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On a Friday evening, a 12-year-old girl was bought to the paediatric acute assessment unit by her parents. She was complaining of feeling dizzy, shivery and seeing colours. Her parents were concerned that she was not herself and unsteady on her feet. On examination she was shy and difficult to engage. She had bilateral symmetrically dilated pupils (8 mm in diameter) that were slowly reactive to light. She was found to be mildly ataxic, the rest of her neurological examination including cranial nerves was normal. Visual acuity was not formally assessed. She was slightly tachycardic and hypertensive, otherwise her observations were within normal limits. The patient denied any intake of medications or drugs.
Approach to initial clinical assessment
General principles apply when taking a history from a young person. There must be an opportunity for time without parents. It is important to build a rapport. Confidentiality rules need to be discussed and ideally should be outlined at the beginning of the consultation. Thorough history-taking can be directed towards key points that may indicate intoxication, and direct questioning will give the young person an opportunity to disclose information.
Examples of questions that might be asked are
Have you seen anything unusual today?
How are you feeling? Do you feel hot? Do you feel dizzy?
Are you worried or anxious about something?
Where have you been in the past 24 h?
Have you taken any medications or drugs?
It is important to ask the parents if there are any prescription medications in the household, particularly antidepressants. Psychosocial morbidity is extremely important to assess, the framework HEADSS (Home, Education and employment, Activity, Drugs and alcohol, Sex and Suicide) is a helpful pneumonic to remember (box 1) and should be encouraged as part of any clinical history taken from an adolescent patient. A history of thrill and danger-seeking behaviour may become …
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