Paediatric SBAs Dr Michael Malley.

Paediatric SBAs Dr Michael Malley

Some general rules: What’s the question actually asking you?
Scott is 5 years old and presents with an acute exacerbation of asthma. On auscultation he is wheezy bilaterally and is working hard. SATS are 90% in air. What is the most appropriate initial management? A) IV Salbutamol B) Inhaled salbutamol C) Facemask oxygen D) Magnesium Sulphate E) Prednisolone

Some general rules: What’s the question actually asking you?
Scott is 5 years old and presents with an acute exacerbation of asthma. On auscultation he is wheezy bilaterally and is working hard. SATS are 90% in air. What is the most appropriate management to relieve his symptoms? A) IV Salbutamol B) Inhaled salbutamol C) Facemask oxygen D) Magnesium Sulphate E) Prednisolone

Some general rules Are there any ‘gimme’s? Why include information?
Term Meaning Pale Anaemic/shocked Fat teenager SUFE Pale and jaundiced Haemolytic anaemia Gower’s sign positive Duchenne’s Drooling Epiglottitis Cap refil >3 Shocked Recently moved from abroad and don’t have a red book Unimmunised Measles/epiglot/meningitis Recently moved from abroad and don’t have red book No guthrie screening. Think thyroid/PKU/cystic fibrosis “mum has a new boyfriend” Child abuse Heart appears boot shaped on CXR Tetralogy ‘Pins and needles’ in hands Panic attack Port wine stain Sturge-Weber 6 days of fever Kawasaki’s Disease Confusion Encephalitis/opathy Mum unable to let go of your hand Myotonic dystrophy Barking cough Croup Rash with amoxicillin EBV Birthday party Anaphylaxis Irritability Meningitis

Some general rules Eliminate at least 2 answers out of 5 as ridiculous
Tommy is 3 weeks old. His mother asks if you can get him circumcised but refuses to tell the father. What is the most appropriate action? A) Call social services and ask for marriage counselling B) Perform the circumcision urgently as mum has consented C) Refuse to perform the circumcision because you need consent from both parents D) Explore why mum doesn’t want the father to know and suggest that these decisions are best made as a team E) Perform DNA testing to confirm the mother and father’s identity.

Question 1 A healthy 10 month old boy has a 3 day history of coryza and fever up to 38 degrees. He has a barking cough and over the last few hours has developed inspiratory stridor. He has mild-moderate respiratory distress, and oxygen saturations of 99% on air. He is not drooling. His temperature in the department is 38.2 degrees.

What would be the most appropriate management?
A – Oral dexamethasone and observe in the day unit until respiratory distress settles. B – Obtain IV access and take a blood culture, commence IV ceftriaxone C – Adrenaline nebuliser and discharge from A+E if respiratory distress has resolved. D – Give facial oxygen and a salbutamol nebuliser, and review after 20 minutes E – Discharge home with 10 puffs 4 hrly inhaled salbutamol and advice to return if increasing respiratory distress

What would be the most appropriate management?
A – Oral dexamethasone and observe in the day unit until respiratory distress settles B – Obtain IV access and take a blood culture, commence IV ceftriaxone until BC negative C – Give an adrenaline nebuliser and discharge from A+E if respiratory distress has resolved. D – Give facial oxygen and a salbutamol nebuliser, and review after 20 minutes E – Discharge home with 10 puffs 4 hrly inhaled salbutamol and advice to return if increasing respiratory distress

Airway compromise Interventions Anaphylaxis Decrease inflammation:
Dexamethasone Budesonide Hydrocortisone Adrenaline Treat bacterial infection: Cefriaxone Penicillin / Antitoxin People: Anaesthetic support ENT support Anaphylaxis Croup Epiglottitis Foreign Body Diphtheria

Question 1a Lucy is 3 years old and presents with cough and stridor. She appears unwell and is drooling. She has subcostal, substernal recessions and tracheal tug. What is the most appropriate initial management?

