The clinical consultation

2.1 The clinical consultation



Mike South, Sean A. Beggs


The clinical consultation is the central act of medicine, with its primary aim being to arrive at a diagnosis and management plan that will assist the patient. For children, as with adults, there are three main pillars for arriving at a diagnosis, namely history, examination and investigations. In most presentations, the majority of the information required for a diagnosis comes from the history, with a smaller amount coming from the physical examination. In many cases, no investigations are required. A common paediatric scenario is one in which a difficult diagnosis is able to be made by an experienced clinician who simply takes a thorough history.



image Practical points




• Skills in history-taking and examination cannot be acquired adequately by reading a textbook. Ensure you have lots of practice with children of all ages and in different clinical settings.


• Learn to appreciate what constitutes normal growth, development and physical findings on examination. Take every opportunity you can to observe normal children (who might be visiting the hospital or community health centre, in the cafeteria, or even travelling on public transport). Try to guess their ages from your observations (based on size, development and behaviour) and then ask how old they really are.


• Adapt the content and techniques of history-taking and examination to fit the age of the child and the urgency of the medical problem.


• Learn to be flexible in your approach – some patients will need to be examined on the floor, while in a play area, or from a distance.



Planning your approach


To ensure you gain as much information as possible it is important to have given consideration to how you will approach the consultation. The basic structure of the clinical consultation is to take an accurate history and elicit all the relevant clinical signs in order to generate a differential diagnosis list and management plan. The use of a framework such as the SOAP note (below) is of great assistance when planning your initial approach to a consultation. This framework is also of great use when it comes to recording your notes. It facilitates recording them in a clear and concise manner that is easily understood by others involved in the care of the patient.



S – subjective: the history as given by the carers and child


O – objective: physical examination and results of investigations


A – assessment: primary diagnosis and differential diagnosis


P – plan: immediate and long-term plan to manage the patient.


When planning your approach to a paediatric consultation it is important to understand how children differ from adults. Consideration needs to be given to the age and developmental stage of the child, the setting and acuity of the presentation and how to best establish rapport with the child and family.



Age and developmental stage of the child


The approach to clinical history-taking and physical examination of children differs from that used for adults; it also differs with the age and developmental stage of the child. These differences relate to the fact that children are growing and are acquiring new developing skills. There is also generally a third party (parent or caregiver) present, providing a significant component of the history. Therefore the description of symptoms may be modified by the parent’s perceptions or interpretations, and by factors such as anxiety. These factors vary with age also. You will need to modify your approach to establishing rapport with the patient and how the examination is conducted according to the age and developmental stage of the patient. There are differences in the techniques of physical examination and in expected findings at different ages. Different aspects of the history will require emphasis at different ages. For example, details of the pregnancy and birth are relevant in infancy, whereas immunizations, growth and developmental milestones are important in preschool-aged children, and behaviour and schooling need to be explored in older children.



Acuity of the presentation


The urgency of the presenting problem will impact significantly on how the consultation is conducted. In an emergency presentation, urgent treatment will obviously take priority over obtaining a complete history. It is, however, usually appropriate to return to aspects of the history at another time. For example, a complete past history and developmental assessment would not be necessary in a 4-year-old presenting with acute diarrhoea and vomiting, prior to commencing rehydration. However, it would be essential if the presentation was because of parental concern over the child’s speech. In other cases it may be appropriate to split the consultation into more than one session. This is often appropriate for the assessment of more complex problems. Young children often become bored, tired, hungry or irritable if a consultation lasts more than about 30 minutes. This can limit their ability to concentrate or cooperate with the assessment.



image Clinical example


Louise, a 4-month-old girl, was the first baby in her family. She was taken to the general practitioner by her mother, Mary, who was very anxious because she felt that her baby was constipated, with a bowel action only once every 3 days. Mary was worried that this was because she was not producing enough breast milk to meet Louise’s needs. Mary had been advised by a relative to give Louise laxative drops and to switch to bottle-feeding.


Careful history-taking revealed that Louise was feeding well and was passing a partly formed stool every third day without difficulty. There were no abnormalities on examination. Her growth chart showed that she was gaining weight well and was tracking just above the 50th centile for her age. Mary was shown the chart to reassure her that her baby was thriving. It was explained that Louise’s stool frequency was within the normal range for breastfed babies. Mary was encouraged to continue breastfeeding.



