History and examination
Common presentations
Common presentations
Sepsis pathway- Clinical excellence commission - this is a 2 pg document which is like a flow chart for how to assess vitals signs, do tests , and resuscitate a child with sepsis.
Fever: assessment and management in the emergency (SCH) (note for children under 3 months of age , there is a separate guideline and the authors recommend consulting senior clinicians in ED +/- paediatrics early for consideration of full septic workup)
Fever and petechial rash (SCH) Note: 1) Dubbo Paediatric does not yet recommend home observations and treatment 2) get prompt IV access and blood tests recommended: a) sterile blood culture (1ml minimum aseptic technique) b) CRP and c) procalcitonin
Febrile child (RCH)
Fever and petechiae (RCH)
Dr FITZGERALD's TIPS for assessing and managing the febrile child in the emergency
1) If the child represents to the emergency with a fever for a 2nd opinion- the author recommends after ED has completed its assessment to discuss with Paediatrics prior sending home.
2) Be particularly careful with :
a) Infants less than 6 months (and the author recommends that in a child under 3 months with a fever >38.5c , with no focus should be treated as a medical emergency. Dubbo Paediatric Department practice varies from doctor somewhat but the approach is fairly closely with the SCH policy in child < 3 months with fever). One reason for this is that children under 6 months DO NOT localise meningitis symptoms reliably.
b) be careful with children who are taking oral antibiotics while you assess the patient- this may interfere with how an underlying disease presents ( e.g. a partially treated meningitis)
3) In the post vaccination era, UTI is the commonest cause of serious bacterial infection in children presenting to ED with fever and no focus
Overall, we don't do urine collections well in the non-toilet trained child- so ask for help early on how to best obtain it.
A bag urine can be used as screening tool to look at the urinalysis results - see below. Bag urines are not sent for culture, the exception being if the child is well and you are not starting antibiotics. If the urine culture on bag is positive, you will need to a do a clean catch/catheter prior to starting antibiotics for UTI.
So put a urine bag on early, or attempt a clean catch early, and get on with examining the child.
If it is fever with no focus in a sick child, who is not toilet trained, proceed to in/out urine catheter. The exception is a boy less than 3 months of age, in whom it is hard to push a 5 French feeding tube.
If a UA is completely "clear" for UTI screen ie no leucocytes, no red cells and no nitrates it rules out UTI in over 95% of cases. Nevertheless if there is no cause for fever a urine culture is still indicated
If ketone are > +1 or Specific gravity > 1.030 then the child may be dehydrated
Urinalysis , if it shows nitrates positive on clean catch or catheter urine (not on a bag), this indicates a >95 probability of gram negative urinary tract infection eg E. Coli. Catch sterile urine as you are able, and start treatment for UTI
Fever itself can cause leucocytes and red cells in the urine ; but rarely would be be UA > 2+ white cells or UA > 3 +. (or on microscopy > 100 WCC)
If a clean catch is done- chase the microscopy for bacteruria. If bacteria are noted on wet preparation there is a > 95 % chance of UTI- start treatment
4) Top to tail examination is done with variable levels of expertise and accuracy, areas for considering and watching are :
Calm the child down, place on parents lap, or get them to give the parent a front hug to hear the lower lobes.
Before laying hands on the child , stand back and note levels of activity and communication. Is the child normal/ tired/lethargic?
Remember an anxious child may well have tachycardia and tachypnoea caused by anxiety; be ready to re-examine when child is calmer.
a) persistent tachypnoea for clue for underlying pneumonia. Many children with fever are tachypnoeic so reassess the patient after antipyretics, if the breathing rate remains high consider pneumonia/bronchiolitis etc
b) pulse rate- note if the PR is HIGH (e.g. into the BTF red zone tachycardia) and if it remains high, treat on sepsis pathway (PIC)with urgent consultation with senior ED staff +/- paediatrics
c) O2 saturations < 95% are not normal- find out why. If the O2 saturations are 94% or less and you cant hear anything abnormal in the chest- you are probably missing something- ask someone with more experience to double check your findings
c) check glucose- we often to do not check this , which is sloppy, and it may be low from sepsis or fasting. If less than 3.5mmol check hypoglycaemia guideline and think about 0.5ml/oral dextrose child , oral sugary drinks etc
d) chest auscultation: Calm the child down, place on parents lap, or get them to give the parent a front hug to hear the lower lobes.
