Pediatric Interview Scott 2024-Student_Aubrey Scott.pdf

The Pediatric Interview Lee Scott, M.D. Objectives To compliment Chapter 15 of Macleod’s Clinical Examination 15th Ed. (Babies and Children) To understand the content differences in obtaining a medical history on a pediatric patient compared to an adult. To become familiar with...

The Pediatric Interview Lee Scott, M.D. Objectives To compliment Chapter 15 of Macleod’s Clinical Examination 15th Ed. (Babies and Children) To understand the content differences in obtaining a medical history on a pediatric patient compared to an adult. To become familiar with “Bright Futures” Guidelines for Health Supervision of Infants, children, and adolescents To encourage age-appropriate adaptation of patient and doctor centered H&P techniques To understand the ramifications of the parent as historian in obtaining a medical history in a pediatric patient. Text/Reference Macleod’s Clinical Examination 15th edition Ch. 15. Babies and Children Bates’ Guide to Physical Examination and History Taking 13th edition Ch. 25 Children: Infancy through Adolescence Introduction This lecture will encompass review of the history of the newborn and older child history. The ILA of the Macleod’s video introduced you to the school aged child physical exam. There will be a lecture on the adolescent interview in a few weeks and the exam of the newborn will be covered in an excellent short video in 1½ weeks. Taking a comprehensive pediatric history can at first seem daunting due to the depth and breadth of the topics to be covered. With experience there are short -cuts but it is best for newcomers to the pediatric history to be thorough and work systematically through the process. Introduction Opening the pediatric exam room door is Life was like a box of chocolates. You never know what you are gonna get. - (Professor) Forrest Alexander Gump Tips on Communicating with Pediatric Patients and Parents Children are often anxious and afraid when going for a doctor visit. Parents are often stressed as well. Keep a comfortable distance from the child at the beginning of the visit. Younger children often feel more comfortable and secure in their parent’s lap or arms and may take some time to relax in your presence. The sterile appearance of many exam rooms, the sounds from other parts of the clinic e.g., babies/children crying, can add to their anxiety. Tips on Communicating with Pediatric Patients and Parents (if old enough) Talk to the child about a topic other than the medical reason for which they are being seen. Find some common ground topic to talk to school-aged children. Some school children may be more advanced in their maturity and and communication skills than their age. Some developmentally delayed children would struggle to communicate at the average level of their age group. Communicate based on developmental level of the patient – not age! Tips on Communicating with Pediatric Patients and Parents Some pediatric patients are nervous because they do not know what to expect or worse, someone has told them something unpleasant would happen when that is not the case. Walk them through the visit verbally so they will really know what to expect. Avoid medical terms and use terms or analogies that they can understand. Equally be aware that many parents do not understand medical terms and adjust your language accordingly. Tips on Communicating with Pediatric Patients and Parents Sit down, if possible, when talking to pediatric patients and are not looking down at them. Be at the same level they are. Maintain eye contact when talking to your patient. You want to send the message that your attention is on them and not their parent, grandparent, babysitter, or family friend. One of the “tricks of the trade” is keeping the parent in the conversation while keeping plenty of attention on the patient. Child Development Understanding the normal physical, cognitive, and social development of children facilitates effective interviews and physical examinations and is the basis for distinguishing normal from abnormal findings. Bates’ Guide to Physical Examination and History Taking 13th Edition. 2020  “I must warn you, however, of one difficulty which you will encounter at the very outset – a difficulty that disheartens many, and makes them abandon in despair the study of children's diseases. Your old means of investigating disease will here to a great degree fail you, and you will feel almost as if you had to learn your alphabet again, or as if, entering a country whose inhabitants you expected to find speaking the same language and having the same manners as the people in the land you had lately left, you were to hear around you everywhere the sounds of a foreign tongue, and to observe manners and customs such as you had never seen before. You cannot question your patient; or if old enough to speak, still, through fear, or from comprehending you but imperfectly, he will probably give you an incorrect reply…. I speak of interrogating them; for though the infant cannot talk, it has yet a language of its own, and this language it must be your first object to learn, if you mean ever to acquire the character of successful practitioners in the diseases of children. But, if you have not cultivated your faculties of observation, you cannot learn it, for it is a language of signs.” (1816-1898) Charles West, founder of Great Ormond