Common Paediatric Histories - OSCEstop

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© 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision Common Paediatric Histories
Common Paediatric Histories Presenting complaint Failure to thrive

Exploding symptom

Relevant system reviews

Differential diagnoses Grouping

•Ask to see growth chart and determine age of onset •Input: detailed dietary history, feeding history (inc time of weaning), hunger •Use: energy, activity level, exercise, anorexic? •Output: wet nappies, stools & GI symptoms •Others: behaviour, general health, happiness, parents health

General •Fever, behaviour, activity/apathy/alertness, cough

Gastrointestinal

Coeliac disease

Dietary protein intolerance (e.g. cow’s milk protein allergy) Carbohydrate intolerance (e.g. lactose intolerance)

Gastrointestinal •Work down body: dysphagia, reflux/vomiting, abdominal pain/colic, diarrhoea/constipation, stools (blood/mucus/pale)

Pyloric stenosis GORD/oesophagitis

Cystic fibrosis Inflammatory bowel disease Nongastrointestinal

Not enough food being offered or taken Nutritional neglect Emotional neglect Eating disorder

Weight increase

•Ask to see growth chart and determine age of onset •Input: detailed dietary history, feeding history (inc time of weaning), hunger •Use: energy, activity level, exercise •Others: behaviour, general health, happiness, parents health and BMI

General •Fever, behaviour, activity/apathy/alertness, cold intolerance Top to toe •Stature (short/normal) •Appearance changes (skin/hair/acne) •Hirsutism •Fat distribution •Bowel habbit •Pubertal changes (inc menstrual periods)

Clues to differential

Differentials •Presents any age after weaning •Diarrhoea (pale stools) •Bloating •Cow’s milk protein allergy presents in first few months •Diarrhoea after being fed with formula milk for a few months •Flatulence, diarrhoea, bloating and cramps within a few hours of consuming lactose •May be congenital (rare) or develop after gastroenteritis (transient) •Projectile non-bilious vomiting after feeding •Starts around 3-6 weeks of age •Effortless regurgitation •Crying during feeding •Cough/hoarseness •Recurrent chest infections •Pale stools that float •Older child (e.g. teenager) •Abdominal pain •Diarrhoea with blood/mucus •Commonest cause

•Not offered enough food •Hungry, food seeking/hoarding •Poor interaction between child and parent •Withdrawn, fearful, anxious •Adolescent girls •Fear of weight gain •Feel fat when thin •Efforts to lose weight: diuretics/laxatives, vomiting, excessive exercise •Consequential symptoms: amenorrhoea, developmental delay, myopathy, poor sleep, GI symptoms

Other differentials

Prenatal Prematurity IUGR Chromosomal abnormalities Toxins (alcohol, smoking, drugs) Others Poor feeding Inborn errors of metabolism (e.g. abetalipoproteinaemia) Chronic infections (inc HIV) Chronic illness Malignancy

Endocrine

Hypothyroidism

Non-endocrine

Other differentials

•Delayed growth/puberty •Fatigue, cold intolerance •Dry skin, coarse hair Cushing’s •Delayed growth/puberty syndrome •Central obesity •Easy bruising •’Moon’ face, buffalo hump PCOS •Adolescent female •Oligo/amenorrhoea •Hirsutism, acne Simple obesity •Snacking •Lack of exercise Familial •Parents with high BMI Oedema (cardiac or renal) Steroid use Genetic syndromes (e.g. Turners, Prader-Willis)

© 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

General •Fever, behaviour, activity/apathy/alertness Neurological •General: fits/LOC, headache, dizziness, vision/hearing •Motor: weakness/wasting

Generalised delay (can also cause any of the specific delays below)

Prenatal

Development •Current developmental stage in each category (learn paeds history table) -Gross motor -Fine motor and vision -Hearing and language -Social •Ages of key milestones in each

