Paediatric Notes

Question 1

Important points to consider when taking paediatric history?

Answer 1

• 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

Question 2

Respiratory symptoms key to ask in paediatric history?

Answer 2

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

Question 3

Cardiology symptoms key to ask in paediatric history?

Answer 3

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

Question 4

GI symptoms key to ask in paediatric history?

Answer 4

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

Question 5

Urological symptoms key to ask in paediatric history?

Answer 5

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

Question 6

Neurological symptoms key to ask in paediatric history?

Answer 6

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

Question 7

Thyroid symptoms key to ask in paediatric history?

Answer 7

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

Question 8

MSK symptoms key to ask in paediatric history?

Answer 8

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

Question 9

CAGE screening? Alcohol symptoms key to ask in paediatric history? Signs of dependence?

Answer 9

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?

Question 10

Depression symptoms key to ask in paediatric history?

Answer 10

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?

Question 11

Suicide risk symptoms key to ask in paediatric history?

Answer 11

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?

Question 12

What to ask after HPC in paediatric history?

Answer 12

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?

Question 13

PMH in paediatric history?

Answer 13

• Ever had anything like this before?
• Anything you see your GP about regularly?
• Any previous surgery?
• Any recent hospital admissions?
• Any mental health issues?

Question 14

BINDS in paediatric history?

Answer 14

• 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?

Question 15

DH in paediatric history?

Answer 15

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?

Question 16

FH in paediatric history?

Answer 16

Any problems in the family?
Have you had any recent contact with unwell people?
Parents in good health?

Question 17

What is a HEADSS social assessment?

Answer 17

Home
Education
Activities
Drugs
Sexuality
Suicide

Question 18

Questions to ask for home situation?

Answer 18

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

Question 19

Questions to ask for education situation?

Answer 19

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?

Question 20

Questions to ask for activities situation?

Answer 20

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?

Question 21

Questions to ask for drugs situation?

Answer 21

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?

Question 22

Questions to ask for sexuality situation?

Answer 22

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

Question 23

Questions to ask for suicide situation?

Answer 23

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

Question 24

Other SH questions to ask in paediatric history?

Answer 24

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

Question 25

Systems enquiry - CV?

Answer 25

- Cardiovascular – Chest pain / Palpitations/ Dyspnoea / Syncope/ Orthopnoea / Peripheral oedema

Question 26

Systems enquiry - Resp?

Answer 26

- Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

Question 27

Systems enquiry - GI?

Answer 27

- GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit

Question 28

Systems enquiry - Urinary?

Answer 28

- Urinary – Volume of urine passed / Frequency / Dysuria/ Urgency / Incontinence

Question 29

Systems enquiry - CNS?

Answer 29

- CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Question 30

Systems enquiry - MSK?

Answer 30

- Musculoskeletal – Bone and joint pain / Muscular pain

Question 31

Systems enquiry - Dermatology?

Answer 31

- Dermatology – Rashes / Skin breaks / Ulcers / Skin lesions

Question 32

End pieces of a history?

Answer 32

Summarise – anything I have missed? Differential Diagnosis Investigations – imaging, bloods, exams

Question 33

Health promotion - reasons for?

Answer 33

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

Question 34

Health promotion - smoking?

Answer 34

 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

Question 35

Health promotion - alcohol/drugs?

Answer 35

 Alcohol consumption should be kept to a minimum, with avoidance of binge drinking and there is much to commend complete abstention

Question 36

Health promotion - nutrition?

Answer 36

 Breast-feeding encouraged  Healthy diet • Not too much sugar and salt, avoid food colouring

Question 37

Health promotion - exercise?

Answer 37

 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

Question 38

Health promotion - Dental health?

Answer 38

 As soon as teeth erupt, brush twice a day with smear of toothpaste

Question 39

Health promotion - Sexual health?

Answer 39

 Use contraception for every sexual act |  Best way to prevent STI transmission is through condom usage

Question 40

Definition of growth?

Answer 40

o Defined as increase in height & weight | o Not linear

Question 41

Average birth weight (how to calculate from age), head circumference, height, teeth??

Answer 41

 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)

Question 42

Normal nutritional requirement of child?

Answer 42

o Normal requirement – 150mls/kg/day after first week until weaning

Question 43

Best form of nutrition in child?

Answer 43

o WHO say breast milk is best form of nutrition

Question 44

Recommended daily calorie intake for child aged 0-1 and 1+?

Answer 44

 0-1 year – 110kcal/kg/d  1+ years – 1000 + (100xage) kcal/d  150ml milk contains 110kcal

Question 45

What special milks are available for babies suffering from GORD, faltering growth and cow's milk protein intolerance?

Answer 45

 GORD – Enfamil AR  Faltering Growth – Infatrini  Cow’s milk protein intolerance – Nutramigen

Question 46

Number of daily feeds for child aged 0-6w, 6w-4m, 4-6m, 6-9m??

Answer 46

6-8 5 4-5 3-4

Question 47

Feed volume for 0-6w, 6w-4m, 4-6m, 6-9m??

Answer 47

60-120mls 150-180mls 180-200mls 200mls

Question 48

Feed volume for 0-6w, 6w-4m, 4-6m, 6-9m??

Answer 48

60-120mls 150-180mls 180-200mls 200mls

Question 49

When to wean a child?