Get the child to open its mouth , which may amplify chances of successful hearing faint crepitations, wheeze , reduce air entry or bronchial breath sounds.
If child has persistent tachypnoea, respiratory distress , grunting +/- O2 saturations < 95% , consider a chest x-ray for pneumonia
e) heart murmurs- remember Aboriginal children in Dubbo and surroundings have a risk of rheumatic heart disease, new onset murmur could be a flow murmur with fever (re-examine later).
f) examine for lymph nodes, abdomen for hepatomegaly (more than 3cm below the costal margin is enlarged of ptosed), splenomegaly (spleen is not usually palpable
g) skin rashes
h) joint pains- are there any swollen joints or limping/refusal to weight bear , does the child have focal bone or joint pain?
i) ear examination: looking for acute otitis media (AOM) and mastoiditis (RCH AOM guide with images)
j) mouth , tonsils and pharynx (see Tonsillitis or sore throat- below on this page under T)
5) Blood tests
a) Blood culture- take in a sterile manner, so as to not obtain a contaminant on culture
b) FBC - looking for high neutrophil count > 20 in bacterial infection
c) CRP- if > 100 consider bacterial infections more likely (but some severe viral infections , such as enterovirus& VZV may be this high)
CRP may take 24-36 hours to become elevated- consider what stage in the febrile illness the child is up to
d) procalcitonin (PCT) if > 1.0, and in particular if > 2.0 consider serious bacterial infection. If PCT > 10 serious bacterial infection is very likely (>90% odds). Only very rarely will a viral infection elevated PCT.
6) Prolonged fever > 5 days.
Most viral infections will have a febrile period of less than 5 days, but occasionally may go on for 14 days.
A fever for > 5 days raises questions around alternative diagnoses, thought above approach is still valid.
A prolonged fever generally is a paediatric referral, where alternative diagnoses will be considered.
Kawasaki disease (RCH) is always worth thinking about, as it both problematic if clinicians fail to diagnose it and it is treatable.
For city slicker doctors don't forget Q fever, zoonoses in general (in addition to the usual suspects below)
a) Fever without a source in children 3 to 36 months of age: Evaluation and management (Up To Date)
b) Fever of unknown origin ( Up to Date)
Gastroenteritis (RCH has approach to vomiting and diarrhoea and gives differential diagnoses and red flags)
Vomiting in children (RCH has differentials)
NOTE: Dubbo Paediatric Department recommends in pubertal adolescents, in whom the cause of the abdominal pain is not known, that cases are discussed with both General Surgery and Gynaecology on call, prior to Paediatric Department.
Please see the paediatric guidelines below which outline the surgical, gynaecological and medical causes of abdominal pain.
Acute abdominal pain (PIC)
Adolescent gynaecology- lower abdominal pain (PIC)
DUBBO HEALTH SERVICE ACUTE ABDOMINAL PAIN TEMPLATE FOR JUNIOR STAFF:
This template is a simple approach to taking the history, performing a physical examination, and assisting with interpretation of investigations. We will attempt to support junior clinicians in these areas providing some clinical commentary in italics, for education purposes. For background information on likely differential at various age groups , please refer to the abdominal pain guideline on the Paediatric Improvement Collaborative, the link is above
HISTORY
When did the abdominal pain begin?
Is the abdominal pain mild or severe?
Is the abdominal pain coming and going in spasms (intermittent severe, colicky, spasms of inconsolable abdominal pain, associated with pallor of the child's face and vomiting is a good story for intussusception)
Has the pain changed in position from around the belly button (periumbilical) to down lower in the abdomen, example right or left lower abdomen?
Has the pain changed from coming and going to a constant pain?
Or is the abdominal pain constant and localised to a particular spot?
Where is the abdominal pain the worst?, periumbilical (the belly button)? right iliac fossa (right lower abdomen)?
Has there been vomiting with the abdominal pain?
How many vomits have been noted?
Is the vomiting noted to have coffee-ground (black content), or does it have blood (hematemesis)?
Does the vomiting have yellow or green pigmentation (bile is green) ? Is it dark green? How many green vomits have been noted? (Green vomiting is a surgical abdomen until proven otherwise and discuss with senior clinicians (and/or surgical team and paediatrics, but children with repeated vomiting, may have ileus and then biliary reflux with viral gastroenteritis)
Does your child have a blown up stomach, i.e. "abdominal distension?"
