Thursday, 18 June 2015

The Doctor didn't examine my child properly


One of the challenges in paediatrics is examining children.  While some are cooperative and a few comply with a traditional examination, neurological examination is one of the most difficult aspects of the assessment to achieve.   The difficulties of achieving a ‘tone, power, reflexes, sensation and coordination’ examination in a toddler for example are substantial.  (If you ever want to see what a medical student looks like when their fight or flight response is kicking in, ask them to do cranial nerve examination in a baby.)

The thing is, neurological examination of children is easy.  In most cases they will do it for you.  You just need to know what you have accidentally examined.

Let’s take a scenario.  A three year old is brought for assessment.  The parent reports an episode that sounds like a classical reflex anoxic seizure.  There are no red flags (1) and you are confident in your diagnosis.  The child is however, completely uncooperative with examination.  Everything looks normal and you reassure the parent as well as giving a full explanation.  Later there is a complaint: ‘The doctor did not examine my child properly.’

I suspect that many clinicians would feel that they were in an impossible situation here.  They know that they assessed the child.  Is that the same as examining the child?  In paediatrics it may well be.
 

You see, cooperative children can be formally examined and uncooperative children can be passively examined.  They don’t mean to be helpful.  It just happens to be the case that they will give you everything you need.  All you need now is to prove it, which really requires very simple documentation.   For example: ‘cried and ran into corner of room and hid.’  Here we have cognition, visual acuity, use of the 7th, 9th, 10th and 12th cranial nerves as well as a fair assessment of power, gait and coordination.  Once you have added up all the behaviours observed, along with a little trickery you can cover most of the central and peripheral nervous system examination.

I will return to the subject of how to be clever about examining and assessing children.  For now though, there is only one simple message.  Think about what you saw and then ask yourself what you can tell from that observation.

Edward Snelson
DCH RCPSG
@sailordoctor

Disclaimer:  Child walks into a bar... Not my fault - they should have been looking.  But, it tells me a lot about their neurology...



(1)  http://www.gponline.com/paediatric-medicine-syncope-childhood/article/842747
Red flags for cardiac syncope - (from GPonline, 3/9/08 by Dr Hindley  consultant paediatrician)
  • Syncope in a child with known congenital heart disease.
  • Syncope during exercise or when supine.
  • Family history of sudden death (especially if <30 years of age), prolonged QT syndrome or HOCM.
  • Syncope preceded by palpitations.
  • Heart murmur or other abnormalities on cardiovascular examination.

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