19/10/17

RACHEL ANTONIA ALBERT

Clinical Stations

1) History taking
Demographics - AGE, name, sex. Presenting Complaint
History of presenting complaint- previously well, known medical illness
Review of systems
Past Medical History
Drug History
Birth History
Development
Immunization
Nutritional status
Family History
Social History
Summary.

For every child ask- cold + cough, vomiting + diarrhea, pain, difficulty feeding/sleeping,
rash, fever, sick contacts, passing urine

Fever
Most common differentials: viral illness (dengue), URTI, otitis media, tonsillitis,
pneumonia, meningitis, UTI, gastroenteritis

HPc:
Characteristics - onset, temperature (was the temperature measured?) , intermittent
Associated symptoms - sweating, chills, seizures, rigors
Aggravating factors - nil
Alleviating factors - tepid sponging, fan therapy, panadol.
Evolution - better or worse since it started
Of interest:
Rash/headache/neck stiffness/drowsiness/irritability - meningitis
Sick contacts/runny nose - URTI
Recent travel
Abdominal pain - surgical cause
Diarrhoea/Vomiting - gastroenteritis
Diarrhoea and vomiting
Most common differential: gastroenteritis

HPc:
Diarrhoea - how many episodes? Blood or mucus?
Vomiting - how many episodes? When was the last episode? Content? Able to tolerate
now? Bile/blood/mucus?

Of interest:
Passing urine like normal?
Change in diet
Recent travel
Fever
Abdominal pain
Anorexia

Respiratory (asthma)
Wheeze: Bronchiolitis, Viral episodic wheeze, Asthma
Stridor: Croup, Epiglottitis, Bacterial tracheitis, inhaled foreign body.

Of importance in an asthma history:

Nocturnal cough
Exercise intolerance

Of interest:
Family history of atopy
How often do symptoms occur?
Any A&E visits or time of similar wheeze at home? What was done?
Ever given any medications by A&E physicians?

Febrile seizures vs epilepsy vs meningitis

 Febrile seizures:
6mo - 6yrs
Simple vs complex: Ask parent to describe what they saw (generalized vs focal),
duration ( more or less than 15mins. Do not confuse post-ictal phase as actual seizure occurring),
frequency within the past 24hrs.

HPc:
As for fever. Aim to find the source of the fever.
If given Panadol ask how much, how often, relief or no relief?

Epilepsy:
History of unprovoked seizures. Has this ever happened before?

Meningitis:
Fever, headache, neck stiffness.
Irritability/lethargy, varied levels of consciousness, poor feeding.

Nephrotic vs Nephritic ?
Nephrotic syndrome: edema
Nephritic syndrome: haematuria

Puffy eyes- when did it start? One vs both? Which part of the eyes? -eyelids Any redness,
itching, tearing up, nasal discharge? Worse in morning vs night?Has it gotten worse? Use
anything to make it better?
Swelling anywhere else (legs, groin and abdomen)
Contact with foods or medication that he might be allergic to?
Was he sick recently?
Sore throat, skin rash, fever, runny nose, cough, vomiting, diarrhea.
Urine - wetting nappies as usual? Colour, froth (proteins), blood, pain.

Faltering growth
Definition: BMI drop to below the second centile.

To illicit upon taking a history:

History of milk feeding? Breast/Bottle fed?
How often does the infant feed?
If formula, how is it prepared?
 Age of weaning?
Range and type of foods now taken
Mealtime routine and feeding behaviours
Any additional symptoms eg diarrhoea, vomiting, cough, lethargy.

Main causes of faltering growth:

Inadequate intake, inadequate retention, malabsorption, failure to utilize nutrients, increased
requirements.

Bronchiolitis vs Cardiac Failure

Bronchiolitis: Runny nose, nasal obstruction and sneezing prior to onset of dry cough,
increasing breathlessness, feeding difficulty. Low grade fever
Cardiac Failure: Breathlessness (while feeding as well), sweating (while feeding), poor feeding,
recurrent chest infections.

