Lesson 3: Clinical Problem Solving

=UNIT 3: CLINICAL PROBLEM SOLVING=

=INTRODUCTION:=

Welcome to the first unit of the Child Health Course. In this unit, you will be acquainted with the basics of clinical problem solving. Clinical problem solving is the process of making a correct diagnosis. That is starting from a problem and working it out until you establish what is wrong with your patient and then solving it. It involves taking your patient’s history, carrying out a physical examination and making relevant investigations to establish what the problem is. Once this is identified then you need plan how to manage the problem (ie. the solutions).

Please read each section thoroughly and do the activities as you go. Take as much time as you need to do each activity. If you have any difficulty completing any activity, study the section again and if you still cannot do.the activity write to your tutor for assistance.

3.1: TAKING THE PATIENT’S HISTORY
In clinical problem solving, it is important that you begin with history taking.

Check your answers as you read on.

History taking can be defined as a systematic inquiry into the patient or client’s life. It is the process of obtaining relevant information from the patient or patient’s caretaker (such as the mother or father) for the purpose of making a diagnosis.

History taking in children is different and more detailed than in adults. Often you must take the history from the mother, the father or guardian. Ordinarily, it is the mother that brings her child to the clinic, so we will refer only to the mother in our discussion. If the father or another guardian brings the child, the procedure remains the same.

You should sit next to the mother and child as you take the history. Do not have any barrier, such as a desk, between you and them. In this position, you can then easily begin examining the child while he or she is sitting on the mother’s lap. Watch what the child is doing while you take the history, as you can learn a lot from observation. If the child is breastfed, encourage the mother to feed the child while you take the history.

What are the components of a child's history?

The following is a list of the components of a child's history:
 * Identification data
 * Presenting complaint
 * History of presenting complaints
 * Systemic review
 * Past medical history
 * Treatment history
 * Developmental milestones
 * Nutritional history
 * Immunisation history
 * Family social history

We shall now look at each of these components in more detail:

a)	Identification data: This is the child's personal information. It includes the child’s names, age, sex, tribe, religion, next of kin (parents) and address (residential), and the date of seeing the child in the health unit. After all these have been recorded the child should then be weighed and the weight recorded also.

b)	Presenting complaint: The presenting complaint is the problem(s) that has caused the caretaker to bring the child for medical help. For instance, it may be:


 * fever (the child feels hot)
 * cough
 * vomiting
 * diarrhoea

It is important to establish the duration of each complaint. For example, if the child has a cough, ask "How long has the child been coughing?" If there is more than one complaint, ask which complaint came first, which was next and finally, which came last. You should then present these complaints in order beginning with the one that came first.

When writing down the patient’s history, always use the caretaker’s words. For instance, if the mother says that the child feels hot, then write: “the child feels hot.” Avoid describing it as a high temperature.

c)	History of the presenting complaint: The history of the presenting complaint is additional information about the presenting complaint. You must ask more questions about the symptoms that the mother has mentioned. This means asking questions like:


 * “When did the illness begin?”
 * “How did it start?”
 * “Was it sudden or was the onset slow?”

Find out when each symptom began and whether it seems to be getting better or worse. Ask about associated symptoms. For example, a cough may present with difficulty in breathing, diarrhoea may present with blood in stool or with vomiting. Fever may be constant or on and off. Ask and then listen until the mother has finished talking. Avoid interrupting her as much as possible to be sure you have all the information she can offer. You can then ask leading questions to help her remember what she might have forgotten. She may answer in the positive or negative.

d)	Systemic review

In a systemic review we try to find out how the presenting complaint has affected the child's other systems like feeding/drinking habits, respiration, playing, and sleeping as well as gastrointestinal and urinary habits. This is also important in excluding symptoms from other systems or symptoms shared by many systems. This may also remind a mother of important symptoms she had earlier left out.

For ALL sick children aged 2 months up to 5 years, check for these general danger signs:

Ask the caretaker:
 * Is the child able to drink or breastfeed?
 * Does the child vomit everything?
 * Has the child had convulsions?

Look and determine:


 * Is the child lethargic or unconscious?
 * Is the child breathing fast?
 * Is the child dehydrated?

