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THE PAEDIATRICS STATION- HISTOR Y OSCEAZY Dr Victoria Leigh (FY2)T opics Paediatrics history structure Case 1- Cough Case 2- Vomiting Case 3- Rash Case 4- Jaundice T AKING A P AEDIA TRICS HISTOR Y Opening the consultation • Introduce yourself and wash hands • Confirm patient’s name and date of birth • Confirm who you are speaking to i.e. Are you the parents of…? • Explain purpose of consultationPresenting complaint and HPC • Identify presenting complaint(s) • Explore history of presenting complaint:OPERATES ■ Onset:when did symptoms start? ■ Progress: Have the symptoms worsened, improved, remained the same? ■ Exacerbating factors: Does anything make symptoms worse? ■ Relieving factors: Does anything relieve/improve symptoms? ■ Associated symptoms: fever?vomiting?diarrhoea?lethargy?reduced oral intake?rash? ■ Timing:worse at certain time of day?intermittent? ■ Episodes (previous) • *SOCRATES* for pain specifically— site, character, radiation • Systems review- particularly check fluid intake and urine output • ICE • SummarisePast medical history • Any medical conditions? • Drug history: Any OTC medications? Any regular medications? Any allergies? • Family history:Anyone else unwell at home? Any unwell contacts? Any conditions in the family? E.g. hayfever, eczema, asthma, cancers • BINDS ■ Birth history:Issues during pregnancy? method of delivery? issues at labour? required special care baby unit admission? ■ Immunisations: Up to date with vaccines? ■ Nutrition: Babies-bottle or breast? volume and frequency of feeds?, Infants- are they drinking >50% of normal fluid intake? ■ Developmental history: Meeting developmental milestones? Any concerns about development? ■ Social history: Who lives with the child? Does anyone smoke at home? Any pets? Any previous involvement with social services?HEEADSSS • Home: Who lives with you? Any issues at home? • Education and employment:Do you go to school/college ? Do you have a job?: • Activities and peer relationships:What do you do in your spare time? Do you participate in any sports? • Drugs and alcohol:Some people your age try smoking, alcohol and drugs, is that something you’ve experienced? • Sexual activity:Are you in a relationship currently? Are you sexually active? • Self harm:How is your mood at the moment?Do you ever feel sad or stressed? What do you do about that? • Safety:Is there anyone in your life that you don’t feel safe around? Closing the consultation • Summarise • Any questions? Any further concerns? • Thank child/parent for their timeCASE 1- COUGH +/- INCREASED WORK OF BREA THING Role Foundation year 2 doctor Location Emergency department Scenario 8 month old girl is brought in by parents due Student Instructions Case 1 to worsening cough. Name: Emily Young DOB:14/06/2024 Instructions 1.Please take a collateral history 2.Explain your differentials, investigations and management plan to the examiner. SPOT DIAGNOSIS 1)A 2 year old girl presents with a barking cough and inspiratory stridor when agitated. Has had a few days of fever and rhinorrhoea. Cough is worse at night. 2)A 1 month old boy presents with a 3 day history of a worsening hacking cough and recent apnoeic episodes. Appears like they are gasping for breath between coughs. Mum did not have her routine vaccines during pregnancy. 3)An 8 year old girl comes in with an asthma exacerbation. Sats 90% on room air, peak flow 40%, struggling to complete full sentences. SPOT DIAGNOSIS 1)A 2 year old girl presents with a barking cough and inspiratory Croup- commonly caused by stridor when agitated. Has had a few days of fever and rhinorrhoea. Parainfluenza virus Cough is worse at night. 2)A 1 month old boy presents with a 3 day history of a worsening Whooping cough- caused by Bordatella hacking cough and recent apnoeic episodes. Appears like they are Pertussis gasping for breath between coughs. Mum did not have her routine vaccines during pregnancy. 