Paediatric BLS
DRSABCDE
D - danger R - response - stimulate (not shake) S - Shout for help A - head in Neutral position B - look/listen/feel 10s --> 5 rescue breaths C - Chest compressions, 1 finger above xiphi
15:2
–> go get help after 1 min CPR
Differences between adult and child:
1) PBLS: 5 rescue breaths before circulation
2) CPR 1 min before leaving
3) Different airway position (neutral)
4) 15:2 , not 30:2
5) Chest compression different
6) In adults check breathing/circulation at same time
DR ABCDE CROUP
DRS
A - look in airway without distressing child
B - look listen feel - signs of resp distress
measure (02/RR), treat : 02, CXR?
C
D
E
Tx:
- Single dose oral dex 0.15mg/kg
- Nebulised budesonide 2mg
- Nebulised adrenaline up to 5ml 1:1000
- Call ITU
- Write in notes
- Monitor O2 + HR
Ethics + Law : Paediatric refusal of treatment
- Find out why tx refused
- Find out if parents want tx or not
LAW (Gillick vs HA 1985)
- Children
Headache hx
SOCRATES
Aura? Visual/auditory/sensory/speech
Associated (N+V, photo/phonophobia)
Aggravating factors: light, routine activity, tiggers (chocolate, cheese, caffeine, alcohol, anxiety)
Red flags:
- Fever, neck stiffness, rash
- Fits
- Reduced consciousness
- Traumatic injury
- Travel abroad (malaria)
- Scalp tenderness (TA)
- Loss/change in vision
- Loss of power/sensation in limbs
Ddx:
- Stress/tension/cluster/migraine
- Chronic raised ICP
- Medication misuse
- Sinusitis/otitis media
- TIA
- Meningitis
- Encephalitis
- SAH/ head injury
- Glaucoma
- TA
OCP for 15 yr/old
Brief Sexual & Menstrual history: partner age, consensual, previous contraception, exchanging money. Possibility of current pregnancy?
PMH/SH:
- FH of breast/ovarian cancer/ clots
Gillick competence to fraser guidelines:
- Understands advice
- Cannot be persuaded to tell parents/allow doctors to
- Likely to continue having unprotected sex without
- Physical/mental health liekly to suffer unless receives contraceptive advice
Will you tell her parents:
- No law imposing duty on doctors to disclose information young person wants to keep confidential
EXCEPT in cases where child at risk of neglect/abuse - Children act 1989 - duty to disclose to child protection service.
Meningococcal sepsis medication dose?
Ceftriaxone IV 80mg/Kg
Psoriasis station:
1) What is psoriasis
2) Can it be cured?
3) treatments available
4) What happens if worsen/other tx?
1) Common, hereditary Inflammatory T cell mediated disorder characterised by thickening (hyperproliferation) of the top layer of skin (epidermis).
Results in itchy, scaly red plaques
Often one xtensor surfaces and scalp
- Non infectious
Triggers; stress, infection, trauma, drugs, Alcohol
Associated features:
- Nails: pitting, onycholysis
- Psoriatic arthropathy
2) Lifelong relapsing-remitting condition with no current cure, but can be managed very effectively
3) Tx:
1) Emolliants/bath oils/soap substitutes
2) Topical treatments:
- Vit D
- Coal Tar
- Dithranol
- Topical steroids
3) Phototherapy:
pUVA
UVB
4) Systemic:
- Retinoids
- Fumaric Acid
- Hydroxycarbamide
- Immunosuppressants:
- -> Methotrexate
- -> Ciclosporin
5) Biologics
- Anti-TNF Eg. Etanercept
- Anti IL-12/23
Paed wheeze Resp Hx:
SOCRATES eg. for Wheeze. Intermittant/constant Associated symptoms (cough, pyrexia, coryza, poor freeding, weight loss, rashes, sweating with feeds - Previous episodes
PMH:
- Atopy
- FH
Neonatal period
Developmental hx
Immunisation Hx
Wheeze Ddx:
- VIW/ Asthma
- Bronchiolitis (RSV/adenovirus)
- GORD/aspiration
- Chronic lung disease of prematurity
- CF
- Atypical pneumonia (mycoplasma)
- HF : Cardiac wheeze
Ritalin communication station;
What is it?
Why is it used?
What are the SE?
How will you monitor George?
1) Ritalin (methylphenidate) - stimulant that works as an indirect sympathomimetic to increase the release of DA and NA
- -> NOT a cure, only modifies behaviour
2) Benefits:
- Control difficult behaviours by increasing conc + attention and reducing impulsivity
- effective in 70% individuals
3) Like having too much coffee: Decreased appetite, anxiety, GI disturbance, insomnia, tics, hypertension, seizures, growth suppression
- -> Drug holidays required - long term use may lead to growth suppression
4) Investigations before treatment:
- Height, weight, blood pressure, LFTs
Regular monitoring by specialist:
- Height every 6 months
- Weight at 3 months, then every 6 months
- HR + BP every 3 months
–> med stopped if no response after 1/12
- Suspend med every 1-2 yrs to assess condition
Stopping drug:
- not addictive if correct dose taken
- Avoid abrupt withdrawal to prevent SE
Other treatments:
1) Cognitive behavioural therapy
2) Parent management training
3) family therapy
4) Educational intervention
LEAFLET
Child with UTI in GP
1) Clarify symptoms: dysuria, frequency, urgency, loin pain, haematuria, fever
2) PMH, DH, allergies, FHx
–> Ask risk factors for diabetes, pregnant, problems with water works as a child
Advice about how caught:
a) 20-40% of women will get during life
b) close proximity of anus and urethra
c) Urinary stasis
d) Sexual intercourse
Mx:
eg. Trimethoprim 200mg BD for 3 days
- Increase fluid intake
How to prevent: A) Urinate frequently - Double void b) increase fluid intake c) Void after intercourse d) Wipe from front to back
LEAFLET
Paediatric vomiting Hx
Vomit: Timing, freq, volume, contents, colour, odour, bile/blood, projectile? Hungry after?
Associated fever, cough, diarrhoea?
Signs of dehydration: Wet nappies, soiled nappies, dry tears, sunken eyes
Neonatal/developmental/immunisations
FH: Childhood vomiting?
DDx: Pyloric stenosis, GORD, Gastroenteritis, Intersusception, Overfeeding, Milk allergy, UTI
OSCE: High Cholesterol Councelling in GP
Set Agenda
What do they know
2 types: HDL (Good) & LDL (Bad)
Risks: Heart disease, Brain (stroke) & Kidney
Pt risk factors:
- FH
- PMH: HTN/Diabetes?
- Smoking/alcohol
- Diet & Exercise
- Current Wt
Secondary causes of hypercholestrolaemia:
- Alcohol
- Nephritic syndrome
- Hypoth
General hx: Pmh, FH, SH
Mx:
- Diet/ Lifestyle
1) Exercise/lose weight
2) Reduce animal fats (Sat) and increase plant (unsat) - -> try little things first eg. margarine –> butter
- add salad
- Reduce fried food content (Baked instead)
3) Medical; - Statins - protects vessels & lowers cholesterol
- Only when absolute QRISK >20% in 10yrs
F/U in 1 mo, monitor HDL/LDL, Leaflet
OSCE: Woman at GP with UTI, explain Diagnosis & Mx to her
Quick history: Dysuria, frequency, urgency, loin pain, haematuria, fever
Find out what she knows
Explain UTI + how you get (common, anus, stasis, sex)
Check Risk factors: diabetes, pregnancy, problems with waterworks as a child
Explain Mx (check allergies/previous tries) - Trimethoprim 200mg BD for 3 days - Ask about pill
Tips on prevention
- Drink lots
- double void
- Wipe front to back
- Urinate after sex
Pt.co.uk Leaflet
OSCE: Smoking cessation at GP
Current smoking habits
Why quit?
- -> Motivation
- -> Confidence
What have you tried before
What worked/didn’t work
Suggestions? - Cold turkey vs nicotine replacement: - Patch Gum Inhalator Nasal spray
Meds:
Buproprion
- Antidepressant - stops enjoyment of cigarettes
SE: GI, Taste change, dry mouth, insomnia, tremors
CI
GP OSCE: parent wants Abx for childs sore throat
Agenda
ICE
History:
- Exudates
- Cough
- Temperature
- Lymphadenopathy
- Watery eyes
- Runny nose
Mx; If centor less than 3, no abx
Most likely viral - we don’t have drugs that can kill viruses like abx
Don’t want to give you abx just in case:
- may upset stomach
- interact with other drugs
- Make our natural body bugs resistance
Self-care recommendations
- Analgesia - ibuprofen/Paracetamol + Difflam gargle (Local anesthetic/NSAID)
- Fluids + rest + salt gargle
- Don’t whisper
SAFETY NET:
- sx not better in 1/52, come back
- if fever worsens >38.5, neck swelling making it hard to swallow liquids or breathe, call us urgently
Alcohol dependence Hx?