2) Cardiovascular examination

http://mrcpch.paediatrics.co.uk/cardiovascular/examination-guide/

Introduce yourself.
Ask Permission.
Ideal exposure for this examination is from the waist up so I’d ask the patient to remove their
shirt at this time.
The bed should also be at 45 degrees. (To check JVP)
Introduce yourself to child. Ask if “anywhere hurting.”

On general inspection, we have ____ year old, John Doe who appears to be:
resting comfortably/ ill looking
obvious cardiopulmonary distress
cyanosis
Plot height and weight on growth charts
Looking at his chest, there are no chest wall deformities and no visible surgical scars.

On examination of the patient’s hands:

Palmar surface: pink/pale, warm/cold, dry/moist
Janeway lesions, Osler’s nodes (infective endocarditis)
Extensor surface: splinter haemorrhages (infective endocarditis)
Clubbing (cyanotic congenital heart disease, infective endocarditis)
Capillary refill time (>2 secs = peripheral cyanosis)

Assessment of pulses:
Radial pulse: assess rate, character and rhythm (higher than lower limb pressure in
coarctation of the aorta)
Radio - radial delay: time and volume differences
Radio - femoral delay : time and volume differences (coarctation of the aorta)
Ask patient if they have pain in their shoulder: Collapsing pulse

Request blood pressure (Low/Narrow pulse pressure ie <25mmHg = congestive cardiac

failure, Aortic stenosis.
High/Wide pulse pressure ie >100mmHg = anaemia, Aortic regurgitation, AV malformation)

Face and eyes:

General: dysmorphic features
Eyes: mucous membranes pale/pink/dark red and moist
Mouth: adequate dentition, central cyanosis (heart failure)

Neck:
Inspect then palpate for Tracheal Deviation
Carotid pulse: Palpate for volume and character.
JVP

Chest :
Inspection: chest wall deformities, active precordium, surgical scars.
Palpation: dextrocardia, localize and describe apex beat (displaced in cardiomegaly), heave
(right ventricular hypertrophy), thrills (loud heart murmur).
Auscultate: Use bell to auscultate apex… roll patient to their left (mitral stenosis), then
auscultate major positions using the diaphragm.
Listen to left infraclavicular area (radiation of patent ductus arteriosus).
Listen in the axilla (mitral regurgitation).
Listen over the carotid arteries. (Carotid bruits. Radiation of aortic stenosis).

Describe heart sounds - Normal S1 S2.

Describe additional heart sounds.

Ask patient to sit up. Listen for basal crepitations.

Abdomen:
Palpate for sacral oedema (heart failure).
Palpate for hepatomegaly (heart failure)

Cover and thank patient.

In summary this is ___ year old John Doe who on examination was not found to have any
signs of infective endocarditis, or heart failure. Normal S1 and S2 were heard with/without
additional heart sounds. A (describe) murmur. Altogether, findings were consistent with that
of a normal cardiovascular examination. Or Altogether, it is possible that John Doe has
either a ____ or a _______ . To confirm my diagnosis, I would like to perform a 4 limb
blood pressure, CXR, ECG and echocardiogram.

Apex character
Normal
Diffuse - barely or not palpable (pericardial effusion, left ventricular failure, dilated
cardiomyopathy)
Thrusting - exaggerated normal apex beat caused by volume overload (mitral or aortic
incompetence)
Tapping - essentially a palpable S1 (mitral stenosis)
Heaving - outflow obstruction (aortic stenosis or systemic hypertension)

Murmur description:
Timing →
Ejection systolic - Aortic stenosis, pulmonary stenosis, ASD, coarctation of the aorta.
Pansystolic - VSD, Mitral regurgitation, tricuspid regurgitation.
Diastolic - Aortic/ pulmonary regurgitation
Continuous - PDA, coarctation of the aorta.

