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NAC-OSCE > Pediatric cases: Overall Approach > Flashcards

Pediatric cases: Overall Approach Flashcards

1
Q

Vomiting

A

** Pre-door:
*Red flags:
-BINDE
-Impact: Dehyd, FTT
-Admission??
Can you tell me what brought you in?
1. OCD (based on what has not been said)
*Quality: Projectile?
*Timing: Related to feeding? Hungry after?
*AA (aggravates or alleviates): Position

Summary of OCD

  1. COCA +- B
  2. Severity: malnutrition/dehydration sxs
    - Drowsy? Floppy?
    - Is his/her sucking weaker?
    - Dehydration: How many diapers?/lips dry?
    - FTT: Weight

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * GI symptoms: Bowel movements? Abdominal distention?
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing?

5.PMH: BINDE/HEADSSS

  1. FH:
    * Pyloric stenosis?
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2
Q

Cough (Asthma)

A
  • *** Pre-door:
  • Red flags:
    - BINDE/HEADSSS
    - Impact: how it affects their life/daily activities, sleep
    - Constitutional symptoms
    - Admission??

Can you tell me what brought you in?

If FU for prior visit to ER: Clarify everything about the event: How serious?/ admitted? / medications?/ambulance? If yes, did someone called 911 or you did?

  1. OCD (based on what has not been said)
    * Quality: Bark?
    * Timing: Day/night?
    * AA (aggravates or alleviates): Activity? Cold weather?
    - Triggers of asthma

Summary of OCD

  • If acute:
    - Continuous /productive/fever
    - Seen by a doctor before? ATB? x-rays?
  • If chronic:
    - Intermittent/dry cough/on and off
    - SOB, noisy breathing, wheezes, chest tightness, N/V
    - Cough to the extent of voimiting or LOC?
    - Pertussis vaccination?
  1. COCA +- B +- phlegm
  2. Severity: Impact on his daily activities
    - Purple?
    - Gasping for air?
    - Neck or chest retractions?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * GI symptoms: Chronic diarrhea? (R/O CF)
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing?
  2. PMH:
    - BINDE
    - Allergic disease: Atopic dermatitis/allergic rhinitis
  3. FH:
    - Allergic disease: asthma/skin allergies
  4. Social History: HEADSSS
  5. Triggers:
    * Infection:
    - Chest infections? Flu-like symptoms?
    * Medication:
    - How do you use puffers? /Stored properly? Expired?
    - Did you start a new medication?
    * Outdoor:
    - Exercise
    - Cold air
    - Pollens
    - Dust/smug
    * Indoor:
    - Smoke?
    - Pets?
    - Fabrics related?
    - Relation to any type of food? + perfumes?
    - Live in house? Basement (mold)
    - Construction renovation? Exposure to chemicals?
    * Stress?

DO YOU HAVE ANY QUESTION OR CONCERN FOR ME??

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3
Q

Fever

A
  • *** Pre-door:
  • Red flags:
    - BINDE
    - Impact
    - Admission??
    - Constitutional symptoms?

Can you tell me what brought you in?

  1. OCD
    * Quality: Projectile?
    * Timing: Diurnal variation? Special pattern (more every 2nd or 3rd day)?
    * AA (aggravates or alleviates): Medications? Flu at the time?

Summary of OCD

  1. Impact:
    - Drowsy? Floppy? Tired?
    - Is his/her sucking weaker?
    - Cry? High-pitched cry?
  2. Constitutional symptoms?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * Skin: Skin rash? If yes, OCD and details (distribution, color, elevated?).
    - Buttocks-abdomen : Henoch Shonlein
    - Trunk: Chickenpox
    - Face: Measles / Rubella?
    - Cheeks: 5th disease
  • CNS: Headache/drowsy? neck pain/rigidity? N/V?
  • ENT: Pulling ear? / SOB/Cough/wheezing? Phlegm?
  • GI symptoms: Bowel movements? Abdominal distention? Diarrhea?
  • Liver: Yellow color? itching? Dark urine? Pale stools?
  • Urinary: Urine changes? Pain while urinating?
  • Joints: Pain/swelling/mouth ulcers?
  1. PMH: BINDE/HEADSSS
  2. FH:
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4
Q

Jaundice

A
  • *** Pre-door:
  • Red flags:
    - BINDE
    - Impact: Dehydration, kernicterus, weaker?
    - Admission??

