A general assessment should be done for every unwell child along with an in-depth relevant system examination.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent

Airway

• Listen: stridor (croup, foreign body), secretions, grunting (bronchiolitis, pneumonia, asthma)

Breathing

• Inspect
  • Respiratory rate 
  • Recession (subcostal, intercostal, sternal), nasal flaring, tracheal tug, accessory muscle use
• Oxygen saturation (>97% normal, <94% significant illness, <90% alarming)
• Auscultation: if the child is crying, try to listen during inspirations. Listen anteriorly and posteriorly.

Circulation

• Colour: pallor, mottled arms/legs, blue (poor perfusion)
• Radial pulse rate (brachial if <6 months)
• Hydration signs
  • Wet nappies
  • Mucous membranes
  • Skin turgor
  • Capillary refill (central and peripheral; press for 5 seconds; normal refill time is <2 seconds) and 
  • Temperature of hands and feet compared with trunk (peripheries will be cooler in sepsis or dehydration due to peripheral vasoconstriction)
• Auscultate heart sounds
• Blood pressure if very unwell (maintained until late in shock) 
• Palpate for hepatomegaly (sign of cardiac failure)

Disability (neurological)  

• Alertness and activity
  • Note how alert and reactive to surroundings (may be drowsy after fit or fever)
  • Look at behaviour (true irritability, i.e. cannot be consoled = raised intracranial pressure or meningitis)
  • AVPU score/GCS
  • Fontanelle (bulging = raised intracranial pressure)
• Pupils: check with torch if very unwell (sluggish response = post-ictal or drug toxicity; changing sizes = seizure; asymmetrical = SOL, e.g. sub-/extradural; gaze may be abnormal after a seizure) 
• Limb tone and movement (also check for joint swelling)
• Rash (inspect everywhere) and check for neck stiffness
• Capillary glucose: measure if decreased alertness

	<1 year	1-2 years	2-5 years	5-12 years	>12 years
Resp rate	30-40	25-35	25-30	20-25	15-20
Heart rate	110-160	100-150	95-140	80-120	60-100

Everything else

Warning features

	Amber flags	Red flags
A		Stridor
B	Nasal flaring, tachypnoea, sats ≤95%, crackles	Respiratory distress (RR>60), grunting, moderate-severe chest in-drawing
C	Pallor, tachycardia, reduced capillary refill, reduced UO, dry mucus membranes, poor feeding	Pale/mottled/ashen/blue, reduced skin turgor
D	Reduced activity, not responding normally to social cues	No response to social cues/won’t stay awake, non-blanching rash, neck stiffness, seizures/neurology, bulging fontanelle
E	Fever in 3-6month old (or for ≥5 days), rigors, limb or joint swelling/not using limb	Fever in <3 month old

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