Definitions  

• Neonate  = <28 days
• Infant = 1-12 months
• Child = 1-12 years
• Adolescent = >12 years  

Presenting complaint

• Determine symptoms which brought patient in

History of presenting complaint

• Explore each symptom (including further symptoms you elicit in system reviews)
  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Symptom-specific questions, e.g. SOCRATES for pain (see exploring symptoms)
• Paediatric systems review (similar to adults but slightly different)
  • General: fever, behaviour, activity/apathy/alertness, rashes, growth and weight
  • Cardiorespiratory: cough, noisy breathing (stridor, croup, wheeze), dyspnoea, cyanosis
  • Gastrointestinal: vomiting, abdominal pain, diarrhoea/constipation
  • Genitourinary: wetting nappies/toilet trained, dysuria, frequency
  • Neuromuscular: seizures/fits, headaches, abnormal movements
  • ENT: sore throat, snoring, noisy breathing, earache

Birth

• Pregnancy: scan results (dating and anomaly; if had extra scans – why?), any problems (e.g. maternal illness/alcohol/drug use)
• Birth history
  • Location, mode of delivery, gestation (term = 38-42 weeks) and birth weight (normal = 2.5-4.5kg)
  • Birth complications, e.g. resuscitation required, birth injury, maternal/fetal compromise, risk factors for sepsis (group B Streptococcus, maternal fever, prolonged rupture of membranes), any meconium?
  • Neonatal problems, e.g. jaundice, fits, fevers, bleeding, feeding problems, admissions to neonatal unit/neonatal ICU

Feeding

• Diet and appetite – ascertain what the child normally feeds and compare against current feeding
  • Breast/bottle milk (usually <12 months): type (breast, standard formula, modified formula e.g. hydrolysed, high energy etc.), volume and frequency, feeding difficulties (e.g. latching difficulties, reflux symptoms, SOB)
  • Weaning (usually from 6 months): starts with pureed jars, then mashed up food, then solids gradually added
  • Solid meals and cow’s milk (usually >12 months)
• Toileting
  • Toilet training (between 2-4 years; dry by day at 2 years; dry by night at 3-4 years)
  • Frequency: wet nappies? (usually ~5 soaking wet nappies per day and 3 yellow stools)

Growth

• Weights: ask to see The Red Book (personal child health record) – used from birth to 5 years
• Puberty if older child/adolescent (on average, starts at 11 years for girls, 12 years for boys)

Development

• Any concerns
• School progress and attendance
• Developmental screen if <5 years
  • Smiling by 6 weeks
  • Turns to sounds by 6 months
  • Sitting by 9 months
  • First words by 18 months
  • Walking by 18 months
  • Short sentences by 3 years

       

Normal developmental milestones

Some developmental red flags

• Loss of skills
• Not fixing/following objects
• Hearing loss
• Low muscle tone/floppy
• Can’t hold objects by 5 months
• Can’t sit unsupported by 12 months
• Can’t walk by 18-24 months
• Persistent toe walking
• No speech by 18 months

Past medical history

• Medical problems
• Previous illness, accidents, surgery
• Previous hospital/emergency department visits

Drug history

• Immunisations: up to date? – see schedule below
• Current medication (including creams etc.): include dose, route, compliance
• Relevant recent medication, e.g. course of corticosteroids for asthma
• Allergies: drugs, foods, others

Family history

• Anything relevant to HPC
• Anyone else ill?
• ‘Anything in the family that affects newborn babies or children?’

Social history

• Family unit: parents, siblings, who lives at home – draw family tree of who’s at home
• Does anyone smoke in the family (inside or outside)?
• Housing situation
• Social services involvement (child, parents or siblings) or any other safeguarding concerns
• Playgroup (2-5 years), nursery school (3-4 years) or school (5-16 years) – performing well?
• Other, e.g. hobbies, travel, pets

Ideas, concerns and expectations

• How has the illness affected the family?
• Have the symptoms kept the child from attending nursery/school?
• What are the parents’/child’s concerns, beliefs, hopes etc.?

Immunisation schedule  

• 2 months: 6 in 1, rotavirus, meningitis B
• 3 months: 6 in 1, rotavirus, pneumococcal
• 4 months: 6 in 1, meningitis B
• 1 year: MMR, pneumococcal, meningitis B, Haemophilus influenzae type B/meningitis C
• Preschool (3 years 4 months): MMR, 4 in 1 (diphtheria, polio, tetanus, pertussis)
• 12-13 years: HPV (two injections 6-12 months apart)
• 14 years: 3 in 1 (diphtheria, tetanus, polio), meningitis ACWY

6 in 1: diphtheria, tetanus, polio, pertussis, Haemophilus influenzae type B, hepatitis B

MMR = measles, mumps, rubella   NB: influenza annual nasal vaccine is also offered to 2-7 year olds  

Why don’t you test your knowledge?

Try some OSCE stations

1. Child vomiting
2. Neonate unwell
3. Failure to thrive
4. Rash
5. There’s more here!