Intensity →
Grade 1 - very soft, heard in a quiet room
Grade 2 - easily heard but not loud
Grade 3 - loud but no thrill
Grade 4 - loud with palpable thrill
Grade 5 - loud with thrill, audible with steth at 45 degrees.
Grade 6 - loud with thrill, audible without steth

Location →
Mitral area → Diastolic - mitral stenosis. Systolic - Mitral regurgitation
Left lower sternal border → Holosystolic - Tricuspid regurg, VSD. Diastolic - tricuspid
stenosis, ASD
Upper left sternal border → Pulmonary stenosis, ASD
Upper right sternal border → Aortic stenosis

Radiation…
Pulmonary stenosis - upper left sternal border radiating to the back
Aortic stenosis - upper right sternal border radiating to the neck
PDA - left infraclavicular border

Causes for midline n lateral sternotomy scars

Median + clubbing = palliative surgery
Left lateral = PDA, coarctation
Right lateral = esophageal atresia.
Williams… Noonan’s

3) Abdominal Examination

http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examination-guide/

Introduce yourself.
Ask permission.
Ideal exposure for this examination is from the xiphisternum to the symphysis pubis but I’ll just
ask the patient to remove their shirt at this time.
The bed should be flat.
Introduce yourself to the child. Ask if anywhere hurting

On general inspection, we have ___year old, John Doe who appears to be:
resting comfortably / ill looking.
Appears to have a normal BMI however I would like to confirm this by measuring the patient’s
height and weight.
Is/is not obviously jaundiced.

On examination of his abdomen, comment on:

Distension (fat, fluid, flatus, faeces)
Asymmetry/Masses
Surgical Scars
Movement with inspiration/expiration
Inverted/Everted umbilicus (flat or everted in ascites)
Caput medusae (portal hypertension)

On examination of the patient’s hands:

Pink and moist
Palmar erythema (liver disease)
Koilonychia; spoon shaped nails (chronic iron deficiency)
Leukonychia; white nails (hypoalbuminemia - malnutrition, malabsorption, nephrotic)
Clubbing (liver disease, IBD)

Asterixis (hepatic encephalopathy)

On examination of the patient’s arms:

Petechiae/bruising (hepatic dysfunction)
Scratch marks (hyperbilirubinemia)

On examination of the patient’s face:

Eyes: jaundice, anaemia
Mouth:
Ulcers (IBD - Crohn's)
Glossitis (atrophic - IDA, beefy - vit B12 deficiency)
Angular stomatitis (iron deficiency)

Neck:
Cervical lymphadenopathy (gastric/pancreatic Ca)
Virchow’s node

Abdomen:
Inspection: on closer examination of the abdomen findings are consistent with that of the foot of
the bed with no surgical scars or visible peristalsis.
Palpation:
Ask if tummy hurting.
Kneel down on the ground and remember to keep looking at the patient’s face.

Light palpation: tenderness, guarding.

Deep palpation: masses, rebound tenderness.

Assessment of organomegaly:
1) Liver: Palpate from right iliac fossa. Feel for liver edge on inspiration. If liver edge palpable,
describe edge (smooth/irregular)), surface (smooth/irregular), consistency (soft/firm/hard),
tenderness.
Percuss from upper edge to lower edge of the liver and measure liver span.
Liver will be in right hypochondrium…
-dull to percussion
-moves with respiration
-cannot get above it

2) Spleen: Palpate from right iliac fossa. Feel for spleen on inspiration. Ask patient to place their
left hand on your shoulder and roll over. Palpate again. If spleen palpable, describe edge
(smooth/irregular), can’t get above it, moves toward right iliac fossa on inspiration.
Percuss from right iliac fossa.
Spleen will be in left hypochondrium...
-notch
-dull to percussion
-moves with inspiration
-cannot get above it

3) Ballot kidneys.
Kidneys would be ballotable…
-ballotable
-resonant to percussion
-does not move with inspiration
-can get above it.

Assessment of Ascites (either or)

1) Shifting dullness
2) Fluid thrill - ask examiner and not child to place hand in the midline of the abdomen.

Hernia examination:
Umbilical, inguinal; check for palpable cough impulse.

Auscultate:
Bowel sounds
Aortic bruits
Renal bruits
Hepatic hum
Splenic rub

Cover and thank patient.

