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Paediatric Consultations andmedical note keeping Dr Leena Patel 14 September 2012
Aim of the session Understand how to engage and interact with children, young people and their carers during a consultation Understand the meaning of a focused consultation Discuss some of your consultations Review medical note keeping History sheet
Structure • History must be adapted for the age of child and focused on the problem
General Advice • Paediatrics – wide age range, not just small adults! • Look & Listen carefully to what a parent says/feels about their child • they are the expert on their child and intuitively know if something is not right • Clarify what child/parents mean by the language used – do not assume e.g. ‘diarrhoea’ vs constipation with overflow • Bear in mind safeguarding and child protection issues
Introduction Be yourself • Introduce yourself • Establish child’s name (and preferred name) and DOB • Confirm identity and relationship of all present in consultation • Gain consent and ensure confidentiality • Establish rapport • Eye contact and SMILE! • Get down to patients level • Have toys available, observe how child plays and interacts • Allow child time to get to know you
Conversation starters My name is … What’s your name? How old are you? Who is this? (pointing to parent) Do you have any pets? What’s your favourite food? How is school/ your teacher? Favourite subject? What’s your favourite cartoon? Comment on what you see- school uniform, football jersey, paint on hands What football team do you support? What did you do this weekend?
Presenting complaint • Ask child why they have come to see you today and what they would like to talk about • Encourage child to speak first and speak to parent after • What does child/parent think is wrong? • What did they first notice? When? • Have daily activities and school been affected? • When was the child last well? • ICE, What would they like to happen next?
Medical note keeping Patient’s ID details on all sheets Date, time, place Who is present, who gives the history Consent for examination, chaperone during examination Your name, signature and contact details
What is the purpose of a history? Gather information Assess impact on patient and family Identify problems Guide further assessment & management Make Dx “test” evidence to support or refute preliminary Dx Exam Ix Mx
Case 1 13m, female A&E with parents (not referred by GP) 2 day history of fever → acute febrile illness • Is the child well or unwell? • Appearance, colour, T core and peripheral, P, cap refill, tone, GCS • Is there a rash? • Are there any localising features? ENT, chest, abdomen, CNS, MSK
Case 2 19 months, male infant Respiratory symptoms for 2 days • Is this acute, chronic or acute-on-chronic? • Upper or lower respiratory or both? • Infective or non-infective aetiology? • ? • If infective, is it viral or bacterial or other pathogens? • Are there any predisposing factors?
Case 3 6 years old, female child with Down’s syndrome Suddenly “turned blue” and brought to hospital by ambulance Preceding 5 day history of increasing cough, vomiting, difficulty breathing and not eating or drinking Past history of recurrent “chest infections” and surgery for VSD at 9 months age
Case 4 5 days, female infant of Chinese ethnicity Referred by nurse who did a home visit Weight loss from BW 3.3 kg to current weight 2.8 kg Associated with persistent crying, vomiting 2/day and jaundice Uneventful pregnancy and delivery • Breast fed but doesn’t suck well • Passing urine normally
Examining children - General Principles • Make friends with the child/YP - Keep eye contact and SMILE! - Get down to level of child • Examination approach determined by child’s age/developmental stage • Adapt structure and be opportunistic • Use distractions to keep child interested and cooperative
Introduction to physical examination • Explain what you are going to do and why in a way that the child can understand • Ask permission – child if able to understand, parents • Observe child walking, interacting and playing • Positioning – consider child’s preference • Young babies – parent’s lap or examination couch • Toddlers - parent’s lap • Preschool children - whilst playing if possible • Older children/teenagers - greater privacy & chaperone • Ask child if anywhere hurts before touching them • First examine what you can without undressing – less threatening • Undressing - ask child or parent
During Examination Keep chatting and repeatedly reassuring/praising Distract and involve child as much as possible Must be opportunistic - e.g. Auscultate at beginning if infant not crying Leave intrusive/unpleasant procedures until end to avoid early upset Say ‘thank you’
Keeping the child interested • Involve child as much as possible e.g Ask them if they know where their lungs are and get them to point • Make examination into a game e.g. Palpate abdomen & guess what cereal they had for breakfast • Use toys/props e.g. Auscultate teddy bear or parent first to reduce anxiety Ask parents to distract infant/toddler by waving coloured objects in front of them or giving something to hold.
Reflective learning portfolio Hands-on-experience Look back on what you did and what happened Think about what you might do differently Learn more from each experience Develop more and more expertise