In this block there are several online cases for you to work through. The cases are all allocated to a specific week of the block and this is the order in which you should work through them. Remember, the online case work is required preparation for your weekly Theme Case Discussion (Clinical Reasoning) session.
Child H-Y5-2023- Block 1 -2023 – Timetables
ILOs, Therapeutics and Topic Lists
· Therapeutics List- week 1-2023
Week 1 cases Grouped Learning outcomes
· Therapeutic list-week 2-2023
· Therapeutic list-week 3-2023
· Therapeutic list-week 4- 2023
Announcements:
· This pre-placement material introduces the Paediatric learning for your placement.
· The material will help you learn and revise material relevant to paediatrics which you will need within the clinical module and as you work through the associated online cases.
· Guidance and Resources – Children’s Health Pre-placement - MED 35
· Introduction – Children’s Health Pre-placement - MED 35
· Further Material – Children’s Health Pre-placement - MED 35
· Background Science – Children’s Health Pre-placement - MED 35
·
In case Children’s Health – Pre-placement
This pre-placement material introduces the Paediatric learning for your placement.
The material will help you learn and revise material relevant to paediatrics which you will need within the clinical module and as you work through the associated online cases.
Each week you will be presented with fictional cases focussing on key presenting features within Paediatrics, differential diagnoses and initial management steps allied to the Learning objectives for the Paediatric Module.
The four-week module is divided into themes; with broad differential diagnoses explored each week. The breadth of the module means that 3 or 4 groups of symptoms are discussed each week, reflecting the common presenting symptoms encountered within your clinical module. Continuous themes each week introduce communication skills, ethics and law and prescribing which are embedded within the cases. There will be web-links and other references to support your learning in each of the packages.
You are expected to complete the online material prior to attending the Themed Case Discussion as you will be expected to apply this learning during the teaching session.
Paediatric Early Warning Score (PEWS) Chart
Another example of Pediatric Early Warning Score
Updated Vaccination Schedule -KSA
Textbooks:
1. Nelson Essentials of Pediatrics, 6th or 7th Edition; Editors:Karen Marcdante and Robert M. Kliegman (ISBN-13: 978-1437706437 and ISBN-13:978-1455759804)
2. Illustrated Textbook of Paediatrics, 4th edition; Editors: Tom Lissauer and Graham Clayden (ISBN: 978-0723435662)
Electronic resources:
http://www.medscape.com/pediatricstrics
https://pediatriceducation.org/pediatric-differential-diagnoses/
Introduction – Children’s Health Pre-placement – MED 35
In case Children’s Health – Pre-placement
Children make up 50-60% of the Saudi Arabia population. Studies have shown that although not all Medical Graduates will become Pediatricians approximately 70% of graduates will be assessing and caring for children in their daily clinical practice (with almost 100% of graduates regularly looking after vulnerable young adults). It is therefore essential that all students receive robust training in the clinical assessment of infants and children.
One of the challenges in children is that they come in all different sizes from your premature baby, no bigger than your hand, to an adult size teenager. They also have different diseases and disorders, symptoms, signs and skills required in different age-groups.
To be able to help with this, paediatric patients are divided into five groups
Neonate – birth to 1 month
· Infant – 1 month to 2 years
· Young Child – 2 -6 years
· Child – 6-12 years
· Adolescent – 12-18 years
By now you will be familiar with the structured approach in taking a history and examination in an adult
The assessment and treatment of children has important differences to that in adult practice. A great deal of information from the history may be gained from a child even as young as 2-3 years with the support of their parent or carer, examination skills and clinical signs may be different and special consideration is required regarding drug and fluid treatment, and the ethical and legal responsibilities of parents, carers and medical professionals.
Why is the use of closed questions problematic in childhood?
Children will often say yes to closed questions in order to please the questioner.
For example:
"Have you got a tummy ache?" > "Yes"
Versus
"Where does it hurt / does it hurt anywhere?" > Child points to hip.
Why is taking a history only from a parent/carer problematic?
For example: "He is in pain" reported by a carer: this is more likely to be an interpretation of the behaviours associated with symptoms, and specific information about the nature, site, radiation of the pain will therefore be missed if a history is not obtained from the child. In addition the carer may have their own agenda or preconceived ideas, influencing their reporting of symptoms.
Immunisation
One of the areas this block will touch on is immunisation.
The schedule will be covered in your GP placement but it is really important you are aware of it in the context of disease and this will be discussed throughout the cases in the next four weeks.
· The Saudi routine immunization schedule
A fully immunised baby presents at 5 months with a diahorreal illness. Which of the following is NOT likely to be a cause?
· Adenovirus
· Norovirus
· Rotavirus
· Salmonella
· Shigella
Rotavirus
The child should have received all of their vacinations for rotavirus at 8 and 12 weeks.
Developmental Progress
Progress in development is also unique to paediatric patients and needs to be explored both in the history and the examination. Normal development of the infant and child will be covered in your GP placement ,it is, however essential that you are familiar with the normal sequences within this placement to be able identify delayed /regressed development.
