Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OSCE SERIES THE PAEDIATRIC STATION MOVIN PERAMUNA GAMAGE PROUDLY IN COLLABORATION WITH TERMINOLOGY • THE PAEDIATRIC STATION • • •OVERVIEW OF A PAEDIATRIC HISTORY THE P AEDIA TRIC HISTOR Y HISTORY OF PRESENTING COMPLAINT • • • • BIRTH • DEVELOPMENT • • • • • FEEDING GROWTH • • • • • THE P AEDIA TRIC HISTOR Y PAST MEDICAL HISTORY • • ICE DRUG HISTORY • • • • • • SOCIAL HISTORY FAMILY HISTORY • • • • • • • • • • • • • • • • • SYSTEMS REVIEW • • • • • • • • • DEVELOPMENT AL MILESTONES GROSS MOTOR FINE MOTOR AND SPEECH AND SOCIAL BEHAVIOUR VISION HEARING < 3 months Moves all limbs Looks, startles Startles to noise Smiles (6 weeks) 3 months Head control, lying Reaches for objects, Squeals, turns Laughs on abdomen toward sound 6 months Rolls front to back Holds in palmar Localises sound, Alert, not shy grasp*, object babbles transfer 9 months Sits alone*, crawls Pincer grip, finger Inappropriate sounds Stranger anxiety, pointing takes everything to mouth 12 months Stands alone, cruises Knows and responds Waves ‘bye’ to name 18 months Walks alone* Uses spoon Uses words (2-6)* Tantrums 2 years Runs, can use stairs Draw circular Combines 2 words Knows identity scribbles and lines *DEVELOPMENTAL RED FLAGS: Hearing loss, loss of muscle tone, can’t hold objects by 5-6 months, cannot sit unsupported by 12 months, cannot walk by 18-24 months, no speech by 18 months, hand preference before 12 months IMMUNISA TION SCHEDULE AGE IMMUNISATIONS 2 months 6 in 1*, rotavirus, meningitis B 3 months 6 in 1*, rotavirus, meningitis B 4 months 6 in 1*, rotavirus, meningitis B 1 year MMR, pneumococcal, meningitis B, *6 in 1 = diptheria, tetanus, polio, pertussis, Haemophilus influenzae type Haemophilus influenzae type B, hepatitis B B/meningitis C Preschool ( 3 MMR, 4 in 1 (diptheria, polio, years) tetanus, pertussis) Girls 12-13 years HPV (x2, 6-12 months apart) Adolescents 3 in 1 (diptheria, polio, tetanus), meningitis ACWY • • HISTORY KEY • POINTS • •CASE 1 Role Medical student Setting Paediatric assessment unit (PAU) STUDENT Patient Jack Frost, a 8 month-old infant presents with a cough INSTRUCTIONS Student task Take a collateral history from his mother. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. HISTOR Y HISTORY OF PRESENTING COMPLAINT • • • • • • SYSTEMS REVIEW • • HISTOR Y PAST MEDICAL HISTORY • BIRTH • • • • FEEDING • • • • • • GROWTH & DEVELOPMENT • • HISTOR Y FAMILY HISTORY • DRUG HISTORY • • • • SOCIAL HISTORY • • • ICE • • • • • SUMMARISING THE HISTORY Patient details, occupation I took a history from Megan Frost, the mother of 9-month-old Jack Frost who came in with an acute cough. & key presenting complaint The infant has been having a dry cough for the last 2 days, worse at night or when he is crying. History of presenting complaint It was described to have a sharp ‘seal-like’ sound. He has also had a fever of 38.2 °C and has been coryzal. He has not been playing or drinking like usual. He also not had many wet in the last 2 days.usually consumes mashed up food, but his appetite has significantly reduced Relevant negatives No blood in cough, no rashes, no fits, no cyanosis. Relevant PMH/PFH/SH/DH is not on any medication but was given Calpol to reduce the fever. NKDA! He lives at home with his parents and older sister who is well in herself. Parents do smoke around him at Relevant Birth and home. He was born at term via normal vaginal delivery. He Is up to date with all his development history immunisations and has been meeting all his developmental milestones. Ideas, concerns & expectations The mother is very worried about her son’s health and has no idea of a possible cause. Top differential & why My top differential is Croup Other differentials that I would like to rule out are bronchiolitis, acute epiglottitis and Other differentials pneumoniaSPOT DIAGNOSIS P AEDIA TRIC COUGH ACUTE CHRONIC • Croup • Cystic