Welcome to Finals Revision.com - a learning resource for students studying towards paediatric finals exams. The website covers the major paediatric body systems with a focus on the more common diseases.
Introduction to History and Examination
Cardiology
History and Examination
- History
Fetal anomaly scan/fetal echocardiography Maternal medical history (diabetes mellitus, SLE, alcohol) Congenital infections Prematurity Family history of congenital heart disease Maternal medications Post-natal history (collapse, heart failure, poor feeding, cyanosis) Previous investigations and medications
- Examination
Similar in all ages – adapt as necessary (babies lying down, young child on parent’s lap, older child at 45º) Undress to pants
Inspect from end of bed (cyanosis, respiratory distress, pallor, bedside monitoring) Hands (clubbing, temperature, sweat, peripheral cyanosis) Brachial pulses – feel together (pulse rate/rhythm/character/volume, equal) Face for dysmorphic features (Down’s, Edwards’s, Noonan’s, Turner’s) Central cyanosis and anaemia (JVP in children >4-5yrs) Capillary refill time Inspect praecordium (scars median and lateral thoracotomy) Palpate apex bilaterally (prominent or diminished apex, dextrocardia) Auscultate (heart sounds, murmur) Auscultate carotids if murmur heard (aortic stenosis) Palpate for liver edge Femoral pulses (Auscultate chest in older children) Ask for oxygen sats and blood pressure
Initial investigations include ECG and CXR Secondary investigation might include echocardiography Further management might include drugs, catheterisation or surgery
Murmurs Systolic or diastolic Describe where loudest (LLSE, ULSE, URSE, apex, subclavicular) Grade I-VI (I v.soft, III moderate, IV loud with thrill, VI heard in room) Thrill (grade IV+) Change with posture (innocent) Radiation (to carotids with AS) Innocent murmurs are soft, systolic, short, symptomless, sternal edge (L)
Respiratory
History and Examination
- History
Antenatal and perinatal history (prematurity, ventilation, CLD, congenital disease) Family history Failure to thrive Recurrent chest infections Immunisations Allergies/atopy Smoking Symptoms (wheeze, cough, pyrexia) Previous investigations and medications
- Examination
Undress to pants Adapt to age of child and maintain child dignity
Look from end of bed (oxygen, cyanosis, work of breathing, grunting, stridor, growth) Peripheral signs (cyanosis, clubbing) Radial/Brachial pulse Face for central cyanosis, lymphadenopathy Inspect praecordium (respiratory rate, signs of respiratory distress, expansion, chest wall deformities) Apex beat Percussion (children >3yrs, symmetrical approach) Auscultate (air entry, wheeze, crackles, transmitted sounds, ENT examination
Ask for sats reading First line investigations might include CXR, PEFR, or sputum culture Further investigations include sweat test, full pulmonary function testing, sleep studies, or CT/MRI
Ante- and perinatal history (meconium ileus) Congenital disorders (tracheo-oesophageal fistula, Hirschprung’s, malrotation) Feeding (lactose or cow’s milk intolerance) Growth and nutrition (failure to thrive) Symptoms (pain, distension, vomiting, bowel opening, jaundice) Family history Travel abroad Previous investigations and medications
- Examination
Undress Lying down, arms by side for abdominal palpation
End of bed (distension, jaundice, cachexia) Assess hydration status (see below, fontanelle in babies) Hands (clubbing) Pulse Face (jaundice, anaemia, dentition, tongue, lymphadenopathy) Inspect abdomen (scars, distension) Palpate (tenderness, masses, organomegaly – liver, spleen, kidneys, bladder) Percuss (shifting dullness, liver) Auscultate (obstruction or peritonism) Inguinal region for hernia Genitals/anus (as appropriate for age/history)
First line investigations may include growth charts, urine dip or blood tests Further investigations may include abdominal USS, CT/MRI, or pH studies
Maternal medications/alcohol/drugs Birth events (APH, birth asphyxia, APGARs) Inherited disorders (Duchenne’s, spinal muscular atrophy) Congenital infections (CMV, Rubella) Developmental milestones (4 subgroups) Behaviour and emotional state (Autism) Tasks of daily living School progress (learning difficulties) Family History Seizure episodes/epilepsy (type, frequency, duration) Previous investigations and medications
- Examination
Very much adapted to age Knowledge of developmental milestones therefore vital
Babies/infants - Dysmorphism Hydrocephalus Fontanelle Pupils and tracking Truncal and peripheral tone (and power) Primitive Reflexes Head control
Young Children - Facial features/dysmorphism Watch child play and interact Posture and movements/coordination Tone and power Gait and run Hearing and vision Language skills and speech
Older Children - More formal assessment, similar to adult examination Inspect Tone Power (graded 0-5) Reflexes Coordination (include Romberg’s) Sensation Plantars Gait (walk, run, skip)
Further Information
Extra bits to remember in paediatric history/examination
Birth and obstetric history (infants) Developmental history Immunisation status Social history • Who does the child live with/who has parental responsibility? • Parental smoking/alcohol • Are any agencies involved in child’s care? • What school is the child at? ENT examination • Part of the general examination in a child • Check both ears and throat for erythema/exudate or pus etc • URTIs incredibly common in children!
