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 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 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 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 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 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: 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 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 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 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 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 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 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 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 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 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: Community paediatricians School teachers and nurse Social 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 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 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