fibrosis (CF) • Bronchiolitis • Asthma • Asthma • Secondary to GORD • Epiglottitis • Ciliary dyskinesia • Inhaled foreign body • α1- antitrypsin deficiency • Pneumonia INVESTIGA TIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Always remember to ask for Senior Support! Basic observations All patients should have this, especially pulse oximetry and temperature measurement Respiratory/ENT Examination To look for respiratory pathology, e.g. expiratory wheeze on auscultation or ENT pathology BEDSIDE Peak flow measurement To look for signs of obstructive lung disease, e.g. asthma Sputum culture If productive cough, to determine causative organism Viral nasal swab To check for causative agent, e.g. Parainfluenza virus in croup Full blood count (FBC) Assess for signs of infection Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities, signs of dehydration BLOODS Capillary blood gas (CBG) To look for signs of respiratory distress, e.g. respiratory alkalosis Blood cultures If you suspect sepsis secondary to infection CRP If you suspect an underlying inflammatory process due to infection IMAGING CXR To look for consolidation or other acute chest pathology, visualise foreign body Sweat Test If you suspect CF Immunofluorescence of SPECIAL nasopharyngeal secretions To look for RSV in bronchiolitis TESTS Spirometry with BDR testing If you suspect asthma, to confirm the diagnosis FeNO test If you suspect asthma, to confirm the diagnosis DA T A INTERPRET A TION • B – Breathing (lung fields & margins)y) • C – Cardiac (only on PA CXR, cardiomegaly) • D – Diaphragm (blunting of costophrenic angles due to lower lobe pneumonia, etc) • E – Everything else (bones, mediastinum etc) • PA CXR • ‘Steeple sign’ – subglottic tracheal narrowing seen in croup, aka inverted V sign CROUP MANAGEMENT • Educate patient’s family • Admit to hospital if • Nil about the condition – e.g. moderate or severe croup provide leaflets/website • High flow 15L oxygen using links non-rebreather if O2< 94% • Make sure patient is or respiratory failure comfortable as agitating • 0.15 mg/kg PO patient may worsen dexamethasone, nebulised symptoms adrenaline • Safety netting patient if • Analgesia, anti-pyretics symptoms worsen • Fluids – oral/IV, breastfeeding BRONCHIOLITIS MANAGEMENT • Educate patient’s family • Admit to hospital if poor • Nil about the condition – e.g. feeding (< 50%) and/or provide leaflets/website unable to maintain O 2ats links > 90% during sleep • Make sure patient is • Humidified oxygen if O <2 comfortable as agitating 92% • NG tube feeding in severe patient may worsen bronchiolitis to prevent symptoms • Safety netting patient if gastric enlargement and symptoms worsen impaired ventilation • Suction if excess upper airway secretions EPIGLOTTITIS MANAGEMENT • Educate patient’s family • A-E assessment with senior • Nil about the condition – e.g. support important if there provide leaflets/website is a serious risk of airway links obstruction (e.g. with • Make sure patient is anaesthetists/ENT) comfortable as agitating • Endotracheal intubation is patient may worsen airway severe airway compromise compromise • DO NOT examine throat! • Safety netting patient if • Oxygen symptoms worsen • IV antibiotics • • COUGH ST A TION • KEY POINTS • •CASE 2 Role Medical student Setting Paediatric assessment unit (PAU) STUDENT Patient Emma Cotton, a 5 month-old infant presents with vomiting INSTRUCTIONS Student task Take a collateral history from her mother. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. HISTOR Y HISTORY OF PRESENTING COMPLAINT • • • • • • • • SYSTEMS REVIEW • • HISTOR Y PAST MEDICAL HISTORY • BIRTH • • • • FEEDING • • • • • GROWTH & DEVELOPMENT • • • HISTOR Y FAMILY HISTORY • DRUG HISTORY • • • • SOCIAL HISTORY • • • ICE • • • SUMMARISING THE HISTORY Patient details, occupation I took a history from Janine Cotton, the mother of 5-month-old Emma Cotton who came in with vomiting. & key presenting complaint The infant has been having periods of recurrent vomiting for the last 3 weeks, notably worse History of presenting complaint after feeding. She also cries during her feeds. She has not been as active as usual and has been feeding less as well. He also not had many wet nappies either- probably only 2/day. She has significantly decreased in the last 3 weeks. given formula milk, but her appetite has Relevant negatives No blood in vomit/stools, no fever, no diarrhoea, no dysphagia, no SOB/cough. Relevant PMH/PFH/SH/DH not on any medication. NKDA! She lives at home with her parents and Emma is their first is child. She was born at 34 weeks gestation via an emergency C-section due to PROM and had Relevant Birth and a weeklong stay in NICU. She is up to date with all her immunisations and has been meeting development history all her developmental milestones. She has not been growing well. Ideas, concerns & expectations The mother is very worried about her daughter’s health and has no idea of a possible cause. Top differential & why My top differential is GORD Other differentials milk protein allergythat I would like to rule out are coeliac disease, gastroenteritis and cow’sSPOT DIAGNOSIS P AEDIA TRIC VOMITING ACUTE CHRONIC • Pyloric stenosis • Coeliac disease • Gastroenteritis • GORD • Constipation • Cow’s milk protein intolerance/allergy • Intussusception • Hirsprung disease • Necrotizing enterocolitis INVESTIGA TIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Always remember to ask for Senior Support! BEDSIDE Basic observations All patients should have this GI Examination To look for GI pathology Full blood count (FBC) Assess for signs of infection, anaemia Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities, signs of dehydration LFT Assess for liver function Capillary blood gas (CBG) To look for signs of metabolic abnormalities, e.g. metabolic acidosis secondary to dehydration BLOODS Blood cultures If you suspect sepsis secondary to systemic infection Total IgA and Anti-TTG If you suspect Coeliac disease Iron studies To look for Iron deficiency anaemia (microcytic anaemia) B12 & Folate To look for macrocytic anaemia Abdominal X-ray To look of acute abdominal pathology, e.g. bowel dilation secondary to constipation IMAGING Erect CXR To look for signs of bowel perforation (pneumoperitoneum) Abdominal USS To look of acute abdominal pathology, e.g. pyloric stenosis Endoscopic biopsy testing If you suspect Coeliac disease and anti-TTG positive SPECIAL Rectal biopsy If you suspect Hirsprung disease TESTS Skin prick testing If you suspect IgE mediated cow’s milk protein allergy GORD MANAGEMENT • Educate patient’s family • Trial of thickened formula • Nissen fundoplication for about the condition – e.g. or alginate therapy very severe disease where risk of infections • PPI if severe faltering of previous treatment has • Provide advice on feeds- growth failed small and frequent feeds, keep their head up at a 30° angle, avoid infant from sleeping on their front • Safety netting patient if symptoms worsen COELIAC DISEASE MANAGEMENT • Educate patient’s family • Steroids if refractory • Nil about the condition – e.g. disease using leaflets/website links • Provide advice on lifestyle modification- removing gluten foods from diet (e.g. wheat, barley, rye) • Regular follow up COW’S MILK PROTEIN ALLERGY/INTOLERANCE MANAGEMENT • Start extensively • Educate patient’s family hydrolysed formula milk about the condition – e.g. • Nil using leaflets/website links • Start amino-acid based • Provide advice on lifestyle formula if hydrolysed modification- completely formula milk is eliminate cow’s milk from unsuccessful diet, encourage more • Use of milk ladder for breastfeeding if infant is reintroduction of cow’s milk into diet also breastfed • Refer to specialist paediatrician if severe symptoms are present, e.g. failure to thrive • • VOMITING STATION KEY • POINTS • •CASE 3 – SBA BASED Role Medical student Setting Paediatric assessment unit (PAU) STUDENT Patient Ryan Raynaud, a 7 month-old infant presents with fever INSTRUCTIONS Student task Take a collateral history from his father. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. HISTOR Y HISTORY OF PRESENTING COMPLAINT • • • • • SYSTEMS REVIEW • • HISTOR Y PAST MEDICAL HISTORY • BIRTH • • FEEDING • • • GROWTH & DEVELOPMENT • HISTOR Y FAMILY HISTORY • DRUG HISTORY • • SOCIAL HISTORY • • • ICE •The infant’s rash is shown below. Given all the previous information and the picture below, what is your top differential diagnosis? How would you describe this rash?The infant’s rash is shown below. Given all the previous information and the picture below, what is your top differential diagnosis? How would you describe this rash?SPOT DIAGNOSISGiven the most likely diagnosis, what is an essential investigation that must be carried out immediately?Given the most likely diagnosis, what is an essential investigation that must be carried out immediately? INVESTIGA TIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Always remember to ask for Senior Support! Basic observations All patients should have this, especially pulse oximetry and temperature measurement BEDSIDE Neurology and/or ENT Examination To look for neurology pathology, e.g. for signs of raised ICP and ENT pathology Throat swab To confirm causative organism, e.g. Group A strep in scarlet fever Full blood count (FBC) Assess for signs of infection Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities, signs of dehydration BLOODS LFT Assess for liver function Capillary blood gas (CBG) To look for signs of metabolic abnormalities, e.g. metabolic acidosis secondary to raised lactate Blood cultures If you suspect sepsis secondary to infection IMAGING CT Head To look of any signs of raised ICP SPECIAL TESTS IgM antibodies Can be detected after the onset of the rash in measlesGiven the most likely diagnosis, what antibiotic must they be started on immediately?Given the most likely diagnosis, what antibiotic must they be started on immediately? MENINGICOCCAL SEPT ACAEMIA MANAGEMENT • Educate patient’s family • A-E assessment with • Nil about the condition – using senior input essential!! leaflets & website links • SEPSIS 6: • Isolate patient in hospital 1. IV antibiotics (ceftriaxone • Notify public health and +/- amoxicillin) antibiotic prophylaxis of all 2. IV Fluids close contacts 3. O2 via 15 L non- (ciprofloxacin) rebreather • DO NOT GIVE STEROIDS! • Cerebral and urine output monitoring • Anti-pyretics KAWASAKI DISEASE MANAGEMENT • Educate patient’s family • High dose aspirin* • Nil about the condition – using • IV Ig leaflets or website links • ECHO scan to look for any • Warn patient’s family coronary artery aneurysms about possible • Supportive treatment – complications, e.g. fluids, analgesia, anti- coronary artery aneurysms pyretics SCARLET FEVER MANAGEMENT • Educate patient’s family • Oral antibiotics (penicillin • Nil about the condition using V) for 10 days leaflets or website links • Oral azithromycin if • Warn family of potential penicillin allergic complications – otitis • Supportive treatment – media, rheumatic fever, etc fluids, analgesia, anti- • Notifiable disease and pyretics children can return to school 24 hours after commencing antibiotics • • FEVER ST A TION • KEY POINTS • •P AEDIA TRIC BASIC LIFE SUPPORT • • • • • •CHOKING ALGORITHM REFERENCES • https://nursekey.com/pediatric-respiratory-disorders-2/ • https://epictures.homes/croup-steeple-sign • https://abdominalkey.com/constipation-6/ • https://www.nhs.uk/conditions/scarlet-fever/ • https://www.gponline.com/infectious-diseases-scarlet-fever/infections- and-infestations/infections-and-infestations/article/1324924 • https://www.nhs.uk/conditions/measles/ THANK YOU FOR LISTENING! PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK