Paediatrics Long Case Templates

By Samuel Lee,2014-04-08 21:03
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Paediatrics Long Case Templates


    Long Case Templates








    1. While greeting and introduction: eyeball patient (and parent) and decide if child looks normal

    or not

    2. Presenting complaint: A seizure! ;

    3. History of presenting complaint: sta. 1 question: Is this the first time this happened? If yes, then can’t say its epilepsy

    b. Who witnessed it?

    c. Describe the seizure:

    i. Prodrome : Any aura? Change in behaviour?

    ii. Seizure :

     Tonic clonic? (tensing, then shaking, LOC)

     Atonic? (Drop attack)

     Absence? (Just staring, not respoinding when called, + blinking)

     Partial? Child may be fully conscious, only ? limbs


     If temporal lobe Automations, strange behaviour, sltered conscious


     How many?

     How long did it last? (>20mins status epilepticus)

     Any loss of consciousness? Any tongue biting?

     What did you do for the child? (Appropriate vs. Inappropriate first aid


    iii. Post ictal : Drowsy? Sleeping? Vomiting? Temporary paralysis (Todd’s


    d. Did the child have a fever?

    i. Do seizures occur only when child has fever?

     Tmax of fever

     Associated symptoms (e.g. cough, sorethroat etc)

     Exclude meningitis, encephalitis as a cause. e. Any head injury just before the seizure?

Now establish:

    ; Is it a febrile fit?

    o OR epilepsy? sto OR 1 time seizure with no defined cause?

    o OR seizure, probable cause _______?

     e.g poisoning, hypoglycaemia

    o OR is it a pseudoseizure

     Rigors, breath holding attack?

    4. Past history

    a. Seizures:

    i. Frequency of seizures

    ii. Time, occurrence of seizures

    iii. Date of last seizure

    b. Epilepsy: sti. Age at 1 seizure, describe seizure, a/w fever?

    ii. h/o febrile seizures when young?

    iii. When and how diagnosed. Any event preceding seizure?

    iv. Treatment:

     Anticonvulsant medications

     How many?

     Any ?/?/? in drug dosage & types?

     Compliance, how often is a dose missed & what to do if it is


     For how long; any attempt to stop medications?

     Sde effects of medications?

     Outpatient review


     Test done @ f/u

     Other Inxs e.g EEG to date


     How many? Reasons?

    v. Any identifiable triggers for seizures, e.g. fever, emotion, lack of sleep, bright


    vi. Any identified medical problem/cause associated with seizures? Diagnosis

    given? e.g.:

     Neurocutaneous syndromes (NF-1, TS, S-W)

     Cerebral palsy

     Neurodegenerative syndromes (Rett’s, Lennox-Gastaut)

     Past h/o brain tumour, head trauma, meningitis/encephalitis/brain


    To exclude /note on Inborn errors of metabolism

    physical examination How are these problems managed?

    vii. Any other past medical history?


    5. Developmental history

    a. Antenatal history

    b. Development in infancy milestones

    Assess on physical c. Interaction with friends, children his age, family

    examination d. If schooling: keeping pace with classmates? e. Any regression e.g. loss of walking/talking ability

    6. Social history

    a. Impact on child:

    i. Schooling

    ii. Athletic participation

    iii. Self esteem, peer relationships

    iv. Does teacher know of condition?

    b. On family : Financial burden

    c. CONTINGENCY PLAN : What to do in the event of a seizure?

    7. Summary

    a. Type of seizure Classify

    b. Associated problems/possible cause

    c. Treatment and complications


Recall :

    CP is a non progressive motor disorder of movement and posture, due to a defect or lesion in the

    developing brain.