Consideration and Rapport
Students who interact well and engage with children will do better in exams! Handling babies, gaining parental and child trust, and being relaxed and confident with children of all ages are skills to develop. Include the child in history-taking where appropriate, respect their dignity during examination, and be considerate towards parental anxiety.
Age of child and focussing a history
Considering the child’s age should begin the history and examination. - Should you direct questions to the child (10yrs +), parents (<4yrs) or a mixture of both (4-10yrs)? - What points are relevant in the history? (e.g. congenital infections and careful birth history in babies; developmental history not important in asthma exacerbations) - Different conditions may be specific to age (e.g. bronchiolitis <18months, asthma >2yrs) or present late in the disease’s natural history (e.g. Eisenmenger’s in older children with VSD) - How should you approach and tailor the examination? - Is the developmental stage appropriate for age?
Baby Check
History
Check the gestation, weight and head circumference Ask about the pregnancy (scans, maternal infections, maternal drugs) Ask about risk factors for sepsis (PROM, maternal pyrexia, GBS) Ask about the delivery (type, complications, meconium) Check that the baby has had vitamin K Check if the baby needs vaccination (e.g. BCG/hepatitis) Ask about feeding and if the baby has urinated and passed meconium Ask if mum or the midwives have any other concerns Top to toe examination
Vaccination Schedule
The normal vaccination schedule in the U.K. can be accessed at:
Contraindications
There are very few true contraindications to vaccination, but these include febrile illness, immunosuppression (live vaccines), severe local inflammatory responses, previous allergic reactions, and specific allergies (e.g. kanamycin for MMR, egg for influenza).
Prematurity
Premature babies have their vaccinations at their chronological age and not their corrected age (i.e. they begin 2 months post-birth rather than 2 months post-term date).
BCG
Only high-risk groups are now vaccinated with BCG, and this occurs at the initial baby check. High risk groups include parents of certain nationality (e.g. areas of Asia, Africa or Eastern Europe), intravenous drug users etc. In older children who wish to have BCG (e.g. travel), a Mantoux test is performed first to look for undiagnosed TB infection. This involves injection of (0.1mls of 1 in 1000) tuberculin into the forearm. If the test is negative (induration <10mm) the BCG can proceed. The test may have false negatives (disseminated TB infection, poorly administered tuberculin, infants, HIV/immunosuppression).
Inheritance
Different diseases are inherited in various ways:
Autosomal dominant - Gene will be expressed even in heterozygotes - E.g. Marfan’s, Achondroplasia, Neurofibromatosis
Autosomal recessive - Gene only expressed in homozygotes - E.g. Cystic Fibrosis, Sickle Cell Anaemia, Homocystinuria, Phenylketonuria
X-linked - May be recessive or dominant - E.g. Recessive - Haemophilia A, Duchenne’s MD, G6PD-deficiency - E.g. Dominant - X-linked Hypophosphataemic Rickets, Rett Syndrome
Trisomy - Whole extra chromosome is inherited - E.g. Down’s (21), Edward’s (18), Patau’s (13)
Sex chromosome aneuploidies - E.g. Turner’s Syndrome (45 X) - E.g. Klinefelter’s Disease (47 XXY)
Uniparental disomy - Occurs when both copies of a chromosome are inherited from one parent - E.g. Prader-Willi, Beckwith Wiedemann, Angelman’s
Anticipation - Due to inherited sequence of trinucleotide repeats - With each generation, sequence becomes longer and phenotype more severe - E.g. Huntington’s, Dystrophia Myotonica, Fragile-X
