PACES Revision: Paediatrics
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Transcript of 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