Transcript - Imperial College Union

PACES Revision:
Paediatrics
Kathryn Wright & Sarah Hewett
Kindly sponsored by:
Schedule
• 9:00 - 10:00 Paediatrics PACES Talk + Questions
• 10:00 - 10:15 Practical demonstration of a station
• 10:30 - 11:00 – short break
 station 1 - 11.00 - 11.35
 station 2 - 11.40 - 12.15
 station 3 - 12.20 - 12.55
 station 4 - 13.00 - 13.35
The Objective
 Know what to expect from a station
 Know how to take the perfect history
 Use your history to demonstrate your breadth of
knowledge
 Be familiar with key topics
 Know where to look for further resources
 Feel more confident and less daunted by Paediatrics!
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
PACES
 Practical Assessment of Clinical Examination Skills
 This will assess your history, examination and
communication skills in six 15 minute stations
 Can’t fail on one station
 Expect overlap between specialties
 Teen - depression/substance abuse/self harm/poor compliance
 Teen - contraception: competence/confidentiality
 GP - Rash/vaccinations/development
 COMMUNICATION skills
The Paediatric station
 May or may not have a patient in
 History
 Examination/explain how you would
examine/examination findings
 Investigations/management/questions around a topic
 Discussion with family – answer questions, explain,
reassure, ICE
 SAFETY NET!!
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
The Handbook
 History
 Examination
 Key topics
 Emergency algorithms’
 Top tips and handy hints
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
The history
 By taking a history you aim to show the examiner your
thought process:
 Consider all differentials
 Narrow the diagnosis down
 Place the child in context
 Show your communication skills
History Overview
 Introduction
 Presenting complaint
 Systems review
 Past medical history
 Developmental
 Family
 Social
 Adolescent Questions
 Conclusions
Introductions
 Who are you you
 Who is the patient
 Who is with them
 What are you there for
Presenting Complaint
 Open ended questions
 The main cause for concern
 Associated symptoms
 Time frame + duration
 Why have they come to you
Our patient
 Lucy, 3 years old
 PC: Does not seem herself, C/O abdominal pain
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Last couple of days
Some diarrhoea, 1 episode of vomiting
Not wanting to E+D much
PU – reduced volume
Low grade fevers
Systems review
 General – fever, skin colour, sleep, weight loss
 Cardio – sweating, cyanosis, pallor, SOB, faints
 Resp – coryza, sore throat, earache, cough, wheeze, SOB,
snoring
 Gastro – infant feeding, appetite, diet, vomiting, abdo pain,
distention, bowel habit
 Urological – passing urine, enuresis, dysuria
 Neuro – headache, fits, hearing, vision
 Musc – limp, joint or limb pain, swollen joint, gait
 Derm – lumps or bumps, rashes
Our patient
 Lucy, 3 years old
 PC: not herself, abdo pain, mild D&V, reduced oral
intake, low grade fevers
 SR:
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Lethargic
URTI last week
Limping since yesterday
Small dark red spots over her bottom
Past medical hx
 Specific questions to paeds:
 Pregnancy and birth
 Feeding
 Previous admissions
 Common conditions
 Drug history
 Allergies
 Vaccinations
The vaccination schedule
 This is on page 47 of the guide
 Common theme in PACES
 Always check they are up to date, check the red book.
 If not ask why
 Reassurance about the safety of immunisation
 Importance of herd immunity
 Also, for at risk groups, BCG and HBV at birth
Our patient
 Lucy, 3 years old
 PC: not herself, abdo pain, mild D&V, reduced oral
intake, low grade fevers
 SR: Lethargic, URTI last week, limping since yesterday,
small dark red spots over her bottom
 Pmhx:
 Nil of note
 UTD with vaccinations –3 yr booster 10 days ago
Developmental
 On page 45 of your handbook
 Limited in a systems review
 Ask parents if they have any concerns, is the child
doing what they would expect (easier if not the 1st child)
 Screening with red flag signs
 Could be shown a video
 Could be asked “what you you expect of a child of this
age?”
Some examples of
development
Developmental red flags
Age
Features
Any age
Maternal concern
10 wks
Not smiling
6 mths
Persistent primitive reflexes
Hand preference
Persistent squint
Little interest in people, toys or noises
10-12
mths
No sitting
No pincer grasp
18 mths
Not walking independently
Regression of any previously acquired skill
No double-syllable babble
Fewer than 6 words
2.5 yrs
No 2-3 word sentences
4 yrs
Unintelligible speech
Persistent mouthing or drooling
Family history
 Who is in the house?
 Parents and sibling most important but ask about whole
family.
 Consanguinity
 Always draw a family tree!
Social history
 Who is at home?
 School/day care?
 Anyone else unwell?