Types : Spastic (70%) Hemiplegic/Diplegic/Quadriplegic

     : Dyskinetic (15%)

     : Ataxic (5%)

     : Mixed (10%)

Consider various associated problems

    Look for possible cause of CP


    1. Presenting Complaint

    a. May be complications of CP, e.g. swallowing problem, aspiration pneumonia, seizures

    b. May be for elective surgery, e.g. tenotomy (correction of contractures), tendon transfer

    (correct deformity from muscle imbalance)

    2. History of presenting complaint Onset, duration, progression… (according to complaint)

    3. Current symptoms/Functioning

    a. Intellectual ability/Present developmental status

    b. Current placement (education/domestic e.g. home)

    c. Behaviour, affect

    d. Vision. E.g. strabismus/myopia/blindness

    Hearing, speech, communication problems

    e. ADL dependent/independent?

    f. Feeding/nutrition:

    i. Sucking/swallowing ability

    ii. Tube feeds/gastrostomy

    iii. GER

    iv. Aspiration

    v. FTT

    g. Seizures : Type, duration, frequency, last episode

    h. Mobility Able to walk? If so, gait pattern? Abnormal posturing?

    i. Others, e.g. constipation, chest infection, urinary incontinence, pressure sores…

    4. Birth history

    a. Prenatal : PIH, GDM, drug history, findings on ultrasound, IUI, fetal movements

    b. Delivery : Gestational age, BW, mode of delivery, any complications, APGAR score,

    any resuscitation needed?

    c. Postnatal : Respiratory distress, Feeding difficulties, Seizures, Hydrocephalus, Jaundice

    requiring phototherapy/exchange transfusion, IVH/PVL, any NAI in infancy, e.g. head


    5. Developmental history

    a. Milestones achieved: Ascertain quality of attainment! i. Gross and fine motor e.g.bottom shuffling, development of early hand ii. Social preference, splaying of fingers when attempting grasp iii. Language

    6. Past medical history

    a. Any illnesses in infancy e.g.meningitis/encephalitis, severe jaundice, severe sepsis

    b. Any HI/NAI/neurosurgery

    7. Family history of CP

    8. Management so far:

    a. Recent management in hospital

    b. Usual treatment at home

    c. Usual doctors seen

    d. Compliant with follow up?

    e. Frequency of therapy (PT/OT/ST) 9. Social history

    a. Disruption to family routine

    b. Financial considerations

    c. Social support, including self help groups

    d. Special school/sheltered workshop?


    ; Classify type of CP

     Spastic hemiplegic/diplegic/quadriplegic



    ; List associated problems, e.g.

     Poor swallowing, chest infection, urinary incontinence, behaviour problems, contractures


     Functional status: Mobility/Wheelchair bound? ; Postulate underlying cause if confident



    ; Differential diagnoses


    ; Know social support avenues, e.g. Spastic Children’s Association.


    ; MRI/CT scan of the brain

    ; TORCH screen

    ; Urinary metabolite screen

    ; Karyotyping

    PHYSICAL EXAMINATION (As part of the long case as well as short case)

1. Greet, introduce yourself to the parents and patient


    a. Dysmorphic features (e.g. chromosomal abnormalities)

    b. Growth parameters

    i. OFC (usually obvious microcephaly in quadriplegics)

    ii. Height (usually decreased)

    iii. Weight ( often there is FTT)

    c. Posture

    i. Increased extensor tone

    ii. ATNR (persisting beyond 6 months)

    iii. Fisting (thumbs buried in fists)

    iv. Hemi/quadri/diplegic

d. Movement:

    i. Involuntary : Dystonic, choreoathetoid

    ii. Voluntary : Hemi/diplegic gait, immature gait pattern (tiptoeing, wide base)

    e. Asymmetry

    f. Behaviour lack of interaction with the environment, crying g. Eyes squint, not fixating, cortical blindness (roving eye movements)

    h. Bulbar signs dysarthria, drooling

    i. Interventions NG tube, gastrostomy tube, scars from previous interventions,

    j. Clothing Nappies in child > 4 years old abnormal

    k. Peripheral aids Wheelchair, orthoses, walking aids


    a. Older, mobile child Standard gait examination (hemiplegia, ataxia shows up)

