Children and Doctors

The history

A structured approach to history taking is important to avoid forgetting things, but this must not become too rigid, as it is sometimes necessary to pursue a different line of questioning to gain essential information. The table opposite is a list of useful headings in pediatric history taking, and this should be memorized.

Talking to the child

Children should be asked to give their account of events with parental corroboration. Children under 5 years old will lack the vocabulary and communication skills to describe their symptoms, but will be able to point to parts that hurt.

Talking to the parents

Most of the history is likely to be gained from the parents or guardians.

• Ask if they have the infant medical record book ”this contains information about height and weight centiles, immunizations, development, and illnesses in the first few years of life.
• Ask whether the parents have any views on what the cause of the child's trouble is. Listen carefully to the parents; they are acute observers of their children.
• Ensure that all terms used are appropriately defined and you should be gleaning information from the parents' observations and not their interpretation of the symptoms. Further, the parent may interpret a baby's cries as pain when, in fact, it is your task to establish the circumstances of the cries and, therefore, the cause.
• As children get older, the parents may have a hazy memory for early events. Establishing symptoms in relation to easily remembered events (e.g. first walked) may clarify the timeline.

Outline of paediatric history

· Presenting complaint and history of presenting complaint.

· Birth history:

o Place of birth.

o Gestation and pregnancy.

o Birth weight.

o Delivery.

o Perinatal events and SCBU admission.

· Feeding methods and weaning.

o If bottle fed, note how the bottle feed is mixed (how many scoops/number of ounces).

· PMH including hospital admissions, infections, injuries.

· Developmental history.

· School progress.

· Immunizations.

· Drugs.

· Allergies.

· Family tree with sibling's ages, including deaths, miscarriages, and stillbirths.

· Parental age and occupation.

· Family illnesses and allergies.

· Housing.

o This should include a discussion about the child's bedroom as they may spend 12 hours of each day there.

· Travel.

· Systems review

You can do anything with children if you only play with them.

21. Translate the text III, give its abstract:

Text III. The Examination: an Approach

Examination in children varies depending on the age and co-operation of the child. School-age children and babies may be examined on a couch with a parent nearby, whereas toddlers are best examined on the parent's lap. If the child is asleep on the parent's lap, much of the examination should be completed before waking them up.

Undressing

Let the parent undress the child: and only expose the part of the body you will be examining.

Positioning

Some children may prefer to be examined standing up. Only lay the child down when you have to, as this can be very threatening.

Putting the child at ease

Slowly introduce yourself to the child's space during the examination by exchanging toys, for example.

Explain what you are going to do and be repeatedly reassuring, children can be embarrassed by silence after a doctor's question, but will be comforted by endless nattering. And remember-don't ask permission, as this will often be refused!

The examination

Firstly, use a hands-off approach. Allow the child to look at you, and let them play in your presence. Watch the child. How do they interact with their parents? Do they look well or ill? Do they look clean, well nourished, and well cared for?

Kneel on the floor so that you are at the child's level. Use a style and language appropriate to the age of the child, a toddler will understand the word ˜”tummy” better than the word ˜”abdomen”.

Be opportunistic

Do not adhere to a rigid examination schedule, e.g. you may have to listen to the heart first while the child is quiet, then look at the hands later. Never examine the presenting part only. Be thorough and train yourself to be a generalist. Leave unpleasant procedures, such as examination of the tonsils, until last.

Presenting your findings

When presenting your findings, translate what you see into appropriate terminology. Informing a senior that a child looks funny is not very helpful but the saying the child is dysmorphic, followed by a detailed description is acceptable. Describe in simple terms the relevant features that make the child look unusual, e.g. low set ears, wide set eyes.

There is no substitute for examining lots of normal children.

Paediatrics is a specialty bound by age and not by system. Some distraction techniques to help with examination

• Playing peek-a-boo.
• Letting toddlers play with Letting toddlers play with your stethoscope.
• Giving infants something to hold.
• Asking mum or dad to wave a bright toy in front of them.