3)An 8 year old girl comes in with an asthma exacerbation. Severe asthma exacerbation Sats 90% on room air, peak flow 40%, struggling to complete full sentences. ● Symptoms started with a runny nose 3 Scenario 8 month old girl is brought indays ago. parents due to worsening cough. Name: Emily Young ● She then developed a dry cough 2 days DOB:14/06/2024 ago which is worsening. ● She’s breathing faster than usual, After taking a history.. sounds wheezy and is sucking in under her ribs. ● She’s not been feeding well. ● She was born and term and is normally fit and well.BR ONCHIOLITIS Usually <12 months(up to 24months), RSV SYMPTOMS INVESTIGATIONS -Low grade fever BEDSIDE IMAGING MANAGEMENT -Usually does not require admission. -Nasal congestion -Observations -Consider CXR -Viral panel -Nasal drops and suctioning -Persistent cough -Safetynetting -Poor feeding BLOODS ADMISSION TO HOSPITAL IF: -Apnoeas -Consider FBC, U+Es, CRP, capillary gas -Apnoeas -Sats <92% SIGNS -Intercostal, subcostal and supraclavicular -<50% oral intake -Significant signs of increased work of -Tachypnoea recessions. -Grunting breathing -Inspiratory crackles and expiratory wheeze -Nasal flaring -Cyanosis and pallorBR ONCHIOLITIS MANAGEMENT cont. -Supportive management -O2 if sats <92% -High flow nasal oxygen or CPAP -Nutrition and fluids: PO, NG or IV -In rare cases children may require intubation and transfer to PICUCASE 2- VOMITING Role Foundation year 2 doctor Location Emergency department Student Instructions Scenario 5 week old boy brought in by parents as they Case 2 are concerned about his vomiting. Name: Samuel Pierce DOB: 21/03/2025 Instructions 1.Please take a collateral history 2.Explain your differentials, investigations and management plan to the examiner. SPOT DIAGNOSIS 1)A 4 month old girl presents to GP with a 4 week history of frequent vomits after feeds. She is fully breast fed and had been gaining weight. Vomits are milky, no blood, small volume and non forceful. Normal stools. 2)A 9 month old boy is seen in A+E with vomiting and abdominal pain. The pain is episodic and severe, causing the child to draw their knees up. Vomit was initially clear but had turned yellow. Parents report a red ’jelly‘ like substance in most recent stool. 3)A preterm neonate born at 31 weeks gestation, currently on the special care baby unit starts vomiting on day 14 of life. Vomit is green and blood in stool is noted. Abdomen feels distended. Baby passed meconium <48h of life. 4) An 11 year old girl is seen in A&E with a 1 week history of increased thirst and urination. She feels very unwell, tired and has vomited twice (non-bilious). SPOT DIAGNOSIS 1)A 4 month old girl presents to GP with a 4 week history of frequent vomits GORD after feeds. She is fully breast fed and had been gaining weight. Vomits are milky, no blood, small volume and non forceful. Normal stools. 2)A 9 month old boy is seen in A+E with vomiting and abdominal pain. The pain is episodic and severe, causing the child to draw their knees up. Vomit Intussusception was initially clear but had turned yellow. Parents report a red ’jelly‘ like substance in most recent stool. 3)A preterm neonate born at 31 weeks gestation, currently on the special care baby unit starts vomiting on day 14 of life. Vomit is green and blood in stool is Necrotising enterocolitis noted. Abdomen feels distended. Baby passed meconium <48h of life. 4) An 11 year old girl is seen in A&E with a 1 week history of increased thirst DKA and urination. She feels very unwell, tired and has vomited twice (non-bilious). ● Vomiting started 1 week ago and Scenari5 week old boy brought in by parents as happens after feeds. they are concerned about his vomiting. Name: Samuel Pierce ● Vomit is milky, not yellow or green. DOB: 21/03/2025 ● Initially was just regurgitating foot but After taking a history.. vomit has become forceful and travels 