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OSCEAZY x GEEKY MEDICS THE PAEDIATRIC STATION – HISTORY JoJo Li & Megan HodgsonOverview of a Paediatric History Case 1 - Cough Case 2 - Vomiting Case 3 - Rash Case 4 - JaundiceOVERVIEW OF A PAEDIATRIC HISTORY THE P AEDIA TRIC HISTORY HISTORY OF PRESENTING COMPLAINT BIRTH FEEDING BFG’S ID • Mode of delivery (caesarean, • Input (diet & appetite) - vaginal, instrumental) normal vs current, fluid • Born at term, late or premature? intake, volume & • Any complications during pregnancy frequency • Output - wet nappies, or delivery? • Prolonged stay in hospital after birth? frequency, toilet training GROWTH SCHOOL IMMUNISATIONS DEVELOPMENT • Do they have a red book • Any problems • Immunisations • Has the child been meeting (for under 5)? at school? up to date? their developmental • Growing along centiles? • Keeping up milestones (gross motor, fine • Weight - changes? with peers & motor & vision, hearing Concerns? schoolwork? • How far are they along in & language, social & behaviour)? puberty (older children)? THE P AEDIA TRIC HISTORY PAST MEDICAL HISTORY DRUG HISTORY • Medical conditions • Previous surgery? • Medications – current/previous • Drug/food allergies • Previous hospitalisations? FAMILY HISTORY SOCIAL HISTORY ICE • Any relevant medical • Who lives at home? • Ideas, concerns and conditions? • Does anyone in the family expectations • Are any other smoke? members of the family • What is the housing also unwell? situations? • Social services? Safeguarding?GENERAL CARDIORESPIRATORY GASTROINTESTINAL • Fever • Rashes • Cough • Vomiting • Bowels? • Activity • Growth & weight • Dyspnoea, cyanosis • Abdominal pain SYSTEMS REVIEW GENITOURINARY NEUROMUSCULAR ENT • Dysuria • Seizures • Noisy breathing • Frequency • Abnormal movements • Sore throat • Earache • Wetting nappies? • HeadacheCASE 1 – COUGHCASE 2 – VOMITINGCASE 3 – RASHRASH STATION You are a junior doctor working in general practice A 5-year-old boy is brought in by his parent with a rash STUDENT INSTRUCTIONS Please take a focused history• Rash – SOCRATES • No altered mental state • Site: cheeks • No photophobia • Onset: 2 days ago • No pain • Character: large erythematous macule in • No bleeding/exudate a "slapped cheek" distribution • No bullae/vesicles • Radiation: torso • No swelling • Associations: coryza and fever • No pruritus • Alleviating factors: paracetamol (Calpol®) • No specific pattern/shape • Time: progressive • No neck lumps • Exacerbating factors: none • No conjunctivitis • Severity: mild• Ideas: "At first I thought it might be heat rash or • Previous episode of croup something, but it's odd that it hasn't gone away.” • Up to date with vaccinations • Concerns: “I'm worried • No developmental concerns that the rash is spreading • Normal height and weight onto his chest." for age, normal feeding • Expectations: “I'm hoping • No previous hospital you'll reassure me that it admissions or issues with isn't anything serious.” birthRASH HISTORY (CONITNUES) DRUG HISTORY FAMILY HISOTRY • None • None • NKDA SOCIAL HISTORY • Lives at home with parents with no siblings • Currently in school • Parents are non-smokers • Parents occasionally drink alcohol • Parents do not use recreational drugs • Normal activities, feeding and potty trainedWhat are your differentials? • Erythema infectiosum/fifth disease/slapped cheek syndrome • Scarlet fever • Roseola infantum What pathogen causes this condition? • Parvovirus B19What are next step managements? • Supportive care – self limiting infection • Treat associated symptoms (e.g. fever) with paracetamol/ibuprofen School exclusion advices? • No exclusion is required. • The child is no longer infectious after the presentation of the rash.CASE 4 – JAUNDICE • Role: 4th Year Medical Student • Setting: Paediatric A&E Department • Patient: Olivia Steward, a 14-days-old female STUDENT baby, present with jaundiced skin. INSTRUCTIONS • You have 10 minutes to take a focused history from the patient. You will then be stopped and asked to summarise your history and provide your differential diagnoses.