Childhood illness – assessment and management of primary survey negative children

Chapter 6 Childhood illness – assessment and management of primary survey negative children



Fiona Jewkes, Malcolm Woollard



Introduction 93

Secondary survey 93

Subjective assessment 94

Objective examination 95

Analysis (differential diagnosis) and treatment and disposal (plan) 97

Communication and follow-up 113


Introduction


This chapter describes the assessment and findings associated with illnesses that commonly affect children. It aims to be a guide to common presentations and treatment rather than a comprehensive review of all paediatric conditions. Chapter 5 describes the identification and initial management of potentially life-threatening problems. Box 6.1 describes the objectives for this chapter.



Box 6.1 Chapter objectives



image To describe the approach to the secondary survey in children and its main features

image To discuss differential diagnosis for children with common presenting symptoms

image To describe the differential diagnosis, management and disposition of children with a range of common conditions

image To review indicators of the need for hospital referral

image To describe the care of common problems affecting technologically assisted children

image To consider the importance of communication in the care of the sick child


Secondary survey


A secondary survey will be required for all children who have not required transfer to hospital following the primary survey (see Chapter 5). Its aim is to fully assess the child so that decisions about their future management and disposal can be safely made. The SOAPC system (Box 6.2) can be used to undertake this survey but is modified to take account of the particular needs of children (see Chapter 5).



Box 6.2 SOAPC assessment strategy



image Subjective assessment

image Objective examination

image Analysis and diagnosis (assessment)

image Plan (treatment and disposal)

image Communication


Subjective assessment


Most parents and carers will be very sensitive to changes in their children’s health. Consequently, if they express concern about their child’s wellbeing they are often right. It is important to ask parents or carers what they think the matter is and, if appropriate, what treatment they might be expecting. They may relate treatments that have helped the child during similar illnesses, and this will help to identify the parent’s expectations about what they believe is required.


It may be necessary to ask parents what constitutes normal behaviour and appearance for their child, but the patient should always be involved in the discussion. Even toddlers and younger school-age children should be spoken to directly, using language appropriate to their ability to understand. It may be helpful to assess teenagers without parents or guardians present, to encourage them to discuss their illness and any concerns they may have openly.


As well as a detailed history of the presenting complaint, details of past illnesses or operations, medications, and allergies should be sought and recorded, as should the family history. Birth history may also be important, particularly in infants and younger children. On occasion a brief developmental history may also shed light on the problem.


The parents of children with chronic illnesses (such as renal disease) or congenital problems are likely to have considerable expertise about assessment and management of the condition – as indeed may the children themselves. Practitioners should not be dismissive of information provided and suggestions made by ‘expert’ parents and children. It is important to remember, however, that although they be very knowledgeable about their field of expertise, they are likely to know no more than other people about other medical problems.



Objective examination


Before approaching a child directly, it is a good idea to observe their general behaviour (Fig. 6.1). Are they passive or active? Are they playing normally? Do they pay attention to their surroundings?


image

Fig. 6.1 A happy, alert baby (reproduced with permission of Dr Claudia Morley).


When approaching a child, their behaviour should be noted. Is this normal for their age group? Have they reacted to your presence (perhaps by hiding behind the furniture)? Consider the child’s general condition – do they appear well cared for, or are they grubby and thin?


The content of the physical examination should be similar to that for an adult, although the order in which each system is assessed may be modified depending on the age and behaviour of the child (see Chapter 5). A cardiovascular, respiratory and abdominal examination should be undertaken as appropriate and opportunistically. There are some aspects, however, that are particularly important to the examination of the child.



Skin


The presence of a rash may be significant. The morphology, pattern and distribution should be noted and its significance assessed in the light of the associated symptoms and signs.



Ear, nose and throat


The ears should be examined using an auroscope, and the throat inspected for evidence of tonsillitis or other pathology.



Lymphadenopathy and meningism


Cervical lymphadenopathy is extremely common in upper respiratory tract infections and its presence may lead the child to complain of pain when their neck is flexed. This should not be confused with the neck stiffness seen in meningeal irritation. True meningism may be associated with the child adopting a posture of hyperextension of the head and trunk and the child will be truly unable to flex the neck without stiffness occurring. Meningism may also be associated with a high-pitched cry and patients may present with drowsiness or irritability. Signs of meningism should alert the practitioner to strongly consider meningitis. Lymphadenopathy may also indicate glandular fever, other viral infections, or even relatively rare pathology such as leukaemia. Meningism is often absent in infants with meningitis and in those who have been previously treated with antibiotics (even very small amounts). A lowered threshold for referral is indicated as lumbar puncture may be necessary.



Abdominal examination


Mild splenomegaly is fairly common in viral illnesses but its presence must be noted and the assessment repeated when the child recovers to ensure that it has resolved. The liver may be palpated without difficulty in the young baby but is commonly easily pushed down in conditions where the lungs are hyperinflated such as bronchiolitis. Cardiac failure in children and babies is rare, but must be considered if the baby appears to have an enlarged liver.



Temperature


Taking the child’s temperature is of limited value in primary care as the presence or absence of a fever does not confirm or rule out serious disease. There are various confounding problems, such as whether or not the child has received an antipyretic and what part of the body is used to assess temperature. Indeed authorities still debate what the upper limit of normal is. It is, however, recognised that very young babies (for example, less than 6 months old) who have a significant fever (>38.5 °C) or who are hypothermic (<35 °C) are more likely to have serious disease. Young children may sometimes tolerate very high temperatures (>40 °C) with little apparent discomfort or serious pathology. Significant fever can usually be detected, if no thermometer is available, by touching the skin of the child’s trunk.



Urine cultures


A sterile urine sample needs to be obtained in any child who is unwell and in whom the cause is not clear. Urinary tract infections are a common cause of febrile convulsions. Urine dip sticks which test for nitrite and leukocytes as well as blood and protein can be helpful as a guide as to whether an infection is present and if positive the urine must be sent for bacteriological diagnosis and antibiotic sensitivity. It is important to obtain urine for culture before starting antibiotics for suspected urinary tract infection. The parent can be instructed to collect the urine before starting antibiotics and store it in the refrigerator until the next day, when the staff at the child’s general practice can send it for culture.


It is important not to withhold antibiotics for culture results, particularly in young children. Babies under the age of 6 months in whom there is a high likelihood of urinary tract infection should be referred to hospital the same day, as the risk of renal scarring from infection is high in this age group and intravenous antibiotics are usually employed initially even if the baby seems to be well.



Blood sugar measurement


Whilst blood sugar measurement is essential in all children who have a disturbed conscious level or are diabetic, it need not be done routinely in the child who does not appear to be seriously ill, unless there is a particular reason such as a suspicion of diabetes.



TIP


There are almost no indications for a rectal or vaginal examination in children in the primary care setting



TIP


Children who grab your stethoscope and play with it, and can be made to laugh by wobbling their tummy are not usually seriously ill!



Analysis (differential diagnosis) and treatment and disposal (plan)



Common presentations



The irritable child


A common presentation that can be difficult to address is a baby who is reported to cry excessively. A truly irritable baby dislikes handling and must be assumed to have serious illness and be admitted urgently to hospital. More common is the baby who will not settle or settles only briefly, or the misery of the febrile toddler: these children can cause considerable concern to new parents and healthcare professionals alike but are not necessarily very ill. The cause may be due to a multitude of reasons from significant pathology to poor parenting skills. Even when the practitioner can confidently determine there is no significant clinical problem (difficult at the best of times) admission to hospital or referral for further support should be considered if parents remain anxious.



TIP


Children who have become suddenly and unusually irritable or drowsy and floppy should be considered to be acutely ill until proven otherwise



Abdominal pain


Abdominal pain can also cause diagnostic conundrums. If a child is seriously ill (primary survey positive) he or she should be managed with immediate transfer to hospital and appropriate resuscitative measures. If the child is not seriously ill, the diagnosis can be divided into acute and chronic presentations.


Acute abdominal pain is common. Potential surgical pathology must be excluded and if this is not possible, the child referred for more detailed assessment. Appendicitis may be very difficult to diagnose in small children and must be actively considered. Other serious causes such as intussusception or volvulus may occasionally underlie the acute abdomen. Urinary tract infection must be sought as it often presents non-specifically with abdominal pain with or without urinary symptoms. One of the commoner causes of acute abdominal pain is mesenteric adenitis (acute lymphadenopathy in the abdominal lymph nodes) and a concurrent upper respiratory infection is characteristic. Infective gastroenteritis, Henoch–Schonlein purpura (HSP) and many other disorders all have their own spectrum of associated features and symptoms. If in doubt, refer.


Chronic abdominal pain

Related posts:

The ill child – assessment and identification of primary survey positive children Introduction, summary, the system of care Chest pain The assessment and care of musculoskeletal problems The system of assessment and care of the primary survey positive patient Abdominal pain, abdominal pain in women, complications of pregnancy and labour
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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Childhood illness – assessment and management of primary survey negative children

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