2-3 meters. ● He’s lost weight over the past week. ● No issues at birth and had been well up until the vomiting started.PYLORIC STENOSIS Usually 3-6 weeks (up to 6 months) SYMPTOMS INVESTIGATIONS -Non-bilious, projectile BEDSIDE IMAGING MANAGEMENT MEDICAL vomiting after every -Observations -Abdominal USS -NG tube feed -Test feed -IV fluids -Weight loss BLOODS -Constantly hungry -FBC, U+Es, CRP, capillary gas SURGICAL -Ramstedt’s pyloromyotomy SIGNS -Visible gastric peristalsis -Palpable olive-sized mass -Dehydration CRT <2s, sunken eyes during feed and fontanelle, dry mucous membranes - A Hypochloreaemic, hyperkalaemic alkalosis Normochloraemic, hypokalaemic alkalosis Question 1 B In severe pyloric stenosis, what values would C Hyperchloraemic, hypokalaemic acidosis you see on a capillary gas? Hypochloraemic, hypokalaemic alkalosis D E Hyperchloraemic, hyperkalaemic acidosis A Hypochloreaemic, hyperkalaemic alkalosis Normochloraemic, hypokalaemic alkalosis Question 1 B In severe pyloric stenosis, what values would C Hyperchloraemic, hypokalaemic acidosis you see on a capillary gas? Hypochloraemic, hypokalaemic alkalosis D E Hyperchloraemic, hyperkalaemic acidosis A Wall thickness <3mm, length <15mm Wall thickness >3mm, length >15mm Question 2 B What wall thickness and length of pyloric muscle C Wall thickness 1-2mm, length 13-15mm would suggest pyloric stenosis? A Wall thickness <3mm, length <15mm Wall thickness >3mm, length >15mm Question 2 B What wall thickness and length of pyloric muscle C Wall thickness 1-2mm, length 13-15mm would suggest pyloric stenosis? A Corkscrew appearance on upper GI contrast study Question 3 B Portal venous gas on abdominal x-ray A 7 month old is brought into hospital after mother discovered Hypertrophy of pyloric sphincter on USS blood in nappy. In ED, he begins vomiting. On examination a C ‘sausage’ shaped made is felt in right upper quadrant. On call D Pneumatosis intestinalis on abdominal x ray paediatric surgeon is called. Target sign appearance on abdominal USS Which of the following ix. results are most in keeping with the E likely diagnosis? Corkscrew appearance on upper GI A contrast study Portal venous gas on abdominal x-ray Question 3 B C Hypertrophy of pyloric sphincter on USS Pneumatosis intestinalis on abdominal x ray D E Target sign appearance on abdominal USS Common GI causes of vomiting in neonates and infants Bilious Non-bilious Pre-term Term baby Infant Non-projectile Projectile Intussusception NEC Malrotation Pyloric stenosis +/- volvulus GORD and Gastroenteritis CMPADIFFERENTIALS Neurological Urology • Meningitis • UTI • Brain tumour • Testicular torsion • Head injury • Non-accidental injury Respiratory • Bronchiolitis • Pneumonia ENT • Asthma • Tonsillitis • Otitis media • Pertussis • Croup Endocrine • Post-tussive • DKA • Foreign bodyFLUID CHALLENGE + IV Urology 10CASE 3- RASH Role Foundation year 2 doctor Location Emergency department Student Instructions Scenario 5 year old girl has developed a non-blanching Case 3 rash over past few hours. Name: Samantha Lewis DOB: 01/09/2019 Instructions 1.Please take a collateral history 2.Explain your differentials, investigations and management plan to the examiner.DESCRIBING RASHES SPOT DIAGNOSIS 1)An 8 year old boy is brought in by ambulance. Looks very unwell and drowsy. He has a 1 day history of high grade fevers. Parents noticed a non blanching rash and called the ambulance. 2)A 7 year old boy is brought into A&E as parents are concerned about a blanching rash. 1 week ago he developed a fever, cough and red eyes. The rash started on his face and has spread to his trunk and arms. Parents did not consent to all his immunisations. SPOT DIAGNOSIS 1)An 8 year old boy is brought in by ambulance. Meningococcal septicaemia Looks very unwell and drowsy. He has a 1 day Non blanching petechial and purpuric rash history of high grade fevers. Parents noticed a non blanching rash and called the ambulance. 