To complete this exam I would like to examine the external genitalia and perineum.

In summary, this is ___ year old John Doe who does not appear to be obviously jaundiced.
Abdomen was soft and nontender without organomegaly. Findings were consistent with that of a
normal abdominal examination.

Hepatomegaly-
Haematological - sickle cell anaemia, thalassemia, malignancies ie AML, ALL, CML
Infection - CMV, hepatitis, malaria, toxoplasmosis
Cardiovascular - congestive heart failure, constrictive pericarditis
Inflammatory - SLE, idiopathic juvenile arthritis
Storage/metabolic- glycogen storage disease, Wilson’s disease, alpha-1-antitrypsin deficiency

Splenomegaly -
Hematologic - beta-thalassemia , myeloproliferative disorders - CML, myelofibrosis,
malignancies - leukemia, lymphomas
Infection - malaria, toxoplasmosis, EBV
Inflammation-Rheumatoid arthritis (Felty’s Syndrome), SLE, sarcoidosis
Other - portal hypertension, amyloidosis.

Hepatosplenomegaly -
Hepatic - cirrhosis, biliary atresia, sclerosing cholangitis
Haematological - thalassemia, hereditary spherocytosis
Infection - EBV, TORCH
Malignancy - leukemia, lymphoma
Metabolic -alpha1-antitrypsin, cystic fibrosis

Jaundice -
Prehepatic - hemolysis eg Sickle cell disease
Hepatic - Hepatitis, Cirrhosis
Post-hepatic - cholelithiasis, trauma, infection, drugs

4) Lower Limb Neurological Examination

Introduce yourself and ask permission.

Asks for child’s name and age.
Ask if child can follow instructions.
Introduce yourself to child.
Ensure that child is adequately exposed before continuing.

General inspection of bedside:

Walking aids, oxygen masks, suction tubes.

General inspection of patient:

posture. Neurocutaneous markers. Scars. Growth paraneters. Drooling. NG tube. Comment on
everything seen... Small for their age, microcephalic.Ideally I would like to plot these
parameters on the respective WHO growth charts.
Sustained flexion at the elbow, wrist, knees and ankles.

Legs:
Inspection: symmetry,bony deformities, wasting, spontaneous fasciculations, tendon release
scars
Palpation: bulk, induced fasciculations.
Assessment of tone: move limbs for patient. Assess each muscle group. (hypertonic, normotonic,
hypotonic). Clonus
Assessment of power: against gravity and against resistance. Elicit movement by forcefully
“tickling” under feet, or if patient uncooperative comment on movement and estimate power
from observation.
1) Flexion and extension at hip
2) Abduction/Adduction at the hip
3) Flexion/Extension at the knee
4) Dorsiflexion/Plantar flexion at the knee

Assessment of reflexes: Patellar, ankle, babinski. (Hyper, normo, or hyporeflexia).

Assess coordination.
Assess gait.
-walk normally, heel-toe, tip toes

Examine spine. (Goes toward global score)

In summary, we have ___ year old John Doe who appears small for age. He/she has visible
muscle wasting, hypertonia, grade ⅗ power and hyperreflexia. Findings are consistent with that
of an upper motor neuron lesion. To complete this examination I would like to perform a sensory
lower limb examination, a cranial nerves and upper limb neurological assessment.

Upper Motor Neuron Lesion Lower Motor Neuron Lesion

Tone Increased Reduced

Deep tendon reflexes Increased Decreased

Fasciculations Absent Present

Babinski Upgoing toe Absent

Upper Motor Neuron Lesion causes:Cerebral Palsy, stroke, multiple sclerosis, traumatic brain
injury.
Lower Motor Neuron Lesion causes: Guillain–Barré syndrome, C. botulism, polio, and cauda
equina syndrome.