Street Hospital (from his lectures to medical students in 1848)  The mere knowledge that certain diseases exist, and the usual methods of diagnosticating them, prove to be very inadequate when we are brought face to face with a sick and fretful child, or with an infant who is unable to describe its symptoms…. In studying, then, the different stages of development in children, we are in reality acquiring an alphabet, which when once thoroughly mastered will enable us to read the otherwise obscure language presented to us for translation by the various diseases of early life. The proper method of learning to understand sick infants and children is first to notice their peculiarities in health and to follow these peculiarities through the different stages of their development up to puberty…. The lack of this preliminary training, this alphabet, places the student who is endeavoring to understand diseases in children, in the position of attempting to read without having first learned his letters. (1849-1914) Thomas Morgan Rotch Pediatrics: the hygienic and medical treatment of children. 1896 First chair in pediatrics at Harvard Pediatric Age Groups (definitions) Neonates 0 – 30 days of age Infants 1 month – 1 year Pre-school 1 year – 5 years School-aged 6 – 11 years Adolescents 12 – 18 years Child Development From birth to later school age, children will: Weight increases 20X Acquire sophisticated language and reasoning Develop complex social interactions Progress toward mature adulthood Four Principles of Child Development Children’s development proceeds along a predictable pathway The range of normal development is wide Various physical, social, and environmental factors, as well as diseases, can affect child development and health. The child’s developmental level affects how you conduct the history and physical examination. Differences of a Pediatric History Compared to an Adult History Prenatal and birth history Developmental history Social history of family Immunization history Differences of a Pediatric History Compared to an Adult History Parent as Historian Children > 4 years old may can provide some of their own history Reliability of parent’s observations varies Parent may be distracted by the child’s behavior and interaction through history taking Observe parental behaviors and emotions Listening to Mothers Mothers are excellent observers of their offspring and do know when they are sick. Mom may not know what’s wrong, but she certainly knows when something is wrong. No one can replace the mother in providing an accurate and thorough description of the child and his/her complaints. Other caretakers – grandparents, aunts, will vary widely in their knowledge of the child. Listening to Mothers Establish rapport with the mother. Get into the habit of quoting verbatim from mother. Many pediatricians have had the experience of saying : ‘If only I had listened to that mom; she was trying to tell me what was wrong’. “ Listen to your patient, he is telling you the diagnosis” Sir William Osler Listening to Mothers Ask her to define her terms (What do you mean by... ?). A good opening is, ‘Tell me about what concerns you with _________’, and then simply let the mother talk. (Learn through history taking to be a good listener – to parents primarily, but also to experienced pediatricians as they elicit clinical histories.) Listening to Mothers Always ask the parents to relate the sequence of events leading to the present complaints. A suitable start ‘When was he/she last well?’ Parents appreciate a doctor who gives them individual attention and devoted time. Time spent on history taking will be repaid. Mothers may, of course, unintentionally deceive. Outline of the Pediatric History Chief Complaint (it is not unusual that the stated complaint is not the true reason why the clinic visit was scheduled) Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying. Never forget, “Is there anything else going on today?” History of Present Illness A. Identify the historian, relationship to patient, reliability B. Age, race, sex C. Concise chronological account of the illness, pertinent neg/pos Past Medical History (vaccine history) A. Major medical illnesses B. Major surgical illnesses C. Trauma D. Previous hospitalizations E. Current Medications F. Known allergies ( not limited to drugs ) and reaction G. Immunization status Outline of the Pediatric History Pregnancy and Birth History Maternal health during pregnancy Gestational age at delivery Labor and delivery Neonatal period Developmental History Ages at which milestones were achiever and current developmental abilities Present grade in school, specific problems, interaction with peers Behavior Feeding History Breast or formula feeding Solids Fluoride use Outline of the Pediatric History PRENATAL HISTORY Age of the mother Health of the mother during this pregnancy: any infections (GBS, GC/chlamydia, hepatitis, syphilis, HIV, rubella, herpes) other illnesses, vaginal bleeding, toxemia, or care of animals, such as cats or other animal- borne diseases, substance abuse Number of previous pregnancies and their results X-rays/CT’s or medications taken during the pregnancy, Results of prenatal labs and other tests such as amniocentesis. If the mother's weight gain has been excessive or insufficient, this also should be noted Outline of the Pediatric History BIRTH HISTORY The duration of pregnancy, the