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PAEDIATRICHISTORY,
EXAMINATIONANDPROCEDURES
E.O.D. ADDO-YOBO MD FGCP MWACP MSc DTCH MB ChBSeptember 2010
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HISTORYAND
EXAMINATION
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Objective
Towards the establishment of a diagnosis
which leads to appropriate management:Why is THIS child (name, age, sex, Wt, Ht, etc.)......from this area (environment)
...having this problem (presenting complaints andpeculiar examination findings)
....at this time? (time/seasonal variations inpresentation)
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FOCUS IN CHILD HEALTH Prenatal/Conception issues
Congenital problems/abnormalities; Genetic problems
Peri-natal problemsMishaps around delivery leading to immediate/long term health
problems Post-natal problems
Infections e.g. meningitis leading to Cerebral palsy, hearing loss
Growth and DevelopmentPhysiological and anatomical changes e.g. Jaundice and liver immaturity,
Milestones (myelination )Nutrition and environmental influences
Failure to thrive, abnormal milestones
Behavioural changes
Disease prevention and Control Measures(Immunisations)
Need to know whatconstitutes normality ina child to appreciate the
abnormal child
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Key Points in History taking -1
Presenting complaints Peculiar Issues in Child health:
Poor feeding Convulsion, Startling
Reduced activity Irritability Vomiting and regurgitation Beware maternal perception of symptoms, local terminologies
History of presenting complaints
Direct Questioning To clarify presenting symptoms To assess all other systems Beware: subjective symptoms
Drug History(regular drugs used vrs drugs used in current illness)
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Child Examination From Head to Toes By systems Genitals remove clothing Systematic reporting Child on couch Babies on lap/ couch Basic measurements
Wt, Ht, Length, Head circumference(Use of centile charts)
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Guide to examination INSPECTION
General appearance importante.g. size, colour, facies, symmetry, movement, etc
The more you see, the better you perceive
PALPATION gentle but objective PERCUSSION AUSCULTATIONappropriate tools essential NB: Variation of characteristics with age: e.g. anthropometrics, Head
circ, Pulse, BP,Respiratory rates.
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On Inspection
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On Inspection - 2
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Notes May be difficult to stick to a systematic approach
Need to develop a comprehensive style and stick to itMake it work for you should allow you to be thorough
You may have to Examine first what child allows you to doBUTpresent in orderly and logical manner. Critical inspection veryuseful
Count Respiratory Rate when child is calm/before getting too close, ortouching
Conjunctival pallor not always reliable: check palms, soles
Always ask for and examine Child Health Record Book, Road-To-Health-Chart especially in
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Child Health Record Book
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Synthesis of information
USING KNOWLEDGE TO DECIPHER INFORMATION INTODIAGNOSIS
Its an art. Expertise comes with practice.
E.g.: Well- nourished, severely pale, jaundiced child: ??Skinny, severely pale, jaundiced ??Well- nourished, severely pale, not jaundiced child: ??Wasted, severely pale, not jaundiced child: ??
Impressions: Should summarise the problem and put it in context: e.g.
Severe Anaemia secondary to Malaria Severe Anaemia secondary to Sickle Cell Disease Severe Anaemia secondary to Haemorrhagic diathesis Severe Anaemia secondary to Malnutrition
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Discuss Diagnosis, Investigations, treatmentwith Doctor on duty SMO/Resident Specialist/Consultant.
Investigations:
Each investigation should help confirm or reject one or more of the suspecteddiagnoses e.g. CXR, Lateral Cervical Xray; WBC total and Diff; ESR
Develop Initial Treatment plan:Immediate life-saving measuresLater remedial measures
e.g. IV fluids (specify), Antibiotics, etc.
There should be a reason for every action.Spell out clearly signs that need to be monitored ......
..... and subsequent actions to be taken
State Final Diagnosis/Diagnoses: the faster the better!
Specific treatment & Counselling
Other Notables:
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Objective & OutlineOutline Relevance General principles Specific Procedures Blood letting Procedures Restraints and Torniquets Peripheral & Central lines Lumbar puncture Catherisation Pleural and Pericardial taps CPR Approach to FB aspiration
Objective
To give a quick
overview of what toexpect andapproach tolearning
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Relevance of procedures
Life saving
Life supportingDiagnostic
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General principles
Benefits vs Risks
Invasiveness
Anatomical considerations
Subsequent processes
Costs Is it worth all that?
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Paediatric Patient Needs
Pediatric-sized equipment
Pediatric medications and formulary
Tables of age-based normal values
Paediatric scales, and appropriate sizedassessment tools for children of all ages.
Child-friendly staff Child-friendly environment
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Disinfection
Absolute alcohol
Swabbing technique Sterile vs clean technique?