Perinatal

Developmental delay

Postnatal

If motor problem •How mobile? •Hand dominance •Balance problems •Behavioural problem If language/social problem •Senses: vocals, hearing, vision •Comprehension: follows commands, responds to voice •Non-verbal communication: pointing, gestures, facies •Socially responses: how acts in new situations, tantrums, playing, gestures

Motor delay

Chromosomal/genetic disorders e.g. Downs Alcohol/drugs in pregnancy TORCH infections in pregnancy Extreme prematurity Hypoxic brain injury Hypoglycaemia Intracerebral haemorrhage Meningitis/ encephalitis Head injury or hypoxic/hypoglycaemic episode Cerebral palsy

Duchenne muscular dystrophy (or other muscular disorders) Hip dysplasia

As part of history •Prenatal problems (e.g. alcohol/drugs in pregnancy, maternal infections) •Perinatal problems (e.g. prolonged/difficulties in labour) •Postnatal problems (i.e. PMHx e.g. meningitis/ encephalitis)

Language delay

Deafness Articulation problem (e.g. cleft palate) Familial Lack of stimulus Autism

Social delay

The key is in a thorough history! ADHD Precocious puberty (boys <9y, girls <8y)

Puberty staging and order Boys order: •Testicular enlargement •Penis enlargement •Pubic hair •Height spurt Girls order: •Breast development •Pubic hair •Axillary hair •Height spurt •Menarche

General •Fever, behaviour, activity/apathy/alertness, general health

Gonadotrophin dependant (CENTRAL)

Neurological •General: fits/LOC, headache, dizziness, vision/hearing •Motor: weakness/wasting

Gonadotrophin independent (PERIPHERAL) (i.e. sex hormones not under pituitary control) Other differentials

Other development •Previous growth and development •Height •Weight and nutrition •Behavioural changes

Familial/idiopathic CNS abnormalities e.g. hydrocephalus, hypoxic brain injury Intracranial tumour Adrenal tumour/hyperplasia Ovarian/testicular tumour

•Dysmorphic features •History of mother taking alcohol or drugs in pregnancy •History of toxo/rubella/CMV/herpes •Born very premature •Prolonged difficult labour (dystocia) •Period of neonatal hypoglycaemia •Risks = abnormal labour, prematurity •Usually diagnosed within first few days •Onset after episode of meningitis/encephalitis •Delay subsequent to episode

•Muscle stiffness/weakness/floppiness •Spasm or dyskinetic or ataxic •Caused by prenatal/perinatal/postnatal (<3y) insult •Progressive muscle weakness (beginning proximally) •Onset 2-3 years •Usually identified at birth but may present later with a limp •e.g. due to chronic otitis media •Birth defects •Similar history in family •Poor interaction with parents •May be signs of neglect •Imposition of routines •Doesn’t seek friendships, prefers own company •Limited gestures and expressions •Hyperactivity, inattentiveness •Majority of girls •Relevant history

•Associated neurological symptoms •Excessive pubic hair, penis/clitoris enlargement •Weight gain •Ovarian: bloating, menorrhagia, pelvic pain •Testicular: painless lump

Premature thelarche (breasts only) Premature pubarche (pubic hair only) External sex hormones

Family history •Parents pubertal age (inc mother menarche) and height Delayed puberty (boys >15y, girls >14y)

Puberty staging and order Boys order: •Testicular enlargement •Penis enlargement •Pubic hair •Height spurt Girls order: •Breast development •Height spurt •Pubic hair •Axillary hair •Menarche Other development •Previous growth and development •Height •Weight and nutrition •Behavioural changes

General •Fever, behaviour, activity/apathy/alertness, general health •Symptoms of other systemic diseases (CF, thyroid, anorexia, Crohns Neurological •General: fits/LOC, headache, dizziness, vision/hearing •Motor: weakness/wasting