Set Agenda
Hx: How much, when, who, where etc
CAGE if screening
WITHDRLLL if dependence: Withdrawal sx/ Relieved by drinking more Interest (most important thing) Tolerance (increased) Harms (aware of harms? Difficulty controlling at one drink Reduction Lost memory? Love life? Labour? Ever affected Job Law? Problems with popo?
Depression screen
- Mood
- Anhedonia
- Fatigue
- Self-harm/suicide
PMH: Peptic ulcer, pancreatitis, HTN, Liver disease
DH
FH: relatives that drink
SH: How do you afford?
Insight:
- Do you feel you need help?
- Would you accept if offered?
Falls Hx?
HPC
- Before: Did you stand (PH), any neck movements (carotid sinus hypersensitivity), emotional news (vasovagal), any coughing or straining?
- During: did you hit head, any pain, any LOC? Did anyone else see (Collateral?), Any Sx (palpitations, dizziness, curtain across, Epilepsy sx: Tongue biting, jerks , incontinence
- After: How did you feel, any residual tiredness/weakness / any change in speech
Ever happened before
PMH: Cardiac/Neurp
DH: Antipsychotics, TCAs, Anti-HTN (PH)
Any recent change in meds?
Paeds OSCE: Starting a 15y/o on Oral contraeptive; Fraser guidelines
Why? How long, who with, any contraceptives so far Pressured/exchanged money etc Any chance pregnant? Any STI screen?
What do you know about contraception Would you consider LARC Personal history - menstrual history - PMH + FH (Breast/cervical cancer), migraines, stroke, BP, height, weight BMI - DH - SH
Explain OCP
- What
- Missed pill rule
- advantages and disadvantages
Would you tell parents?
Would you allow me to tell your parents
If I didn’t , would you continue having sex anyway?
Assess if mental/physical health would suffer if I didn’t prescribe the pill?
Paeds OSCE: starting a child on Ritalin
What do they know?
What is it: Stimulant. Not cure, only adjuts behaviour
How it works: Increases conc + attention spam. Decreases impulsivity
Side effects: Like too much coffee: Decreased appetite, anxiety, insomnia, tics, High BP, seizures, growth suppression
What they’ll check before it starts: Height, Weight, BP, LFT
Monitoring during: check up to every 3 months + drug holiday discussion with doctor - to prevent long term side effects like growth suppression.
How long they’ll be on it for
- no response after 1mo - stop GRADUALLY
- Drug not addictive as long as correct doses taken
ALTERNATIVES:
- CBT
- Parent mx training
- Family therapy
- Educational interventions
OSCE: Pt comes in requesting Methadone
‘before I can agree to prescribe anything, I need to get a full understanding of how you’re getting on, and order some investigations like a urine sample’
HPC of drug type & Use
Dependence: Cravings, Withdrawal symptoms, Tolerance
Effect on Life: Lost memory, Love, Labour, Law
RISK ASSESS
Insight: What’s good, what’s bad, concerned? Cut down?
PMH: Any contact with mental health services or counselling?
DH/SH/ICE
OSCE: Suicide Risk?
’ I understand that if you’ve just tried to end your life. Many people find this extremely difficult to talk about, but it’s important for me to try understand a bit more about it so we can help you. Is that okay?
Before the attempt:
- Specific trigger? General Mood?
- Planning: Did you plan for this to happen? Did you get tablets beforehand?
- Seeking help: tell anyone
- Precautions - To not be found?
- Final acts: Will or a note?
The Attempt: - How, when, where and why? - Did you think it would kill you? - Under the influence? Discovery - how found?
After:
- How do you feel now? Angry? Resentful?
- Do you still want to end your life?
- How do you see the future?
PMH: previous attempts/SH
- Psych history
DH/FH
SH: Who’s at home, any relationships, children? Working? Stressful Job? Alcohol + smoking + drugs?
INSIGHT: do you feel you need help? Would you accept help if offered?
