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Common paediatric histories

Failure to thrive

Exploring symptom

  • Ask to see growth chart and determine age of onset
  • Input: detailed dietary history, feeding history (including time of weaning), hunger
  • Use: energy, activity level, exercise, anorexic?
  • Output: wet nappies, stools and GI symptoms
  • Others: behaviour, general health, happiness, parents’ health

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness, cough
  • Gastrointestinal
    • Work down body: dysphagia, reflux/vomiting, abdominal pain/colic, diarrhoea/constipation, stools (blood/mucus/pale)

Differential diagnoses and clues

Gastrointestinal

Coeliac disease

  • Presents any age after weaning
  • Diarrhoea (pale stools)
  • Bloating

Dietary protein intolerance

For example cow’s milk protein allergy

  • Cow’s milk protein allergy usually presents in first few months
  • Diarrhoea after being fed with formula milk for a few months
  • Reflux

Carbohydrate intolerance

For example lactose intolerance

  • Flatulence, diarrhoea, bloating and cramps within a few hours of consuming lactose
  • May be congenital (rare) or develop after gastroenteritis (transient)

Pyloric stenosis

  • Projectile non-bilious vomiting after feeding
  • Starts around 3-6 weeks of age

GORD

  • Effortless regurgitation
  • Crying during feeding
  • Cough/hoarseness

Cystic fibrosis

  • Recurrent chest infections
  • Pale stools that float

Inflammatory bowel disease

  • Older child (e.g. teenager)
  • Abdominal pain
  • Diarrhoea with blood/mucus

Non-gastrointestinal

Not enough food offered / taken

Commonest cause

Nutritional neglect

    • Not offered enough food

    • Hungry, food seeking / hoarding

Emotional neglect

  • Poor interaction between child and parent
  • Withdrawn, fearful, anxious

Eating disorder

  • Adolescent girls
  • Fear of weight gain
  • Feel fat when thin
  • Efforts to lose weight: diuretics / laxatives, vomiting, excessive exercise
  • Consequential symptoms: amenorrhoea, developmental delay, myopathy, poor sleep, GI symptoms, poor dental hygiene

Other non-gastrointestinal differentials

  • Prenatal

    • Prematurity
    • Intrauterine growth restriction
    • Chromosomal abnormalities
    • Toxins (alcohol, smoking, drugs)

  • Others

    • Poor feeding
    • Inborn errors of metabolism (e.g. abetalipoproteinaemia)
    • Chronic infections (including HIV)
    • Chronic illness
    • Malignancy

Weight increase

Exploring symptom

  • Ask to see growth chart and determine age of onset
  • Input: detailed dietary history, feeding history (including time of weaning), hunger
  • Use: energy, activity level, exercise
  • Others: behaviour, general health, happiness, parents’ health and BMI

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness, cold intolerance
  • Top to toe
    • Stature (short/normal)
    • Changes in appearance (skin/hair/acne)
    • Hirsutism
    • Fat distribution
    • Bowel habit
    • Pubertal changes (including menses)

Differential diagnoses and clues

Endocrine

Hypothyroidism

  • Delayed growth/puberty
  • Fatigue, cold intolerance
  • Dry skin, coarse hair

Cushing’s syndrome

  • Delayed growth/puberty
  • Central obesity
  • Easy bruising
  • Cushingoid facial features
  • Intrascapular and supraclavicular fat pads

PCOS

  • Adolescent female
  • Oligo/amenorrhoea
  • Hirsutism, acne

Non-endocrine

Simple obesity

  • Snacking
  • Lack of exercise

Familial

  • Parents with high BMI

Other non-endocrine differentials

  • Oedema (cardiac or renal)
  • Steroid use
  • Genetic syndromes (e.g. Turner’s syndrome, Prader-Willi syndrome)
  • Hepatosplenomegaly (e.g. in leukaemia)

Developmental delay

Exploring symptom

  • Development
    • Current developmental stage in each category (see notes on paediatric history)
      • Gross motor
      • Fine motor and vision
      • Hearing and language
      • Social
    • Ages of key milestones in each
  • If motor problem
    • How mobile?
    • Hand dominance
    • Balance problems
    • Behavioural problem
  • If language/social problem
    • Senses: hearing, vision
    • Vocalisation/articulation
    • Comprehension: follows commands, responds to voice
    • Non-verbal communication: pointing, gestures, facies
    • Social responsiveness: reaction to new situations, tantrums, playing, gestures
  • As part of history
    • Prenatal problems (e.g. alcohol/drugs in pregnancy, maternal infections)
    • Perinatal problems (e.g. prolonged/difficulties in labour)
    • Postnatal problems (e.g. meningitis/encephalitis)