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Blood Letting / Vascular Access
Capillary sampling Finger / Heel prick
Venous sampling
Arterial blood sampling
Precautions:SiteSize of vessel vrs needleBleeding tendency
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Blood letting: - Heel Prick Suitable for infants
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Blood letting: - Finger Prick Best use for children
> 6 mths / > 9 kg
Middle and Ring fingers
Index and Thumb have thicker skin (avoid)
Little finger, thin tissue (avoid)
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Max. Amounts of blood to be drawn from children
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Vascular Access - Peripheral lines
PurposeHydration, Transfusion, Drugs venous access
IV Peripheral, Ext. jugular Central
Femoral, Umbilical, int. jugular veins
Intraosseous
Cut-down distal saphenous / saphenofemoral
Precautions
Complications
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Vascular Access - basics
Immediate Access is best with Peripheral IV or
IntraOsseous (IO)
Central venous and cut-down requires
more time but more secure
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Factors influencing choice of vein
Age of child
Previous uses and condition of veins
Weight: obese / wasted Clinical status of the infant / child
Other clinical procedures required
Type and length of treatment
Child / parental preference Anticipated degree of co-operation
Medication, infusates to be administered
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IV lines
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Undesirables!!
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Site Selection
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Site Selection
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Restraints
Protective measure
Limits movement
Necessary
Appropriate
Safe
Effective Comfort
Move other parts
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Tourniquets Essence: Venous and not arterial occlusion
Ideal: Human hand grip by assistant
Broad band better than narrow strip Release immediately after access
Complications:IschaemiaBiochemical interruptions
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Intraosseous Lines:Commercially available Needles
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Intraosseous Needles -
Alternatives
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Umbilical Vein Catheterization
Potential IV site for neonates < 2wks old
Single, thin walled, large-diameter lumen
Insert till free flow or 4 - 5cm depth Resistanceportal vein/ductus venosus
Complications
Haemorrhage Infection
Thrombosis
Air Embolus
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Exchange Blood transfusion Definition
Principle
to exchange up to 2x total blood volume Indications:
Hyperbilirubinaemia Kernicterus
Severe infection
Severe malaria
Sickling crisis involving vital organ
* Polycythaemia
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Circulating blood volume
Age Blood volume (ml/kg)
Neonate 75 - 80
Infants 75 80
Children 70 75
Adult 65 75
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Exchange Blood transfusion
Equipment Blood, Lines (giving set), 3-way taps,
Drugs: - Calcium gluconate
Complications: Hypothermia Hypoglacaemia Hypocalcaemia Infections Cardiac arrest Stress/Shock
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Lumbar Punctures
Position Max. flexion
Note Breathing
Superior edge of iliaccrest L4/5, L3/4
Needle bevel up &perpendicular to skinor towards umbilicus
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CONTRAINDICATION TO LP
Recent / Prolong convulsive seizures
Deep Coma
Signs of increased Intra-Cranial Pressure Altered pupillary size / responses
Absent Dolls eye reflex, decerebrate / decorticate
Abnormal respiratory pattern
Papilloedema, Hypertension & Bradycardia
Cardiopulmonary instability
Local infection / Coagulation disorder
Other focal neurological signs
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Suprapubic tap
Disinfection Absolute alcohol
Swabbing technique Mode of entry
Scapel Needle
Post proceduredressing
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Bladder Catheterization
Female patients Labia/Vulva adhesions are contraindication
Uncircumcised male patients Do not forcibly retract the foreskin
All patients Determine correct catheter size and do not use
excessive force in catheter placement
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Airway & Breathing Support
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Effective Bag-Mask Ventilation Is an Essential BLS Skill
Use only the amount offorce and tidal volumeneeded to make the
chest rise Avoid excessive volume
or pressure Increased inspiratory
time may reduce gastricinflation Cricoid pressure may
reduce gastric inflation
Cricoid cartilageOccluded esophagus
Cervical vertebrae
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Cardio-pulmonary Resuscitation - 1 Rescuer
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Two ThumbEncircling Hands Technique
2-Rescuer CPR
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Cardio-pulmonary Resuscitation
Compression landmarks, method & ratio
Lower half of sternum 1-2 fingers above xyphisis & Heel of one hand other hand on
top (>1yr) @ 1 2 inches depth
1 fingers width below intermammary line & 2 thumb-encirclinghands or 2-finger technique (100 events/min
30:2 (>8yrs old) @~100 events/min
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Pleural / Pericardial Taps Pericardiocentesis
Indication life-threatening cardiac tamponade Site Lt xyphoid
@ 45
tip of Lt scapulaLt 5thICS adjacent to sternum ECG , Ultrasound
Needle Thoracostomy Site: 7th 9thICS,inferior angle scapula 3-way taps / stopcock optional Precautions
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Pericardial taps
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Passage of Tubes
Nasogastric / Orogastric tubes NG smaller, easier to tolerate
epistaxis, avoid in maxillofacial injury OG larger lumen for lavage and/or charcoal
more noxious, patient might bite it
Indications
Feeding / Medication Decompression / drainage (Ryles & Flatus tubes) Lavage
Precautions avoid endotracheal intubation
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Foreign Body Aspiration
Food items are
the mostcommonlyaspirated FB.
Balloons are themost common FBto result in death.
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Foreign Body Airway ObstructionFBAO
Age-specific obstructed airway support:(FBAO) Universal choking sign
FBAO? If victim > 1yr ( 1-8yr, or > 8yr) Abdominal thrust
FBAO? If victim < 1yr (Infant or Newborn) Noabdominal thrust
Back blows or Chest thrusts
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Summary
Diff. b/n adult and child
Anatomy, Physiology ,total blood volume
Cost benefit analysis Use appropriate equipment for children
Consider other methods and sites
Observe Standard precautions
Reasonably restrain child but do not suffocate orinjure
Take just enough blood, not too much
Do NO harm!3/2/2014 55
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