 Smokers, pets at home, (if relevant)
Adolescent questions
 Home – relationships/problems
 Education/Employment – problems
 Alcohol
 Drugs – smoking, illicit, tried/regular use
 Sex – orientation, active, partner, contraception, STIs,
menstrual history
Our patient
 Lucy, 3years old
 PC: not herself, abdo pain, mild D&V, reduced oral intake,
low grade fevers
 SR: Lethargic, URTI last week, limping since yesterday,
small dark red spots over her bottom
 Pmhx: Nil of note, recent vaccinations
 Fhx/Shx:
 normal development
 Lives with parents and older sister who has also been coryzal
recently
Conclusions
 Summarize back to the family/patient
 Ask if you have missed any thing
 Is there anything else concerning them?
 Is there anything they would like to ask you?
 Do not forget to look at the red book
Our Patient
 Diagnosis HSP
 PACES questions
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Examination findings
Investigations, management
Pathology behind the diagnosis
May be asked to speak to the parents;
 Chance to show communication skills
 Jargon free explanations
 Reassurance
 Offer written as well as verbal advice
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Examination
 Pages 38 - 40 in the handbook
 Detail is beyond the scope of this lecture but a few keys
points….
 General appearance
 Hernias & genitalia
 ENT
 Skin
 Hydration status
 Utilise parents, nurses, play specialists
 Make it fun!
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Hydration status
Fluid resuscitation
 Correcting shock:
 IV rehydration: 20ml/kg bolus of 0.9% saline. If still
shocked then PICU
 If shock resolves then: IV 100ml/kg 0.9% saline over 4hrs
plus maintenance
 Maintenance:
Body Weight
Fluid Requirement over 24
hours
Volume/kg/hour
First 10kg
100 ml/kg
4ml
Second 10kg
50 ml/kg
2ml
Each kg thereafter
20 ml/kg
1ml
Vital signs in children
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Describing a rash
 What if you can’t guess what it is??
 Describe what you see:
 http://dermnetnz.org/terminology.html
 Derm net Nz: great lesion terminology and photos, good
for derm revision too!
Describing a lesion
 INSPECT in general
 Site and number of lesion(s)
 Pattern of distribution and configuration
 DESCRIBE the individual lesion
 SCAM
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Size (the widest diameter)
Shape
Colour
Associated secondary change
Morphology, Margin (border)
 ABCD: If Pigmented, increased chance of malignancy:
 Asymmetry (lack of mirror image in any of the four
quadrants)
 Irregular Border
 Two or more Colours within the lesion
 Diameter > 7mm
 PALPATE the individual lesion
 Surface Consistency Mobility Tenderness Temperature
 SYSTEMATIC CHECK
 Examine the nails, scalp, hair & mucous membranes
General examination of all systems
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Basic Life Support
Other Emergencies
 Pages 48 – 58 of your guide
 Shock/sepsis
 Acute Asthma
 Anaphylaxis
 DKA
 Epilepsy/status/febrile fits
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Non Accidental Injury
 More details in your guide, page 61
 Different types of abuse
 Physical/emotional/neglect/sexual
 General appearance?
 Growth, development, demeanor, clothing, hygiene
 How did they present?
 Delayed, who brought them in
 History – does the mechanism fit the injury
 Plausible, possible
 Consistent
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Consent + Competence
 Family Law Reform Act 1969: children age 16 and over
are deemed competent to consent
 Gillick competence: sufficiently mature to:
 Understand the nature, purpose, risks
 Understand the alternatives
 Must be decided on a case to case basis
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
The MDT
 The usual suspects:
 Dr’s from all specialties
 Nurses + specialty nurses (CF, asthma etc)
 OT + PT
 Paeds specific:
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Community paediatricians
School teachers and nurse
Social workers
Play specialists
CAMHS
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
Handy hints
 Be familiar with the red book
 Know how plot and read off a growth chart
 Know your milestones and vaccination schedule
 Be aware of age and its influence on presentations
 Listen carefully to pick up all clues
 Common things are common!
 Practice, practice, practice!
Exam resources
 Lissauer
 “Get ahead” books
 Core Clinical Cases
 Clinical Cases Uncovered
 100 cases in paediatrics
 MedEd handbook
 Patient.co.uk
 Royal college websites: RCPCH, BTS, Resuscitation
Council
Thank you for listening!
 Please fill in the feedback forms, helpful to us and
helpful for improving this course for future years!
 Example case coming up if you would like to stay
 First of the stations starts at 11:00
QUESTIONS???
The plan
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Introduction to PACES and paediatric stations
The handbook
The history
The examination
Hydration status and fluid management
Rashes
Paediatric emergencies
Non-accidental injuries
Paediatric ethics
The MDT
Handy hints and resources
Practice station
The Mock Station