If the answer is “yes” to any of the above questions, the child has one or more of the general danger signs and needs URGENT attention. Refer appropriately. See Appendix 1 for a chart on how to assess and classify the sick child age 2 months up to 5 years.

e)	Past medical history: A past medical history is important. Ask:
 * 1) Has the child had the same illness before? This information is important because some illnesses can be recurrent, such as convulsions;
 * 2) What other illnesses has the child had in the past? This question is important because the present illness may be a complication of a previous illness. For instance, a child may be malnourished as a complication of measles.
 * 3) Ask if the child has had hospital admission and if so for what.
 * 4) Ask to see the child’s old medical forms or medical card. This is a good way to get an accurate past medical history.

f)	Treatment history: Before mothers seek professional attention, they will often try other remedies at home or from other sources. Always ask about any other treatment received by the child during the present illness before prescribing more. Determine if there has been any response to this treatment

g)	Immunisation history: Because of the importance of disease prevention, particularly the six killer diseases, it is absolutely necessary to ascertain the immunisation status of every child. Ask every mother about vaccines already received by the child. Look at the immunization card to ascertain which immunization the child has received and has not received.

h)	Nutritional history: Malnutrition is a risk factor for all types of illness, especially in children. Well-nourished children rarely fall sick. Therefore it is important to find out:


 * If the child is still breastfed
 * If the child is breastfed exclusively
 * How often it is breastfed
 * What other foods the child receives, how much and how often
 * Whether there are any feeding problems
 * Find out whether the child is bottle fed, especially those with diarrhoeal illness

Whatever interferes with a child’s nutrition has a direct bearing on the child’s health and should be dealt with.

i)	Developmental history: In normal childhood growth and development there are certain milestones to be passed at certain ages. The following is a brief summary of developmental assessment needed:

Ask about the antenatal care and the delivery of the child:


 * Did the mother attend antenatal care?
 * Did the mother suffer any illnesses during pregnancy?
 * Was the delivery spontaneous or assisted?
 * Was it a home or hospital delivery?
 * Was the child born at term?
 * Were there any complications during or after delivery?
 * What was the birth weight?
 * Did the child cry at birth?
 * Did the child breathe spontaneously at birth?

All of this information is needed for assessing the health of the child.

Table 1.1: Developmental Milestones

j)	Family and social history: It is important to obtain information about the health of the rest of the family. Ask:


 * Is anyone else in the family ill?
 * What is the general health of other siblings? Find out if any have died.
 * Where and with whom does the family live?
 * Are both parents alive and staying together?
 * Any other family diseases, such as sickle cell disease, asthma, etc.
 * Is family income adequate and what is the source of their income?
 * Does the family have an adequate source of food, water and other resources?
 * What is the source of water

Family and social status can influence a child’s health and should not be left out in history taking.

POINTS TO NOTE WHEN TAKING CHILDRENS HISTORY: In taking the history of a child, it is important to treat the caretaker with respect and courtesy. When a child is sick, the caretaker feels worried and may be impatient about getting treatment. The following points are important to keep in mind when taking a child’s medical history.


 * 1) Always greet the mother appropriately and ask her to sit with her child.
 * 2) Establish good communication with the mother from the beginning of the visit and let her feel at ease with no embarrassment.
 * 3) Listen carefully to what the mother tells you. This will show that you are taking her concerns seriously.
 * 4) Use words the mother understands. When necessary, paraphrase your questions.
 * 5) Give the mother time to answer the questions. For example, she may need time to decide if the symptom or sign you asked about is present or not.
 * 6) Ask additional questions when the mother is not sure about an answer.
 * 7) Use good questioning techniques. Ask open-ended questions, encouraging the mother to give you the information you need. Avoid questions that call for just a “Yes” or “No” response.
 * 8) With babies and young children you have to take the history from the parent or guardian who brings the child. Older children can speak for themselves, but you need to hear the parent’s story as well. When speaking to a child, address him or her by name.

An accurate history is the first and most important step in making a correct diagnosis and will direct further investigations as well as the management of an illness. History taking accounts for over 70% of the diagnosis. It should precede both physical examination and treatment of all except extremely ill patients like those with convulsions or coma.

Now that you have finished reading the material on taking the medical history of a child, you are ready for the next activity.

3.2: PHYSICAL EXAMINATION
Conducting a physical examination is the next step after history taking. It is guided by the history that has been taken. Complete the following activity before proceeding with the reading material.

Did your answer include any of the followings? Proceed with the reading.

A health worker conducts a physical examination in order to assess the bodily state of a patient or client by doing the followings:

a)	Inspection: Look and see. This is the first step.

b)	Palpation: Touch and feel.

c)	Percussion: Use the middle fingers of both hands to elicit resonance in cavities like the thoracic and abdominal cavities.

d)	Auscultation: Use a stethoscope to detect sounds in the thoracic and abdominal cavities. The same is used for detecting pulsation, such as the brachial pulse when taking blood pressure.

