THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next?

Parent’s Arms

Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the mother and sometimes that is enough for examination.

Examination By Proxy

If all else fails you can deputize the mother to do the localizing examination. In this case she tries but the child still cries. You decide to leave the room to let her calm down and you ask the mother try to better define the area that is tender. You suggest a gentle scalp massage starting away from any areas of pain.

Come Back Later

Once the limbic system is aroused and heated it takes a few minutes to cool off. Come back later to reassess the child. Of course, treating pain is important for enabling a good examination.

You come back and she thinks it is the left ear. You expect external otitis but see nothing. Then you look at the scalp in that area and see bulging and redness behind the ear. You order a CT scan and find mastoiditis with abscess formation.

Take Home Points:

-Examine the child in the parent’s arms if needed for calmness

-In the uncooperative child, try localization by proxy

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