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The letters ‘SOAP’ remind us of the 4 main steps of a general examination:
The four main steps in the examination are the story, the observation, the assessment of the problems, and the management plan.
The first step of the general examination is to introduce yourself to the child and his or her mother, father or caregiver (guardian). At the start, find out whether the child is a boy or girl. Always make sure that you know the gender of the child. If you get that wrong the parent may not trust you with your medical management. Never refer to a child as ‘it’. Always greet the child and parents with respect. This first meeting establishes the relationship between the caregiver (doctor or nurse) and the child and parents. The rest of the general examination and management of the child depend on a good, trusting relationship. A friendly, caring approach builds trust and confidence. Often in a busy clinic, the introduction is unfortunately bypassed. Always take time to ‘make friends’ with the child first before starting the examination. Avoid strong eye contact with toddlers until you have ‘made friends’.
It is very important to take time to establish a good relationship with the child and mother at the start of the general examination.
Always introduce yourself by name. Find out what the child’s name is and use it throughout the examination. Some children prefer to be addressed by their pet name (‘nickname’) e.g. ‘Bobby’ rather than ‘Robert.’ Never refer to the child as ‘the kid’ or any other term of disrespect. Do not pretend that the child is not present when speaking to the mother.
One of the most dangerous mistakes to make when examining a child is not listening to what the mother (or caregiver) has to say. She usually knows the child best and the opinions and insights of mothers are often right. Always allow the mother time to give her story and ask questions.
Always pay careful attention to what the mother says about the child.
One of the main complaints by patients is that doctors and nurses do not use simple language. Avoid technical terms, complicated words and medical jargon. Make sure that you and the patient understand one another at all times. Sometimes a simple drawing may help to obtain an accurate history or give a clear explanation. Taking a clear history is often difficult when the patient comes from a different cultural or social background.
The child may arrive with a referral letter from a colleague, crèche or school. The referral letter is important because it draws attention to the problem. It is important to read any referral information carefully. Always reply to a referral letter.
It is always very important to ask for and review the child’s Road-to-Health Card as it provides much useful information about the child’s past medical history, immunisation record, growth pattern and wellbeing. If the Road-to-Health Card is lost or not available, ask why. A lost or forgotten Card may be due to a family or social problem. The crèche, school, clinic or hospital must not keep this patient-carried card.
Always look carefully at the Road-to-Health Card before examining a child.
Figure 1-1: A WHO Road-to-Health Card Growth Monitoring Chart
Before the history and examination, some basic information is often taken and recorded by the staff that meet the mother and child when they arrive at the clinic or hospital. This basic information usually includes the following:
Age is needed to plot the infant’s size on the growth chart of the Road-to-Health Card and to assess whether the child’s development is normal. Boys are usually slightly bigger than girls at any given age, while girls tend to be slightly more advanced in their development.
The infant’s size measurements (weight, head circumference and standing height or lying length) must be accurately measured and noted. The measurements must then be carefully plotted on the growth chart of the Road-to-Health Card.
Weight is a very good measure of the child’s general health and must be measured and recorded at every visit.
The head circumference is important, especially in the first year of life, as it is a measure of brain growth.
If the child can stand, the standing height (stature) should be recorded, as it is the best measure of growth. In younger children, the lying length should be recorded. While weight is a good measure of growth in an infant, height is the best measure of growth in older children.
Details of the measurement and plotting of an infant’s size are discussed in chapter 3.
The child’s weight must be measured and plotted on the Road-to-Health Card at every visit.
Body temperature is measured with a digital or mercury thermometer. In younger children the axillary temperature must be recorded. In older children the oral temperature can be measured under the tongue. Rectal temperatures should not be taken.
If a mercury thermometer is used, always shake the mercury down before measuring a temperature. Leave the thermometer in the axilla for 1 to 2 minutes, with the arm held against the body, before reading the temperature. The normal axillary body temperature is 36.5 to 37 °C. If the axillary temperature is higher than 37 °C, the child has a fever. The normal oral temperature is slightly higher than the axillary temperature, with a normal range up to 37.5 °C. Always clean the thermometer before taking a child’s temperature.
If no thermometer is available, feel the child with you hand and assess whether they are normal, cold or hot.
It is best to begin by simply asking the mother (or child) what is worrying them. Make sure that you understand what the complaint is. Ask ‘What is worrying you?’
The history (the story) is often the most important part of the general examination. Most problems can be identified and diagnoses can be made on a good history. Every effort must, therefore, be made to obtain a clear and detailed history.
A carefully taken history will provide the information needed to make the correct diagnosis.
It is best if the history can be obtained from the child. However, in small children this is not possible and the history is usually given by the mother or someone else (the caregiver) who knows the child. Sometimes it is helpful to get the history from both the child and mother as each may emphasize different parts of the history. Some patients may need help to describe and explain their symptoms. Adolescents may wish to be seen without a parent present.
