Paediatric Notes Flashcards
Important points to consider when taking paediatric history?
- Make friends with child and be opportunistic
- Get down in child’s level
- Always leave unpleasant things to the end of consultation to avoid upset
Respiratory symptoms key to ask in paediatric history?
o SOB – exertion/rest, quantify severity, what exactly stops you carrying on?
o Cough – dry/productive/barking/paroxysmal, worse at any point
o Sputum – volume, colour, consistency, blood, mucus
o Haemoptysis – colour, amount
o Wheeze/Stridor
o Chest Pain – SOCRATES
o Systemic – fever, feeding, weight loss, night sweats, anorexia
Cardiology symptoms key to ask in paediatric history?
o Chest Pain – SOCRATES
o SOB – exertion/PND/orthopnoea
o Palpitations – tap out the rhythm
o Syncope – before/during/after – exertional/postural/epilepsy
o Leg Swelling – how long/stopping anything
o Cough – (haemoptysis)
o Murmurs
o Systemic symptoms – fatigue/fever/weight loss/gain/sweating
GI symptoms key to ask in paediatric history?
o Nutrition
o Dysphagia – solids/liquids/progression
o Nausea & Vomiting – frequency/volume/projectile/appearance (posseting suggests GORD, undigested=pouch, non-bilious=pyloric obstruction)
o Haematemesis – colour (coffee ground=GI ulcer bleed, fresh red=acute bleed)
o Abdominal Pain – SOCRATES, intermittent=colic/obstruction
o Abdominal distention – 5F’s
o Weight Loss/Anorexia – how much/how long?
o Change in bowel habit
a. Diarrhoea – mucus (IBD), blood (fresh red=lower GI, IBD) (melaena=upper GI bleed), Recent ABx, Food
b. Urgency – IBD, gastroenteritis
c. Constipation – duration/passing flatus
d. Colour – melaena, fresh red, pale (biliary obstruction)
e. Encopresis/soiling
o Jaundice/Itching
o Systemic – fever, fatigue
Urological symptoms key to ask in paediatric history?
o Pain o Frequency o Urgency o Nocturia o Haematuria o Hesitancy/Terminal Dribbling o Poor Stream o Systemic – nausea, vomiting, fever, rigors, weight loss, back pain
Neurological symptoms key to ask in paediatric history?
o Headache – SOCRATES, effect on daily life, before, after, worse on waking, bending forward
o Episodes of losing consciousness – before/during/after, triggers, witnesses, skin colour, movements, tongue biting, continence, recovery
o Nausea and Vomiting
o Visual Problems
o Photophobia
o Neck Stiffness
o Systemic – fever, rigors, rash, weight loss
o Red Flags – change to mental state
Thyroid symptoms key to ask in paediatric history?
o Energy levels o Mood o Weight changes o Appetite o Bowel Habits o Concentration o Tolerance to heat o Skin changes o Heart Rate/Palpitations o Menstrual Changes
MSK symptoms key to ask in paediatric history?
o Pain – SOCRATES
o Mono – OA, gout, septic arthritis
o Poly – RA, osteoarthtis
o Back – muscle, disc prolapse, ankylosing spondylitis, AAA
o Loss of Function
o Inflammation
o Gait Problems – limp with pain, tip-toe walking
o Stiffness
o Crepitus
o Numbness or tingling
o Bowel and Bladder Working
o Systemic- Fever, malaise, weight loss, headaches, psoriasis
o Timing to exercise, rest, NSAIDS
CAGE screening? Alcohol symptoms key to ask in paediatric history? Signs of dependence?
o CAGE
Ever think about cutting down the amount you drink
Ever feel annoyed at people who question the amount you drink?
Ever feel guilty about your drinking?
Ever had a drink when you wake up as an eye opener?
o First Drink
o How often they drink?
o Amount they drink?
o Where? Who with? How much do they spend?
o Dependence
If you stop drinking do you notice any physical symptoms?
Do you have to drink more to get the same affect?
Do you feel the need to drink?
How important is drinking to you?
Do you feel anxious or down if you stop drinking?
Depression symptoms key to ask in paediatric history?
o In past month have you noticed persistent low mood (worse at any point in day?), low energy, lack of interest in doing things
o Have you noticed any other symptoms?
