From StudyingMed

< OSCE
Jump to: navigation, search

Young kids

  • Very busy
  • Short attention span
  • Very impressionable
  • See the world differently
  • Talking with them is different to talking with adults
    • Less vocabulary
    • Use the words of the language they speak
  • How can you encourage children to follow instructions?
    • Make things fun
    • Integrating toys
    • Turn it into a game
    • Sound enthusiastic
    • Ask them about themselves/show an interest in them/talk about things they like doing
    • Get down on their level, don't point, body language
  • How kids change in development
    • Hard to tell what's normal
  • When do children present?
    • Illness
    • Check ups
    • Immunisation
    • Usually an adult doesn't want to present even if they are sick, but a child will come even if not sick (conscientious parents)

Paediatric history

  • Paediatric history starts at pregnancy
  • Was the pregnancy normal? Complications?
  • Birth
    1. mode of delivery?
      • Caesarean
      • Vaginal (normal)
      • Vaginal (instrumentation)
    2. preterm or term?
      • Low birth weight?
      • Respiratory infections?
      • Cried well after birth?
        • APGAR (immediately after birth, before giving to the mother)
        • Weight at birth (growth parameters on centile charts)
        • Height at birth ("")
        • Head circumference (""). Important because it's one of the fastest growing organs in the first year (good measurement of growth rate -- measured for whole first year)
        • Normal range: 5th-95th centile. The charts are separate for different ethnic groups
  • Check immunisation history (usually complete within first 2 years)
  • Developmental milestones
    • Language (newborn - crying to communicate, babbling (3 months), monosyllables (8 months)); understanding
    • Gross motor (lie flat on floor- lift head up, sit with support (3 months))
    • Fine motor (palmar grip comes before pincer grip (at 12 months, for pens))
    • Social (attachment, eye contact, 2nd months starts focussing on things within a foot, recognises mothers' face, starts giving a social smile when they recognise faces, sharing (4-5 years))
    • Cognitive

Sequential development - one thing has to precede the other. Development is an ongoing process, unlike height and other physical parameters.

  • Assess much of this by playing with the baby and observing
  • Listen to the mother - if the parents are concerned, then there is good evidence to suggest that if the mother says there's something wrong then there is (over 85% of the time)
  • If the developmental delay is detected early then we try to intervene to give the child a good quality of life because:
    • If the child can't hear, then speech is affected, then learning is affected, then personality is affected

APGAR scores

Apgar tests are measured at 1 and 5 minutes after birth; 7-10 is normal, 4-7 may require resuscitation, <3 require immediate resuscitation. Indicators and scores:

0 1 2
Activity (muscle tone - on flicking heel) Limp, no movement Some flexion Active motion
Pulse (heart rate) No heart heate <100bpm At least 100bpm
Grimace (reflex response) No response Grimace during suctioning Grimace and pull away, cough, or sneeze during suctioning
Appearance (colour) Bluish-gray or pale Good color, bluish extremities Good colour all over
Respiration (breathing) Not breathing Weak cry Good strong cry

Baby is assessed at 1 minute and 5 minutes after birth. Improvement of the scores indicates the baby is recovering. APGAR scores are usually mentioned in the blue book.

Preparation for a three-way interview

  • Dynamic depends on the age
  • UNSW TV: see BGDB Dynamics of a Peadiatric Consultation
  • Adolescent: may ask the parent to leave for part of it
  • Child: may need parent there the whole time
  • If you're getting contradictory information from the two people then you need to ask the parent to leave, ask individually
  • Encourage with toys, body language, explanation, being open

Video

  • Start off with very open questions
  • Mother worried about toddler who has gone from independent to being very clingy
  • "Lovely birth" -- ??? x_x"
  • Baby was indpendent and fun
  • 12 month immunisation, since which toddler has been notthe same
  • Give the baby a pen to play with
  • Doesn't want to be with anyone but the mother
  • Toys to distract crying baby
  • Active, inquisitive, interested in things
  • Asked about feeding
  • Allergies, medication
  • Nothing in the family
  • Up to date with immunisations
  • Concern amounted to nothing (normal developmental stage)
  • Development seems normal
  • Auscultates from down on the ground
  • Sit at level of child
  • Always have distractions
  • Vision, eye movement, grip with the toys
  • Offer pen to child, see if it grabs it
  • 1.5 year old baby - if it's sitting quietly, be concerned (should be fidgety and active)
  • Does a general exam: knees, hips, legs, musculature, quadriceps tendon reflex, examines abdomen, looks in ears (show baby you looking in mummy's ears and doctor's ears as well), similarly for looking in mouth as well
  • Don't ignore the child - talk to the child as well, so the child gets interested in the doctor, then can assess the child (better rapport)

Focus changes according to the age of the patient

  • Allow interruptions to occur, can't speak over the child, need to let the mum attend to the child
  • Flexible in history taking and examination
  • Continue history taking during examination (e.g. constipation, nappy-wetting etc)
  • Reassure the mum - about development, acknowledge that she's doing a good job acknowledge that she's doing the right things, observe interaction between mum and child
  • ENT exam is tough in children