The history not only provides information about the present illness but can also give important details about the child’s past health, social and home environment.
The main parts are:
It is best to start by asking why they have come to see the doctor or nurse. What is worrying them? First let the child or mother tell their story. Give them time to speak without interrupting. In getting an accurate present history make sure that you obtain the following information:
It is important to make an assessment about whether you think the information is reliable or trustworthy. Sometimes it can be very difficult to understand what the complaints are.
It is important to note:
It is most important to determine whether the present complaints can be related to anything in the past history.
It is important at every visit to review the child’s immunisation record. Children may present with an infectious disease because they have not been fully immunised against that infection. An incomplete immunisation schedule may suggest social problems. All missing immunisations must be given.
Children are greatly influenced by their environment and by those around them. Many childhood problems are caused by problems at home (poverty, malnutrition, abuse, neglect, poor housing, unemployment) or at school (discipline, fear, bullying). The presenting complaint may be a warning of deeper social problems. Poverty and poor maternal education are the cause of many childhood problems. Some mothers bring their child to a clinic because they have a problem themselves. This may not always be obvious. Therefore, a social history must always be taken. Suspect abuse if the history does not explain any sign of injury.
Useful questions to ask are:
It is difficult but important to ask the mother whether she knows her HIV status. HIV infection is the cause of many illnesses in children today. Most of these children are born to HIV-positive mothers and infected by mother-to-child transmission.
Special questions should be asked about each system e.g. respiratory, gastrointestinal or cardiovascular system. Questions are mainly limited to the body system involved in the present history. For example, if the presenting complaint is abdominal pain it would be important to ask about appetite, vomiting, diarrhoea or constipation, worms, blood in the stool and weight loss. If the right questions are not asked, you will not be able to get the correct answers.
Many mothers and children do not speak the same home language as the doctor or nurse. Even if you are able to understand each other a little, it is very difficult to take a detailed history without a good understanding of each other’s language and traditions. Here a translator is very helpful. Unfortunately, skilled translators are often not available and local nurses or cleaning staff have to help. Always express your concern and willingness to help the child, and make sure you understand what the main problem is.
Often the history has to be taken in a busy clinic or ward with many other people around. Always be aware that the mother and child may be embarrassed or unwilling to discuss the details of their problem in front of others. This is particularly important if the mother is afraid that her child may have AIDS. If at all possible, try to arrange that histories can be taken in a quiet, comfortable, private area.
Information provided by a patient must always be treated with respect and confidentiality.
Much can be learned by observing the child and mother. Watch their facial expressions, hand movements and body language. These give clues about anxiety, guilt, embarrassment or lack of interest. Observe what kind of clothes they wear.
The steps are:
Usually the general and regional inspection are done first and then followed by the systematic (systems) examination. A special examination (e.g. rectal examination) is only done if there is a good indication.
It is important to do the physical examination in a fixed order. Otherwise, parts of the examination may be forgotten. However, the steps are flexible and in younger children parts of the examination that may hurt or frighten the child or require an instrument (e.g. examining the throat) are often left for last. Most mistakes in diagnosis come from incomplete examination.
In a brief examination, percussion is often left out unless particularly indicated. Always inspect (look) before palpating (touching). Palpate before auscultating (listening). In a small child who is likely to cry, it may be better to listen before palpating. Children are less threatened if you start by examining their limbs first, before examining their chest and abdomen. It is important to make the examination as non-threatening and comfortable as possible. With young children it often helps to turn the examination into a game.
Always observe first.
All components are important. However, it is particularly important to look and see. Inspection is the best means of telling whether a child is well or sick. It also helps to decide whether a child is anxious, frightened or embarrassed. Many diagnoses can be made by careful inspection alone. As children often cannot tell you how they are feeling, you need to obtain this information by observing them.
Many diagnoses can be made by careful inspection.
If possible, an infant should always be examined with one or both parents present. Infants under a few months are usually examined on the couch or bed. Examining a small child of 3 to 36 months is often easier if the mother holds the infant sitting on her lap. This is particularly important when examining the throat and ears when the mother may have to sit the child upright on her lap, looking away from her, while she holds the child’s head firmly against her chest.
Older children may not like lying down and can be examined while standing in front of the mother, depending on the child’s wishes. Always be gentle and friendly. Never rush or move suddenly.
If possible, all the infant’s clothes should be removed slowly and gently. Toys or sweets may help to distract the child during undressing and examination. Never touch a child with cold hands. Most children do not mind being undressed provided due respect is paid to their feelings. Older children may be sensitive and embarrassed about getting undressed in front of strangers.