Can you tell me what brought you in?

  1. OCD
    * When: Early vs late?
    * Who noticed it? When? Where?
    * How about his feet? Is it spreading? Increasing or decreasing?
    * How about his urine? Stools?

Summary of OCD

  1. Impact:
    - Drowsy? Floppy? Tired?
    - Is his/her sucking weaker?
    - Cry? High-pitched cry?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Constitutional symptoms?
  2. Associated
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing? Discharge from ears? Foul-smelling urine?
  3. PMH:
    * BINDE
    - Pregnancy!!!:
    * Full-term/Pre-term?
    * Planned?
    * Prenatal visits? Everything normal?
    * Screenings, e.g. GBS—swab at 36 weeks?
    * Blood group?!!
    - Birth!!!:
    * Full-term/Pre-term?
    * Delivery, i.e. prolonged, time from water broke, route of delivery, instrumentation?
    * Baby cried immediately?
    * Any bruises?
    * Did you have fever discharge?
    - Nutrition/Diet!!!:
    * How many times you feed him?
    * Breastmilk or formula or both?
    * How long does the lactation last? Both breasts?
    * Do you feel your breasts engorged still?
    - Environment!!!:
    * Any other children? Did any of them develop jaundice after birth?
  4. FH:
    - Jaundice
    - Liver disease
    - Blood disease
    - Cystic fibrosis
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5
Q

Crying baby

A
  • *** Pre-door:
  • Red flags:
    - BINDE
    - Impact: Parents’ well-being? Baby is drowsy?
    - Admission??

Can you tell me what brought you in?

  1. OCD
    * When: All day?
    * Colic: >3 hours/day for >3 days/week for >3 weeks
    * What initiates/increases the crying?
    - Hungry? What do you feed him?
    - Hot/cold?
    - Wet? Rash?
    * What improves/decreases?
    - Hug/hold/burp?
    - Rock/Shake??
    * When he cries:
    - Pulls his legs?
    - passing gases?
    - abdomen distended?
    - related to feeding?
    - How are you coping with this?

Summary of OCD

  1. Impact:
    - Drowsy? Floppy? Tired?
    - Is his/her sucking weaker?
    - Cry? High-pitched cry?
    - How are you and your partner coping?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Constitutional symptoms?
  2. Associated
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing? Discharge from ears? Foul-smelling urine?
  3. PMH:
    * BINDE
    - Pregnancy:
    * Planned?
    * Prenatal visits? Everything normal?
    - Birth:
    * Baby cried immediately?
    * Did you have fever / discharge?
    - Nutrition/Diet!!!:
    * How many times you feed him?
    * Breastmilk or formula or both?
    * How long does the lactation last? Both breasts?
    * Do you feel your breasts engorged still?
    - Environment!!!:
    * Any other children?
    * With whom do you live? Support?
    * Financial situation?
    * Repeated visits to ER?
  4. FH: Mental Problems? SAD?
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6
Q

Diarrhea

A

** Pre-door:
*Red flags:
-BINDE
-Impact: Dehyd, FTT
-Admission??
Can you tell me what brought you in?

  1. OCD (based on what has not been said)
    * Timing: Related to feeding?
    * AA (aggravates or alleviates): Juice (Excess fruit juice)
  2. COCA +- B
    * Quality: watery / loose / bulky / undigested food? Difficult to wipe?
  3. Severity: malnutrition/dehydration sxs
    - Appetite? / Vomiting
    - Drowsy? Floppy?
    - Is his/her sucking weaker?
    - Dehydration: How many diapers?/lips dry?!!!!
    - FTT: Weight ->today, at birth, last visit?!!!!

