The paediatric consultation

Communication Skills in Paediatrics

Paediatricians need to be happy with informality, enjoy humour and appreciate the unpredictability that children bring to consultations! Young children do not have a full understanding of the role of health professionals. Children will naturally be anxious and uncertain in an unfamiliar environment. They may not understand all of the language in the consultation but they quickly detect a sense of personal warmth, friendliness and relaxed mood in adults around them. It helps to have pictures, toys and videos to help children understand that the room is a good place for children.

In paediatrics the focus of the consultation changes with the age and understanding of the child. In a young baby the discussion is entirely with the carers (usually parents) who act as advocates for the child’s needs. As children mature they need to be included in the discussion. It is important to understand the child’s concerns and their right to be involved in decisions. Paediatricians need also to consider the concerns of the family and communicate sensitively with all family members.

Approaching the Consultation

  • Make friends with the child to gain their cooperation. Try to be confident and non-threatening. It may be best to examine an exposed part of the body first before undressing the child, or do a pretend examination on their teddy bear.
  • Try to get down to the child’s level—kneel on the floor or sit on the bed. Look at the child as you examine them. Use a style and language that is appropriate to their age—‘I’m going to feel your tummy’ is good for a small child but not for an adolescent.
  • Explain what you are going to do, but be careful of saying ‘can I listen to your chest’ as they may refuse!
  • Babies are best examined on a couch with the parent nearby; toddlers may need to be examined on the parent’s lap.
  • In order to perform a proper examination the child needs to be undressed, but this is often best done by the parent and only the region that is being examined needs to be undressed at any one time.
  • Older children and adolescents should always be examined with a chaperone—usually a parent but, if the child prefers, a nurse. Allow as much privacy as possible when the child is undressing and dressing.
  • Sometimes you may need to be opportunistic and perform whatever examination you can, when you can. Always leave unpleasant things until the end—for example; looking in the throat and ears can often cause distress.
  • Hygiene is important, both for the patient and to prevent the spread of infection to other patients. Always wash your hands before and after each examination.
  • Always sterilize or dispose of equipment that has been in contact with a patient, such as tongue depressors or auroscope tips.

History Taking

The history often indicates the diagnosis before examination or investigations. The history can be taken from a parent, a carer or from the child. Record who gave the history and in what context. Use an independent interpreter if there are language difficulties.

Beginning the Examination—observation

Much information can be gained by careful observation of the child. This starts while you are first talking to the parents.

  • Signs of acute severe illness (need urgent intervention):

    • shock
    • severe respiratory distress
    • altered consciousness level

  • Signs of pain or anxiety
  • Growth and nutrition
  • Features of syndromic disorders
  • Developmental progress:

    • gross motor and fine motor movement
    • social interaction
    • speech and understanding

  • Interaction with carers
  • Hygiene and clothing
  • Mood and behaviour

The examination of individual systems is discussed in detail on the following pages.

Presenting complaint Record the main problems in the family’s own words
History of presenting complaint Try to get an exact chronology from the time the child was last completely well.
Allow the family to describe events themselves; use questions to direct them and probe for specific information.
Try to use open questions—‘tell me about the cough’ rather than ‘is the cough worse in the mornings?’ Use direct questions to try to confirm or refute possible diagnoses.
Past medical history In young children and infants this should start from the pregnancy, and include details of the delivery and neonatal period, including any feeding, growth or early development problems.
Ask about all illnesses and hospital attendances, including accidents.
Developmental history Milestones during infancy and school performance.
Are there any areas of concern?
Do the parents feel the child’s development is comparable to their peer group?
School performance—any academic or behavioural problems?
Immunizations Review immunizations against national schedule.
Are there any missed or extra vaccinations?
Drugs and allergies What medication is the child taking? Include over the counter preparations.
Does the child have any allergies to drugs or foods?
Systems enquiry Ask a series of screening questions for symptoms within systems other than the presenting system
Family and social history What is the family make-up and who lives at home?
Draw a genogram with the family to discuss extended family history
Consanguinity—having first-cousin parents increases the risk of genetic disorders
Illnesses or developmental problems in the family
Has there been any serious illness previously?
Contact with infectious illness or foreign travel
Social history Which school or nursery does the child attend?
Parents’ education background, jobs, physical and mental health
Home environment—adults who smoke, housing problems, family stresses
Problem list At the end of the history, prepare a clear problem list to guide further management

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Jul 2, 2016 | Posted by in PEDIATRICS | Comments Off on The paediatric consultation
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