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness
  • Neurological
    • General: fits/LOC, headache, dizziness, vision/hearing
    • Motor: weakness/ wasting

Differential diagnoses and clues

Generalised delay

Prenatal causes

  • Chromosomal / genetic disorders (e.g. Downs = Dysmorphic features)
  • Alcohol / drugs in pregnancy (history of mother taking alcohol or drugs in pregnancy)
  • TORCH infections in pregnancy (history of toxoplasmosis / rubella / CMV / herpes)

Perinatal causes

  • Extreme prematurity (born very premature)
  • Hypoxic brain injury (perinatal hypoxic insult, e.g. prolonged/difficult labour)
  • Hypoglycaemia (period of neonatal hypoglycaemia)
  • Intracerebral haemorrhage (risks = abnormal labour, prematurity) – usually diagnosed within first few days

Postnatal causes

Onset after episode of…

  • Meningitis/encephalitis
  • Head injury
  • Hypoglycaemic or hypoxic episode

Precocious puberty  

(BOYS <9 YEARS, GIRLS <8 YEARS)

Exploring symptom

  • Puberty staging and order
    • Order for boys:
      • Testicular enlargement
      • Pubic hair
      • Penis enlargement
      • Height spurt
    • Order for girls:
      • Breast development
      • Pubic/axillary hair
      • Height spurt
      • Menarche
  • Other development
    • Previous growth and development
    • Height
    • Weight and nutrition
    • Behavioural changes
  • Family history
    • Parents’ pubertal ages, heights and maternal menarche

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness, general health
  • Neurological
    • General: fits/LOC, headache, dizziness, vision/hearing
    • Motor: weakness/ wasting

Differential diagnoses and clues

Gonadotrophin dependent (central)

Familial / idiopathic

Majority of girls

CNS abnormalities

For example: hydrocephalus, hypoxic brain injury

  • Relevant history

Intracranial tumour

Associated neurological symptoms

Gonadotrophin independent (peripheral)

i.e. sex hormones not under pituitary control

Adrenal tumour / hyperplasia

  • Excessive pubic hair, penis/clitoris enlargement
  • Weight gain

Ovarian / testicular tumour

  • Ovarian: bloating, menorrhagia, pelvic pain
  • Testicular: painless lump

Note: it is also important to know the terms premature thelarche (breasts only) and premature pubarche (pubic hair only)

Delayed puberty

(BOYS >15 YEARS, GIRLS >14 YEARS)

Exploring symptom

  • Puberty staging and order
    • Order for boys:
      • Testicular enlargement
      • Penis enlargement
      • Pubic hair
      • Height spurt
    • Order for girls:
      • Breast development
      • Pubic/axillary hair
      • Height spurt
      • Menarche
  • Other development
    • Previous growth and development
    • Height
    • Weight and nutrition
    • Behavioural changes
  • Family history
    • Parents’ pubertal ages, heights and maternal menarche

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness, general health
    • Symptoms of other systemic diseases (CF, thyroid disorder, anorexia, Crohn’s)
  • Neurological
    • General: fits/LOC, headache, dizziness, vision/hearing
    • Motor: weakness/ wasting

Differential diagnoses and clues

The majority of cases are constitutional/familial, but other differentials include:

Hypogonadotropic hypogonadism

Systemic disease

For example: IBD, CF, anorexia

  • Symptoms of underlying disease

Hypothyroidism

  • Delayed growth
  • Fatigue, cold intolerance
  • Dry skin, coarse hair

Others

  • Kallmann syndrome
  • Intracranial tumour
  • Panhypopituitarism
  • Syndromal

Hypergonadotropic hypogonadism

Klinefelter / Turner syndrome

  • Turner (female): short stature, amenorrhoea
  • Klinefelter (male): small testes, gynaecomastia, tall and thin

Klinefelter / Turner syndrome

  • Turner (female): short stature, amenorrhoea
  • Klinefelter (male): small testes, gynaecomastia, tall and thin