    b. Child who can crawl Asymmetry (hemiplegia), buttock crawling (di/quadriplegia)

    c. Gross motor assessment (180? maneouvre)


    i. Supine Extensor posturing

    ii. Sit Poor trunk control

    iii. Tilt sideways Assess head righting

    iv. Stand Scissoring

    v. Parachute reflex Detect asymmetry

    d. Inspect for tension release scars

    e. Palpate muscle bulk in each muscle group

    f. TONE:

    i. Early CP Hypotonia, often with increased reflexes

    ii. Later CP Hypertonia Spasticity (clasp knife rigidity) g. DEEP TENDON REFLEXES

    i. Increased reflexes (3+)

    ii. Sustained clonus

    h. POWER:

    i. Assess voluntary movement

    ii. Functional power e.g. grasp of toys

    i. Test for persistence of primitive reflexes.


    a. Measure OFC (microcephaly)

    b. Vision, extraocular movements (squint, blindness,…)

    c. Hearing (sensorineural deafness)

    d. Ears (Chronic serous OM)

    e. Teeth (Dental caries)

    f. Back (Kyphoscoliosis)

    g. Chest (Signs of consolidation Chest infection)

    h. Abdomen (Constipation)

    i. Hips (Dislocation)

    j. Screen nutritional status

    k. Functional assessment for ADL (more in diplegic/hemiplegic/ataxic)

    l. Assess other areas of development (social, language).




    a. Reason for current admission


    a. Ask in detail!

    b. Usually those of acute exacerbation c. Ask whether attempted treatment at home d. Anything that suggest another problem, e.g. pneumonia, pneumothorax


    i. SOB

    ii. Wheeze

    iii. Cough

    iv. Chest pain/tightness

    v. Decreased exercise tolerance

    vi. Day/night?

    b. Pattern:

    i. Frequency Day/Night (GINA Classification)

    ii. Severity

     Number of attacks per year (or month)

     Need for bronchodilators/oral steroids

     Admitted to hospital? ICU? A&E?

    iii. Precipitants:

     Dust (faeces of house dust mites!)



     Cigarette smoke

     Pet fur/ dander


     Temperature changes

     Exercise (in EIA)



    4. DESCRIBE a typical acute exacerbation a. Initial symptoms

    b. Precipitant(s), if identified

    c. Tempo of progression

    d. Rate of recovery

    e. How child handles illness

    i. Still able to talk?

    ii. Breathing fast?

    f. Usual outcome

    g. Treatment used

    5. PAST HISTORY (may be asked at the same time as )

    a. Age of onset of symptoms

    b. Age of diagnosis

    c. As a baby : Any respiratory complications in perinatal period? Recurrent bronchiolitis?

    d. Number of A&E visits/hospitalization/IV therapy/ventilation

e. Previous investigations e.g. spirometry, skin prick test

    f. Change in clinical course - ?/? frequency of symptoms

    g. Past history of, or concurrent allergic rhinitis, eczema, food/drug allergies.

    6. FAMILY HISTORY of asthma or any atopic conditions.


    a. Present treatment in hospital

    b. Usual treatment at home

    i. Reliever

    ii. Preventer

    iii. Mode of delivery

    iv. Before exercise?

    v. Any changes in medicines before?

    vi. Any ADRs?

    vii. Allergy avoidance (ask about HOME ENVIRONMENT)

    viii. Crisis plan?



    a. Home environment

    i. Carpets, rugs

    ii. Pets

    iii. Types of pillows

    iv. How frequently is the house cleaned, and how is it cleaned?

    v. Any construction/upgrading going on nearby?

    vi. Any smokers at home?

    b. Impact on child

    i. Amount of school missed

    ii. Impact on exam grades

    iii. Limitation of ADL/physical activity?

    iv. Effect on development/behaviour?

    v. Peer interaction

    vi. Developmental milestones

    c. Impact on family

    i. Financial considerations Can afford medications, hospital fees?

    ii. Disruption of family routine

    iii. Support groups?

    d. Teens ASK ABOUT SMOKING! If positive :

    i. For how long?

    ii. Number of cigarettes per day

    iii. Where/how they get their cigarettes (and the moolah for it! :p)

    iv. Why they smoke

    v. Do their parents know?

    vi. Who they usually hang out with?

    vii. Tried to quit?

    viii. Aware of adverse affects of smoking?

    ix. Do they think it makes their asthma worse?