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Constitutional symptoms?
  2. Associated
    * GI symptoms: Vomiting? Abdominal distention?
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing?
    * Someone else at home with same symptoms?
  3. PMH: BINDE/HEADSSS
  4. FH:
  5. DDx:
    * Acute diarrhea:
    - Use of ATB
    - Infectious:
    * Camping/travelling
    * Anybody else with diarrhea?
    * Does he goes to daycare?
    * Chronic diarrhea WITHOUT FTT:
    - Toddler’s diarrhea: does he drink too much fruit juice?
    - Infectious: Parasitic / traveler’s
    - Lactose intolerance:
    * Does he pass a lot of gas
    * Redness / skin rash at his buttocks
    * Chronic diarrhea WITH FTT:
    - What about appetite?
    - Associated symptoms? Respiratory/gluten
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7
Q

Counselling: Delayed speech

A
  1. Intro
  2. Clarification:
    * Not gaining words?
    * Losing words?
    * Not speaking clearly?
    * Not speaking at all?
  3. OCD
    * Verbal assessment:
    - When you noticed it? / Did you seek medical attention before?
    - Able to speak? How many words in total? Words/sentence?
    - He gained words and then lose them?
    - How he communicates with you?
  4. Rule out:
    * Hearing:
    - How do you describe the hearing?
    - If you call him, does he respond? What about behind? What about from other room?
    - Increases the volume of tv?
    - Repeated ear infections? Discharge? Tubes?
    - Did he take any medications? Antibiotics (Amino)?
    - Ever screened for hearing?
  • Autism:
    - Maintain eye contact?
    - Show emotions?
    - Is he aggressive? Plays at school?
    - Repetitive movements?
    - Family history?
    - Reports from teacher at school?
  1. PMH: BINDE
    * Start with Developmental milestones!!
    - What can he do?
    - As a child, strangers make him nervous?
    - Does he control his urine/bowel?
    - Red flags:
    - 6 months: No response to loud noise or mother’s voice
    - 10 months: No response to their name
    - 15 months: No imitation of voice
    - 2 years: No 2-word phrase / 50% of speech not understood.
  • Nutrition: Growth chart
  • Environment:
    - Screen for neglect
    - Family factor: Languages at home?
  • Pregnancy/Birth:
    - Skin rashes during pregnancy? TORCH infection? SAD during pregnancy?
    7. FH:
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8
Q

Seizure

A
  1. Analysis of CC:
    * During:
    - Seizure duration? Part of your body or all?
    - Any events during the seizure?
    - Did he bite his tongue? Roll eyes? Wet?
    - How it stopped?
  • After:
    - What happened after the seizure stopped?
    - Decrease in the level of consciousness? Was he able to respond to you? Headache? Weakness?
  • Before:
    - Previous illness? Medication or trauma? Previous seizure?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Constitutional symptoms?
  2. Associated
    * Fever: Characteristics
    * R/O infection: skin rash/ear pulling/cough-wheezing?/ Vomiting / Sore throat / bowl or urinary complaints?
    * Someone else at home with same symptoms?
  3. PMH: BINDE/HEADSSS
  4. FH:
  5. Counselling
    * Intro:
    - Based on what you told me… “benign febrile seizure”
    - What do you know about it? Would you like me to tell you more about it?
    * Febrile seizures:
    - Affects kids from 6 months to 6 years
    - Not uncommon (3%)
    - Exact reason is unknown, maybe child brain not fully developed
    - Self-limiting / benign / typical attack: <15 min, not recur in 24 h!!
    * Recurrent attacks:
    - For each 100 children
    * 65 will not have it again
    * 30 will have another atack
    * 3 will have many other even without fever
    * 2 will develop seizure disorder
    - Best treatment is prevention
    - If it happens:
    * Turn child on his side / protect from hitting / do not force objects into his mouth
    * If > than 15 min ->bring to ER
    * Diazepam 5 mg PR suppository
    * CT, EEG
    - I will give you brochures and web sites
    - Questions or concerns????
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9
Q

