Week 4: Paediatrics 1 (consultation and immunisation)

Question 1

Challenges when consulting with children

Answer 1

• Extra people in the room
• Different range of problems
• Communication
• Lack of confidence
• Different illnesses

Question 2

Tips do good consultation etiquette with children and teenagers

Answer 2

• Direct questions to child, but do include parent
• Ask questions about child to get to know them better
• Don’t use jargon- age appropriate
• Use active listening and empathy
• Respect the knowledge patients may have
• Make environment relaxed and informal
• Involve teenagers in decision making
• Ask young people if they’d like to speak on their own if they have come with a parent/guardian
• Talk mental health
• Check children’s understanding
• Recap what the patient saying
• Check if anything’s happening at school e.g. bullying

Question 3

Structure of child consultation

Answer 3

• Check name, DoB, PMH. Safeguarding issues
• Greet the child by name and check who is with them
• If the child is over 4 ask them the first question ‘do you want to tell me why you’re here’
  
  • Usually the child will ask the parent to talk on their behalf

Question 4

3 minute toolkit – acutely ill children

Answer 4

Children symptoms tend to be vague e.g. vomiting or temp. Need to examine a child to find the focus of infection.

• Children decompensate later in their illness, so important to look for physiological signs of serious diagnosis

Top to toe assessment tool

• A-E and checks childs physiology
• Order may vary depending on child
• Carried out after history

Question 5

Airway

Answer 5

• Secretions (bronchiolitis) or stridor (croup)
  
  • Childs airw ay an become blocked easily because small
• Foreign body
• Unprotected airway
  
  • Decrease conscious level
  • Useful test is a gag reflex – trying to insert oropharyngeal airway → if child coughs = good → if child allows airway = call an anaesthetist

Question 6

Breathing

Answer 6

• Resp rate
  
  • Measure of distress or more systemic problems
  • Count each breathe over 30s and x2
  • Try and do when child calm
  • Normal range changes with age of child
• Recession and accessory muscle use
  
  • Represents difficulty in breathing
• Oxygen sat
  
  • Pulse oximeter
  • Place on childs finger
  • Useful because children can be close to decompensating even with low sats
  • Cyanosis will only appear when oxygen sats are <85% - early warning
  • Children <10  different equipment
    
    • If child moves the reading may be artificially low (hold limbs still)
  • Should be at least 96%
• Auscultation
  
  • Children may be sacred of stethoscope, if children crying catch the breathe sounds as they breathe in
  • Warm stethoscope if warm
  • Could turn it into a game
  • Finding’s less valuable since smaller chest so noises tend to transmit across chest

Question 7

Circulation

Answer 7

• Colour
  
  • If child pale ask parent what normal colour is
  • Look for mottled arms or legs (this may be normal) – could be a sign of poor perfusion
• Heart rate

• When child is calm
• If crying will increase HR
• Measure RP at wrist for 30 x2
• In babies <60 use brachial pulse
• Capillary refill
  
  • Shows if child has compromised circulation
  • Press for 5 second on Childs skin and count until normal colour <2s
  • Can be measured centrally by pressing on the sternum and peripherally by pressing on the fingers, toes, hands or feet
  • Early sign of decompensation
• Temperature of hands and feet
  
  • Compare hands and feet to the chest basically comparing if difference in peripheral and central perfusion e.g. sepsis
• Blood pressure
  
  • Difficult to measure in children because they can get upset when cuff goes on arm
  • Not worth measuring unless children very drowsy late sign of decompensation
  • Cuff should measure 2thirds of the length of the upper arm
  • Could use thigh

Question 8

Disability

Answer 8

• Pupils
  
  • Usually always normal in a child awake and orientated
  • May be sluggish after a fit or drug overdose
  • Changing pupils sizes may be due to ongoing seizure
  • Asymmetrical pupil size means a space occupying lesion in brain
    
    • E.g. extradural haemorrhage
• Limb tone and movement
  
  • Compare movement of limbs i-mportant if worried about SoL
  • Only likely to find symptoms if patient is not alert and orientated
• AVPU score/ GCS
  
  • Note child’s behaviour and how alert
    
    • Ask some questions
  • Ask parent if normal behaviour
  • Irritablity may indication raised intracranial pressure or meningitis
    