Is your child passing regular bowel motions and does your child have a history of constipation (hard stools which are not usually passed daily, straining and painful passing of stools?
(Note : constipation usually presents with abdominal pain, a past history of constipation, and abdominal distension. Less commonly will it present with vomiting (but if severe it may) , and a fever would be unexplained by constipation)
When was your child's last bowel motion passed?
Has your had watery stools , i.e. diarrhoea, if so how many?
(Note1: somewhat unkindly appendicitis may present with vomiting, diarrhoea and fever, perhaps in part due to irritation of the appendix on the large bowel- so do not be confident that, if diarrhoea is present, that appendicitis is much less likely)
(Note 2: diarrhoea presenting with more than 10 episodes per day may be consistent with bacterial colitis or dystentery
Was your child noted to have black stools (malaena) or did it have blood-stained stools (hematochezia).
Has your child had a fever noted?
How many days has the fever been noted? What was the maximum height of the fever e.g. 38.5c, > 39c?
GYNAECOLOGY HISTORY , EXAM AND INVESTIGATIONS IN PUBERTAL FEMALES
Please read PIC guideline on lower abdominal pain in adolescent females (PIC)
GENERAL SYSTEMS HISTORY
Has your child been noted to have a cough or chest pain or have you noticed your child to have shortness of breath?
Has your child had reduced urine output?
How many times has he passed urine in the last 24-48 hours? (If those were nappies, how many wet nappies have been noted).
Has your child had pain in its back or pain when passing urine?
HISTORY of PRESENT ILLNESS
Has your child ever had a bowel operation ? (considering the possibility of adhesions as cause of abdominal pain)
Has your child ever had their appendix out?
Is your child taking any medication, in particular has taken Panadol or Nurofen, if so how much has been taken over the past few days.
Is your child taking antibiotics? (may partially treat acute abdomen)
Is your child taking any other medication?
Is your child fully immunised?
Does your child have any drug or food allergies?
Has your child been hospitalised for any other reason?
EXAMINATION
Vital signs:
Pulse rate - note whether the pulse rate is inceased ,ie tachycardic and if so is it mild or severe tachycardia. (A red zone Between the Flags chart , which persists is concerning ; an elevated pulse rate may indicate a surgical problem, shock, dehydration, pain, or anxiety)
Respiratory rate - note whether the child has rapid panting breathing , i.e. tachypnoea; not if the child has heavy breathing or grunting (this may point to pneumonia, which somewhat unkindly may present with vomiting and fever due to ileus).
Fever - note height of fever (for example early appendicitis , viral gastroenteritis typically have low-grade temperatures example 37.9-38.2c. Peritonitis, pneumonia, pyelonephritis, dysentery, typically have spikes of high-grade temperatures > 38.5c-39c).
Oxygen saturations - (If O2 saturation are <95%, this is consistent with hypoxaemia and may be due to pneumonia - consider a chest x-ray)
Central capillary return- push on chest and if capillary return is >> 2 seconds (outside of neonates in whom > 3 seconds is abnormal), consider causes of sepsis or hypovolaemia
Blood pressure - note if child is hypertensive or hypotensive. Hypotension in children is a late sign of sepsis check capillary return and pulse
EXAMINATION
Beware children under 5 years as the abdominal findings are often unreliable to rule out appendicitis clinically. The perforation rate is over 80% in some studies- so the author recommends early paediatric review.
The acute abdominal pain (+/- vomiting and fever) presentation in children requires a top-to-tail examination as children may localise pain poorly, and the abdominal pain may represent referred pain from other areas (e.g. back, spine, chest, testes)
ENT is done last as it annoys everyone, but tonsillitis can present with vomiting, fever and abdominal pain.
First begin examination by observing child's behaviour and abdomen lying on its back/side in the bed, or on parent's lap
If you are uncertain whether there is abdominal distension or not ask the parents (is your child's abdomen distended?)
Typically children with peritonitis will sit still in the bed and are reluctant to move freely in the bed or roll around in the bed. Watch the child closely to see how much spontaneous movement is noted. Children under 8 years of age, usually fidget a lot. Almost all children with peritonitis will lie still, and grimace when the try to roll over.
