A quick but comprehensive assessment of the non-specifically unwell child in the ED

(with thanks to Mr Imran Zia, Emergency Department consultant)

(Taken from the August edition of the Paediatric Pearls for Emergency Departments)

Say hello to the child first and take the history from them if possible. When you come to “was he/she born at the right time?”, turn to the parent. The child then has a few minutes to observe you while you finish off your history and will not be so affronted when you accost them with your stethoscope.

A 15-monther has a very large personal space; they are more likely to trust you if you have won over their parent first. Watch the way the nurses and paediatricians chat their way through the history, assessing the child out of the corner of their eye at the same time; you will find extra time taken at this stage pays dividends.

The aide memoire below should prevent you from missing anything significant in your examination. First, note the Paediatric Early Warning Score (PEWS), in particular the heart rate (of vital importance in assessing how sick a child is), the capillary refill, respiratory rate and saturations. Then perform a FULL external clinical examination as you would normally do paying attention to elements of particular importance in children:

RS Respiratory effort includes rate and signs of distress eg. nasal flaring, intercostal, subcostal, sternal recession, tracheal tug and head bobbing. Feel the neck and axilla for lymph nodes.

CVS Document capillary refill in all children. Press on the sternum for 5 seconds and let go. Colour should return in less than 2 seconds.

Abdo Look and feel hernial orifices and testes. Torsion can present as abdominal pain. Inspect the bottom for bruises/rashes and groins for lymphadenopathy. Assessing peritonitis? Ask the child to jump or “blow your tummy out to touch my hand”. NEVER examine PR or PV.

Limbs Palpate all joints including fingers and toes to look for signs of inflammation (osteomyelitis? Septic arthritis? Sickle cell disease?)

Back Inspect and palpate the spine

Skin Rashes and unusual pigmentation? Check groins, axilla and buttocks.

ENT Examine both ears, oropharynx (back of the tongue is not enough)
and nose

Any photophobia, neck stiffness, Kernigs sign? Ask the child to kiss their knee.

Any concerns about interaction with parents? Involve paediatricians.

Blood tests are rarely needed in children. Ask for advice first.

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