Question 1a A) Cannulate the child as soon as possible and give IV Ceftriaxone B) Do not approach the child and call for immediate anaesthetic and ENT support C) Examine the child’s throat to confirm the diagnosis D) Give an adrenaline nebuliser and prepare to cannulate E) Give oral dexamethasone and facial O2

Answer 1a A) Cannulate the child as soon as possible and give IV Ceftriaxone B) Do not approach the child and call for immediate anaesthetic and ENT support C) Examine the child’s throat to confirm the diagnosis D) Give an adrenaline nebuliser and prepare to cannulate E) Give oral dexamethasone and facial O2

Question 1b Lucy is 3 years old and presents with stridor and a spreading rash after returning from a playdate at a friend’s house. She is given IM adrenaline in the ambulance and presents to A&E 10 minutes later. She has loud stridor, swollen lips and respiratory distress. Her SATS are 92% on air and she is wheezy. What is the most appropriate initial management?

Question 1b A) 15L O2 via a non-rebreathe bag B) IM adrenaline
C) Nebulised adrenaline D) Nebulised salbutamol E) Obtain IV access and give IV Hydrocortisone

Answer 1b A) 15L O2 via a non-rebreathe bag B) IM adrenaline
C) Nebulised adrenaline D) Nebulised salbutamol E) Obtain IV access and give IV Hydrocortisone

Question 1c Caoimhe is 4 weeks old. She is brought to A&E with noisy inspiratory breathing which has been more prominent over the last few weeks. She appears well on examination but has some inspiratory stridor, more obvious when she cries. She is gaining weight and is afebrile What is the most likely diagnosis?

Question 1c A) Croup B) Epiglottitis C) Foreign body aspiration
D) Laryngomalacia E) Subglottic stenosis

Answer 1c A) Croup B) Epiglottitis C) Foreign body aspiration
D) Laryngomalacia E) Subglottic stenosis

Question 2 Sunayna is 1 year old and presents with abdominal pain and vomiting. You have been asked to write up full maintenance fluids for her. She weighs 12kg Which fluid regime would be most appropriate?

Question 2 A) 500ml bag of 0.9% NaCl followed by 500ml bag of 10% dextrose over 24 hours B) 1100ml of NaCl 0.9% over 24 hours C) 1100ml of NaCl 0.9% plus 5% dextrose over 24 hours D) 1200ml of NaCl 0.9% over 24 hours E) 1200ml of NaCl 0.9% plus 5% dextrose over 24 hours

Answer 2 A) 500ml bag of 0.9% NaCl followed by 500ml bag of 10% dextrose over 24 hours B) 1100ml of NaCl 0.9% over 24 hours C) 1100ml of NaCl 0.9% plus 5% dextrose over 24 hours D) 1200ml of NaCl 0.9% over 24 hours E) 1200ml of NaCl 0.9% plus 5% dextrose over 24 hours

Paediatric fluids 3 options Maintenance fluids Bolus fluids
0.9% NaCl + 5% Dextrose 100mls/kg/day for each of first 10kg (ie 0-10kg) 50ml/kg/day for each of next 10kg (ie 10-20kg) 20ml/kg/day for every further kg Eg 24kg = (100 x 10) + (50 x 10) + (20 x 4) = = 1580 over 24 h Bolus fluids 20ml/kg 0.9% NaCl in most situations 10ml/kg when…… DKA, Trauma, Fluid overload or heart failure Dehydration corrections

Paediatric fluids Dehydration corrections: Usually over 24 hours
Maintenance fluids PLUS %dehydration Most of your body is water -> estimate the % lost Weigh the child if possible. 1kg weight loss = 1000ml lost Estimate clinically if not possible 3% weight loss in 20kg child. 20kg = 20000g = 20000mls fluid 1% = 200ml, therefore 3% = 600ml ADD the correction onto maintenance fluids over 24h

Question 2a Maria is 4 years old and weighs 17kg. She presents with a non-blanching rash and a fever of 39 degrees Her heart rate is 180 and her blood pressure is 64/40 What is the most appropriate initial fluid management?

Question 2a A) 1350ml 0.9% NaCl and 5% dextrose over 24 hours
B) 170ml 0.9% NaCl bolus C) 340ml 0.9% NaCl bolus D) 340ml 0.9% NaCl and 5% dextrose bolus E) 340ml ringer’s lactate bolus

Question 2b Marco presents following 2 days of profuse diarrhoea and vomiting. He has dry lips and is tachycardic, but is not shocked. He is not tolerating any oral intake. You estimate that he is 3% dehydrated. He weighs 10kg. What would be the most appropriate fluid regimen to correct his dehydration?