Physical examinations are classified, or divided, into two main types:


 * 1) General examination
 * 2) Systemic examination

While this classification applies to adults there are some modifications when it comes to children. In carrying out a physical examination of a child, ensure that:


 * 1) The child is comfortable
 * 2) There is adequate light
 * 3) It is carried out gently
 * 4) The child is calm
 * 5) You talk to him as you proceed with the examination
 * 6) The child has all the clothes removed

EXAMINING A CHILD:

Examining a child begins as soon as the child arrives in your clinic. Notice what the child is doing while you talk to the mother. Is he/she lively, playing, interested in its surroundings? Or is the child obviously ill or sick looking? Observe how well a baby feeds when put to the breast.

Do as much as you can without taking the child away from the mother. Examine small children while they are sitting on the mother’s lap.

Leave until last that part of the examination that is likely to make the child cry. For example, babies and small children must be completely undressed for a thorough physical examination, but this sometimes makes them cry. Therefore, observe carefully, count respiratory rate and listen with stethoscope before undressing the baby.

ALWAYS take the temperature. In babies and infants below one year of age the most reliable way of taking the temperature is rectally. If you are the one to take the temperature and you decide to use this method, do it at the end of the examination. The normal range of temperature is 36.5 - 37.5oC.

You may not need to do a complete examination for every child but the following FIVE points should always be checked.

ALWAYS:


 * Assess the general condition of the child
 * Look and listen to the way the child is breathing
 * Count the respiratory rate
 * Look for signs of dehydration, anaemia, wasting, oedema and cyanosis;.
 * Check for neck stiffness

ASK YOURSELF: How does the child look?


 * Is she or he well? A bit unwell? Or severely ill?
 * Is the child fully alert? Drowsy/lethargic? Unconscious?

If a sick child seems to be sleeping, awaken the child to make sure he or she is not unconscious at the end of your examination. Remember to count the respiratory rate first.

EXAMINATION PROCEDURE

The following procedure can be used in examining a child:


 * 1) Inspect (look at) how the child is breathing.
 * 2) Count the respiratory rate.
 * 3) Look for chest indrawing. You may also notice flaring of the nostrils and may hear grunting or wheezing (noise on expiration) or stridor (harsh noise on inspiration). Respiratory rate is very important. The following are cut-offs:
 * 4) *60/min and above is fast breathing in children up to the age of 2 months.
 * 5) *50/min and above is fast breathing in children aged 2 months up to one year.
 * 6) *40/mm and above is fast breathing in children aged 1-5 years.

Fast breathing is a sign of serious illness and may be caused by any of the following:

a)	Pneumonia: Fast, shallow breathing, grunting, flaring of the nostrils and fever. Chest indrawing may be present in severe pneumonia.

b)	Asthma: Recession between and below the ribs plus wheezing, in children above 2 years of age.

c)	Bronchiolitis: Recession and wheezes or crackles (in an infant under 15 months).

d)	Severe dehydration/Acidosis: Rapid, deep breathing in a clear chest.

Remember:.

4.	Palpate the abdomen for:
 * Any areas of tenderness or masses
 * Enlargement of the liver or spleen

5.	Check the genitalia. Look for hernia. Palpate both testes in males.

6.	Check for anaemia in the conjunctive, on the tongue, nailbed, palm, etc.

7.	Check for jaundice in the white part of the eye and the palms and soles.

8.	Check for cyanosis in the eye, palms and soles even if it is difficult in dark skinned children;

9.	Check for dehydration.


 * Signs of severe dehydration are:
 * Lethargy
 * Sunken eyes
 * Very slow skin pinch (a slow pinch that goes back very slowly)
 * Failure to drink or drinking poorly


 * Signs of some dehydration are:
 * Sunken eyes
 * Slow skin pinch
 * Drinking eagerly

10.	Palpate for enlarged lymph nodes in the neck, armpits and groin.

11.	Palpate for tenderness or swelling of bones or joints. Make sure the child is moving all four limbs normally.

12.	Inspect the ears using an auriscope. In otitis media you will see a bright red ear drum with or without pus. In case of a foreign body in the ears, refer appropriately.

13.	Inspect the throat using a torch and spatula. Are the tonsils inflamed? Is there oral thrush, koplik spots or any other abnormality?

14.	Finally, if the child is unable to sit, stand, walk or if the child’s movements do not seem normal, first rule out neck stiffness. If the child cannot perform these movements because of illness, the child may be very seriously ill. Refer appropriately.

