Spotting a Focus in Child Examination

Spotting a Focus in child examination Top to toe approach to search for a source of infection Always begin by checking for a rash: E.g. non blanching rash after vomit may not indicate a serious illness if the child is otherwise well Use the glass test to assess blanching Assess general condition Alertness Temperature Respiratory rate Heart rate Head and Neck Check for: Bulging fontanelle in infants Neck stiffness Unreliable and late signs in young children Photophobia ENR Look for coryza – runny nose Examine ears and throat Do at the end in younger children to avoid distress Careful not to overdiagnoses: Otitis media Pink eardrums alone -> do not mean infection Look for fluid levels, dullness or asymmetry Tonsillitis Large/red tonsils alone do not mean an infection True tonsillitis has exudate on enlarged tonsils Chest Respiratory rate Signs of distress Recession Grunting Abdomen Palpate for organomegaly Enlarged spleen in a child with a sore throat and rash after antibiotics -> likely glandular fever Urinary Tract If there is no clear focus Check urine sample UTIs are a common hidden source Next steps based on Clinical Findings based on NICE Guidelines RED category Must be seen face to face by a paediatric trained doctor AMBER category Referral depends on: Age Clinical reason Family’s ability to cope will illness Hospital setting Children who are either red or amber often have the following done: FBC Blood culture CRP CXR VBG LP Role of Temperature Degree of fever is a poor predictor of serious illness Poor correlation between high fever and serious bacterial infection Children vary in how their temperature responds to illness Temperature Measurement locations Babies -> measure under arm Infants and older children -> measure in ear Important red flags Babies under 8 weeks may not develop fever even with a serious infection Instead, they become hypothermic instead – RED FLAG A septic baby may require a septic device Role of antipyretics Paracetamol/ibuprofen Lowering fever with medication does NOT indicate a mild illness The drop in temperature is pharmacological effect NOT A DIAGNOSTIC CLUE Most children respond to antipyretics regardless of infection severity Why give antipyretics To reassess physiology: Fever elevates heart and respiratory rates Once fever is reduced, can better assess for tachycardia or tachypnoea as signs of serious infections To reassess behaviour: Fever makes children miserable Improvement in alertness and interaction after fever reduction is reassuring If the child remains subdued or uninterested in surroundings or toys even after fever drops -> RED FLAG Parental guidance on fever Educate parents on effective fever control Warn against fever paranoia Especially common in parents worried about febrile convolutions No evidence that strict fever control prevents febrile seizures Red Flags Condition Description More common in children under 3 years with signs of sepsis Doctors often perform a CXR in these cases due to: Subtle clinical signs in young children Key suggestive features Child appears more unwell and lethargic than viral infections Fever of more than 38.5 Refusal to eat or drink Clinical signs Tired Noisy breathing Signs of resp distress Tachypnoea Use of accessory muscles Subcostal recession Pneumonia Cough Less reliable than in adults May be absent in some cases Chest auscultation Less reliable than in small children Small chest size transmits sounds difficult Focal localisation difficult Diagnostic Clues General signs: lethargy, fever, high heart rate (esp. if disproportionate to fever) Most important discriminating sign Raised resp rate Children who are unwell enough requiring hospitalisation alone justifies a CXR low oxygen saturation Common in babies and children – MUST NOT OVERLOOK Often lack classic symptoms in young children e.g. dysuria Should be considered when no other source of fever is found on history or examination Non-specific symptoms in younger children: Fever, vomiting, poor feeding, abdominal pain, irritability Complications: In children less than 3 -> infection can ascent to the upper urinary tract UTI May cause permanent kidney damage -> detected later in life In babies UTIs rapidly progress to septicaemia Urine sample collection Use multiagent DipSTix for initial screening If nitrates and leucocytes are negative -> UTI is unlikely If positive -> send urine for lab culture Start empirical antibiotics while awaiting results Children under two are susceptible to osteomyelitis or septic arthritis Suspect when no other source of infection is found and examine: Elbow Hip Knee Clues from history and observation Reluctance to use a limb Bone or Joint Infection Pain on movement Limping or refusal to walk in ambulant children Warmth or redness over the joint May be absent in early stages Septic arthritis is a surgical emergency May require urgent joint washout If suspected -> immediate referral to a senior orthopaedic surgeon Mainly affects children under 2 A type of vasculitis that has a potential for serious cardiac complications such as the coronary arteries Early management with appropriate medications can prevent long-term damage Key clinical features High grade fever that is persistent for days Child is usually very irritable Rash is common and non-specific Usually maculopapular Fingers Kawasaki Disease ad toes are often swollen in the acute phase Eyes are red, with bilateral conjunctival infection, but without discharge Sore mouth that includes red lips, strawberry tongue and oral mucosal changes Cervical lymphadenopathy with a large lymph node on one side of the neck Skin peeling may happen later in the illness Especially on fingers and toes Importance of early recognition Prevent coronary artery aneurysms Reduces the risk of long-term cardiac complications Can cause significant systemic illness and even death especially in epidemic and pandemic areas Most are self-limiting, but some may become seriously unwell Clinical features in older children: Headache Muscle aches Sore throat Tiredness Cough Clinical features in younger children: Less specific: Vomiting Diarrhoea Influenza Rash General listlessness Symptoms may overlap with bacterial meningitis, pneumonia and minor viral infections. In high-incidence period e.g. winter have a high index of suspicion Use the three-minute toolkit Management: In flu epidemic -> consider antivirals Otherwise, symptomatic relief: Paracetamol Ibuprofen Criteria for admission Based on physiological values Clinical judgement Difficult to diagnose in children because: Young children often lack specific symptoms or signs Wide spectrum of presentations Depending on how the infection affects the body Types and causes Viral: common, often mild – may present as just a headache Bacterial: serious, potentially rapidly fatal Septicaemia: can occur with or without meningitis. Often deadly Symptoms and signs: Meningitis: headache, drowsiness, seizures, bulging fontanelle in infants, irritability Meningococcal septicaemia purple rash (due to capillary leakage from endotoxins) Meningitis and Meningococcal May start as a pink blanching rash Sepsis Use the glass test -> to see if rash fades Rash can evolve rapidly and lead to skin necrosis, grafts or amputation Signs of circulatory failure E.g. tachycardia, mottled skin A child may have meningitis without septicaemia or vice versa The mode of death differs depending on which is predominant Always do a top to toe examination In teenagers’ symptoms may be misattributed to: Alcohol or drug use Behavioural issues Immediate management Do not delay antibiotics – give IM or IV penicillin or ceftriaxone immediately Modern DNA based diagnostics can confirm the infection even after antibiotics are started