleeding? 03_McClure_03.indd 26 11/14/2012 7:04:54 PM SYMPTOM REVIEW 27 Genitourinary \200 \200 \200 \200 \200 Is there a history of infection? How frequent is urination? Is there any dysuria, or haemat uria, or discharge? Is there a history of bedwetting? What was the age of menarche? Joints, limbs, and tissue \200 \200 \200 \200 Is there any pain? Is there swelling or limitation in movement? Is there muscle weakness? I s there any dif \201 culty walking or a limp? Nervous system \200 \200 \200 \200 Is there a history of \201 ts, faints, or funny turns? Is there a history of febrile seiz ures? Are there any abnormal involuntary movements or tremors? How has the child being doin g at school \200\224has there been a recent change that has concerned the teachers or the f amily? Is there a history of hyperactivity? Skin \200 \200 Is there a rash? Are there any birthmarks or unusual marks on the skin? 03_McClure_03.indd 27 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 28 Family history In pediatrics, the family history is one of the most important components of the history: \200 Ages tree. Include the whole extended family with ages. Illness in the family: does anyone have a history of seizures, asthma, cancer, heart disease, tuberculosis, or any other medic al condition? What was the age of onset and the medical advice so far? Death in the family: have there been any deaths in the family? What was the cause and age at death? Were any in infancy or childhood? Social occupations of the family members? Are there any pets? of parents and siblings: you will need to be able to draw the family history: where and how does the family live? What are the Practice point Draw a family tree to assist your note-taking, and identi \201 cation of key family and so cial history information Examining a child: introduction The physical examination of a child is one of the hardest p arts of the doctor \200\223patient interaction. You will need to have gained the con \201 dence of the family and the child if you are to get the information that you require. How y ou approach the family (and how you communicate with them) throughout the interaction will be picked up by the child. In fact, a child may decide very early into the interview whethe r you \200\231ve gained their con \201 dence, and whether or not they will let you examine them. No amount of coercing will improve the situation \200\224the parent will often be yo ur advocate and do the convincing for you. It is therefore very worth- while investing in t he art of communication \200\224how to talk with toddlers to teenagers and how to speak eff ectively with parents of sick children. The following description is not meant to be prescriptive. There is much overlap between th e different systems and you will have to decide on when, and in what order, you do things. For example, the tongue is assessed in the respiratory, cardiovascular, and GI systems \200 \224just look at it once! 03_McClure_03.indd 28 11/14/2012 7:04:54 PM GENERAL CONDITION 29 General condition \200 State any evidence of chronic illness? Make an assessment of their mental state: is their b ehavior appropriate. Does the child interact with the parents? Is the child alert, tired, l ethargic, or uncomfortable? Height , weight, and head circumference: these measurements are often made before you see the child. Acquaint yourself with how they are done in the clini c or on the pediatric ward. Certain measurements, e.g. the head occipitofrontal circumferen ce (OFC), you will want to do yourself. In a growth clinic, length or height measurements a re best done by the auxologist. Hydration: sunken eyes, skin turgor, and pulse. of health: make a note of the child \200\231s general appearance. Is there capillary re \201 ll, mucous membranes, anterior fontanelle, Practice point \200 In those under 2yrs old, obtain a length measurement using a table stadiometer. In older ch ildren, height can be measured standing Weigh the child unclothed Measure the head OFC at t he maximum point of the occipital protuberance posteriorly and at the mid-forehead anterior ly Each of these measurements should be plotted on standard charts and the centiles recorde d with the raw data \200 03_McClure_03.indd 29 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 30 Vital signs See also b p.37. See Tables 3.1 and 3.2 for normal values of respiratory rate, heart rate (HR), and BP at different ages. \200 Temperature can be measured. Different units use different methods: \200 \200 \200 A sick child could have a high, or abnormally low, temperature. Pulse rate: the pulse rate sh ould be assessed from the radial pulse. (In the younger child you may \201 nd it easier t o use brachial pulse.) Assess the rate, character, and rhythm at the radial pulse. Respirat ory count the number of breaths/min. Breaks or pauses in breathing that last longer than 15 s are abnormal. In the infant, count abdominal movements over 1min, if you \201 nd it is easier to see diaphragmatic, rather than chest wall movement. BP: method with BP displayed on-screen. It is important that the size and width of the cuff is appropriate for the size of limb in which pressure is being measured. It should cover 50 \200\22375% of the upper ar m or thigh. A single measurement is required in most cases, but if heart disease is suspect ed, 4-limb measurements are needed. If considering hypertension, a standard technique is re quired; plot observations on BP centile charts. : there are various ways in which the body temperature an electronic thermometer in the axilla; a chemical dot thermometer in the axilla; an infra red tympanic thermometer or b p.696. \200 rate: in the older child you can observe the chest and measurement is commonly performed using an automated Table 3.1 Normal values of respiratory rate and heart rate at different ages Age Respiratory rate (breaths/min) Heart rate (beats/min) 0 \200\2236mths 30 \200\22350 120 \200\223140 6 \200\22312mths 20 \200\22340 95 \200\223120 1 \200\2235yrs 0 \200\22330 90 \200\223110 6 \200\22310yrs 18 \200\22325 80 \200\223100 >10yrs 12 \200\22325 60 \200\223100 Table 3.2 Normal values of blood pressure at different ages Age BP, mean (mmHg) BP range, 90% (mmHg) 0 \200\2236yrs 95/65 80/50 \200\223115/80 10yrs 110/70 90/55 \200\223130/85 15yrs 120/75 110/60 \200\223145/90 03_McClure_03.indd 30 11/14/2012 7:04:54 PM RESPIRATORY SYSTEM 31 Respiratory system See also b p.254. \200 