At the end of the physical examination, you must decide what is wrong with the patient. You must also decide on management and follow up. It is important to explain your decision to the mother. This is also a good time to give health education. Time spent talking after you have made your diagnosis is time well spent. Mothers frequently imagine that their children are much worse than they are, and this is because they have not been reassured. Parents have a right to know about the condition of their child as well as the required treatment. They will have confidence in you if you give them this information.

Now that you have read the section on physical examination, you are ready to complete the next activity.

3.3: FURTHER INVESTIGATIONS
When you have taken the patient’s history and conducted a physical examination, you may find it necessary to confirm your suspicion with some sort of investigations. An investigation can range from a simple laboratory procedure to radiological scanning or other complex procedure.

There are a number of investigations that are commonly carried out at health facilities. These are listed below, along with the reasons for each investigation:

1.	Blood slide for malaria parasites could be used for the following reasons:


 * Diagnosis of malaria
 * Rule out malaria in a child with fever
 * As a follow up of treatment for malaria
 * For screening donated blood
 * To investigate anaemia

A malaria blood slide may be a thick blood film used for screening for parasites, especially when they may be scanty, or for counting malaria parasites. A thin film may also be used for identification of the various species of malaria parasites, or for typing of the parasites.

2.	White blood cell (WBC) total count and differential. This may be ordered for
 * Pyrexia of unknown origin (P.U.O.)
 * Lymphocyte count
 * Leukaemia

3.	VDRL/RPR. This can be used to:


 * Diagnose syphilis
 * Screening in antenatal clinics
 * Screening of contact
 * Follow-up
 * Screening for blood transfusion.

4.	Haemoglobin (Hb) estimation. Haemoglobin is the red pigment inside red blood cells that transports oxygen from the lungs to body tissues, and carries carbon dioxide from the tissues to the lungs for excretion. Reduction in the circulating Hb below normal levels is referred to as anaemia. Reasons for Hb estimation are:
 * To diagnose anaemia
 * To screen for anaemia during pregnancy, assess blood donors and in medical examination
 * To monitor and follow up during treatment for anaemia

Normal ranges of Hb are:
 * Males: 13.0 - 18.0g/dl
 * Females: 12.0 - 16.0g/dl
 * Infants: 13.5 - 19.5g/dl
 * Children 1-7 yrs: 11.0 - 14.0g/dl

5.	Urinalysis. Reasons for carrying out urinalysis are
 * To rule out systemic conditions such as:
 * Diabetes
 * Hepatitis
 * Haemolysis
 * To rule out kidney diseases such as:
 * Nephrotic syndrome
 * Glomerulonephritis
 * To diagnose Schistosoma Haematobium
 * To check bleeding in the urinary tract
 * To rule out TB of the urinary tract.
 * To rule out urinary tract infections (UTI)

6.	Stool for microscopic examination. Stool may be examined in cases of:
 * Abdominal pains/distension/worm infection
 * Diarrhoea/dysentery
 * Skin itching
 * Anaemia

7.	Blood grouping and counting. This may be ordered:
 * Before blood transfusion
 * In screening of antenatal mothers
 * In paternity disputes
 * In population surveys
 * In forensic medicine (criminology)

8.	Sputum microscopy for acid-alcohol fast bacilli (AAFBs). It is carried out by the Zeihl Neelsen staining method. This is often ordered:


 * To rule out TB
 * To diagnose TB
 * For follow up in treatment of TB

9.	Laboratory screening for HIV. This test may be required for:
 * Screening donated blood
 * For surveillance purposes
 * Conforming a clinical diagnosis of HIV/AIDS
 * Satisfying some authorities such as churches, governments, etc.

For proper patient management, the three procedures of history taking, physical examination and investigation should be carried out.

We hope you now understand the process of clinical problem solving and that you are now able to reach the correct diagnosis. Next, we shall discuss a common complaint that children present with in our health facilities, that is Fever.

3.4 FEVERS
Fever is one of the most common complaints at out patient clinics. It is the most common symptom of various childhood illneses. Sometimes parents think fever is synonymous with malaria and therefore treat their children unnecessarily with antimalarial tablets. It is therefore important that as a health worker you understand what fever is, its causes, and how to management. This will also help you to counsel and educate the mothers appropriately.

Types of Fevers:

There are at least four different types of fevers.


 * 1) Intermittent fever, in which the body temperature falls to normal every day before rising again.
 * 2) Persistent/continuous fever, in which there is persistent elevation of body temperature without significant variation
 * 3) Remittent fever, in which the fever falls each day but does not reach normal Levels.
 * 4) Relapsing fever, in which short febrile periods occur between one or more days of normal temperature.

Causes of Fevers in Children:

There are various causes of fever in children. These include the following.


