Osteopathic Paediatrics Case Sheet

Osteopathic Paediatrics Case Sheet Walter Llewellyn McKone, DO

University College of Osteopathy, UK. Akademia Osteopathi, PL. Panta Rhei, Postgrad. Osteopathy, NL.

Referred by…………………………………………………………………………………. Date………………………………………

Patient’s Name…………………………………………………………………………….M/F DOB…………………………………..Age….

Parents/Guardian Name………………………………………………………………………………………………..

Home ‘phone…………………………………………Mobile/Handy………………………………………………..

Address…………………………………………………………………………………………………………………………………………………………………….Post Code……………………………….

Family Doctor and Address………………………………………………………………………………………….

School/Nursery………………………………………………………………………………………………………….

I would not mind if the information on this case history is used for research purposes:

Name………………………………………………………………… Signature………………………………………………………………………………….

Presenting complaint (from patient or parent): Positive and negative factors – site. Where, when. What. Distribution. Pain – sharp, dull, throbbing, – deep, superficial, constant, intermediate, no patter, radiations, referral.

Birth weight………………Length/Height………………Present weight…………………Growth rate………………………..

24-hour Pattern: AM/PM. Worse morning or day or night. Sleeping and feeding pattern. Does anything change for better or worse? Any association with family or baby behaviour?

Onset: Sudden, slow. Over what period. After birth? How long after birth? After activity/inactivity. Aetiology: Emotion during pregnancy. Smoking. High BP. Delivery method – Ventouse, forceps. Long last stage (labour). Environmental. Moving house. Breast to formula milk. Trauma. Infection. Fear. Past experiences. Is there anything else?

Aggravating factors: Does movement change complaint? Does feeding change complaint? Emotion. Fear. Travelling. New school. Relieving factors: Calmness. Change in diet/fluids. Clothing. Temperature. Time. Movement. Non Aggravating factors: Calmness. Change in diet/fluids. Movement. Time. School. Siblings. School: Settled. Education standard. Doing well? Any problems?

Sporting activities: What sports? What level? How often? Overtraining? No activity? Why?

Sleeping pattern: All night? Day time? How long? How often? Rested? Agitated?

Feeding/Eating: Healthy. Breast. Bottle. Formula. Mixture. Solids. Fluids.

Past medical history: Operations. Injuries. Infections. How long? Any lasting effects? Action taken? Medications. Hospital visits: Why, When, What for, How long?

Medications: Have BNF at hand. Make sure you record proper spelling. Side effects?

Family history: Congenital heredity diseases – Down syndrome, cleft palate, CDH, Talipes, heart problems, spina bifida, glaucoma, kidney malformations etc. Environmental: Smoking at home. Cleaning materials. Lead pipes. Water source. Furry pets. Sun exposure. Growth/Developmental history: Use a chart. Enquire about growth/development landmarks from a parent. Gross motor, running, fine motor, drawing, vision, speech, hearing, socialisation, eye contact, reading.

Appearance Pulse Grimace Activity Respiration Score

Score 0

Score 1

Score 2

Skin colour

Blue/pale over all

Blue extra

Body pink

No cyanosis

B&Ext pink

Appearance

Pulse rate

Absent

<100 b/pm

>100 b/pm

Pulse

Reflex

No response

Suction & Stimulation

Cry on stimulation

Grimace

Activity

None

some flexn

Resist extn

Activity

Resp Effort

Absent

Weak, gasping

Strong cry

Respiration

Immunisations: Keep up to date with changes.

8 wks: 6-in-1. Pneumococcal (13 serotypes). Meningococcal gp B (MenB). Rotavirus gastroenteritis.

12 wks: 6-in-1 (2nd). Rotavirus (2nd). 16 wks: 6-in-1 (3rd). Pneumococcal (13 serotypes) (2nd). MenB (2nd). 1yr: MMR. Hib. MenC. Pneumococcal (3rd). MenB (3rd). 2-9yrs: Flu vaccine.

3yrs 4m: 4-in-1. MMR (2nd) 12-13yrs: Human papilloma virus (HPV). Cervical CA & Genital warts.

6-in-1 Diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenza type b (Hib), hepatitis B. 4-in-1: Diphtheria, tetanus, pertussis, polio. Measles, mumps, rubella (MMR). As 2019.

Some Common Signs and Symptoms

Sudden change in behaviour. Mother, father or guardian’s feelings should never be dismissed.

Symptoms of serious illness in < 6 months old: Drowsiness, less activity, less than half normal feeds in 24 hours, fewer than 4 wet (soiled) nappies in 24 hours, breathing difficult, HR rapid or slow (for infant), looks hot, pale, colour not normal, dusky/grey in dark skinned child.

Sick baby/child: Lethargy, cyanosis, agitation, jaundiced, fever, bleeding, bruising, vomiting, diarrhoea, constipation, floppy [hypotonia], tension [hypertonia], infections, jittery, persistent crying, teething. Bruising: Trauma, bleeding – von Willebrand disease, thrombocytopenia purpura, anaemia, leukaemia, meningococcal sepsis, SLE. Earache: Otitis media, otitis externa, blocked eustachian tube [air travel or URT infection], wax impaction, foreign body, tonsillitis [referred pain]. Cough: Barking cough = laryngotracheobronchitis or croup, paroxysmal cough, pertussis or whooping cough, vomiting after coughing common, RSV = respiratory syncytial virus, asthma.