    • Will not be easy to calm
  • Drowsiness also common when child has high temp
  • Persistent drowsiness very worrying

Question 9

Ears, nose and throat

Answer 9

• Needs examining in any child with a fever
• Should be left to the end in case the child gets upset

Question 10

Ears

Answer 10

• Have a firm grip on the child to prevent otoscope damaging ear
• TM often pink if they are hot

Question 11

Throat

Answer 11

• Do after ear examination
• Hold child like this
• Use tongue depressor
• Children often have large tonsils that look red due to increased blood supply
• True tonsilitis= covered in exudate

Question 12

Temperature assessment

Answer 12

• Using ear thermometer (tympanic thermometer)
• Children may not want this- do this as quick as poss
• Paper strips such as tempa dots can be placed in mouth or arm pit
• Axillary temp recommended in babies (ears too small)

Question 13

Tummy assessment

Answer 13

• Best examined lying flat
• May have to make do on parents lap if too upset
• Ensure child is relaxed and trusts you
• Feel around abdomen gently and ask for pain
• Once child is relaxed you can do firmer palpation
• Palpation of liver and spleen same as adults
• Examine testicles
• Look for strangulated hernias in groin
• Urine sample tested at bedside

Question 14

Blood glucose assessment

Answer 14

• Most commonly check using blood drop on a reagent strip- BM stix
• Should be measured in confused or drowsy child
• Finger or toe prick
• Occurs in children quite easily
• Hypoglycaemia
  
  • Alcohol
  • Haven’t eaten for a day or so
  • DKA
    genetic abnormality
• Blood glucose assessed through blood gas machine (3-5 mmol/l normal)

Question 15

Environment

Answer 15

• Provide child friendly environment putting the child at ease
• Relaxing them will make assessment more accurate and quicker
• Provide toys and books
• Calming child down is medically important e.g. in asthma attack

Question 16

Assessing and treating children

Answer 16

• If child very distressed let child calm down without going near them
• Engage siblings in conversation
• Involve child in history
• Engage them with questions e.g. about their clothes
• A lot of history will come from parent (may be feeling very anxious)
• Befriend the child before you examine them so you can make an accurate exam (e.g. if distressed HR and RR will be higher)
• Get down to their level
• Listen to mums arm first and then put it on child – make it a game
• Try and explain what you are going to do
• Have a happy face
• Start at a distance  to not freak child out
• Do abdomen when child iis relaxed
• When child is asleep get listening done
• Do ears and throat last

Question 17

immunisation schedule runs from

Answer 17

the 1st year of life to the 65th year of life

Question 18

first year vaccines involve vaccines at weeks

Answer 18

8, 12 and 16

Question 19

8 week vaccines

Answer 19

• 6 in 1
  
  • Diptheria
  • Hep B
  • Hib
  • Polio
  • Tetanus
  • Whooping cough (pertussis)
• Rotavirus
• Men B

Question 20

12 week vaccines

Answer 20

• 6 in 1 (2^nd dose)
• Pneumococcal
• Rotavirus (2^nd)

Question 21

16 week vaccines

Answer 21

• 6 in 1 (3^rd)
• MenB (2^nd)

Question 22

At 1 years old

Answer 22

• MenC
• MMR
• Pneumococcal (2^nd)
• MenB (3^rd)

Question 23

At aged 3 years and 4 months

Answer 23

• MMR (2^nd)
• 4 in 1 pe-school booster
  
  • Diptheria
  • Polio
  • Tetanus
  • Whooping cough

Question 24

between ages of 12 and 13 years

Answer 24

• HPV

Question 25

at 14 yo

Answer 25

• 3 in 1 booster
  
  • Tetanus
  • Diphtheria
  • Polio
• MenACWy

Question 26

freshers

Answer 26

MenACWY→ protects against meningitis and septicaemia

Question 27

Pregnant women

*

Answer 27

• During flu seasons: flu vaccine
• From 16 weeks: whooping cough

Question 28

At 65 yo

Answer 28

• Pneumococcal (PPV) vaccine
• Flu vaccine

Question 29

at 70yo

Answer 29

shingles