 * 1) Malaria: This is the commonest cause of fever in the malaria endemic areas. Malaria is confirmed by the finding of malaria parasites in a blood slide.  However, one negative blood slide does not always rule out malaria.  Carry out at least two slides and if both are negative, malaria is unlikely.
 * 2) Pneumonia: Count the rate of breathing and look for chest indrawing. See Unit 8 on Upper Respiratory Infections for more information.
 * 3) Meningitis: Check for neck stiffness and irritability. If in doubt, do a lumbar puncture.
 * 4) Otitis media: Check ear drums for signs of infection. See Unit 9 for more information
 * 5) Tonsillitis: Inspect the throat, examine the tonsils and feel the cervical lymph glands.
 * 6) Early measles: Look for Koplik’s spots.
 * 7) Urinary tract infections: Check urine for protein and pus cells.
 * 8) Typhoid: Look for a history of fever rising slowly over a week, with loss of appetite, headache and increasing toxaemia. Abdominal distension and cough develop in the second week. Diarrhoea comes late and stools may be haemorrhagic. Isolated cases are rare: typhoid tends to occur in epidemics.
 * 9) Hepatitis: Look for dark urine, tender liver with jaundice.
 * 10) Osteitis/osteomyelitis: Tender bone, very localised at first.
 * 11) Rheumatic fever: Fleeting joint pain and swelling, tachycardia, rashes, fever.
 * 12) Rheumatoid arthritis: Peripheral joint pains and swelling not fleeting, lymph node enlargement, splenonegaly, rash.
 * 13) Septicaemias: Toxaemia, rashes, and jaundice. Think of coliform septicaemia in neonates, staphylococcal septicaemia in infancy, salmonella or meningococcal septicaemia in older children, and salmonella septicaemia in children with sickle cell anaemia. Do a blood culture.
 * 14) Tuberculosis: Low grade fever, weight loss, failure to thrive. Do chest X-ray.
 * 15) In some areas: Relapsing fever or trypanosomiasis. Do clinical examination, blood slide and CSF examination.
 * 16) Immunization: BCG, DPT, measles, and other vaccinations can cause fever.

Sometimes a fever is due to an unknown reason. This is called fever of unknown origin (FUO) or pyrexia of unknown origin (PUO). In this case the fever is most likely as a result of a virus. If you come across many cases of fever of unknown origin in a household or in the community, you should report this to the health authorities for more sophisticated tests.

Management of Fever

The general condition of the child is important for the management. Ask yourself when doing the examination: Does he behave normally? What other symptoms are present beside the fever? Dehydration? Malnutrition?

a.	If the fever is high (38.5 oC), give paracetamol either as tablets (500mg) or as a suspension (125 mg in 5 mls). Give in dosage of:


 * 5 – 10 mg/kg body weight, 3/12 of age
 * 125 mg from 3/12 to 1 year of age
 * 125 - 250 mg from 1 year to 5 years
 * 250 – 500 mg from 6 years to 12 years.

Administer paracetamol every 6 hours. However, note that paracetamol overdose may cause liver damage. Paracetamol can also hide diagnostic fever patterns without curing the disease.

b.	Feverish children should be undressed allow them to get rid of the heat. Wearing warm clothes can worsen the fever. High body temperature can precipitate convulsions.

c.	Children who have fever need to take extra fluids, so make sure that they have plenty to drink. If they are unable to drink, give fluids by nasogastric tube. If they are obviously dehydrated, they need rehydration urgently and if they have collapsed give intravenous fluids.

Complications of Fever

Complications of fever include:
 * Convulsion
 * Dehydration

Convulsions are controlled using an anticonvulsant like Diazepam, paraldehyde, etc. It is important that you manage them as an emergency because convulsions can cause brain damage. They are prevented by proper fever management.

Dehydration is managed by rehydration as already discussed above.

Prevention of Fever in Children

From what we have covered in this section, you should now know that the causes of fever are many and varied. It is, therefore, difficult to suggest a single preventive measure for fever. To prevent fever, you have to prevent its cause. Therefore you must find the cause.

You have now come to the end of this unit. It is hoped that you have achieved all the objectives. Have a look at the learning objectives again. If you feel confident that you have covered them well, then complete the Tutor Marked Assignment before you proceed to the next unit.

PRACTICAL ACTIVITY

Visit the laboratory facility nearest to your health facility and find out the following from the laboratory technologist:

What are the common types of investigations they carry out in that laboratory

What percentage of their clients are children?

What are the common tests carried out among children

How does a positive malaria blood slide look like?

Write a report of your findings and send it to the tutor together with your assignment.

Enjoy the rest of the course!!