Have a look at the clips of a 2 month old, 8 month old, 18 month old and 3 year old in the following link and then view the table below:
“Gross Motor Milestones”
Gross Motor Milestones in the first 12 months
Key Gross motor development Milestones up to school age
Examination
Children will often initially be unwilling to cooperate with examination. Communication with the child during history taking and a flexible approach can assist this. Although similarities exist there are important differences in the way in which we approach the examination in a child. The following video clip will help demonstrate some of these:
Paediatric Early Warning Score (PEWS)
To be able to examine a paediatric patient and interpret the findings it is essential to know what is normal. Unlike in adults, even a simple value such as a Heart Rate changes throughout the different age groups.
Normal ranges and values at which there would be concern regarding the child’s wellbeing are expressed in a Paediatric Early Warning Score (PEWS).
Below is the Chart used in Children’s Hospitals. The normal values found for each observation are recorded in column 0 under the appropriate age of the child:
Paediatric Early Warning Score (PEWS) Chart
Using the PEWS chart, which of the following sets of observations is normal for a 6 month old baby?
· Systolic BP 60, HR 148, RR 30
· RR 26, HR 102, Systolic BP 68
· O2 requirement 95% in air, HR 110, Cap refill 3 seconds
· Cap refill 2 seconds, BP 70, O2 requirement 95% and over in air
· Conscious level - alert, HR 98, RR 29
Cap refill 2 seconds, BP 70, O2 requirement 95% and over in air
Growth Charts
Growth charts are a very important way of assessing a child’s growth and therefore wellbeing. In the cases following over the next few weeks you will be asked to plot the child’s measurements on an appropriate growth chart and comment on your findings
Please see the video below regarding how to plot the results correctly:
Plot the following results for an 8 month old baby boy born at 36 weeks gestation.
Weight – 8.6kg
height – 69cm
Head circumference – 44 cm
Plot an 8 month old baby boy's weight of 8.6kg on the growth chart below by clicking on the relevant area
Reuse
Embed
Plot an 8 month old baby boy's height of 69cm on the growth chart below by clicking on the relevant area
Plot an 8 month old baby boy's head circumference of 44cm on the growth chart below by clicking on the relevant area.
If you found this difficult please re-watch the video and reattempt as it is a very important skill.
During your clinical placement, plot the growth of the children you see and practice interpretation and explanation of these findings.
CASE COMPONENT
Further Material – Children’s Health Pre-placement – MED 35
In case Children’s Health – Pre-placement
Special issues in Pediatrics
Neonatal Examination
One special areas in pediatrics in neonatology (defined as the subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is mostly a hospital-based specialty, and is usually practiced in neonatal intensive care units (NICUs)).
Examining newborns is an essential skill that you are requested to train for during the pediatrics rotation. Below is a starter video that describe some aspects of neonatal examination.
An essential part of neonatal examination is eliciting and judging Primitive (neonatal) reflexes. The following videos explains the idea of neonatal reflexes as well as the some of them.
Some of the most important reflexes are:
1. Grasp
2. Suck and Rooting
3. Moro
Basic Life Support in Children
It is vital that you know how to perform basic life support. This is a skill that everyone should have to saves lives both in hospital and at home. In children it has been shown that early and effective CPR really does save lives!
Please take a look at this learning package created by the Central Manchester Foundation Trust’s Education Department:
What is the ratio of heart compressions to breaths?
· 15 breaths to 2 compressions
· 30 compressions to 2 breaths
· 30 compressions to no breaths
· 15 compressions to 5 breaths
· 15 compressions to 2 breaths
15 compressions to 2 breaths
If you are ever in a situation where CPR is needed and you cannot remember the ratio this is the one question where any answer from the above list would be correct rather than doing nothing!
Why is the resuscitation schedule in children different to that in adults?
The cause of a cardiorespiratory arrest in a child is much more likely to be respiratory (more likely to be cardiac in an adult), therefore the use of rescue breaths and the different ratio, reversing hypoxia may address a reversible cause of arrest.
Background Science – Children’s Health Pre-placement – MED 35
In case Children’s Health – Pre-placement
Pediatrics ER (How to spot a sick child)
Recognition of an unwell child is often challenging as the initial presentation can be subtle and symptoms vague. In addition, children in general have intact physiological compensatory mechanisms making changes in observations and physical signs occur later. Tools are available however to identify children with early signs of serious illness.
Below is a short video to help you recognise the seriously unwell infant:
The paediatric early warning score (PEWS) can be very useful in picking up the subtle signs, for example a degree of increase in respiratory rate.
Within the online cases for this block you will be asked to plot examination results on a PEWS chart, score and interpret the findings.
Why is it important to identify signs of illness in a child early?
Due to physiological compensation in each system, children may not have cyanosis or a low blood pressure even with serious disease in the respiratory or cardiovascular system respectively; these represent a failure of this compensation, and represent a likely rapid deterioration. Identifying and intervening when changes preceding these occur; may prevent failure of compensation and this deterioration.