Question 2b A) 200ml 0.9% NaCl bolus, repeated if necessary
B) 200ml 5% dextrose bolus, repeated if necessary C) 1000ml 0.9% NaCl + 5% dextrose over 24h D) 1030ml 0.9% NaCl + 5% dextrose over 24 h E) 1300ml 0.9% NaCl + 5% dextrose over 24 h

Question 3 Abdul is 6 years old and presents with 24 hours of cough and difficulty in breathing. He is found to be wheezy and is given 3x nebulised salbutamol, 2x ipratropium bromide and oral prednisolone. 30 minutes later he is still wheezy and shows signs of respiratory distress. He appears to be shivering and has vomited twice. What is the most appropriate next management step?

Question 3 A) Magnesium Sulfate bolus IV B) Montelukast orally
C) Salbutamol bolus IV D) Salmeterol inhaled (long acting B agonist) E) Salbutamol nebuliser

Asthmatic Stairs Ward management: 1 hourly salbutamol
Oxygen as required Intubate and ventilate Aminophylline Salbutamol MgSO4 Salbutamol Aminophylline Panic step 3-2-1 Salbutamol x3 Atrovent x2 Prednisolone x1 IV Infusion step IV Bolus Step Burst Step Ward management: 1 hourly salbutamol 2 hourly salbutamol 3 hourly salbutamol 4 hourly salbutamol HOME

Question 3a George has brittle asthma. He presents with a severe exacerbation. He is currently on an aminophylline and salbutamol infusion. His oxygen saturations are 92% on 15L O2 and he appears tired. What is the most appropriate next management step for George?

Question 3a A) Aminophylline level and adjust dose accordingly
B) Atrovent nebuliser C) Hydrocortisone IV D) Intubation and transfer to PICU E) Magnesium Sulfate IV

Question 3b Josh is 3 years old and presents with a 24 hour history of cough and difficulty in breathing. He received inhaled salbutamol and atrovent on presentation. You review him one hour later. He appears comfortable with no wheeze and good air entry. What would be the most appropriate next step in management?

Question 3b A) Admit to the ward B) Magnesium sulfate IV
C) Montelukast orally D) Prednisolone orally and reassess in 1 hour E) Salbutamol via spacer 1 hourly

Question 3c Katie is 3 years old. She has been admitted to hospital 4 times with wheezing and has required IV medications once. She has eczema and was started on very low dose inhaled corticosteroids after her 2nd admission She presents to follow up clinic and her mother reports that she is using her blue inhaler at least once most days. She wakes frequently overnight coughing. What is the most appropriate advice to offer?

Question 3c A) Admit to hospital for a sleep study
B) Start a course of oral corticosteroids C) Start inhaled long acting B agonist D) Start oral montelukast E) Use salbutamol more frequently

Question 3c A) Admit to hospital for a sleep study
B) Start a course of oral corticosteroids C) Start inhaled long acting B agonist D) Start Montelukast once a night E) Use salbutamol more frequently

Outpatient asthma management
Oral steroids in lowest dose to maintain control Increase inhaled steroid dose +/- continue LABA Long acting B agonist >5 years Or Montelukast <5y Low dose inhaled steroid Salbutamol inhaler as required Consider stepping up when needing 3x per week

Question 4 You are called to the post-natal ward to see Billie, a 3 day old baby. The nurse is concerned that he is breathing quickly and appears pale. He was born at term to a low risk pregnancy and required no resuscitation. There were no risk factors for sepsis. Antenatal scans were normal. His RR is 65, HR 180, Cap refil 4 seconds with cool peripheries. Peripheral pulses are difficult to feel. He appears pale. HS I+II+0 and the chest is clear. BM=6. What is the single most likely diagnosis?

Question 4 A – Cardiac Arrythmia B – Co-arctation of the aorta
C – Congenital Pneumonia D – Hypoplastic left heart syndrome E – Inborn error of metabolism

SHOCK CYANOSIS Transposition AVSD Tricuspid atresia Ebstein’s anomaly
Mitral stenosis/atresia Pulmonary Stenosis Pulmonary atresia Fallot’s Hypoplastic left heart Co-arctation Interrupted arch Aortic stenosis VSD Eisenmengers

Timing of presentation:
First Few Hours Pulmonary/aortic atresia/critical stenosis Hypoplastic heart syndrome First few days Transposition, Tetralogy, large PDA in premature infants Co-arctation First few weeks Aortic Stenosis First few months Any left to right shunt as pulmonary resistance falls.

