Comprehensive Clinical Assessment – Pediatric Station Remediation John Schmidt, MD Pediatric Hospitalist July 28, 2005
The Pediatric History • General Tips • Remember to address the patient and parents by name • Introduce yourself by name • Use open-ended questions • Keep the interview organized • Under stress, it will help you keep your focus • Decreases the chances of you forgetting something
General Tips (continued) • Avoid medical jargon • Occasionally summarize sections of your history • Helps you to identify aspects which may not make sense/things you missed and prompt further questioning • Lets the parent know that you have been paying attention
General Tips (continued) • A good portion of Pediatrics is not just the treatment of the patient, but also the parent • Parents are under stress and often feel guilt over their child’s illness (“Could I have done something different?”) • Acknowledge these feelings • Support positive behavior • Ask for whatever questions/concerns they may have
Chief Complaint/HPI • “What brings you in today?” • You are a reporter…literally. Your job is to objectively collect the facts • As a self check, have you asked enough questions to accurately portray the child’s story to your reader? Can they close their eyes and replay the child’s course? • Check your facts/source – Is the patient really sick? • E.g. How do you know your child had a fever? • E.g. What do you mean by difficult breathing?
Chief Complaint/HPI (continued) • Start at the beginning…. • When did the symptoms start? • What was the child doing? • Did the symptoms come on suddenly or gradually? • What happened then? • Have the symptoms been constant or intermittent? • If intermittent, how bad are the symptoms when they do occur (i.e. How high is the fever?, How severe is the difficult breathing?)? • When they do occur, how long do the symptoms last? A few minutes? A few hours?
Chief Complaint/HPI (continued) • Associated symptoms • It is helpful to have your differential diagnosis in mind when you are asking questions – Every positive or negative answer should provide focus to your assessment • Start with broad categories/systems and then fill in what might fit the story within that system
Fever • Review Lorin M, Feigin R, “Approach to the child with fever of unknown origin” UpToDate v13.2 • Is it a fever? • Is it physiologic (e.g. related to exercise)? • Associated symptoms? • How was it taken? – Different thermometers • Intermittent vs. remittent vs. persistent vs. relapsing • Response to anti-pyretics (may also help with your therapeutic choices)
Fever (continued) • Differential Diagnosis (abbreviated) • Infectious • Could it be viral? Bacterial? Other? • Where could the infection be hiding? Review the systems! • CNS – HA? Behavioral changes? Photophobia? • HEENT – Sore throat? Tugging at ears? Cough? Rhinorrhea? • Chest – Cough? Sputum? DIB? • GI – Vomiting? Diarrhea? • GU – Dysuria? Change in urine quality/quantity? • Skin – Rashes? Erythema? • Joints – Pain? Swelling? Erythema? • How did they get it? • Ill contacts? • Travel? • Exposure to animals/insects? • Hygiene/Consumption?
Fever (continued) • Differential diagnosis (continued) • Rheumatologic - What are some classic symptoms? • Endocrine - Hyperthyroidisim • Hematologic (e.g. leukemia) – Think about classic symptoms? • Oncologic – Where would it be hiding? • Toxic – Exposure to certain toxins (Anti-cholinergic toxidrome)
Fever (continued) • What do we worry about? • Dehydration • Increased insensible losses – Sweat, heat • How do you assess clinically/by history? • Behavior • Intake • Output • Brain damage - How would it present? • Other organ damage – Cardiac? • Affects of dehydration – kidneys • Affects of underlying process
Difficulty Breathing • When a child is having difficulty breathing, what does that really mean physiologically? • Not enough oxygen getting to tissues • Not enough carbon dioxide getting out of the blood • In the case that it is a localizing symptom, as opposed to constitutional (like a fever), think about what systems are involved
Difficulty Breathing (continued) • Pulmonary • Think about every component of the structural system (Upper airway, trachea, bronchi, lungs) • Think about what can affect those structures so as to impact air flow and therefore, oxygenation/ventilation • Structural obstruction • Congenital – Long history of noisy breathing • Acquired – New mass • Foreign body – Acute onset, stridor • Infection – Fever, Malaise, Wt, loss, Anorexia • Upper airway/trachea – Rhinorrhea, Cough (barking?), Stridor • Lower airway/lungs – Cough (productive/wet?) • Inflammation – May be due to a preceding factor • Allergies – Think about exposures, classic symptoms • Asthma – Wheezing, triggers (exercise, cold, URI, allergies), timing (night-time
Difficulty Breathing (continued) • Pulmonary (continued) • Interstitial changes – Due to meds, radiation, environmental exposures • Cardiac – What symptoms would you expect? • Hematologic – What will the patient look like?
Past Medical History • Learn from the past – is there a clue to what is going on now and what is going to happen? • Has this happened before? If this happened before, when? Did you see an MD? What did they think? • Is the patient a setup for something? • Did the patient miss immunizations? • Previous surgeries? • Is there an underlying disorder that could be playing a role?
Past Medical History (continued) • Your “crystal ball” - How bad was it in the past? Do we need to worry now? • Were they sick enough that they needed medications? If so, what? • Were they sick enough that they had to come into the hospital? • Were they sick enough to need an ICU? • Were they so sick that we had to support them? • Don’t reinvent the wheel • What worked in the past? Certain meds (e.g. steroids)? Certain procedures?
Medications • May be a clue to his symptoms • Helps guide your intervention • What is the patient on/received already? – May get past medical history that was already missed • Has the patient already started treatment? • Have the interventions helped? – CLUE! • Example: Did he just complete a course of antibiotics? • Example: Did he already receive his max- dose of Tylenol today? • Example: Has he already received NMTs? How often? • Allergies
Family/Social History • Might increase your pre-test probability for a diagnosis • Think through your differential and anything which may have a genetic component • Who is at home? • What is at home/in their life i.e. exposures – Pets? Smoking? • Do you have a complete picture of his day?
Next Steps – Diagnostic Workup/Treatment • Is he symptomatic now? Do you want to do anything about it? • Think about your differential – Does your work-up address the most likely suspects? • Lab work • Diagnostic studies • Procedures
Thanks and Good Luck!!!Contact me with questions John Schmidt, MD Pager: 11001 734-763-9652 firstname.lastname@example.org