Paediatrics - Queensland Health - Queensland Government

Paediatric presentation
Presentation
• When a child presents for health care the clinician is required to gather an orderly
collection of information to identify the patient’s health status. The following is essential
to achieve this:
-- taking a patient history
-- performing standard clinical observations and other vital signs
-- perform physical examination
-- using diagnostic and pathology services, and
-- collaboration with other members of the team
-- note: not all children are at the same stage of development in areas of physical,
cognitive and psychosocial development
• It is a requirement that all clinicians document their findings in a clear and concise way.
This section is set out to assist. It is recommended the page number of HMP / CCG is
referred to in the documentation
Types of history
There are four types of history taking [3] See History and physical examination - adult
History taking
• The purpose of a full history is to ascertain the cause of the child's illness. A careful
history will make the cause clear in the vast majority of cases.
• The first priority is to assess whether the child is:
-- seriously ill and needs immediate management or,
-- is a non urgent presentation, and there is time for a complete patient history and
health education
• Obtaining a full history is done in conjunction with examining the patient
-- In a sick child this entails a full assessment of all systems
-- In a child who has a localised problem it is reasonable to examine the relevant
system only. However, always be guided by the history and be prepared to examine
other systems as necessary. This is particularly important for children who often
present with generalised symptoms and signs
-- Ask open ended questions
-- Believe the carer
Presenting concern
• Ask the child or carer what the problem is
• Ask about length of illness and exact details of symptoms and signs. For each symptom
the following details are important [4]
Site - where is the pain / symptom? does it go anywhere else?
Onset - when did it start, gradual or sudden onset?
Character e.g. sharp, dull or burning
Radiation - does the pain radiate anywhere else?
Alleviating factors - what makes it better e.g. sitting up, medicines?
Timing - how long did it last, have they had it before?
Exacerbating factors - what makes it worse?
Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable
pain or use facial diagrams
• Any associated symptoms e.g. nausea, vomiting, photophobia, headache
-- always ask specifically about fever, pain, shortness of breath / rapid breathing,
diarrhoea and / or weight loss, rash
• Behaviour and activity during this illness
-- is the child active / alert, sleepy or irritable? easy / difficult to wake?
Primary Clinical Care Manual 2011 Controlled copy V 1.0 547