ENT exam

  • In paeds, otitis media is common (Eustachian tube anatomy - small and horizontal; bad drainage)
  • We examine only adults (practice many times to see normal tympanic membrane)
  • Otoscope/auroscope used to look down the EAM, with a speculum in front of the viewing lens
  • Inspection: 1) redness 2) inflammation 3) deformities/tags from development 4) boyles 5) scars (behind the auricle) 6) gently tug the pinna to detect pain (even boyle is very painful because there is no tissue between cartilage and skin) 7) pressure on the mastoid - if it causes pain then it's likely to cause pain 8) preauricular sinus (anterior and inferior to auricle/helix). If infected, it gets painful
  • First ask if there has ever been an ear infection before (on either side), ask if there was recently cough or cold, or ear pain (confirm before examination; examination with speculum in EAM could be very painful in this case)
  • See if the otoscope is functioning properly (need a very bright light). Given a choice, select the widest speculum. The grip of the otoscope - use the right hand for right ear, left hand for left ear. Use a pencil grip (between thumb and index finger). Rest the little finger on the patient's cheek (very important in examining children - reflexly move their head). Tell adults not to move head, prevent injury. Tell them to tell you if any pain
  • EAM is not straight - pull pinna upwards, backwards and outwards.
  • While proceeding in, try to visualise the walls of the EAM, swelling, boyle, visualise the tympanic membrane (an oval, fairly stretched membrane, able to see cone of light anteriorly and inferiorly and a whitish line from the tip of the cone indicating the malleus handle). Check if there is perforation (if whole membrane is intact). Membrane is not flat, but slightly angled. Sometimes earwax is a hindrance. Check for discharge (may be purulent). Check for bulging of tympanic membrane.
  • Dispose of the speculum after use
  • Use left hand in the same way on the other side. (A COMMON MISTAKE - it is very clumsy to put the scope in this way).
  • Always examine the noraml ear first, then the abnormal ear.
    • If you somehow examine the infected ear first, dispose of the speculum
  • Now examine the throat (no nasal examination this time; would look for injury, bleeding, swelling of turbinates, see if septum is deviated, by lifting tip of nose)
  • Look for tonsils, posterior pharyngeal wall, whole of oral cavity. Caries, gingivitis (bleeding gums, pus), postnasal drip, ulcers (acteus ? - normally when you have indigestion etc; non-healing, precursors to malignancies), white spots (leukoplakia on the buccal mucosa (mucous membrane of cheek), check tongue, lips, soft palate, hard palate, floor of the mouth (roll up tongue; openings of the submandibular glands on either side of the frenulum; calculus in duct would show up as swelling of ducts).
  • Pain in the ear and there is no pathology on examination, then look in nose and throat (nerve supply of ear and oral cavity/pharynx/nose is the same).
  • ENT examination comes along with examination of cervical lymph nodes.
  • Also, if patient comes with swelling in the neck or lymph node enlargement, do ENT examination
  • In the throat, may use a tongue depressor to visualise the posterior pharyngeal wall and the tonsils. Sometimes you don't need it. Use dominant hand to hold the tongue depressor. Don't make them gag (do it on the anterior of the tongue, and don't touch the soft palate). Some patients feel ill even at the sight of the tongue depressor.
  • Ask the patient to open their mouth wide and say "ahh".
  • Examine buccal mucosa, lips, tongue, turn it to one side, put it up (borders of the tongue where malignant ulcers originate)
    • Protrusion of tongue = hypoglossal nerve CNXII
    • Saying ahh elevates the soft palate = testing CNX (motor part of this nerve supplies soft palate). Also shows us clearly the palatine tonsils (between the two sets of folds) and the posterior pharyngeal wall, usually inflamed in throat infections
  • Temperature examination - stick thermometers
  • Put on disposable cover
  • Start it, then put it in ear, it beeps then put a display on screen (takes 5-10 seconds)
  • temperature in the ear picked up by IR sensor is closest to core temperature; tympanic membrane is supplied by the same artery that supplies the brain; we want optimal functioning of the core organs -- ear gives a good measurement of core temperature)
  • Other sites: oral, axillary, rectal. Rectal used more commonly in babies (not in adults)
  • There is always a range and temperatures differ at different sites
  • Temperature depends on basal metabolic rate (lower in morning, higher later)
  • Age: older people show lower temperatures and their thermoregulation isn't very good
  • Male or female variation. In females, temperature rises during ovulation
  • Multifactorial determinants of temperature, given as a range: 35.6 to 37.9 degrees
  • Range varies depending on different sites
  • Every student will have a question on TEMPERATURE and BLOOD PRESSURE in the OSCE.
  • After every use, dispose of the speculum cover.

Communications

6 things common across all societies w.r.t. child-rearing

  • Obedience training - taught to obey adults/authority (did you always do what your parents wanted; did you always tell your parents if there was something you did they wouldn't approve of). Counting technique works well. Different families have different values (acceptable vs unacceptable behaviour).
  • Responsibility training - look after yourself and stuff
  • Nurturance training - looking after siblings/animals/family members etc
  • Achievement
  • Self-reliance
  • General independence

There are differences in parenting styles between different people

Some families have ridiculously different values - so long as the child isn't abused, let them call their own shots.