PCOS

  • Oligo/amenorrhoea
  • Hirsutism, acne

Others

  • Steroid hormone enzyme deficiency
  • Acquired gonadal damage

Behavioural problems 

Exploring symptom

  • Expand on nature of problems
  • Ask about specific symptoms of each described disorders 

Get history from school and at home

Differential diagnoses and clues

Psychiatric

ADHD

  • Hyperactivity
  • Inattentiveness

Conduct disorder

  • Bullies / threatens / intimidates
  • Aggressive
  • Cruel to people / animals

Oppositional defiant disorder

  • Loses temper
  • Argues with adults and defies requests
  • Deliberately annoys others

Obsessive compulsive disorder

  • Intrusive thoughts (obsessions)
  • Repetitive behaviours (compulsions)
  • Excessive washing/cleaning/checking

Autism

  • Speech/language delay
  • Imposition of routines
  • Doesn’t seek friendships, prefers own company
  • Limited gestures and expressions

Other psychiatric differentials

  • Anxiety disorders
  • Attachment disorder
  • Schizophrenia
  • Depression
  • Bipolar disorder

Childhood bruising

Exploring symptom

  • Bruising
    • Onset and progression 
    • Pattern
    • Mechanism of injury
    • Associated symptoms

Have a low threshold for raising safeguarding concerns

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness

Differential diagnoses and clues

Injury related

Non-accidental injury

  • Bruises on soft tissues (ears / neck / chest / abdomen / buttocks / calves / thighs)
  • Story inconsistent with injury

Accidental injury

  • Bruising overlying bony prominences (forehead, shins, hips etc.)
  • Story consistent with injury

Non-injury related

Henoch-Schönlein purpura

  • Symmetrical rash on back of legs and buttocks; purpuric and slightly raised
  • May have abdominal/joint pain
  • May have evidence of nephritis

Idiopathic Thrombocytopenic Purpura

  • Spontaneous purpura and petechiae
  • Usually post-infection

Meningococcal septicaemia

  • Non-blanching rash
  • Neck pain/stiffness
  • Photophobia
  • Fever

Other non-injury differentials

  • Acute lymphoblastic leukaemia
  • Coagulation disorders (e.g. haemophilia)
  • Traumatic petechiae (e.g. due to forceful coughing)

Faint / fit / funny turn

Exploring symptom

  • Attack
    • Before: warning, circumstance
    • During: duration, LOC, movements (floppy/stiff/jerking), incontinence/tongue biting, complexion
    • After: amnesia, muscle pain, confusion/sleepiness, injuries from fall 
  • Background to attacks
    • e.g. Previous attacks, frequency, impact on life

Relevant system reviews

  • General
    • Fever, behaviour, activity/apathy/alertness
  • Neurological
    • General: fits/falls/LOC, headache, dizziness, vision/hearing, memory loss, neck stiffness/ photophobia
    • Motor: weakness/ wasting, incontinence 
    • Sensory: pain, numbness, tingling
  • Cardiorespiratory
    • Dyspnoea, cyanosis, chest pain/palpitations

Differential diagnoses and clues

Neurological

Febrile convulsion

  • Short, self-limiting generalised seizure
  • Early in infection when fever is rising

Seizure

Types include:
  • Absence seizure
  • Focal seizure
  • Generalised tonic-clonic seizure (suggested by loss of bladder/bowel control, tongue biting)

Paediatric epileptic syndromes

Characteristic features of epileptic syndromes, e.g. trunk spasms, trunk flexion, myoclonus, eye deviation, language impairment etc.

Reflex anoxic seizure

  • Often precipitated by a bump on head, emotion (e.g. fear, surprise), crying or fever
  • Stops breathing, loses consciousness and falls to floor
  • Very pale

Non-neurological

Vasovagal syncope

Faint after prolonged standing / emotion / pain

Pseudoseizure

Atypical seizures

Breath holding spell

  • Child holds breath and goes blue
  • Usually when upset

Other non-neurological differentials

  • Simple faint
  • Narcolepsy
  • Arrhythmia
  • Hypertrophic cardiomyopathy

Some questions to test your knowledge

What are the TORCH congenital infections and what are their potential sequalae?

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What are the normal developmental milestones of a child?

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How do you define short stature? Please list some causes.

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What are the potential causes of childhood obesity?

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Now try some OSCE stations

  1. An unwell child
  2. Vomiting
  3. Failure to thrive
  4. Behavioural problems
  5. More here!

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