Question 5 Julia is a 6 month old who was born at 33 weeks.
She presents with 4/7 difficulty in breathing and a cough. She has a runny nose and a fever of 38.2 degrees. On auscultation you hear wheeze and creps bilaterally. She has significant recessions. Which investigation is most likely to reveal the diagnosis?

Question 5 A) Blood culture B) Chest X-ray C) Naso-pharyngeal aspirate
D) Per-nasal swab E) Throat swab

Question 5a Julia is a 6 month old baby born at 33 weeks.
She presents with 4/7 difficulty in breathing and a cough. She has a runny nose and a fever of 38.2 degrees. She has wheeze and creps on her chest with moderate subcostal recessions. Her O2 SATS are 89% on air. She is feeding around 40% of normal. What is the most appropriate initial management plan?

Question 5a A) CPAP and NG tube for feeds
B) Inhaled salbutamol, nasal cannulae O2 and encourage breast feeds C) Nasal cannulae O2 and NG tube for feeds D) Nasal cannulae O2, oral augmentin and encourage breast feeds E) Nebulised salbutamol, nasal cannulae O2 and NG tube for feeds

Bronchiolitis Viral infection affecting the lungs in infants < 12 months old Commonly Respiratory synctial virus, but many other viral pathogens Common – 30% of infants get it, and 3% of infants admitted to hospital in first 12 months of life Presentation – URTI, followed by cough, then development of respiratory distress over 3-4 days. Peaks day 5, lasts days. Death rate 8 per

The Bronchiolitic Podium
Breathing Feeding I&V CPAP IV Fluids Oxygen NG feeds Little and often No support

Question 6 Nana Kwame is 2 days old. He became jaundiced yesterday and is receiving phototherapy. He was born at term following an uncomplicated pregnancy with no risk factors for sepsis. Mum’s blood group is O+ve and the family is originally from Ghana. He is exclusively breast fed. What is the most likely cause of his jaundice?

Question 6 A) ABO incompatibility
B) Physiological/breast milk jaundice C) Rhesus incompatibility D) Sepsis E) Sickle cell disease

Prolonged jaundice screen
Causes of jaundice Severe haemolysis: ABO incompatibility Rhesus incompatibility Sepsis AGE ALWAYS ABNORMAL NEEDS ACTION <2 day old UNCONJUGATED Physiological jaundice Breastmilk jaundice Gilbert’s disease Haemolysis eg G siX PD, SpherOcytosis Infection (eg UTI) Hypothyroidism Could be normal. Only investigate if symptomatic NEEDS ACTION Prolonged jaundice screen Any of the above, ongoing Biliary Atresia Congenital Hepatitis Cystic Fibrosis >2 weeks old CONJUGATED

Question 6a Baby Smith is 1 day old and has developed jaundice which is above the phototherapy line. She was born at 37 weeks following an uncomplicated pregnancy. Mum’s blood group is A+ve On examination she appears quiet. Her respiratory rate is 85 breaths per minute. She has not yet tolerated a feed. What is the single most likely diagnosis?

Question 6a A) ABO incompatibility B) G6PD deficiency
C) Inborn error of metabolism D) Neonatal sepsis E) Resus incompatibility

Question 6b Abbey is 10 days old and is referred in by the midwife as she appears jaundiced in her body and sclera. She was born at 36 weeks following a C-section and received 48 hours of antibiotics. She has been well since and is exclusively breast fed. Birth weight : 3.2kg Current weight 3.3kg Abbey appears well on examination and is alert and active. Her observations are stable. What is the most likely diagnosis?

Question 6B A) Biliary Atresia B) Gilbert’s disease C) Hypothyroidism
D) Physiological/breast milk jaundice E) Urinary tract infection

Question 5 Ibrahim, 4 year old boy, presents to A&E with a 1 day history shortness of breath and lethargy. He had presented 2 days earlier with a low grade fever, dysuria and urinary frequency and was sent home with oral antibiotics. He has been previously well, has never been admitted to hospital and was born at term with no complications. He is on no regular medications but is allergic to penicillin. His mother is on iron supplements from her GP for anaemia, otherwise no FHx of note. He is now afebrile. HR 148, RR 40, SATS 98% His sclera are yellow, HS1+2+0, Chest clear and abdomen soft non tender.

Question 5 Blood tests are performed and return as follows:
Hb WCC Plts Retics high Na K Urea Creat 42 Bili AST ALP CRP 4 You request a blood film. What abnormalities would you expect to see?