Apnoea [breath holding > 5 – 10 secs.]: Seizures, raised intracranial pressure, arrhythmias, obstruction of airway, aspiration [gastro-oesophageal reflux], hypoglycaemia, infections [bacterial/viral = pertussis, meningitis/encephalitis], medication/drugs.

Itchiness: General: scabies, eczema, Urticaria, chemicals, drugs, environmental, Local: head lice, bites, threadworms, Systematic: jaundice, renal failure, iron-deficiency anaemia, thyroid.

Rashes and Spots: Eczema, warts, contact dermatitis, meningitis, allergies, chicken-pox, measles, 5th disease [slapped cheek syndrome], scabies. Diarrhoea/Vomiting: Acute GIT infection, septicaemia, meningitis, RTI, otitis media, appendicitis, intussusception, milk intolerance = abdominal pain [tummy ache], hernia, gastro-oesophageal refux,

Systems Examination

HEENT (head, eyes, ears, nose & throat): Head circumference: Under 2 years. Fontanelle inspection: Over riding plates, sutures, pulse, bulging, sunken. Skull shapes: Trigonocephaly (metopic suture), Brachycephaly (coronal and metopic suture), Frontal plagiocephaly (unilateral coronal suture), Occipital plagiocephaly (unilateral lambdoid suture) and Scaphocephaly (sagittal suture). Eyes: Lid oedema, Subconjunctival haemorrhages, conjunctivitis, glaucoma, coloboma (absence or defect of some ocular tissue). Aniridia (absence of iris). Physiological squint up 8 weeks to 8 months? Acuity-near, acuity-distance, focusing, tracking, binocular vision, convergence and eye teaming skills. Ears: Itching, earache, discharge, vertigo. Inspection: External ear, pinna, eardrum. Palpation: Tenderness, mastoid, pinna, pre & post-auricular nodes. Nose: Inspection: Discharge, bleeding, blocked, deviation. Colour of mucosa. Sinuses (transilluminate). Palpation: sinus and nasal tenderness. Sinus percussion. Throat: External (neck) and Internal: Neck, observation, cysts, trachea displacement, muscle, glands, thyroid. Lips, colour, lesions, symmetry. Mouth: mucous membrane, colour, lesions, breath. Teeth and gums. Tongue: colour, texture, lesions, tenderness of sublingual region. Throat: colour, tonsillar enlargement, exudate.

Temperature: Under arm, groin, ear (laser), mouth.

General appearance: Colour, rashes, spots, hair distribution, dysmorphic features, nutritional status, nourished, hydrated, jaundice, pallor, cyanosis, oedema, lymphadenopathy.

IPPA: (I) inspection, (P) palpation, (P) percussion, (A) auscultation.

Respiratory: Cough, wheeze, stridor, whoop, bark, hack. Night cough, wheeze.

Chest shape, Expansion-contraction, respiratory rate, breathing difficulty, percussion, breath sounds, added sounds. Resp. rate: 30-40 breaths/min in infants, 20 breaths/min at 6 years, 16 breaths/min adolescents.

Cardiovascular: Colour, cyanosis, clubbing, face. Pulse: rate, rhythm, volume. BP. Thrill or parasternal heave. Mediastinum: apex, trachea. Heart sounds: added sounds, position and radiation. Carotid, radial and femoral pulses single and in combination [delay!].

Abdomen: Scaphoid/distended? Movement, radiation, symmetry, with breathing and pulse. Masses, tenderness, guarding, rebounding. Organ distribution: size of liver, spleen, kidneys. Ascites. Bowel sounds. Hernias. Testicular size. Perineum inspection and integrity.

Central Nervous System: Level of consciousness. Head shape. Fontanelle [< 18 months]. Movements, tonicity, posture, abnormal movements. Signs of meningitis. Cranial nerves. Motor: power, tone, coordination. Reflexes: knee, ankle, plantars, persistent, primitive, gait. Sensation [where possible].

Musculoskeletal: Power and sensation. Deformity, tenderness, swelling of bones and joints. Infections, osteomyelitis. Kyphosis, scoliosis, torticollis. Limping child. Legg-Calvé-Perthes disease, slipped upper femoral epiphysis (SUFE). Developmental dysplasia of the his (DDH). CDH: Barlow test and Ortolani manoeuvre.

Cranial nerve tests newborn:

Crying, facial movement – fullness and symmetry: Cranial N. 7

Quality and strength of crying: Cranial N. 10

Sucking and swallowing: Cranial N. 5, 7, 9, 10 and 12

Eye moments and vestibulo-ocular reflex (doll’s eyes manoeuvre): Cranial N. 3, 4 and 6

Baby’s response to light (closing eyes): Cranial N. 2

Sound: Cranial N. 8

Papillary light reflex, corneal reflex, gag reflex and funduscopic exam same as adults

Primitive Reflexes

Suck-root reflex: They should hold/suction on the dummy/pacifier; there should be a little resistance to trying to remove the dummy/pacifier. The root reflex is shown by gently stroking the side of the mouth/cheek and the baby should turn towards the dummy/pacifier and suck it.

