paces revision: paediatrics

PACES Revision:Paediatrics

Kindly sponsored by:

Kathryn Wright & Sarah Hewett

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 - 11.35station 2 - 11.40 - 12.15 station 3 - 12.20 - 12.55station 4 - 13.00 - 13.35

The ObjectiveKnow what to expect from a stationKnow how to take the perfect historyUse your history to demonstrate your breadth of

knowledgeBe familiar with key topicsKnow where to look for further resourcesFeel more confident and less daunted by

Paediatrics!

The plan 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 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

PACESPractical Assessment of Clinical Examination SkillsThis will assess your history, examination and

communication skills in six 15 minute stationsCan’t fail on one stationExpect overlap between specialties

Teen - depression/substance abuse/self harm/poor compliance Teen - contraception: competence/confidentiality GP - Rash/vaccinations/development

COMMUNICATION skills

The Paediatric stationMay or may not have a patient inHistoryExamination/explain how you would

examine/examination findingsInvestigations/management/questions around a

topicDiscussion with family – answer questions, explain,

reassure, ICESAFETY NET!!

The plan 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 HandbookHistoryExaminationKey topicsEmergency algorithms’Top tips and handy hints

The plan 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 historyBy taking a history you aim to show the

examiner your thought process:Consider all differentialsNarrow the diagnosis downPlace the child in contextShow your communication skills

History Overview Introduction Presenting complaint Systems review Past medical history Developmental Family Social Adolescent Questions Conclusions

IntroductionsWho are you youWho is the patientWho is with themWhat are you there for

Presenting ComplaintOpen ended questionsThe main cause for concernAssociated symptomsTime frame + duration Why have they come to you

Our patientLucy, 3 years oldPC: Does not seem herself, C/O abdominal pain

Last couple of daysSome diarrhoea, 1 episode of vomitingNot wanting to E+D muchPU – reduced volumeLow grade fevers

Systems reviewGeneral – fever, skin colour, sleep, weight lossCardio – sweating, cyanosis, pallor, SOB, faintsResp – coryza, sore throat, earache, cough, wheeze,

SOB, snoringGastro – infant feeding, appetite, diet, vomiting,

abdo pain, distention, bowel habitUrological – passing urine, enuresis, dysuriaNeuro – headache, fits, hearing, visionMusc – limp, joint or limb pain, swollen joint, gaitDerm – lumps or bumps, rashes

Our patientLucy, 3 years oldPC: not herself, abdo pain, mild D&V, reduced

oral intake, low grade feversSR:

LethargicURTI last weekLimping since yesterdaySmall dark red spots over her bottom

Past medical hxSpecific questions to paeds:Pregnancy and birthFeedingPrevious admissionsCommon conditionsDrug historyAllergiesVaccinations

The vaccination schedule This is on page 47 of the guideCommon theme in PACES Always check they are up to date, check the red

book.If not ask why Reassurance about the safety of immunisationImportance of herd immunity

Also, for at risk groups, BCG and HBV at birth

Our patientLucy, 3 years oldPC: not herself, abdo pain, mild D&V, reduced

oral intake, low grade feversSR: Lethargic, URTI last week, limping since

yesterday, small dark red spots over her bottomPmhx:

Nil of noteUTD with vaccinations –3 yr booster 10 days ago

DevelopmentalOn page 45 of your handbookLimited in a systems reviewAsk parents if they have any concerns, is the

child doing what they would expect (easier if not the 1st child)

Screening with red flag signsCould be shown a videoCould be asked “what you you expect of a child

of this age?”

Some examples of development

Developmental red flags

Family historyWho is in the house?Parents and sibling most important but ask

about whole family. Consanguinity Always draw a family tree!

Social historyWho is at home?School/day care?Anyone else unwell?Smokers, pets at home, (if relevant)

Adolescent questionsHome – relationships/problemsEducation/Employment – problemsAlcoholDrugs – smoking, illicit, tried/regular useSex – orientation, active, partner, contraception,

STIs, menstrual history

Our patientLucy, 3years oldPC: not herself, abdo pain, mild D&V, reduced oral

intake, low grade feversSR: Lethargic, URTI last week, limping since yesterday,

small dark red spots over her bottomPmhx: Nil of note, recent vaccinationsFhx/Shx:

normal development Lives with parents and older sister who has also been

coryzal recently

ConclusionsSummarize back to the family/patientAsk if you have missed any thingIs there anything else concerning them?Is there anything they would like to ask you?Do not forget to look at the red book

Our PatientDiagnosis HSPPACES questions

Examination findings Investigations, managementPathology behind the diagnosisMay be asked to speak to the parents;

Chance to show communication skillsJargon free explanationsReassuranceOffer written as well as verbal advice

The plan 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

ExaminationPages 38 - 40 in the handbookDetail is beyond the scope of this lecture but a

few keys points….

General appearance Hernias & genitaliaENTSkinHydration statusUtilise parents, nurses, play specialistsMake it fun!

The plan 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 resuscitationCorrecting 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

hoursVolume/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 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 rashWhat 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 lesionINSPECT in general

Site and number of lesion(s)Pattern of distribution and configuration

DESCRIBE the individual lesion SCAM

Size (the widest diameter) ShapeColourAssociated secondary change Morphology, Margin (border)

ABCD: If Pigmented, increased chance of malignancy:Asymmetry (lack of mirror image in any of the four

quadrants) Irregular BorderTwo or more Colours within the lesion Diameter > 7mm

PALPATE the individual lesion Surface Consistency Mobility Tenderness

TemperatureSYSTEMATIC CHECK

Examine the nails, scalp, hair & mucous membranes General examination of all systems

The plan 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 guideShock/sepsisAcute AsthmaAnaphylaxisDKAEpilepsy/status/febrile fits

The plan 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 InjuryMore details in your guide, page 61Different types of abuse

Physical/emotional/neglect/sexualGeneral appearance?

Growth, development, demeanor, clothing, hygieneHow did they present?

Delayed, who brought them inHistory – does the mechanism fit the injury

Plausible, possible Consistent

The plan 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 consentGillick competence: sufficiently mature to:

Understand the nature, purpose, risksUnderstand the alternatives

Must be decided on a case to case basis

The plan 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 MDTThe usual suspects:

Dr’s from all specialties Nurses + specialty nurses (CF, asthma etc)OT + PT

Paeds specific: Community paediatricians School teachers and nurseSocial workers Play specialists CAMHS

The plan 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 hintsBe familiar with the red bookKnow how plot and read off a growth chartKnow your milestones and vaccination scheduleBe aware of age and its influence on

presentationsListen carefully to pick up all cluesCommon things are common!Practice, practice, practice!

Exam resourcesLissauer“Get ahead” booksCore Clinical CasesClinical Cases Uncovered100 cases in paediatricsMedEd handbook Patient.co.ukRoyal college websites: RCPCH, BTS, Resuscitation Council

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Example case coming up if you would like to stay

First of the stations starts at 11:00

QUESTIONS???

The plan 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