Walking/jumping/hopping the child is useful and you may notice a right antalgic gait with appendicitis and a collection of fluid in the right iliac fossa.
Abdominal examination:
Note whether there is pain in one area of the abdomen with focal pain or whether there is generalised tenderness.
Note whether there is rebound tenderness (pain which is worse when the hand is released from the abdomen and causes rebound pain.
Guarding or rigidity (this is pain noted where the child stiffens the abdomen and holds the abdominal muscles tight, which tends to minimise pain).
Percussion tenderness and rotating the right hip may elicit pain in appendicitis
Abdominal masses - there may be a fullness due to mass, fluid collection, bowel obstruction etc - this may be present anywhere in the abdomen but most likely right iliac fossa.
Distension - again asking the family. Palpable faeces (abdominal pain and distension is commonly constipation, but fever points to perhaps alternative diagnosis)
Rectal and vaginal examination is really indicated though inspection of the rectum and vagina may be indicated.
It is important to examine both the umbilicus (belly button) and for inguinal hernia in boys and examination of the testes for epididymo-orchitis. (Boys with testicular pathology may present with abdominal pain due to referred pain.
General systems examination:
Note in particular whether there is tachypnoea and recession. Pneumonia may present with non-specific signs in the right upper lobe, left upper lobe.
Fever, vomiting, abdominal pain with tachypnoea and recession should have a chest x-ray performed.
Heart murmurs
Back is checked for pain- loin pain and spine is palpated (renal angle pain with pyelonephritis)
INVESTIGATIONS for sicker child with abdominal pain (+/-vomiting & +/- fever)
It is difficult to make "hard and fast rules around investigations" on children with abdominal pain. Consideration of the child's case, how acutely unwell they are and try to formulate which is the most likely diagnosis , and align investigations accordingly:
e.g.: a) mild colicky pain, non bilious vomiting and watery non-bloody diarrhoea (probably viral gastroenteritis - may just NG rehydration)
versus
b) a 2 year old with severe pain, bilious vomiting, very tachycardic in red zone on BTF, high fever , rigid abdomen (the "works" see all of the below recommendations)
A useful clinical "rule" is: in a child in whom the acute abdomen is strongly suspected (that is fever, abdominal pain and vomiting) , and who the surgical team wish to take to theatres, a chest x-ray should be taken looking for right & left lower lobe and retrocardiac pneumonia BEFORE THEY GO TO THEATRE. The reason for this is that referred pain to the abdomen is not uncommon with lower lobe pneumonia, which may cause ileus (closely mimicking appendicitis and the acute abdomen)
Urinalysis - typically urinary tract infection will have a combination of white cells (leukocytosis), red cells (haematuria) and/or nitrates. All may be present alone (eg just raised red cells) or raised together.
Nitrates are relatively specific for UTI diagnosis on a midstream urine (assuming there is no contamination by faeces) and suggests a urinary tract infection with a gram-negative organism.
If the urinalysis are no white cells, red cells or nitrates it is probably not a UTI (>95% probability); but if there is no clear focus, still send the urine culture.
Electrolytes - with a child who is dehydrated they may have a combination of hyponatraemia, and/or hypokalaemia or hyperkalaemia.
As they progress to 5% dehydration typically they will also have high urea (>7) and/or high creatinine. This reflects a reduced GFR.
Lipase and amylase may be run for pancreatitis (this is relatively uncommon in children but certainly on the differential of abdominal pain and vomiting.
Venous blood gas - looking for acidosis and high lactate.
Blood glucose for diabetic ketoacidosis - diabetic ketoacidosis may present with abdominal pain which is related to ketosis and vomiting.
Liver function tests - acute hepatitis can present with abdominal pain and fever. (In particular note the nephrotic syndrome can present with peritonitis if the albumin is less than 25
If fever is >38.5c , and the child has vomiting with significant abdominal pain, and so appendicitis / peritonitis is suspected then also consider doing:
procalcitonin (PCT)- most of Dubbo's cases of peritonitis, who have had PCT checked have had a significant elevation in PCT. And note, in particular, this applies also to the group of patients who may pose the greatest clinical challenge diagnostically , i.e the < 5 year old group, in whom even experienced clinicians can make clinical errors in their assessment.