2)A 7 year old boy is brought into A&E as parents are concerned about a blanching rash. 1 week ago he developed a fever, cough and Measles red eyes. The rash started on his face and has spread to his trunk and arms. Parents did not Blanching erythematous maculopapular rash consent to all his immunisations. SPOT DIAGNOSIS 3)A 2 year old boy is seen in GP with a bumpy rash which started in his groin and armpits 2 weeks ago. He has been systemically well and is up to date with immunisations. 4)You are an FY2 on NIPE clinics. Your next patient is a baby born 24 hours ago. Mum is concerned about a blanching red mark on his forehead. SPOT DIAGNOSIS 3)A 2 year old boy is seen in GP with a bumpy Molluscum contagiosum/poxvirus rash which started in his groin and armpits 2 Group of firm small papules weeks ago. He has been systemically well and is up to date with immunisations. 4)You are an FY2 on NIPE clinics. Your next Salmon patch patient is a baby born 24 hours ago. Mum is concerned about a blanching red mark on his forehead. SPOT DIAGNOSIS 5)A 4 year old girl presents to ED with a blanching rash which has spread from her abdomen to her neck over past 24 hours. She also developed a fever and sore throat a few days ago. On examination her skin feels rough to touch. SPOT DIAGNOSIS 5)A 4 year old girl presents to ED with a blanching rash which Scarlet fever/ strep pyogenes has spread from her abdomen to her neck over past 24 hours. Blanching erythematous maculopapular rash She also developed a fever and sore throat a few days ago. On with associated ‘strawberry tongue’ examination her skin feels rough to touch. ● The rash started on both sides of her Scenar5 year old girl has developed a legs and has spread upwards. non-blanching rash over past few hours. Name: Samantha Lewis ● She had a cough and cold 1 week ago. DOB: 01/09/2019 ● She points to her knees and tummy After taking a history.. when you ask if anything hurts. ● She is clinically stable and looks well. ● She has no pMHx and is up to date with vaccines.HSP Usually 2-6 years old (peak 4-6y) SYMPTOMS & SIGNS INVESTIGATIONS -Purpuric, petechial and BEDSIDE MANAGEMENT -Usually self-limiting non-blanching rash -Observations esp BP -Paracetamol (caution with -Abdominal pain +/- N&V -Urinalysis and microscopy ibuprofen if renal involvement) -Joint pain (ankles & knees) BLOODS -Repeat urine dip and BP within -Frothy urine -FBC, U+Es, CRP , clotting, LFTs 6 months. -Haematuria IMAGING -Safetynet and to re-revive if -Low grade fever -Abdo USS if suspecting features of relapse of renal -Preceding URTI intussusception involvement. INFECTIOUS NON-INFECTIOUS BLANCHING BLANCHING -Staphylococcus scalded -Erythema infectiosum -Eczema -Steven-Johnson skin syndrome -Varicella zoster -Urticaria syndrome -Impetigo -Scabies -Atopic dermatitis -Erythema multiforme -Bullous impetigo -Molloscum contagiosum -Acne vulgaris -Eczema herpeticum -Scarlet fever -Erythema nodosum -Salmon patch -Measles -Herpes simplex -Melasma -Infectious mononucleosis -Roseola -Hand, foot and mouth -Epstein-barr virus -Seborrhoea disease -Pityriasis rosea -Epidermolysis bullosa -Tinea corporis & capitis -Congenital syphilis and -Kawasaki disease rubella INFECTIOUS NON-INFECTIOUS NON BLANCHING NON BLANCHING -Meningococcal rash -Port wine stain -Henoch-Schoenlein purpura -Idiopathic thrombocytopenia -Acute leukaemia -Haemolytic uraemic syndrome -Trauma -Mechanical i.e. coughing and vomitingCASE 4- NEONA TAL JAUNDICE Role Foundation year 1 doctor Location Paediatrics assessment unit Student Instructions Scenario 5 day old neonate boy brought in by parents Case 4 to be assessed as midwife felt they looked jaundiced. DOB: 12/04/2025 Instructions 1.Please take a collateral history 2.Explain your differentials, investigations and management plan to the examiner. SPOT DIAGNOSIS 1)A 17 day old neonate (born at term) has become jaundiced. Started 4 days ago. Feeding has reduced, stools appear pale and urine is dark. No fever. No jaundice at birth. No complications before birth or during delivery. 