ADHD: Counselling

A
  1. Diagnosis of ADHD:
    * Who?
    * When?
    * How?
    * Rule Out:
    - Organic
    * Neuro: Infection, trauma, genetic
    * Sensory: Hearing/Visual
    - Cognitive
    * Speech
    * Language
    * MR
    - Behavioral/Emotional
    * Mood disorder
    * Depression
    * Anxiety
    * PTSD
    - Environmental
    * Stress
    * Abuse
    * Family disfunction
    * SAD
  2. PMH: BINDE/HEADSSS
  3. FH: ADHD / MR / Autism / Depression
  4. Counselling
    * Intro
    - Who diagnosed it?
    * Concern - Ritalin (amphetamin) to children?
    - Yes. First line of treatment. Effective and used for long time
    - It is not exactly an amphetamin. It is the same family, it is called “methylphenidate”. and approved for that.
    - In children, helps them to focus: INCREASES their concentration and CHANNELS their energy. Even though we might not cure them, we help them with education.
    - It is generally a safe medication in children. It is not addictive.
    - Side effects: insomnia (that is why we give it early), abdominal pain.

Before talking further about ADHD and Ritalin, some questions to see if criteria of ADHD (or any other developmental challenge) is met:

  • Diagnosis (hyperactive / inattentive / impulsive:
    - Teachers complain about full of energy? Spinning all the time? Refuse to stand still? Talk all the time? Answers even if not asked?
    - Focus on subjects >30 min? Can he finish his tasks? Forget his belongings?
    - Only at school or also at home?
    - Did you notice yourself?
    - How much time parents spend with him?
    - How about before?
  • IMPACT:
    - On functioning, school performance, relationship with peers?
  • DDx:
    - ODD
    * No follow instructions?
    * Challenge teachers/family members?
    - Conduct disorder (anti-social if >18 years)
    * Aggressive? Does he fight a lot with other kids?
    * Pet? How he treats the pet?
    * Take others’ belongings?
    * Tell truth all the time?
    * Like to set fires?
    - Learning disability
    * Like to go to school?
    * Specific difficulty reading/writing/maths?
    - Petit-mal epiepsy
    * Hx of seizures?
    * LOC? Abnormal movements?
    - Depression/Adjustment disorder
    * Stressed recently? Any loss of a beloved?
    * Sad/crying? Nightmares? Losing weight?
    - Autism
    - MR
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10
Q

Anemia

A
  • *** Pre-door:
  • Red flags:
    - BINDE
    - Impact: Dehydration, weaker?
    - Admission??

Can you tell me what brought you in?
Clarification: What do you mean pale? Is he yellow?
1. OCD
*When:
*Who noticed it? When? Where?
*Previous history of something similar before?
*How about his urine? Stools?

Summary of OCD

  1. Impact:
    - Drowsy? Floppy? Tired?
    - Cry?
    - Regular activities? Active? Playful like before?
    - If he is doing activities, do you notice SOB/fainting?
    - Is he gaining weight?

Empathy:

  • This might be worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Constitutional symptoms?
  2. Associated
    * R/O infection: Fever/skin rash/ear pulling/cough-wheezing? Discharge from ears? Foul-smelling urine?
  3. PMH/BINDE:
    * PMH
    - Heart/lung/kidney/liver disease?
    - Hospitalizations / sx? Ilnesses (cancer)?
    - Medications (sulphas, G6PD) / Allergies
    - Travel
    * BINDE
    - Nutrition/Diet!!!:
    * What/How many times you feed him?
    * Iron supplements?
    * If breastfeeding: Breastmilk or formula or both? / How long it lasts? Breasts engorged?
    - Pregnancy!!!:
    * Planned?
    * Prenatal visits? Everything normal?
    * Screenings, e.g. GBS—swab at 36 weeks?
    * Blood group?!!
    - Birth!!!:
    * Full-term/Pre-term?
    * Delivery, i.e. prolonged, time from water broke, route of delivery, instrumentation?
    * Baby cried immediately?
    * Any bruises?
    * Did you have fever discharge?
    - Environment!!!:
    * Whom do you live with? Financial support?
    * Any other children? R/O abuse or neglect!
    * Is he eating paint scales?
  4. FH:
    - Similar condition in family?
    - Related by blood to your partner?
    - Ethnicity?
    - Repeated surgeries
    - Jaundice
    - Liver disease
    - Bleeding disorder
    - Cystic fibrosis
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