• Site: Jaundice all over body • No altered mental state • Onset: 5 days ago • No photophobia • Character: Same shade of yellow all over • No pain • Radiation: Eyes • No bleeding/exudate • Associations: None • No bullae/vesicles • Alleviating factors: None • No swelling • Time: Constant • No pruritus • Exacerbating factors: None • No specific pattern/shape • Severity: Not obviously impacting her • No neck lumps wellbeing • No conjunctivitis• Ideas: "I don't know why she's become yellow." • No previous similar episodes • Concerns: "She seems completely well in herself • No other medical conditions or surgeries. so I not overly concerned." • Immunisation up to date • Expectations: “I'm hoping • No developmental concerns you'll reassure me that it • Normal height and weight for isn't anything serious." age, normal feeding • No previous hospital admissions or issues with birthRASH HISTORY (CONITNUES) DRUG HISTORY FAMILY HISOTRY • None • None • NKDA SOCIAL HISTORY • Lives with Mum, Dad and older Brother Archie (4 years old) in a semi-detached house. Everybody else at home is currently well. • No smokers in the house • Pet dog - well trained, no safeguarding concerns • No previous involvement with social services. If asked, you don't feel you need any extra help at home.What is most likely diagnosis? • Breast Milk Jaundice Other examinations or investigations? • Physical examination • Investigation: Check for bilirubin levels, bloods • Olivia will need admitting for phototherapy • Counsel carer on diagnosis/phototherapyOverview of a Paediatric History Case 1 - Cough Case 2 - Vomiting Case 3 - Rash Case 4 - Jaundice THANK YOU FOR LISTENING! PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEKUnconjugated vs Conjugated JaundiceCaused by: • Biliary atresia: early diagnosis and • Neonatal sepsis treatment of this condition is vital • Haemolysis • Neonatal hepatitis (e.g. cytomegalovirus, • Haemolytic disease of newborn hepatitis B, rubella or herpes simplex • Maternal rhesus or ABO antibodies virus) against baby’s RBC • Galactosaemia and other inborn errors of • Hereditary spherocytosis metabolism • G6PD • Endocrine/metabolic disorders • Gilbert’s syndrome, Crigler-Najjar syndrome, congenital hypothyroidism• Baby should be naked and examined in bright, natural light. • Jaundice is often most obvious in the sclerae and gums. The skin can be lightly pressed, which may reveal jaundice in the blanched skin. • It is important to assess if the baby is clinically well and whether there are any signs of infection or bilirubin encephalopathy. • Examination should include inspecting the nappy for stools and urine. Pale, chalky stools and dark urine suggest conjugated jaundice and an underlying pathological cause such as biliary atresia. • Jaundice in the first 24 hours of life and conjugated jaundice are always pathological and require urgent investigation for an underlying cause.InvestigationsMeasure bilirubin level: 1. Transcutaneous bilirubinometry • Bedside test = evaluates light absorption Blood test through the skin and non-invasive • Blood packed cell volume (PCV) 2. Serum bilirubin • Blood group of the mother and baby: to • NICE: visibly jaundiced <24 hours of life, assess for incompatibility with a gestational age <35 weeks, or • Direct antiglobulin test (DAT, aka Coombs’ when monitoring bilirubin after starting test) treatment. • +ve = immune-mediated haemolysis • Serum bilirubin is also used to confirm • -ve = suggests non-immune-mediated a high transcutaneous level. haemolysisManagement• In phototherapy, the baby is placed under blue-green light. The light converts the • Exchange transfusions reduce bilirubin neurotoxic unconjugated bilirubin to a levels by swapping the baby’s blood with harmless, water-soluble isomer called lumirubin, which is readily excreted in the donor blood. • A small volume of the baby’s blood is bile and urine. removed as donor blood is injected. This • Phototherapy can be given in different ways (e.g. with an overhead light or a process is repeated many times. • Exchange transfusions have a high rate of blanket that wraps around the baby) and complications, reserved when baby is not the intensity of the lights can be varied. responding to intense phototherapy.PhototherapyPhototherapy graph interpretation• Bilirubin encephalopathy (kernicterus), which can occur with high levels of unconjugated bilirubin. • Unconjugated bilirubin is lipid-soluble and can cross the blood-brain barrier. It accumulates in the brainstem nuclei, basal ganglia, hippocampus and cerebellum and is neurotoxic. • Bilirubin encephalopathy initially presents with lethargy, hypotonia and poor suck reflex. This progresses to hypertonia, opisthotonos, fever, seizures and a high-pitched cry. • Early damage to the brain can be reversible but if hyperbilirubinemia is pronounced or prolonged then it can lead to cerebral palsy, sensorineural hearing loss or cognitive impairment.