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

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 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

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 1 st 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: Body WeightFluid Requirement over 24 hours Volume/kg/hour First 10kg100 ml/kg4ml Second 10kg50 ml/kg2ml Each kg thereafter20 ml/kg1ml

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

51. 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

52. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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!

60. 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

61. 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???

62. 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

63. The Mock Station