So, for example, if a child has vomiting , fever and abdominal pain, and the PCT > 2, it is unlikely the patient has viral gastroenteritis or mesenteric adenitis. Look hard for a bacterial cause. Pneumonia, urosepsis (pyelonephritis), sepsis, and/or peritonitis (rather than just uncomplicated appendicitis) are likely underlying differential diagnoses, in this scenario.
C-reactive protein - if the CRP > 100 consider bacterial infections carefully
blood culture
IMAGING
An abdominal supine film and an erect chest x-ray are recommended where possible. The abdominal x-ray may show distension of abdominal loops which is defined as a bowel lumen greater than half the width of L2.
Chest x-ray - be wary of missing lower lobe pneumonia; in particular check for retrocardiac consolidation.
Ultrasound - this is a fairly reliable investigation which if it shows an appendix greater than 10 mm is consistent with appendicitis. An appendix that is not visualised on ultrasound does not exclude appendicitis. Also an ultrasound is useful looking for signs of intussusception.
TREATMENT AND REFERRING on to SPECIALIST TEAMS IN DUBBO
In children under 5 years of age it is recommended consultations be held with the paediatrician, in particular if there are: abnormal vital signs, green vomiting, abdominal distension, peritonism and there is concern about the possibility of a surgical abdomen. The paediatrician will assist the ED team "put it all together" and formulate a clinical likelihood of a surgical abdomen being present.
Providing adequate analgesia, intravenous morphine or intranasal fentanyl can be directed by the person in-charge in the emergency department - see acute pain management.
In particular with abdominal distension, bilious vomiting keep the child fasted and hydrate the child with intravenous and/or enteral fluids.
In children over 5 years of age refer to Surgical Team
Pubertal females presenting with abdominal pain - the Paediatric Department in Dubbo recommends
a) general surgical review
b) consider gynaecological review and pregnancy testing if no general surgical pathology found,
and then
c) and if no surgical or gynaecological causes found to explain the pain, then refer on to paediatrics (who may request some of the above investigations
If there is bilious vomiting and bowel obstruction is suspected clinically and radiologically, consider nasogastric tube placement.
Skin condition in children (Dermnet NZ)
Headache (PIC)
Infant who is crying (RCH
1) For the full NSW Health document please see the following: Infants and Children: Acute Management of Sore throat and
Sore throat (Victorian)
2) Children under 5- 7 years seldom cooperate for throat examination. One technique is sit the child on guardian's lap facing you. The guardian holds one arm around both the child's arms and one on the child's forehead. Quickly, yet gently place the wooden tongue depressor over the back of tongue and push the tongue down. Quickly look at the back of throat to work out if there is one of the following patterns a) normal throat b) pharyngitis (red throat) c) tonsillitis d) tonsillar enlargement e) peritonsillar abscess f) mouth ulcers tongue ulcers
Note the below is our local summary for sore throat and tonsillitis.
Tonsillitis and pharyngitis (used interchangeably and collectively throughout this information sheet) are the commonest cause of sore throat in children
Viral tonsillitis accounts for ~80% of cases
Bacterial tonsillitis (typically streptococcus pyogenes aka. Group A β haemolytic streptococcus) account for ~20% of cases
Features increasing the likelihood of viral causation:
- cough , conjunctivitis (red eye with discharge)
-nasal congestion/runny nose
-viral rash (note scarlet fever may cause rash too)
-diarrhoea
-absence of fever
-mouth, lip, gums and tongue ulcers (this could be related to a "cold sore" or herpes simplex type -1 )
Features increasing the likelihood of bacterial causation:
- fever (>38°C)
-tender cervical lymphadenopathy
-absence of cough, rhinorrhoea or nasal congestion
Validated assessment tools such as Modified Centor Criteria can be used to assist clinicians in decision making surrounding viral vs. bacterial cause, and the use (or not) of antibiotics to treat the condition
Throat swab may (contentiously) assist in treatment decision-making, though results are confounded by S. pyogenes being normal pharyngeal flora, meaning a positive swab is not diagnostic of bacterial tonsillitis, nor does it mandate the use of antibiotics in its management
Tonsillitis is a self-limiting condition of approximately 7 days duration
Red Flags for tonsillitis
We recommend you discuss going to hospital with your health clinician , if you have some of the following worrying features (red flags)
RCH severe tonsillitis management
Red flags
unwell/toxic appearance
respiratory distress and any new onset noisy breathing should ideally go to hospital for check
it is important the doctors in hospital consider if the tonsils are so enlarged (image of enlarged tonsils) as to cause airway blockage
stridor - this is noisy breathing in and if recent in onset and has increased work of breathing should go to hospital.