Familial Hypogonadotrophic hypogonadism

Hypergonadotrophic hypogonadism

Constitutional Systemic disease (e.g. IBD, CF, anorexia) Hypothyroidism

Klinefelters/ Turners PCOS

Other differentials

•Majority of cases •Symptoms of underlying disease

•Delayed growth •Fatigue, cold intolerance •Dry skin, coarse hair •Turners: short stature, amenorrhoea •Klinefelters: small testes, gynaecomastia, tall & thin •Oligo/amenorrhoea •Hirsutism, acne

Hypogonadotrophic Kallmann syndrome Intracranial tumour Panhypopituitarism Syndromal Hypergonadotrophic Steroid hormone enzyme deficiency Acquired gonadal damage

Family history •Parents pubertal age (inc mother menarche) and height © 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

Behavioural problems

•Expand on behaviour problems •ADHD symptoms: poor concentration, hyperactivity •Conduct disorder symptoms: hostile, aggressive, cruel •OCD symptoms: intrusive thoughts, repetitive behaviours •Autism symptoms: poor social interaction, emotionless, routines

Psychiatric

ADHD

•Hyperactivity, inattentiveness

Conduct disorder

•Bullies/threatens/intimidates •Starts fights •Cruel to people/animals •Losses temper •Argues with adults and defies requests •Deliberately annoys others •Intrusive thoughts (obsessions) •Repetitive behaviours (compulsions) •Excessive washing/cleaning/checking •Speech/language delay •Imposition of routines •Doesn’t seek friendships, prefers own company •Limited gestures and expressions

Oppositional defiant disorder OCD

Autism

Childhood bruising

Faint/fit/ funny turn

Bruising •Onset and progression •Pattern •Mechanism of injury (detailed if possible NAI) •Associated symptoms

Attack •Before: warning, circumstance •During: duration, LOC, movements (floppy/stiff/jerking), incontinence/bite tongue, complexion •After: amnesia, muscle pain, confusion/sleepiness, injuries from fall Background to attacks e.g. had before, frequency, impact on life

General •Fever, behaviour, activity/apathy/alertness Neurological •General: fits/LOC, headache, dizziness, vision/hearing, neck stiffness/photophobia •Motor: weakness/wasting

General •Fever, behaviour, activity/apathy/alertness Neurological •General: fits/falls/LOC, headache, dizziness, vision/hearing, memory loss, neck stiffness/photophobia •Motor: weakness/wasting, incontinence •Sensory: pain, numbness, tingling

Other differentials

Anxiety disorders Attachment disorder Schizophrenia Depression Bipolar disorder

Injury related

Non-accidental injury

Other differentials

•Bruises on soft tissues (ears/neck/chest/abdomen/buttocks/calves/ thighs) •Story inconsistent with injury Accidental injury •Bruises on sticking out bits (forehead, shins, nose, bony prominences) •Consistent story of injury HSP •Symmetrical rash on back of legs, buttocks •Purpura slightly raised •May be abdominal/joint pain ITP •Spontaneous purpura and petechiae •Usually post-infection Meningococcal •Non-blanching rash septicaemia •Neck pain/stiffness •Photophobia •Fever Acute lymphoblastic leukaemia Traumatic petechiae (e.g. due to forceful coughing)

Neurological

Febrile convulsion

Non-injury related

Seizure

Paediatric epileptic syndromes Reflex anoxic seizure Non-neurological

Vasovagal syncope Pseudoseizure Breath holding spell

Cardiorespiratory •Dyspnoea, cyanosis, chest pain/palpitations Other differentials

•1-2min generalised seizure •Early in infection when fever is rising •Absence seizure •Focal seizure •Generalised seizure (suggested by loss of bladder/bowel control, tongue biting) •Characteristic features of syndromes •Pale and fall to floor •In response to bump to head, emotion (e.g. fear, surprise), crying or fever •Faint after prolonged standing/emotion/pain •Atypical seizures •Child holds breath and goes blue •Usually when upset

Narcolepsy Arrhythmia Hypertrophic cardiomyopathy

© 2015 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

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