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Common Paediatric Histories

Common Paediatric Histories Presenting Exploding symptom Relevant system reviews Differential diagnoses Clues

Presenting

Exploding symptom

Relevant system reviews

Differential diagnoses

Clues to differential

complaint

Grouping

Differentials

Failure to

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

Presents any age after weaning Diarrhoea (pale stools) Bloating

thrive

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

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

•Cow’s milk protein allergy presents in first few months Diarrhoea after being fed with formula milk for a few months

Carbohydrate

Flatulence, diarrhoea, bloating and cramps within a few hours of consuming lactose May be congenital (rare) or develop after gastroenteritis (transient)

intolerance (e.g.

lactose intolerance)

 

Pyloric stenosis

Projectile non-bilious vomiting after feeding Starts around 3-6 weeks of age

 

GORD/oesophagitis

Effortless regurgitation Crying during feeding Cough/hoarseness

Cystic fibrosis

Recurrent chest infections Pale stools that float

Inflammatory

Older child (e.g. teenager) Abdominal pain Diarrhoea with blood/mucus

bowel disease

Non-

Not enough food being offered or taken

Commonest cause

gastrointestinal

Nutritional neglect

Not offered enough food Hungry, food seeking/hoarding

Emotional neglect

Poor interaction between child and parent Withdrawn, fearful, anxious

Eating disorder

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

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

differentials

Weight

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

Endocrine

Hypothyroidism

Delayed growth/puberty Fatigue, cold intolerance Dry skin, coarse hair

increase

Cushing’s

Delayed growth/puberty Central obesity Easy bruising •’Moonface, buffalo hump

Top to toe Stature (short/normal) Appearance changes (skin/hair/acne) Hirsutism Fat distribution Bowel habbit Pubertal changes (inc menstrual periods)

syndrome

PCOS

Adolescent female

Oligo/amenorrhoea

Hirsutism, acne

 

Non-endocrine

Simple obesity

Snacking Lack of exercise

Familial

Parents with high BMI

Other

Oedema (cardiac or renal) Steroid use Genetic syndromes (e.g. Turners, Prader-Willis)

 

differentials

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

Developmental

 

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

General

Generalised

Chromosomal/genetic disorders e.g. Downs

 

Dysmorphic features

delay

Fever, behaviour,

delay

Perinatal PrenatalPostnatal

 

activity/apathy/alertness

Alcohol/drugs in

History of mother taking alcohol or drugs in pregnancy

(can also cause any of the specific delays below)

pregnancy

 

Neurological

TORCH infections in pregnancy

 

History of toxo/rubella/CMV/herpes

General: fits/LOC,

headache, dizziness,

Extreme prematurity

Born very premature

 

vision/hearing

 

Hypoxic brain injury

Prolonged difficult labour (dystocia)

 

•Motor:

weakness/wasting

Hypoglycaemia

Period of neonatal hypoglycaemia

 

Intracerebral

Risks = abnormal labour, prematurity Usually diagnosed within first few days

If motor problem How mobile? Hand dominance

   

haemorrhage

Meningitis/

Onset after episode of meningitis/encephalitis

 

encephalitis

 

Balance problems Behavioural problem

 

Head injury or hypoxic/hypoglycaemic episode

Delay subsequent to episode

 

If language/social problem Senses: vocals, hearing, vision Comprehension: follows commands, responds to voice Non-verbal communication:

Motor delay

Cerebral palsy

Muscle stiffness/weakness/floppiness Spasm or dyskinetic or ataxic Caused by prenatal/perinatal/postnatal (<3y) insult

 

pointing, gestures, facies Socially responses: how acts in new situations, tantrums, playing, gestures

Duchenne muscular dystrophy (or other muscular disorders)

Progressive muscle weakness (beginning proximally) Onset 2-3 years

 

Hip dysplasia

Usually identified at birth but may present later with a limp

 

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

e.g. due to chronic otitis media

 

Articulation problem (e.g. cleft palate)

Birth defects

 

Familial

Similar history in family

 

Lack of stimulus

Poor interaction with parents May be signs of neglect

 

Autism

Imposition of routines •Doesn’t seek friendships, prefers own company Limited gestures and expressions

 

Social delay

The key is in a thorough history!