Answer 49

 From 6 months, carry on with breast milk feeds initially |  Puree to 7 months

Question 50

When should iron containing food be introduced?

Answer 50

 Iron containing foods at 6 months

Question 51

What to avoid until 6 months?

Answer 51

 Avoid egg, wheat until 6 months

Question 52

When can they have doorstep milk and normal food? Full fat milk?

Answer 52

 Doorstep milk and normal food at 12 months |  Full fat milk until 5 years (avoid semi skimmed/skimmed)

Question 53

When is it appropriate to give vitamin supplements to children? Examples?

Answer 53

 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

Question 54

Estimating mild fluid deficit? % deficit?

Answer 54

• Mild (5%) | o Dry mucous membranes, skin turgor, decreased urine output

Question 55

Estimating moderate fluid deficit? % deficit?

Answer 55

• Moderate (10%) | o Decreased skin turgor, oliguric, high pulse, >CRT, lethargy

Question 56

Estimating severe fluid deficit? % deficit?

Answer 56

• Severe (15%) | o Shock, anuric, hypotension

Question 57

Formula for calculating fluid deficit fluids? What fluid to give the child?

Answer 57

* % dehydration x weight(kg) x 10 * Give as 0.45% saline over 48h * Add K+ (20mmol/500ml) once child passed urine

Question 58

What maintenance fluids are given to children?

Answer 58

(0.9% saline with 5% dextrose with 10mmol KCL)

Question 59

What is the formula for calculating maintenance fluids in children?

Answer 59

 1st 10kg 100mls/kg/day  2nd 10kg 50mls/kg/day  3rd & subsequent kg 20mls/kg/day

Question 60

What is the fluid requirements in neonates Day 1-4?

Answer 60

Day 1 - 60ml/kg/day Day 2 - 90ml/kg/day Day 3 - 120ml/kg/day Day 4 - 150ml/kg/day

Question 61

What is the sodium and potassium requirements of neonates per day?

Answer 61

Sodium - 3mmol/kg/day | Potassium - 2mmol/kg/day

Question 62

What is the fluid type and formula for resuscitation?

Answer 62

 0.9% saline – 20mls/kg

Question 63

What is defined as overweight and obesity in paediatrics?

Answer 63

 Overweight - >85th centile |  Obese – 91-98th centile

Question 64

What are the normal visual acuities at birth, 1 month, 6 months, 3-5 years?

Answer 64

o Birth 6/180 o 1 month 6/90 o 6 months 6/30 o 3-5 years 6/6

Question 65

What screening programmes exist for children?

Answer 65

``` 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 ```

Question 66

Define premature and post-mature?

Answer 66

o Premature <37 weeks, post-mature >42 weeks

Question 67

When do neonates usually pass urine and stool?

Answer 67

o 95% micturate within 24h, pass meconium within 48h

Question 68

What percentage weight loss is abnormal in neonate?

Answer 68

o 10% weight loss is abnormal

Question 69

Average sleep times for neonate, 6 months, 4 years, 18 years?

Answer 69

o Birth 16h/day o 6 months 14h/day o 4 years 12h/day o 18 years 8h/day

Question 70

What is child protection?

Answer 70

- Safeguarding is protection and prevention of maltreatment which could impair health and development by ensuring safe circumstances to grow up in

Question 71

How to investigate and detect child protection issues?

Answer 71

o Types of injury o Context, examination o Investigations (skeletal survey, CT head, ophthalmology) o Risk Factors

Question 72

What physical things should you look out for which may present child protection issues?

Answer 72

 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

Question 73

What emotional things should you look out for which may present child protection issues?

Answer 73

 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

Question 74

What neglect may present child protection issues?

Answer 74

 Failure to provide for the development of the child in all spheres

Question 75

What are sexual issues which may present child protection issues?

Answer 75

 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

Question 76

What are exploitation issues which may present child protection issues?

Answer 76

 Commercial or other exploitation of a child refers to use of the child in work or other activities for the benefit of others

Question 77

Management of child protection issues?

Answer 77

o Always discuss and document, refer and pass on if needed

Question 78

What features in S of SBARR?

Answer 78

``` 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 ```

Question 79

What features in B of SBARR?

Answer 79

```  Admission reason  Date  Patients relevant PMH and SH  Investigation results  Interventions ```

Question 80

What features in A of SBARR?

Answer 80

 Vital Signs  Clinical examination findings  Overall clinical impression

Question 81

What features in R of SBARR?

Answer 81

 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

Question 82

What features in R of SBARR?

Answer 82

 Check understanding and clarify any questions  Document discussion in the notes  Thank person

Question 83

What charts are available for paediatrics early warning scores?

Answer 83

PAWS score Usually age appropriate charts available 16+ is NEWS chart See front for management of PAWS score

Question 84

What screening is done on a newborn?

Answer 84

``` NIPE Hearing screening - within 4-5 weeks (usually before discharge) Guthrie Test (heel prick at day 5) ```

Question 85

What does the Guthrie test test for?

Answer 85

``` 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 ```

Question 86

When is the Guthrie test offered? Is it mandatory?

Answer 86

``` Day 5 (5-8) Patient can decline ```

Question 87

What are the parameters of APGAR score? Scores indicate?

Answer 87

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)