Question 5 A – Auer Rods B – Heinz bodies with bite cells
C – Howell-Jolly bodies with macrocytosis D – Microcytic Hypochromic anaemia E – Small round cells (Spherocytes)

Question 5 A – Auer Rods B – Heinz bodies with bite cells
C – Howell-Jolly bodies with macrocytosis D – Microcytic Hypochromic anamia E – Spherocytes

G6PD - Glucose-6-phosphate dehydrogenase deficiency
Important enzyme allowing the red cell to deal with oxidative stress. X-linked recessive inheritance Common precipitants include : Fava beans, antimalarial drugs (chloriquine), sulphonamides, nitrofurantoin, mothballs, infection (esp viral), aspirin, ibuprofen. Blood film: BEANS MEANS HEINZ! (oxidised Hb precipitating) Bite cells – removal of denatured Hb in spleen

Now you see them… now you don’t….

Haemolytic Anaemias: INTRINSIC (the red cell’s own fault)
Membrane Defects (Spherocytosis, eliptocytosis etc) Enzyme Defects (G6PD, PKD) Haemoglobinopathies (Sickle, Thallassaemia etc) EXTRINSIC (red cell is the victim) Immune ABO/Resus disease Warm/cold/paroxysmal haemolytic anaemia Non-immune MAHA (eg HUS/DIC)

Question 6 Joshua is 2 months old and presents to A&E. His mum reports that he has been feeding around 50% of usual over the last 24 hours and she has struggled to settle him to sleep. She says he has felt quite hot. She denies any coryzal symptoms or D+V. He was born at PROM but otherwise uneventful pregnancy. He is otherwise well. He cries inconsolably when examined. HR 175, CRT 2s, RR 50 (crying), SATS 98% Chest clear, abdo SNT. No rashes are seen. Temp 38.3 degrees. What is the most appropriate management?

Question 6 A) Admit for observation on the ward
C) Admit, start IV Amoxicillin and Cefotaxime, perform full septic screen including LP and start maintenance fluids. B) Admit to the ward, start augmentin IV and perform septic screen including LP D) Admit, start IV Cefotaxime, perform full septic screen including LP and give fluid bolus E) Send home with advice to return if a non-blanching rash occurs

Question 6 A) Admit for observation on the ward
B) Admit, start IV Amoxicillin and Cefotaxime, perform full septic screen including LP and start maintenance fluids. C) Admit to the ward, start augmentin IV and perform septic screen including LP D) Admit, start IV Cefotaxime, perform full septic screen including LP and give fluid bolus E) Send home with advice to return if a non-blanching rash occurs

Fever without focus Children under 3 months are particularly vulnerable to severe infection and may have non-specific symptoms.

Febrile illness in children

Question 7 Glory is an 8 year old girl who has found it difficult to walk over the last 24 hours. She is unable to weight-bear on her left leg and complains of a rash over her left shin where she ran into a table 3 days earlier. She has been more lethargic over the last 24 hours and has lost her appetite. Her mum has given her codeine and paracetamol at home which has not controlled her pain. She has a background of sickle cell anaemia and takes Penicillin V and folic acid. Her temperature is recorded at 38.5 degrees, HR 130, RR 30, SATS 99%. Cap refil <2 seconds

Question 7 What is the most appropriate management?
A – Co-amoxiclav orally and regular codeine B – IV Ceftriaxone and blood transfusion C – IV Ceftriaxone and paracetamol D – IV Ceftriaxone, oramorph, regular simple analgesia and IV fluids E – Observe on ward and double dose of Penicillin V

Sickle Cell Anaemia Substitution of glutamic acid for Valine at position 6 on B-haemoglobin gene. HbSS, HbSC (less severe), HbS-Thal. CRISES – Caused by deoxygenated, sickled haemoglobin -> shorter life span, occlusion in small vessels. Vaso-occulsive crises Infective (most common cause of mortality) Functionally asplenic by 1 year old Susceptible to encapsulated organisms eg pneumococcus Osteomyelitis can be unusual organisms like Salmonella. Haemolytic Aplastic (eg Parvovirus B19) Sequestration (mainly spleen but can be liver or lungs)

Sickle cell in pictures

Question 8 Billy is 3 weeks old and presents to A&E with a green-coloured vomit Which of these conditions is this LEAST likely to be?

