PACES Revision: Paediatrics

1. PACES Revision:Paediatrics Kathryn Wright & Sarah Hewett Kindly sponsored by:

2. 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

3. 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!

4. 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

5. 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

6. 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

8. 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!!

9. 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

10. The Handbook • History • Examination • Key topics • Emergency algorithms’ • Top tips and handy hints

11. 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

12. 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

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

14. Introductions • Who are you you • Who is the patient • Who is with them • What are you there for

15. Presenting Complaint • Open ended questions • The main cause for concern • Associated symptoms • Time frame + duration • Why have they come to you

16. 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

17. 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

18. 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

20. Past medical hx • Specific questions to paeds: • Pregnancy and birth • Feeding • Previous admissions • Common conditions • Drug history • Allergies • Vaccinations

21. The vaccination schedule • This is on page 47of 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

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

23. 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

24. 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?”

25. Some examples of development

26. Developmental red flags

27. Family history • Who is in the house? • Parents and sibling most important but ask about whole family. • Consanguinity • Always draw a family tree!

28. Social history • Who is at home? • School/day care? • Anyone else unwell? • Smokers, pets at home, (if relevant)

29. Adolescent questions • Home – relationships/problems • Education/Employment – problems • Alcohol • Drugs – smoking, illicit, tried/regular use • Sex – orientation, active, partner, contraception, STIs, menstrual history

30. 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

31. 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

34. 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

35. 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

36. Examination • Pages 38 - 40 in the handbook • Detail is beyond the scope of this lecture but a few keys points….

37. General appearance • Hernias & genitalia • ENT • Skin • Hydration status • Utilise parents, nurses, play specialists • Make it fun!

38. 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

39. Hydration status

40. 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:

41. Vital signs in children

42. 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

45. 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!

46. 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)

47. 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

48. 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

49. Basic Life Support

50. Other Emergencies • Pages 48 – 58 of your guide • Shock/sepsis • Acute Asthma • Anaphylaxis • DKA • Epilepsy/status/febrile fits