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

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 - 11.35

station 2 - 11.40 - 12.15

station 3 - 12.20 - 12.55

station 4 - 13.00 - 13.35

The ObjectiveKnow 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

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 stationMay 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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

The HandbookHistory

Examination

Key topics

Emergency algorithms’

Top tips and handy hints


The handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


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 you

Who is the patient

Who is with them

What are you there for

Presenting ComplaintOpen ended questions

The main cause for concern

Associated symptoms

Time frame + duration

Why have they come to you

Our patientLucy, 3 years old

PC: Does not seem herself, C/O abdominal painLast couple of daysSome diarrhoea, 1 episode of vomitingNot wanting to E+D muchPU – reduced volumeLow grade fevers

Systems reviewGeneral – 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


PC: not herself, abdo pain, mild D&V, reduced oral intake, low grade fevers

SR: LethargicURTI last weekLimping since yesterdaySmall dark red spots over her bottom

Past medical hxSpecific 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



SR: Lethargic, URTI last week, limping since yesterday, small dark red spots over her bottom

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

DevelopmentalOn 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

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/problems

Education/Employment – problems

Alcohol

Drugs – smoking, illicit, tried/regular use

Sex – orientation, active, partner, contraception, STIs, menstrual history

Our patientLucy, 3years old


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

ConclusionsSummarize 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 PatientDiagnosis HSP

PACES questionsExamination 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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

ExaminationPages 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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

Describing a rashWhat if you can’t guess what it is??

Describe what you see:

http://dermnetnz.org/terminology.htmlDerm net Nz: great lesion terminology and photos,

good for derm revision too!

http://dermnetnz.org/terminology.html

http://dermnetnz.org/terminology.html

Describing a lesionINSPECT in general

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

DESCRIBE the individual lesion

SCAMSize (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

Temperature

SYSTEMATIC CHECK Examine the nails, scalp, hair & mucous

membranes General examination of all systems


The handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

Basic Life Support

Other Emergencies Pages 48 – 58 of your guide

Shock/sepsis

Acute Asthma

Anaphylaxis

DKA

Epilepsy/status/febrile fits


The handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

Non Accidental InjuryMore 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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


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, risksUnderstand the alternatives

Must be decided on a case to case basis


The handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

Handy hintsBe 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 resourcesLissauer

“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 handbook

The history

The examination


Rashes



Paediatric ethics

The MDT


Practice station

The Mock Station

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

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