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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
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 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 HandbookHistory
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 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
Our patientLucy, 3 years old
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
Our patientLucy, 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 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
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
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 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 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 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.htmlDerm 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
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 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 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 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, 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 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 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