2)A baby 6 hours old, born at term appears jaundiced. Mum later is found to be rhesus -ve and has had a previous pregnancy. She is unsure if she received anti D. 3)A baby is born at term with a cephalohematoma. Becomes jaundiced at D2 of life. Nil risk factors for pathological jaundice. SPOT DIAGNOSIS 1)A 17 day old neonate (born at term) has become jaundiced. Started 4 days ago. Feeding has reduced, stools appear pale and urine is dark. No fever. No Biliary atresia jaundice at birth. No complications before birth or during delivery. 2)A baby 6 hours old, born at term appears jaundiced. Mum later is found to be rhesus -ve and has had a previous pregnancy. She is unsure if she Haemolytic disease of the newborn received anti D. 3)A baby is born at term with a cephalohematoma. Becomes jaundiced at D2 of Increased bilirubin production due to life. Nil risk factors for pathological jaundice. breakdown of RBCs within cephalohematoma Scenario 5 day old neonate boy brought in by parents to be assessed as midwife felt they looked jaundiced. ● Baby started looking jaundiced 1 day ago DOB: 12/04/2025 (D4) of life. Not jaundiced at birth. ● Baby has been exclusively breastfed. After taking a history.. ● Baby appears well, gaining weight. ● No infections or complications at birth. ● Mum is rhesus +ve.KEY INFORMA TION ● Timing of jaundice (<24h or >14 ● Risk of G6PD days) ● Family history of liver or ● Preterm or term? haemolytic disorders? ● Delivery method ● Pale stools or dark urine? ● Breast or bottle fed? ● Weight trend ● Unwell? ● Rhesus status ● Have parents or siblings required phototherapyNEONA T AL JA UNDICE SYMPTOMS & SIGNS INVESTIGATIONS MANAGEMENT -Jaundice (sclera and gums) BEDSIDE -Optimisation of feeding -Drowsiness -Observations +/- supplemental feeding, -Irritable, crying -Check weight and plot on growth chart IV fluids -Reduced urine output and BLOODS -Phototherapy feeding -Total serum bilirubin, FBC, blood -Exchange transfusion -Poor weight gain group, reticulocyte +/- CR, U+Es, TFTs, -Antibiotics for infection -Fever LFTs, split bilirubin -Kasai portoenterostomy -Cephalohematoma and -Cultures incl. blood, urine +/- CSF +/- liver transplantation bruising IMAGING -Pale stools, dark urine -Abdo USS +/- liver biopsy -Hepatosplenomegaly NEONA T AL JAUNDICE <14 D A YS 24 hours-14 days <24 hours • Sepsis • Sepsis • Haemolysis • Physiological jaundice ■ Isoimmunisation (ABO or Rhesus D alloantibodies) • Breastfeeding or dehydration ■ RBC enzyme defects (G6PD deficiency, • Breast milk jaundice hereditary spherocytosis, alpha thalassaemia) • Haemolysis ■ Blood extravasation (bruising or birth trauma) Sepsis Haemolysis e.g. G6PD deficiency Insufficient feeding Breastmilk Prolonged jaundice >14 days jaundice Metabolic e.g. alpha 1 Extrahepatic obstruction e.g ccv biliary atresia Hypothyroidism antitrypsin deficiencyUSEFUL LINKS • Teach me paediatrics: https://teachmepaediatrics.com • Geeky medics:https://geekymedics.com/category/paediatric-notes/ • Peds cases: podcast and website https://pedscases.com/medical-student-essentials-0 • Zero to finals:https://zerotofinals.com/paediatrics/ • MRCPCH-paediatrics:https://mrcpch.paediatrics.co.uk • Paediatric emergency playbook: podcast and website:https://pemplaybook.org • Don’t forget the bubbles:https://dontforgetthebubbles.com • Headsmart:https://bettersafethantumour.com • Mind the bleep: https://mindthebleep.com/paediatrics/ • Skin deep:https://dftbskindeep.com/ • You’re kidding right? (podcast):https://yourekiddingright.libsyn.com • GOSH- Master the MRCPCH :https://podcasts.apple.com/gb/podcast/master-the-mrcpch/id1611533668 **particularly good episode on developmental milestones** • Spotting the sick child:https://spottingthesickchild.coThank you for attending! Any questions?