Establishing rapport with the child and family


Your success in obtaining valuable information from the history and physical examination will depend on establishing a good relationship with the child and family. The parents need to know who you are, and to understand the purpose and likely outcome of the consultation. The child needs to feel comfortable in the environment and with you, particularly as you move on to the physical examination. Stranger anxiety, especially in children from about 8 months to 5 years of age, can be a significant obstacle. Experience and understanding help to overcome this.


Introduce yourself to the parents and, for almost all ages, to the child. Explain who you are and your role in the child’s care. A common concern from parents of recently hospitalized children or children attending clinics is that they met many doctors and other health professionals, not really knowing who they were or who was ‘in charge’.


Ask what name the child likes to be called by. How much you should talk directly to the child at this stage will vary with the age of the child and with your assessment of how relaxed the child is. Some children respond well to questions and comments about their favourite sports team, school or a toy they have brought with them, whereas others are shy and anxious if you address them directly. Learn to read children’s responses and adapt accordingly. Young children may initially be very shy and cautious, and become much more confident and interactive later in the consultation.


Children’s behaviour will often reflect how their parents are feeling. It is common for parents to be anxious when attending a medical consultation. If you can form a good relationship with the parents, they will feel more at ease during the consultation and you will also have a better relationship with the child.


Sometimes it is appropriate to reassure the child at the start that nothing unpleasant is going to happen during the consultation (e.g. no blood tests or ‘needles’). The child may associate visits to the doctor with memories of past uncomfortable experiences. Never hesitate to explain why you are asking a certain question or why you are performing a particular part of the examination.



The setting


The physical environment makes a big difference to how children feel. An adult may tolerate undressing in a cold room to be examined, but a 2-year-old will probably cry. A bright, colourful room with pictures on the wall and toys on the floor is much more conducive than a ‘sterile’ clinical environment. A good range of toys, drawing materials, puzzles and other activities for all ages will be helpful.



Observation


It is important to remember that you can gain a significant amount of information regarding a child’s state of health and development, prior to launching into the formal history and examination, simply by observation. It is important when planning your consultation to allow time to sit back and observe the child’s interaction with their parent/carer and the environment. You should be able to assess whether the child looks well or unwell, is appropriately grown and developmentally appropriate for age. Your ability to do this will increase with experience.



Referral information


You will often have referral information from another doctor in the form of either a referral letter from a general practitioner or the notes from the emergency department doctor. You need to take this information into consideration, but not trust it implicitly. It is vital that you assess the child yourself and determine what you believe is the cause of the problem. Parents/patients often dislike having to repeat themselves several times, so it is important to explain clearly why you are asking them to repeat the story again.



Taking the history


As mentioned above, the history is the most important component of the clinical consultation, as this is where the majority of information for making a diagnosis comes from. The basic outline or structure of paediatric history is the same as in adult medicine, but with the need for some variation in the areas that are focused on. This structure includes the following areas, which are described in more detail below:



• Presenting problem


• Past history


• Systems review


• Family history


• Social history


• Developmental history


• Behaviour


• Sleep


• Immunizations


• Medications


• Reviewing your understanding of the history.


It is worth remembering that a number of factors may impact on the taking of a paediatric history, such as how distressed the child is, the level of parental anxiety and sleep deprivation, which is common when looking after sick children. There will also be cases where the family do not speak English and it is vital to use an interpreter.



The presenting problem


Start by asking the parent (and/or child) about the current problem or problems. It is important to find out what they perceive to be wrong and why they have chosen to seek medical attention at this time, and to get this information in their own words. It is also useful to ask what they believe the cause of the problem may be. Remember to use open-ended questions such as: ‘Why have you come to see me today?’ Allow the parent/child to provide the whole story before interrupting to clarify symptoms as this will disrupt their flow and may result in the omission of key information. Understanding the sequence and evolution of symptoms can be just as important as otherwise listing the symptoms themselves. Ensure you get the story from the beginning. Questions such as: ‘When was she last completely well?’ can be very helpful. The pattern of evolution will often reveal the diagnosis (e.g. central abdominal pain, later moving to the right iliac fossa in appendicitis). Parents know their children best and are generally good judges of when something is wrong. Their concerns should be taken seriously.


You then need to explore the symptoms in more detail; for example, if the presenting symptom is cough, you will want to learn its character, whether it is repetitive, whether it occurs under certain circumstances and whether it is moist or dry. When seeking extra detail or clarification, ensure your questions are open (e.g. ‘Can you tell me about his bowel actions?’) rather than closed (e.g. ‘So he has not had any diarrhoea?’). It is important to gain information from the child as well as the carer. How you go about this will depend on the age of the child. For an infant it will be by observation alone, whereas an adolescent may well be the primary provider of the history.


Be sure that the parent understands the terminology you use and always avoid medical jargon. It is also important that you ensure you and the parents have the same understanding of terms that are used in everyday language but are also medical. For example, when a parent uses the term diarrhoea they may mean loose, but not frequent, stools. Or when they say, ‘He vomited bile’, are they referring to yellow gastric juices, which is often the case, or do they mean true bright green bile? You will want to enquire about appropriate epidemiological features such as whether anyone else in the family or other contacts has had similar symptoms, or whether anyone at home is a smoker.


Summarize your understanding of the symptoms and discuss this with the child and their parents once you feel you have a complete picture of the presenting problems and symptoms, to ensure that you have understood the information correctly and also to allow further information to be added if needed.



image Clinical example


William, a 5-year-old boy, was brought by his parents for assessment because they noticed that he was tired each day in the late afternoon. He would lie on the sofa for up to an hour and be uninterested in playing during that time. Following this, he would seem to be his normal self.


This had been going on for nearly a year, since he started school. The rest of the history and examination were unremarkable. The parents’ concerns seemed out of proportion to what is fairly common behaviour in early school-age children. When asked why they had chosen to seek a medical opinion now, they revealed that a child of one of the mother’s work colleagues had recently been diagnosed with leukaemia, and tiredness had been one of the features of her illness. The parents’ major concern was that William might have the same diagnosis.



image Practical points




• To obtain the trust of a child, you also need to gain the trust of the parent/s.


• Do not use abbreviations or medical jargon during discussion with the family (say ‘blue’ rather than ‘cyanosed’ and ‘breathing difficulty’ rather than ‘dyspnoea’).


• When the family use descriptions such as ‘wheezing’ or ‘croupy’, make sure that these words mean the same to them as they do to you.



Past history


The initial enquiry about the past history seeks to gain information relevant to the current problem and age of the child. It is important to ask whether the current problem has ever occurred in the past and about past illness that might relate to the current presentation (e.g. a past history of meningitis will be very relevant for a 2-year-old who now presents with a seizure disorder). Then move on to the child’s general state of health. Are they usually active and healthy? Have they had any other significant illness, operations or hospital admissions in the past?


For infants, it is important to obtain a history of the mother’s pregnancy (her health, nutrition, use of medications, alcohol intake and smoking during the pregnancy, etc.), details of the birth (gestation, problems during labour, breech delivery, use of forceps or caesarean section) and the condition of the infant at birth (including the Apgar score, if known, and the need for any medical interventions such as oxygen therapy). What were the birth weight and other measurements? Ask about the infant’s course in the first few weeks, including any illness and details of feeding and weight gain. Parents may have the child’s health record, which will provide many of these details. Simple questions such as, ‘Was the mother allowed to hold her baby immediately after birth?’ and ‘How soon was the baby discharged from hospital after birth?’ can probe for problems. In young children, the early feeding history is also important.


Details of the pregnancy, birth and early course of postnatal life are usually of less significance for an older child presenting with an acute illness. They will be important, however, for an older child if the presenting problem is neurological or there is a concern about developmental progress.



Systems review


A brief check for other symptoms should be undertaken, using the usual organ systems approach. Questions should be relevant to the current problem and the age of the child, rather than a long list of routine items. Ask about recent travel or potential environmental exposures if they are relevant to the presenting problem.



Family and social history


These are in fact separate but closely aligned, and therefore are often enquired about at the same time. The young child’s world is the family and it is important to obtain an understanding of the family and social contexts of the child’s illness and management. Ask about the age and health of the child’s parents and siblings. Who else lives in the same household, and who provides most of the child’s care? Does the child live in more than one household, as is often the case when parents are separated? Does the child attend day care, kindergarten or school? Is there a family history relevant to the child’s presenting problems?


Find out about the family’s housing and economic situation. Are the parents employed? Do they receive any financial allowances or community services? Look for factors that might adversely affect the child’s health (e.g. smoking by household members), or that may influence management decisions (e.g. if the family lives a long way from hospital and has no car).


It is usually useful to draw a brief family tree (Fig. 2.1.1).


image

Fig. 2.1.1 This brief family tree reveals a lot about the genetic and environmental factors that affect John, who now presents with recurrent cough and wheeze.

Related posts:

  1. Sudden unexpected death in infancy
  2. Birth defects, prenatal diagnosis and teratogens
  3. Resuscitation
  4. The newborn infant: stabilization and examination

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on The clinical consultation

Full access? Get Clinical Tree
Get Clinical Tree app for offline access