If a child is very distressed by being completely undressed, it may be better to undress and examine one part of the body at a time. If a child is shy, it is best to leave the underpants on for most of the examination. However, the genitalia should be inspected. A soft blanket can be used to cover parts of the body while they are not being examined.
The examination room should be warm, quiet and interesting to the child. Always keep the mother close by.
Always have warm hands when examining a child.
Usually the general and regional inspection is followed by an examination of the main body systems. The general and regional inspection often indicates what system needs special attention during the systematic examination.
Always look carefully first before touching the child.
During the systematic examination, each system is examined separately by inspection (looking), palpation (feeling), percussion (tapping) and auscultation (listening with a stethoscope):
The order of the examination is flexible. Usually the examination of the mouth, throat and ears is done last as it is unpleasant for a young child. Sometimes the heart is examined first so that the heart sounds can be heard before the child becomes upset and cries.
Danger signs warn that the child may have a serious illness. During the general inspection, it is important to look for danger signs such as:
A child is dehydrated when:
The signs of dehydration are discussed in chapter 5.
Sometimes it may be necessary to perform a rectal or vaginal examination, or examine the fundi of the eyes. These may need to be done under general anaesthesia in a small child.
The 10 common errors are:
The most important special investigations are:
These are often done routinely in ill children.
Other special investigations, which are often asked for in hospital, are a full blood count (FBC), erythrocyte sedimentation rate (ESR), chest X-ray, urine and stool microscopy and culture, and Mantoux skin test. These tests may not be available in many clinics.
These will be determined by the findings of the history and the physical examination. Any investigations should only be done if they are indicated.
Once the history has been taken and the examination completed, it is very important to make an assessment of your findings and write careful notes. You need to note the patient’s main complaints and draw up a list of problems. If possible, make a diagnosis. If this is not possible yet, it is most helpful to complete a detailed problem list.
This is a precise list of the patient’s current unsolved problems (i.e. problems which are still active and need to be addressed). The problems may be medical as well as social or economic. A carefully drawn-up problem list is one of the most important parts of the whole examination and makes sure that no problem is forgotten. Do not include problems which have already been resolved. As soon as a problem has been solved it should be removed from the problem list. From the problem list, an attempt should be made to reach one or more diagnoses. A diagnosis may be included as a problem.
The following is a typical problem list:
A problem list is a precise list of the patient’s current unsolved problems.
Many childhood diseases have similar signs and symptoms but only a few of these diseases are common. The steps in making a diagnosis are:
If you are unable to make a diagnosis or if you diagnose a serious disease, the child must be referred to hospital or a special clinic for further management.
This is a careful plan of how each identified problem is going to be investigated and managed. It is of little help to complete a full general examination, make a careful problem list and possible diagnosis, but then fail to take any action. Each item of the problem list must be considered and a plan of action decided upon and documented for that problem. The plan of action must be clearly written in the patient’s record (if in hospital or at a clinic) as well as in the Road-to-Health Card.
When writing out the plan of action, it is useful to list each problem in turn and then note what action is needed for that specific problem. This helps to keep track of the various actions which are needed for the whole problem list. What is not wanted is a long, confused list of actions where it is uncertain which problems are being addressed by each action.
The clinical findings, assessment and plan of action must be simply and clearly explained to the parents. The patient and parents should be allowed to ask questions and discuss the important points. Always be patient, polite and caring. A translator may be needed.
The following is a typical plan of action:
It is extremely important to always write good clinical notes.
It is essential that clinical notes can be easily read and understood. It is a waste of time and dangerous practice to make notes which others are unable to read.
It is extremely important always to write good clinical notes.
This depends on whether you are seeing the patient for the first time or at a follow-up clinic. It also depends on the amount of time you have to examine the infant and write notes. Notes must be written at every visit. The aim is to produce the best notes possible under the circumstances.
Usually, detailed notes are written at the first consultation. Thereafter, a brief note should be made about each problem on the problem list at every visit. Do not lose a problem from the list until it has been fully attended to. Always make a note of any problems in the Road-to-Health Card.
Use the SOAP system to lay out your initial notes.
All notes must clearly state the date and your name.
Every time the patient is examined, a careful progress note must be made in the patient record or on the Road-to-Health Card. Continue using the SOAP system. Each item on the problem list must be considered in turn. The history, clinical findings, any special investigations, and plan of action must be recorded for each problem. Only record what is important. One of the greatest mistakes made in writing continuation (follow-up) notes is that they are too long and detailed. Notes must be kept short and simple. No one will read pages and pages of unnecessary writing.
Progress notes should be short and simple and address each unresolved problem.
Once a problem on the list is solved, that problem can be dropped and need no longer be included in the problem list. Any new problem should be added to the list.