Question 8a Which of the following medications is not likely to be required in a child with Cystic Fibrosis? A) Creon B) Hydroxcarbamide C) Insulin D) Tobramicin E) Ursodeoxycholic acid

Question 8a Which of the following medications is not likely to be required in a child with Cystic Fibrosis? A) Creon B) Hydroxycarbamide C) Insulin D) Tobramicin E) Ursodeoxycholic acid

S : Salt deficiency state
R : Respiratory Bacterial infection/colonization eg Pseudomonas, Staph Aureus, Haemophilus Allergic bronchopulmonary aspergillosis (ABPA) C : Cardiac Signs of right heart failure if pulmonary hypertension present H : Hepatic Cholestasis in infancy causing obstructive jaundice. Fatty liver Cirrhosis Biliary obstruction and gall stones. I : Intestinal Meconium ileus (think of with signs of respiratory distress and a laparotomy scar) Rectal prolapse Distal intestinal obstruction syndrome P : Pancreatic Insufficiency in 85% of patients Pancreatitis Impaired glucose tolerance in 10%, IDDM in 7% of patients (DKA is uncommon). S : Salt deficiency state Hyponatraemic, Hypochloraemic metabolic alkalosis

Question 11 Which of the following features is most commonly associated with Down’s syndrome? A) Epicanthic folds B) Single palmar crease C) Cardiac anomaly D) Learning impairment E) Gut abnormalities (including DA, Hirschprung’s)

Question 12 Which of the following features is most commonly associated with Down’s syndrome? A) Cardiac anomaly B) Epicanthic folds C) Gut abnormalities (including DA, Hirschprung’s) D) Learning impairment E) Single palmar crease

Question 9 A baby has been brought to NICU because of bilious vomiting. You’ve found out the baby was born at term after an uncomplicated delivery and nothing was picked up in the fetal anomaly scan. You examine the abdomen and find it is not distended or tender, there is a patent anus. You get an abdominal Xray and it shows a dilated stomach and another smaller bubble of air next to the stomach but otherwise no other gas pattern. There is no pneumatosis coli. What is the most likely diagnosis?

Question 9 a) Colonic atresia b) Oesophageal atresia
c) Pyloric stenosis d) NEC e) Duodenal atresia

Answer 9 a) Colonic atresia b) Oesophageal atresia c) Pyloric stenosis
d) NEC e) Duodenal atresia

Question 13 Princess, 4, has sickle cell anaemia. She presents in a haemolytic crisis. Her Hb is found to be 2.3 and her GCS is 8. Her parents are Jehovahs Witnesses and refuse any blood products under any circumstances after long discussions. What is the most appropriate course of action? A) Ask a local Jehovah’s witness minister to attend tomorrow morning to discuss with the parents B) Give the blood transfusion and remove the parents from the room C) Expand her circulating volume with 0.9% NaCl boluses up to 60ml/kg/day D) Have social services take away parental responsibility E) If parents continue to refuse, apply for an emergency court order and treat in the child’s best interests

Answer 13 Princess, 4, has sickle cell anaemia. She presents in a haemolytic crisis. Her Hb is found to be 2.3 and her GCS is 8. Her parents are Jehovahs Witnesses and refuse any blood products under any circumstances after long discussions. What is the most appropriate course of action? A) Ask a local Jehovah’s witness minister to attend tomorrow morning to discuss with the parents B) Give the blood transfusion and remove the parents from the room C) Expand her circulating volume with 0.9% NaCl boluses up to 60ml/kg/day D) Have social services take away parental responsibility E) If parents continue to refuse, apply for an emergency court order and treat in the child’s best interests

A quick word on PACES 6 stations 15 minutes each Typically
6 minutes history 2 minutes data interpretation 3 minutes explanation 4 minutes viva Research previous stations and think of similar options. Think of cross-over stations between different specialties Treat it like a real patient – PROBLEM SOLVING APPROACH Print out mark sheets and mark each other in the run up

Some classic stations Sepsis in need of fluid resuscitation/ABC discussion Constipation Coeliac Safeguarding with bruising Failure to thrive Limp 15 year old with PID Pyloric stenosis Dx and management Delayed puberty Gillick competence/Fraser guidelines

ANY QUESTIONS?

Paediatric SBAs Dr Michael Malley.

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Paediatric SBAs Dr Michael Malley.

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