Sleep (how long, difficulty getting up or getting to sleep), appetite, concentration (get distracted easily, how is work?), confidence (how do you feel about yourself, do you criticise yourself?), agitation
o Some people who complain of low mood have extreme thoughts, do you ever have any thoughts about harming yourself or ending your life? What stops you?
o Ever thought about harming others?
o Have you ever experienced feeling particularly high?
o Patients who feel this way can often experience bizarre events – any voices in your head, people discussing you or out to get you?
Suicide risk symptoms key to ask in paediatric history?
o Before Was there a cause? Was it planned or impulsive? Was a note or will left? Any precautions to hide themselves? Was alcohol used? o During What method of self-harm? • Overdose – medication, how much, what did you think it would do? • Cutting – where, number, how deep, what did you hope? Was patient alone? Where were they? What was going through their mind at the time? What did they do after? o After How were they found? How did they feel when they were found? Do you regret it? Would you do it again? What is preventing you from re-attempting?
What to ask after HPC in paediatric history?
Summary
Ideas – do you have any idea what may be causing the symptoms you’ve described?
Concerns – do you have any concerns at this moment in time?
Expectations – what would you like from this consultation?
PMH in paediatric history?
- Ever had anything like this before?
- Anything you see your GP about regularly?
- Any previous surgery?
- Any recent hospital admissions?
- Any mental health issues?
BINDS in paediatric history?
- Birth History
o Location, mode, gestation, birth weight
o Any problems? (antenatal, perinatal, postnatal) Require time on SCBU)
o Maternal health?
o Neonatal Period
o Jaundice, SCBU, Ventilation, Antibiotics - Immunisations
- Nutrition - Feeding/Weaning
Breast/Bottle fed, how much, frequency of feeds - Development
o Any concerns regarding development?
o Hit all their milestones?
Smiling, sitting, walking, speech, dry by day/night
o School performance?
DH in paediatric history?
Do you take any regular medications? Any recent course of antibiotics? Any over the counter drugs? Any herbal remedies? Do you have any home oxygen to help with your breathing? ALLERGIES - what reaction?
FH in paediatric history?
Any problems in the family?
Have you had any recent contact with unwell people?
Parents in good health?
What is a HEADSS social assessment?
Home Education Activities Drugs Sexuality Suicide
Questions to ask for home situation?
o Who do they live with? Where? Any new people in family?
o Do you get along with everyone at home?
o Working with youth I have learned from some “kids” that their relationship with their parents is a difficult one; by this I mean they argue and fight
Questions to ask for education situation?
o Are you in school? What are you good at in school? What is hard for you? What grades do you get?
o Enjoy school? Any problems?
o How much school did you miss last/this year?
o Any future plans/goals?
Questions to ask for activities situation?
o What do you do for fun? What things do you do with friends? What do you do with your free time?
o Have you ever been involved with the police?
Questions to ask for drugs situation?
o Many young people experiment with drugs, alcohol, or cigarettes. Have you or your friends ever tried them? What have your tried?
o How much and how often?
o How do you pay for your cigarettes, alcohol or drugs?
Questions to ask for sexuality situation?
o Are you involved in a relationship? Have you been involved in a relationship? How was that experience for you?
o How would you describe your feeling towards guys or girls? How do you see yourself in terms of sexual preference, i.e. gay, straight, or bisexual?
o Using contraception? Type and how often
Questions to ask for suicide situation?
o Sleep disorders (usually induction problems, also early/frequent waking or greatly increased sleep and complaints of increasing fatigue)
o Appetite/eating behavior change
o Emotional outbursts and highly impulsive behaviour
o History of withdrawal/isolation
o Hopeless/helpless feelings; two significant predicators of depression and suicide risk.
o History of past suicide attempts, depression, psychological counselling
o History of drug/alcohol abuse, acting out/crime, recent change in school performance
o Suicidal ideation (including significant current and past losses)
o Decreased affect on interview, avoidance of eye contact – depression posturing
Other SH questions to ask in paediatric history?
Smoking – pack years Exercise tolerance – recent changes
Alcohol – units per week Living situation
Recreational Drug Use Travel History – TB, PE
Occupation (shipyard/plumber=asbestosis) Pets/Hobbies – birds fancier lung
Affecting Daily life – sleep, school, work, home life, Diet
Systems enquiry - CV?
- Cardiovascular – Chest pain / Palpitations/ Dyspnoea / Syncope/ Orthopnoea / Peripheral oedema
Systems enquiry - Resp?
- Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
Systems enquiry - GI?
- GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Systems enquiry - Urinary?
- Urinary – Volume of urine passed / Frequency / Dysuria/ Urgency / Incontinence
Systems enquiry - CNS?
- CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Systems enquiry - MSK?
- Musculoskeletal – Bone and joint pain / Muscular pain
Systems enquiry - Dermatology?
- Dermatology – Rashes / Skin breaks / Ulcers / Skin lesions
End pieces of a history?
Summarise – anything I have missed?
Differential Diagnosis
Investigations – imaging, bloods, exams
Health promotion - reasons for?
o It is the period for starting health-risk behaviours and often continue into adult life
o Health behaviours may have a direct on lives
o Increased morbidity and mortality
Health promotion - smoking?
Stop when ready to stop
Ideally not to smoke within pregnancy and nicotine replacement therapy is better than continuation
Mutually stopping as a couple often more successful
Health promotion - alcohol/drugs?
Alcohol consumption should be kept to a minimum, with avoidance of binge drinking and there is much to commend complete abstention
Health promotion - nutrition?
Breast-feeding encouraged
Healthy diet
• Not too much sugar and salt, avoid food colouring
Health promotion - exercise?
NICE recommends 60 minutes of moderate exercise a day
Can be stuff like walking, using stairs, cycling
The value of exercise is more than just the calories expended in the session. It tends to increase basal metabolic rate and, after vigorous exercise, metabolism is stimulated for the subsequent 36 hours
Reduce time spent doing inactive hobbies like video gaming, etc
Health promotion - Dental health?
As soon as teeth erupt, brush twice a day with smear of toothpaste
Health promotion - Sexual health?
Use contraception for every sexual act
Best way to prevent STI transmission is through condom usage
Definition of growth?
o Defined as increase in height & weight
o Not linear
Average birth weight (how to calculate from age), head circumference, height, teeth??
Birth weight – 3.3kg
• Calculate weight by: <8=2(age+4), >8 agex3
Head circumference – 35cm
Height – 50cm (at birth), 75cm (1yr)
Teeth – primary (6 months – 2 years, permanent 6-12 years, third molars 20 yrs)
Normal nutritional requirement of child?
o Normal requirement – 150mls/kg/day after first week until weaning
Best form of nutrition in child?
o WHO say breast milk is best form of nutrition
Recommended daily calorie intake for child aged 0-1 and 1+?
0-1 year – 110kcal/kg/d
1+ years – 1000 + (100xage) kcal/d
150ml milk contains 110kcal
What special milks are available for babies suffering from GORD, faltering growth and cow’s milk protein intolerance?
GORD – Enfamil AR
Faltering Growth – Infatrini
Cow’s milk protein intolerance – Nutramigen
Number of daily feeds for child aged 0-6w, 6w-4m, 4-6m, 6-9m??
6-8
5
4-5
3-4
Feed volume for 0-6w, 6w-4m, 4-6m, 6-9m??
60-120mls
150-180mls
180-200mls
200mls
Feed volume for 0-6w, 6w-4m, 4-6m, 6-9m??
60-120mls
150-180mls
180-200mls
200mls
When to wean a child?
From 6 months, carry on with breast milk feeds initially
Puree to 7 months
When should iron containing food be introduced?
Iron containing foods at 6 months
What to avoid until 6 months?
Avoid egg, wheat until 6 months
When can they have doorstep milk and normal food? Full fat milk?
Doorstep milk and normal food at 12 months
Full fat milk until 5 years (avoid semi skimmed/skimmed)
When is it appropriate to give vitamin supplements to children?
Examples?
VIT A, C, D
• 0-6 months – only if maternal diet very poor
• 6-12 months – all exclusively breast fed infants, <500ml/day formula
• Continue until 5 if high risk
• Eg. Abidec, Dalivit
Estimating mild fluid deficit? % deficit?
• Mild (5%)
o Dry mucous membranes, skin turgor, decreased urine output
Estimating moderate fluid deficit? % deficit?
• Moderate (10%)
o Decreased skin turgor, oliguric, high pulse, >CRT, lethargy
Estimating severe fluid deficit? % deficit?
• Severe (15%)
o Shock, anuric, hypotension
Formula for calculating fluid deficit fluids? What fluid to give the child?
- % dehydration x weight(kg) x 10
- Give as 0.45% saline over 48h
- Add K+ (20mmol/500ml) once child passed urine
What maintenance fluids are given to children?
(0.9% saline with 5% dextrose with 10mmol KCL)
What is the formula for calculating maintenance fluids in children?