In this way, each active problem (i.e. still on the list) should be considered at each examination. This provides a simple, clear and systematic record of the patient’s clinical progress. Any other nurse or doctor can quickly understand the patient’s problems and progress by reading good notes.
The following is a typical example of progress notes using a problem list and SOAP method:
PROBLEMS 1. Scabies: S: Itching is much better, especially at night. O: Rash improving. No secondary infection. A: Scabies has responded to treatment with Ascabiol. P: Give mother Ascabiol to treat whole family. 2. Iron deficiency anaemia: S: More energy. Good appetite. O: No longer pale. A: Good response. P: Check Hb. Continue oral iron for 3 months.
If the child presents at either a clinic or hospital, a note should always be written in the Card. A brief summary of the problems, assessment and plan of action should be made even if fuller notes are made in the patient’s hospital or clinic record. As the child may be seen at a number of different facilities over months or years, the patient-carried Road-to-Health Card is the one place where all the visits should be recorded.
Always make a note in the Road-to-Health Card.
A doctor is asked to see an ill 9-year-old child in a hospital outpatient department. He ignores the child and asks her mother what the problem is. She gives him the referral letter, which he does not read. Before she can give her story he has already started to examine the child. The child is not weighed. He tells her that the child has rheumatic fever, and should stay in bed and take the prescribed tablets three times a day. He then rushes out without any further explanation.
He ignores the patient. A 9-year-old child should be able to tell the doctor about the presenting complaints. He also does not introduce himself to both mother and child. This is not only bad medicine but it is also foolish and rude.
No. He does not pay attention to the mother and starts examining the child before she has had a chance to tell her full story. Never ignore what a mother has to say, as she knows her child best.
Yes. Always read the referral letter as it draws attention to the clinical problem and often provides important information. The doctor should have replied to the letter.
All children (and adults) should be weighed as part of a general examination. The child’s weight should have been plotted on a weight-for-age chart.
He failed to explain what the problem was and what the diagnosis means. She should have had the management explained to her. The mother needs to know when to return for the next appointment. Even if the diagnosis and treatment were correct, the history and examination were inadequate.
A general practitioner asks about the presenting complaints and takes a present but no other history from a mother and her 10-year-old daughter. The child has a fever and a rash. After a quick general inspection, he lifts the child’s shirt and looks at the rash. After writing a brief note in the hospital folder he tells the mother that the child has measles.
Only a present history was taken. It is important always to take a past, social and immunisation history as well.
It is important to know whether this child has been fully immunised, especially against measles and rubella.
The doctor only did a general inspection. Each organ system was not examined. The doctor also did not palpate or auscultate. Important clinical signs, such as lymphadenopathy, splenomegaly and signs of measles in the child’s mouth (Koplik’s spots) may have been missed.
The child’s temperature and weight. Always record and plot weight to screen for malnutrition.
No. As this is the initial consultation he should have written full notes (basic information, history, special questions, physical examination and any investigations).
An infant is seen by a nurse at a follow-up appointment at a local clinic. She is unable to read the long and confused notes made at the previous visit and does not ask the mother for the Road-to-Health Card. The mother cannot help her, as she was not told what the problem was. She thinks the child has a heart problem. During the examination the infant cries because the nurse’s hands are cold. As a result she cannot hear the heart sounds and refers the child to hospital.
Because they were not written clearly in a logical order. This is a very common finding. With good notes she should be able to quickly find out what the previous problems and management were.
There may be a summary of the previous visit in the Card. The Card would also indicate how the child has been growing, whether the immunisation schedule is up to date and what previous health problems have occurred. It is a serious error not to review the Card at each visit.
There was poor communication between the health professional and the patient. This is a common problem. This can be partially addressed by making a note in the Road-to-Health Card. The parents and the child should always be fully informed after a consultation.
She did not warm her hands first. Cold hands and a cold stethoscope are a common mistake. As a result she could not listen to the heart.
A child from a very poor home presents with scabies at a clinic. His weight is below the 3rd centile. The mother also says that he has coughed for the past month. The nurse takes a full history and completes a physical examination. She writes SOAP notes in the patient folder and also writes a summary in the Road-to-Health Card.
This is a system of writing clinical notes, which includes the story (history), observations (physical examination), assessment and plan of action. All initial or follow-up examinations should be recorded this way.
Yes. The clinic folder should hold the detailed notes while a summary should be written in the Road-to-Health Card.
This is a clear, simple list of the patient’s problems. The problem list is drawn up during the assessment at the end of the complete examination. The problem list is the most important part of summarizing the findings of the history, physical examination and investigations. A problem list must always be made even if the diagnosis is not known.
An action plan is needed for each of the problems. Some problems, like scabies, needs treatment while others, like the chronic cough, need investigation. It is important that social problems are also recorded and addressed.