Video of stridor in child - this is both breathing in and out noise
stertor (this is usually a noisy, muffled, snoring sound, which may be due to either tonsils or the adenoids being swollen)
trismus (lock jaw i.e. the child has difficulty opening its mouth and jaw due to pain and swelling )
Video baby with congenital trismus who cannot open its mouth while crying, as it has lock jaw
drooling
“hot potato” voice (muffled voice associated with pharyngeal/peritonsillar pathology)
Video of adult with hot potato voice (muffled, soft voice , sounds full of mucous and is painful)
torticollis (image) (image from Up To Date) - beware the child with a new onset of stiff or sore neck, and being turned, and held to one side "this is called torticollis" and the child being reluctant to move it. They may have infection at the back of the throat
In the acutely unwell looking child consider alternative diagnosis and/or complications of GAS pharyngitis.
Management is symptomatic, for both viral and bacterial tonsillitis. This should include:
-Hydration
-Paracetamol (15mg/kg, up to 1g, given up to four times per day, no greater than 4th hourly)
-Ibuprofen (10mg/kg, up to 400mcg, given up to three times per day, no greater than 4th hourly, and make sure the child is drinking plenty, and has good urine output) – only for use in children >3 months of age, without bleeding disorders
-Aspirin should never be used in children under 12 (as it may cause Reye's syndrome)
-Clear directions for follow up should symptoms worsen, or there is failure to improve as expected
-Consider giving family a script for appropriate antibiotics, and give directions around when they could consider starting them, and seeking medical review in the next 48-72 hours eg persisting high fever >39c, worsening general clinical state , progressive trouble with swallowing.
- consider local anaesthetic lidocaine 2% gel ( it is expensive on script, but may be obtained from emergency; and if taken may numb a sore throat and prevent the need for hospitalisation for dehydration. Take care with dosing , as an overdose may lead to seizures and cardiac arrhythmias from lidocaine toxicity)
Antibiotics should be reserved for bacterial tonsillitis in higher risk groups only. This is because the benefit of antibiotic treatment is minimal (lessens duration of symptoms by ~1 day) and not without potential harms (eg. diarrhoea, rash, hypersensitivity reaction, antimicrobial resistance). Therefore, antibiotic use should be limited to:
2 – 25 year-olds from populations with a high incidence of acute rheumatic fever (eg. Aboriginal and Torres Strait Islander Australians living in rural or remote settings, Maori and Pacific Islander people)
Patients with existing rheumatic heart disease
Patients with scarlet fever
Severe pharyngitis (eg. severe sore throat, dysphagia, those requiring hospitalisation)
Antibiotic treatment, if required, is:
phenoxymethylpenicillin (15mg/kg, up to 500mg) orally, twice daily for 10 days duration
-for delayed, non-severe hypersensitivity to penicillins use:
cephalexin (25mg/kg, up to 1g) orally, twice daily for 10 days duration
-for immediate or severe hypersensitivity to penicillins use:
azithromycin (12mg/kg, up to 500mg) orally, once daily for 5 days duration
Referral to Ear Nose and throat Surgeon
Consideration of tonsillectomy should be considered in recurrent tonsillitis, for consideration of tonsillectomy if one of the following criteria is met:
7 episodes of documented bacterial tonsillitis in the past 12 months
or
5 episodes of documented bacterial tonsillitis per year, for the past 2 years
or
3 episodes of documented bacterial tonsillitis per year, for the past 3 years
References:
1. eTG Complete. Sore Throat. Therapeutic guidelines. 2019. Accessed 13/11/2020.
2. Patel C, et al. Antibiotic prescribing for tonsillopharyngitis in a general practice setting: can the use of Modified Centor Criteria reduce antibiotic prescribing? Australian Journal of General Practice. 2019, 48(6).
Mitchell RB, et al. Clinical Practice Guideline: Tonsillectomy in Children (update). Otolaryngology – Head and Neck Surgery. 2019, 160(1S): S1-
Dehydration (RCH)
Hydration assessment ( Qld) one page