Moro reflex: With one hand hold baby supine with hand under head and shoulders. Lower half of baby on couch. With other hand hold the baby’s arms in flexion and hands together across chest. Suddenly let the head and shoulders drop an inch and release arms at the same time. Arms should adduct and extend, return to the midline, hand open with thumb and index finger in a “C” shape in reflex fashion. Absent Moro reflex in UMN lesion. Asymmetric Moro seen in brachial plexus injury. Galant reflex (trunk incurvation): With one hand hold baby prone (chest and abdomen) over couch suspending baby; baby’s hands and feet just touching couch. With other hand-finger stroke down one side of baby’s shoulder to hip (back). Shoulder and hip should contract towards the side of the stroking. Stepping reflex: With both hands hold baby upright with toes touching couch. As you lean baby forward she should start to step in a simple manner. Grasp reflex: Place one finger in baby’s palm or sole of the foot will cause flexion and grasping of hand. Pulling on the grasped hand there should be a degree of holding. Hand opening reflex: Stroking/touching dorsum and edge of hand should cause the hand to open.

General Tone Testing

Resting posture: Supine baby – Tight flexion of extremities, closely adducted to trunk. This relaxes after 48 hours. Upper extremity tone: Supine baby – Passive traction of arms to assess for general tone and tension, symmetry, hypotonia, hypertonia. Arm Traction: Supine baby – Hold baby’s wrist and traction (pull) until shoulder is off the couch. Slight flexion at elbow is maintained, full extension is present in hypotonia. Arm recoil: Supine baby – hold baby’s arms to chest for a few seconds, quickly extend and release; arms should spring back to flexion position. Hypotonia is seen as a slow and incomplete recoil. Asymmetry of recoil is seen in Erb’s or brachial palsy. Scarf sign: Supine baby – Take one of baby’s arms and draw it towards the opposite shoulder like a scarf. Hand should not go past the shoulder and elbow should not go past the midline of chest.

Hand position: Supine baby – Fingers and hand should be flexed in a fist with the thumb inside. Hold for few seconds and suddenly release; hand should release immediately. Slow or persistent fist is an UMN lesion. Lower extremity tone: Supine baby – All passive ranges of motion. Flexion, extension, etc. Hips, knees, ankles and feet. Leg traction: Supine baby – Pulling on leg so buttock lifts off the couch. Knee should still be slightly flexed. Full extension of the knee indicates hypotonia. Leg recoil: Supine baby – Fully flex baby’s legs at knees to abdomen. Hold for a few seconds; extend legs and quickly release. Legs should quickly flex. Look for symmetry, hypotonia and movement. Popliteal angle: Supine baby – assessment of hamstrings. One leg at a time. Flex thigh to abdomen with one hand and with other hand extend knee by lifting heel. Knee extension beyond 90° to 120° is a sign of hypotonia. Heel to ear: Supine baby – Raise one lower limb towards ear on same side. Foot should only reach about chest or shoulder level. If it does reach the ear – hypotonia. Neck tone: Supine baby – Passively rotate baby’s head each side alternately. Chin should not go beyond shoulder. Head lag: Supine baby – Hold baby’s wrist/arms and lift to near sitting position. Observe arms and head. Arms should stay slightly flexed, head lags behind trunk, head should move to upright and then fall forwards. Head control: Baby in sitting position – Observe strength and tone of neck extensors. Move the baby slightly posterior to test neck flexion and anteriorly to test extension or raising the head. You can also lean the baby to either side. Prone movements: Prone baby – Baby should show flexion of limb or limbs, buttock rising, slight head lifting to turn head. A flat baby is hypotonic. Ventral suspension: Suspend bay over couch with one hand in prone position. Observe head position, back and limbs. Head should stay with back, back should be capable of slight resistance to gravity and limbs should be flexed. For assessing head and neck tone. Vertical suspension: With both hands hold baby in walking vertical position and assess major tone of thorax and limbs.

Reflexes

Deep tendon reflexes: Use small hammer. Baby’s head to one side reinforces reflexes. Start with knee jerk; leg flexed to 90° gently tap patellar tendon. Next ankle jerk (Achilles tendon) may have to place finger on plantar surface of foot flexing foot and tapping your finger on the foot. The biceps; place thumb on biceps tendon and tap. Triceps jerk rare in newborns. Absence of deep tendon reflexes more important than hyperreflexia. Poor, weak or absent reflex responses could indicate LMN disorder. Exaggerated reflexes UMN disorder. Plantar reflex: Stroking lateral aspect of the plantar surface of the foot results in extension and fanning of the toes. Stimulating across the ball of the foot brings the opposite with a grasp response of foot and toes. Extension and fanning of toes is normal Babinski sign: may be present in first year of life due to incomplete myelination of corticospinal tracts.

  

Copyright © Walter Llewellyn McKone, DO, 2019. Email: osteopath.mckone@gmail.com

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