 
 

ADHD

Hyperactivity, inattentiveness

Precocious

 

Puberty staging and order Boys order:

 

General

Gonadotrophin

Familial/idiopathic

 

Majority of girls

puberty

Fever, behaviour,

dependant

CNS abnormalities e.g. hydrocephalus, hypoxic brain injury

 

Relevant history

Testicular enlargement

activity/apathy/alertness,

(CENTRAL)

 

(boys <9y,

Penis enlargement

general health

girls <8y)

Pubic hair

 

Intracranial tumour

 

Associated neurological symptoms

Height spurt

 

Neurological General: fits/LOC, headache,

Gonadotrophin

Adrenal

 

Excessive pubic hair, penis/clitoris enlargement Weight gain

 

independent

tumour/hyperplasia

 

Girls order:

dizziness, vision/hearing •Motor: weakness/wasting

(PERIPHERAL)

Breast development

Pubic hair

(i.e. sex

Ovarian/testicular

 

Ovarian: bloating, menorrhagia, pelvic pain Testicular: painless lump

 

hormones not

tumour

Axillary hair

under pituitary

 

Height spurt

control)

Menarche

Other

Premature thelarche (breasts only)

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

differentials

Premature pubarche (pubic hair only) External sex hormones

Family history Parents pubertal age (inc mother menarche) and height

Delayed

 

Puberty staging and order Boys order:

General Fever, behaviour, activity/apathy/alertness, general health Symptoms of other systemic diseases (CF, thyroid, anorexia, Crohns

Familial

Constitutional

 

Majority of cases

puberty

Hypogonadotrophic

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

 

Symptoms of underlying disease

Testicular enlargement

hypogonadism

(boys >15y,

Penis enlargement

girls >14y)

Pubic hair

   

Delayed growth Fatigue, cold intolerance Dry skin, coarse hair

Height spurt

 

Hypothyroidism

Girls order:

 

Hypergonadotrophic

Klinefelters/

 

Turners: short stature, amenorrhoea Klinefelters: small testes, gynaecomastia, tall & thin

Breast development

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

hypogonadism

Turners

Height spurt

 

Pubic hair

Axillary hair

 

PCOS

 

Oligo/amenorrhoea

Hirsutism, acne

Menarche

       

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

 

Other differentials

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

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

problems

Conduct disorder

Bullies/threatens/intimidates Starts fights Cruel to people/animals

 

Oppositional

Losses temper Argues with adults and defies requests Deliberately annoys others

defiant disorder

OCD

Intrusive thoughts (obsessions) Repetitive behaviours (compulsions) Excessive washing/cleaning/checking

Autism

Speech/language delay Imposition of routines •Doesn’t seek friendships, prefers own company Limited gestures and expressions

Other

Anxiety disorders

differentials

Attachment disorder

Schizophrenia

Depression

Bipolar disorder

Childhood

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

General

Injury related

Non-accidental

Bruises on soft tissues (ears/neck/chest/abdomen/buttocks/calves/ thighs) Story inconsistent with injury

bruising

Fever, behaviour,

injury

activity/apathy/alertness

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

Accidental injury

Bruises on sticking out bits (forehead, shins, nose, bony prominences) Consistent story of injury

 

Non-injury

HSP

Symmetrical rash on back of legs, buttocks Purpura slightly raised May be abdominal/joint pain

related

 

ITP

Spontaneous purpura and petechiae Usually post-infection

Meningococcal

Non-blanching rash

septicaemia

Neck pain/stiffness

Photophobia

Fever

Other

Acute lymphoblastic leukaemia Traumatic petechiae (e.g. due to forceful coughing)

differentials

Faint/fit/

Attack Before: warning, circumstance During: duration, LOC, movements (floppy/stiff/jerking), incontinence/bite tongue, complexion After: amnesia, muscle pain, confusion/sleepiness, injuries from fall

General

Neurological

Febrile convulsion

1-2min generalised seizure Early in infection when fever is rising

funny turn

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

Seizure

Absence seizure Focal seizure Generalised seizure (suggested by loss of bladder/bowel control, tongue biting)

Paediatric epileptic

Characteristic features of syndromes

syndromes

Reflex anoxic

Pale and fall to floor In response to bump to head, emotion (e.g. fear, surprise), crying or fever

seizure

Background to attacks e.g. had before, frequency, impact on life

Non-neurological

Vasovagal syncope

Faint after prolonged standing/emotion/pain

Cardiorespiratory Dyspnoea, cyanosis, chest pain/palpitations

Pseudoseizure

Atypical seizures

 

Breath holding spell

Child holds breath and goes blue Usually when upset

 

Other

Narcolepsy Arrhythmia Hypertrophic cardiomyopathy

differentials

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