ease or difficulty of labor, and the duration of labor may be important, especially if there is a question of developmental delay. The type of delivery (spontaneous, forceps-assisted, or cesarean section), type of anesthesia or analgesia used during delivery, presenting part (if known) are recorded. Note this child's birth order (if there have been multiple births) and birth weight Condition of the child at birth, resuscitation, APGAR score if known Outline of the Pediatric History NEONATAL HISTORY Birth weight, length, head circumference Problems: jaundice, anemia, convulsions, respiratory problems, infections, feeding problems, excessive weight loss, birth injuries, dysmorphic state, congenital anomalies etc. Age at discharge, NICU stay Was the baby discharged with the mother? Outline of the Pediatric History FEEDING HISTORY Breast- or bottle-fed - relevant until 1 year of age Type of formula used and the amount taken during a 24- hour period. Mother's initial reaction to her baby, the nature of bonding and eye- to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea, or other gastrointestinal or feeding problems should be noted. Ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning Outline of the Pediatric History FEEDING HISTORY The age at which baby foods, toddlers' foods, and table food were introduced, the response to these, and any evidence of food intolerance or vomiting. If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, "How did you manage the problem?" For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems Outline of the Pediatric History I. Review of Systems Weight Skin and Lymph HEENT Cardiac Respiratory GI GU Musculoskeletal Pubertal Allergy I. Family History Illnesses Mental illnesses I. Social History Living situation and conditions Composition Occupation of parents  Tips on the Physical Exam Examination of the infant and young child begins with observing him or her and establishing rapport. The order of the examination should fit the child and the circumstances. It is wise to make no sudden movements and to complete first those parts of the examination that require the child's cooperation. Painful or disagreeable procedures should be deferred to the end of the examination, and these should be explained to the child before proceeding. For the older child and adolescent, examination can begin with the head and conclude with the extremities. The approach is gentle, but expeditious and complete. Tips on the Physical Exam For the young, apprehensive child, chatter, reassurance, or other communication frequently permits an orderly examination. Some children are best held by the parent during the examination. For others, part of the examination may require restraint by the parent or assistant. When the complaint includes a report of pain in a certain area, this area should be examined last. If the child has obvious deformities, that area should be examined in a routine fashion without undue emphasis, because extra attention may increase embarrassment or guilt. Because the entire child is to be examined, at some time all of the clothing must be removed or shifted. Except during infancy, modesty should be respected and the child should be kept as comfortable (and as covered) as possible. Tips on the Physical Exam With practice, the examination of the child can be completed quickly even in most critical emergency states. Only in those with apnea, shock, absence of pulse, or, occasionally, seizures is the complete examination delayed. Although the method of procedure may vary, the record of examination should be in the same format for all children. Completion of the history can be accomplished during the physical examination. Talking to the parent frequently reassures the child. Praising the young child, explaining the parts of the examination to the older child, and reassuring the adolescent of normal findings facilitates the examination. Physical Exam: Differences compared to the Adult Exam exam table Gather as much information as you can by observation FIRST Position : parents lap or exam table Stay at the child’s level as much as possible. DO NOT TOWER over them! Order of exam: least distressing to most distressing Rapport with child: include the child as much as possible / distraction is a valuable tool Examine the painful area last BE HONEST. If something is going to hurt tell the calmly. If you lie, you lose your credibility with the child. Stay at the child’s level as much as possible. DO NOT TOWER over them! A. Order of exam: least distressing to most distressing B. Rapport with child: include the child as much as possible / distraction is a valuable tool C. Examine the painful area last D. BE HONEST. If something is going to hurt tell the calmly. If you lie, you lose your credibility with the child. Vital Signs: normal vary from adult, use a pediatric reference like the Harriet Lane Manuel for normal for age Temp: note the site that was measured Heart Rate: Resp. Rate: observe for a minute. Infants have periodic breathing and a 15 sec sample will not give a fully accurate rate. BP: Growth parameters: A. ther as much information as you can by observation FIRST B. Position : parents lap or exam table C. Stay at the child’s level as much as possible. DO NOT TOWER over them! D. Order of exam: least distressing to most distressing Physical Exam: Differences compared to the Adult Exam Vital Signs: normal vary from adult, use a pediatric reference like the Harriet Lane Manuel for normal for age Temp: note the site that was measured Heart Rate: Resp. Rate: observe for a minute. Infants have periodic breathing and a 15 sec sample will not give a fully accurate rate. BP: Growth parameters: CDC Growth Charts: Birth to 24 months CDC Growth Charts: 2 to 20 years WHO Growth Charts: Birth to 24 months Growth Charts for Males with Trisomy – 21 (Birth to 36 months) Growth Charts for Males with Trisomy -21 (2 to 20 years) Growth Charts for Females with Trisomy – 21 (Birth to 36 months) Growth Charts for females with Trisomy-21 (2 to 20 years) Exam of the Older Child Vital signs vary at different ages Exam of the Older Child Physical Growth and Development Growth after infancy is highly variable Outline of a Pediatric Physical Exam Vital Signs General: Striking features, nutritional status, level of consciousness, hydration status, cooperation level HEENT: head size/shape, fontanels, strabismus, red reflex, position of ears, tympanic membrane nasal mucosa/drainage, tongue, palate, teeth and gums, posterior pharynx Neck: thyroid, nuchal rigidity, adenopathy Respiratory: breathing pattern, breathing rate, equal breath sounds, wheeze, stridor, upper airway sounds Cardiovascular: rhythm, murmur, thrill, pulses in upper and lower extremities Outline of a Pediatric Physical Exam Abdomen: shape (infants usually have protuberant abdomens), diastasis recti, auscultation, palpation – organomegaly, mass, tenderness, guarding, rebound Musculoskeletal/Osteopathic: tone, joints, muscles, gait, in-toeing, out-toeing, bowed legs, knock knees, Hips (newborns) Ortolani’s and Barlow’s sign. Neurologic: (mostly accomplished by through observation) CN’s, cerebellum, muscle tone and strength, reflexes ( DTR’s, neonatal primitive) Genitourinary: external genitalia, hernias and hydroceles, (males) cryptorchidism tanner staging in adolescents rectal and pelvis exam not done routinely Tips for Conducting the Otoscopic Examination Use the largest possible speculum that comfortably fits. (A larger speculum allows you to better visualize the tympanic membrane and is less painful since it is not inserted as far as a smaller speculum. ) A small speculum may not provide a seal for pneumatic otoscopy. If using a pneumatic otoscope, do not apply too much pressure or the child may cry. Insert the speculum ¼–½ in. into the canal.  Mouth and Pharynx For younger children best to leave the mouth and pharynx exam until the near the end. As it may require parental restrain. Often after examining the ears, the mouth is open! The child who can say “ahhh” usually will give a brief but sufficient view of the posterior pharynx so that a tongue depressor is unnecessary. IF you need to use a tongue depressor, push down and pull slightly forward toward yourself while the child says “ahhh,” being careful not to place the depressor too far posteriorly, eliciting a gag reflex. Sometimes, young and anxious children will need to be restrained and will clamp their teeth and purse their lips. In these cases, carefully slip the tongue depressor between the teeth and the cheek in the vertical plane to the back of the gum line. Then turn the tongue depressor horizontally toward the tongue and push down. These techniques will either allow you to push down on the tongue or elicit a gag reflex, which should permit a brief look at the posterior pharynx and tonsils. Careful planning and parental help are needed. Developmental Surveillance Take a developmental history “What has she/he Ask about age-specific learned to do since skills e.g. gross motor, the last well child fine motor, cognitive, exam?” communication Developmental Surveillance Ask about concerns Ask if the parents have any concerns about their child's development, behavior, or learning. Observational studies suggest that parental estimates of their child's development are accurate. Parental concerns are an effective method for early detection of developmental and behavioral problems, but lack of parental concerns does not exclude developmental delay. Developmental Surveillance At each well check up: Take a developmental history Ask about concerns Assess strengths and risks Observe the child Document Developmental Screening Surveillance Use of a standardized test to identify asymptomatic children who are at risk for a developmental disorder. Screening Children who screen positive then undergo developmental- behavioral evaluation. Evaluation Benefits of this Process Earlier Identification Earlier Intervention Improved Outcomes Bright Futures History Launched under leadership by federal Maternal and Child Health 1990 Bureau (MCHB) of the Health Resources and Services Administration. To improve the quality of health services for children by health promotion and disease prevention. 1994 1rst Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents 2002 2nd Edition led by National Center for Education in Maternal and Child Health at Georgetown University 2002 MCHB selected the AAP ( American Academy of Pediatrics ) to lead the Bright Futures initiative and it established the Bright Futures National Center (BFNC) 2008 3rd edition of Bright Futures Guidelines 2017 BFNC updated the guidelines to the 4th and current edition ** at some visits  Today was good Today was fun Tomorrow is another one [email protected] Rm. 215 by appointment Questions