    9. Check inhaler technique


    1. General Inspection


     Atopic facies

Cushingoid features

     Tachypnoeic? Any other signs of respiratory distress?

     Skin : Eczema (elbows, knees, neck) 2. Vital signs

     Pulse (rate, bounding?)

     Respiratory rate (??)

     Blood pressure SE of steroids?

     Temperature Precipitation of URTI


     Hands : Tremors (from β-agonists)

    Will have NO clubbing

     Eyes : Allergic conjunctivitis

    Swollen discoloured lids

     Nose : Pale, swollen mucosa

    Visible inferior turbinates


     (Ears : Serous OM)

     Throat : Redness, exudates

     Cervical lymphadenopathy

    4. CHEST

     Inspection :


     Increased AP diameter (barrel chest)

     Harrison’s sulcus

     Palpation :

     Chest expansion

     Apex beat

     Trachea central?

     Percussion should be resonant, unless:

     Chest infection Dull

     Pneumothorax Resonant

     Auscultation :



     Decreased breath sounds?

    Test inhaler technique

    PEFR difficult in exams


    1. Clinical history and physical examination (especially in infants and toddlers, who can’t follow

    instructions for usual spirometry test) 2. Investigations (helpful in confirming diagnosis in children > 5 years old)

    ; Peak expiratory flow rate

     Reflects large airway patency

     Effort dependent, only in older kids!

     Better to have series of measurements, e.g. for diurnal variation >20% (exaggerated

    compared to normal people), or before/after bronchodilator treatment

    ; Spirometry Time-volume curve, Flow-volume loop

     FEV/FVC Obstructive pathology 1

     Cutoffs : FEV < 75%, FEV/FVC < 75% 11

     Response to bronchodilator treatment > 15%

     Provocation inhalation challenge (Methacholine) ; Allergy testing:

     Skin prick test

     Discontinue antihistamines for > 3 days

     Wheal of 3mm diameter, (+) erythema = positive test

     Histamine as positive control

     RAST for specific IgE

     Useful if taken antihistamines/extensive skin disease/anaphylaxis.

     Food challenge/avoidance

     More for eczema, GI allergies

    ; Chest X-Ray - Asthma DOES NOT have CXR findings. Purpose is to exclude:

     Inhaled FB


     Chest infection

    3. Establish severity (by STEP classification)

    ; Step 1 : Intermittent

     Day : < 1 time a week, asymptomatic in between attacks

     Night : < 2 times a month

    ; Step 2 : Mild persistent

     Day : > 1 time a week BUT < 1 time daily

     Night : > 2 times a month

    ; Step 3 : Moderate persistent

     Day : DAILY symptoms, affects daily activities, β-agonists daily

     Night : > 1 time a week

    ; Step 4 : Severe persistent

     Day : Continuous limited physical activity

     Night : Frequent symptoms

    4. Decide if TREATMENT is ADEQUATE

    ; On bronchodilators only?

    ; If on preventer medications:

     Dosage adequate?

     What’s used? E.g. inhaled steroids, LABA, theophylline, anti-leukotrienes. ; Have the symptoms decreased with medications? Have the symptoms increased with need

    to revise medications?

    ; Any asthma action plan (written, divided into green, yellow and red zones)

    ; Who follows up on the patient, and is this follow up regular? ; Teens who smoke Counselling?

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