1st 10kg 100mls/kg/day
2nd 10kg 50mls/kg/day
3rd & subsequent kg 20mls/kg/day
What is the fluid requirements in neonates Day 1-4?
Day 1 - 60ml/kg/day
Day 2 - 90ml/kg/day
Day 3 - 120ml/kg/day
Day 4 - 150ml/kg/day
What is the sodium and potassium requirements of neonates per day?
Sodium - 3mmol/kg/day
Potassium - 2mmol/kg/day
What is the fluid type and formula for resuscitation?
0.9% saline – 20mls/kg
What is defined as overweight and obesity in paediatrics?
Overweight - >85th centile
Obese – 91-98th centile
What are the normal visual acuities at birth, 1 month, 6 months, 3-5 years?
o Birth 6/180
o 1 month 6/90
o 6 months 6/30
o 3-5 years 6/6
What screening programmes exist for children?
o Birth NIPE exam o 1 week Guthrie test o 6-8 weeks NIPE exam o 4-5 years orthoptist o School entry – height and weight, hearing
Define premature and post-mature?
o Premature <37 weeks, post-mature >42 weeks
When do neonates usually pass urine and stool?
o 95% micturate within 24h, pass meconium within 48h
What percentage weight loss is abnormal in neonate?
o 10% weight loss is abnormal
Average sleep times for neonate, 6 months, 4 years, 18 years?
o Birth 16h/day
o 6 months 14h/day
o 4 years 12h/day
o 18 years 8h/day
What is child protection?
- Safeguarding is protection and prevention of maltreatment which could impair health and development by ensuring safe circumstances to grow up in
How to investigate and detect child protection issues?
o Types of injury
o Context, examination
o Investigations (skeletal survey, CT head, ophthalmology)
o Risk Factors
What physical things should you look out for which may present child protection issues?
Any child who receives physical injury as a result of (or omission on the part of) his /her parents or guardians
Actual or potential physical harm from an interaction or lack of an interaction
Normal bruising over bony prominences, concern if head, face, cheek, inside thigh/arm, genitalia
Non-accidental head trauma (NAHI)
• Shaken baby syndrome
What emotional things should you look out for which may present child protection issues?
Failure to provide a developmentally appropriate, supportive environment, including the availability of a primary attachment figure, so child can develop a stable and full range of emotional and social competencies
What neglect may present child protection issues?
Failure to provide for the development of the child in all spheres
What are sexual issues which may present child protection issues?
The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or that violate the laws or social taboos of society
Behaviour changes, sexualised behaviour, wetting/soiling, vaginal discharge/bleeding, self-harm, disclosure
What are exploitation issues which may present child protection issues?
Commercial or other exploitation of a child refers to use of the child in work or other activities for the benefit of others
Management of child protection issues?
o Always discuss and document, refer and pass on if needed
What features in S of SBARR?
o Situation Who • Introduce yourself, ask whom you are speaking to, identify patient Where • Patients location When What • What you need advice about and your working diagnosis
What features in B of SBARR?
Admission reason Date Patients relevant PMH and SH Investigation results Interventions
What features in A of SBARR?
Vital Signs
Clinical examination findings
Overall clinical impression
What features in R of SBARR?
State
• Suspected diagnosis
• What do you think will happen and the time frame
Ask
• Whether they can review patient and in what time frame
• Whether there is anything further you can be doing
What features in R of SBARR?
Check understanding and clarify any questions
Document discussion in the notes
Thank person
What charts are available for paediatrics early warning scores?
PAWS score
Usually age appropriate charts available
16+ is NEWS chart
See front for management of PAWS score
What screening is done on a newborn?
NIPE Hearing screening - within 4-5 weeks (usually before discharge) Guthrie Test (heel prick at day 5)
What does the Guthrie test test for?
Homocystinuria Isovaleric acidaemia Glutaric aciduria type 1 Hypothyroidism (congenital) Medium-chain acyl CoA (MCAD) deficiency Sickle cell disease Maple syrup disease (MSUD) Cystic fibrosis Phenylketouria
When is the Guthrie test offered? Is it mandatory?
Day 5 (5-8) Patient can decline
What are the parameters of APGAR score? Scores indicate?
Appearance (all blue, blue extremitites, no cyanosis)
Pulse (absent, <100, >100)
Grimace (floppy, minimal cry on stim, cry on stim)
Activity (none, flexed arms/legs, active)
Respirations (absent, slow and irregular, strong & robust cry)
Scored each parameter 0-2 and total from 0-10 (higher the better)