Cerebral Palsy
Definition: permanent disorder of movement and/or posture caused by a non-progressive
abnormality in the developing brain.
Types:
Spastic (pyramidal/corticospinal tract) - unilateral/hemiplegia, bilateral/quadriplegia,
bilateral/diplegia - abnormal movement, increased tone or pathologic reflexes.
Dyskinetic (basal ganglia)- chorea, athetosis, dystonia - abnormal patterns of movement and
involuntary, uncontrolled movements.
Ataxic (cerebellum) - abnormal posture /movement. Loss of orderly muscle coordination or both.
Mixed - when more than one type of motor pattern is present and one does not clearly dominate
another. Associated with more complications : sensory deficits, seizures, and cognitive -
perceptual disturbances.

Risk factors:
(list two each)
Prenatal: cerebrovascular ischaemia/haemorrhage, structural maldevelopment of the brain during
gestation, cortical migration disorders, infection, prematurity, low birth weight
Perinatal: hypoxic-ischaemic injury, hypoglycemia
Postnatal: meningitis/encephalitis, head trauma from accidental or non-accidental injury,
hydrocephalus, hyperbilirubinemia.

Treatment:
Given that CP cannot be cured, a multidisciplinary team approach should be employed to
improve functional abilities, participation in society, and quality of life. This “team” should be
coordinated by a general paediatrician, but should include developmental and orthopedic doctors,
opthalmologist, audiologist, dietitians, physiotherapists, occupational therapy, speech therapy.
When

Complications:
Cognitive delay, seizures, sensory deficits; speech, vision, hearing.
Swallowing difficulties → aspiration, malnutrition
Decreased functionality/independence
Constipation
Recurrent UTI
Hip dislocation, contractures, gait abnormalities

----
Head circumference... Glabella to occiput. MCQ: Normal head circumference of newborn. What
age wud a child who is 41cm be?
Power in each muscle group.
Lift patient to assess spine n scissoring ie sustained contraction of the abductors
Talipes varus vs valgus.
5) Growth Charts Interpretation

Head circumference
Measure from the glabella, and go around the widest part of the head to the occiput. Measure
three times and take the largest measurement correct to the nearest 0.1cm.

Microcephaly- below the -2 Z-score line (2nd centile)

Causes: Familial, congenital infection eg Zika, Acquired infection eg meningitis,
Chromosomal abnormalities eg Trisomy 21, Hypoxic-ischemic injury, CNS malformation,
Chronic disease eg malnutrition, Toxins

Macrocephaly- above the 2 Z-score line (98th centile)

Causes: familial, macrocrania, megalencephaly, hydrocephaly, masses

Length/Height for age

Short stature/ stunted - below the -2 Z-score (2nd centile)
Causes:
Variation of normal - constitutional delay in growth and puberty, familial short stature.
Psychosocial deprivation
Endocrine - hypothyroidism, growth hormone deficiency, corticosteroid excess, Chromosomal
disorders/syndromes - 45 XO, Trisomy 21

Tall stature - above the 3 Z-score

Causes: familial, excess growth hormone secretion, hyperthyroidism, excess
adrenal androgen steroids, syndromes such as Marfan and Klinefelter syndrome

Weight for age / BMI for age

Weight faltering/underweight/wasted: below the -2 Z-score (2nd centile)
 Causes: inadequate availability of food, psychosocial deprivation, neglect or child
abuse, inadequate retention, malabsorption, failure to utilize nutrients, increased requirements.

Overweight:
Causes: genetic factors, lack of physical activity, unhealthy eating patterns
Complications: Type II diabetes, Hypertension, Dyslipidemia, Precocious Puberty, Sleep Apnea,
skin conditions eg acne, fungal infections

6) Basic Life Support

https://www.resus.org.uk/resuscitation-guidelines/paediatric-basic-life-support/
https://www.resus.org.uk/resuscitation-guidelines/paediatric-advanced-life-support/
Points to note:
Recall
1) Safety
2) Stimulate
3) Send for help
4) Airway - neutral position (<1yo), sniffing position (>1yo)
5) Breathing- in hospital setting attach high flow oxygen.
6) 5 Rescue breaths
7) Circulation - femoral/brachial (<1yo), carotid/brachial (>1yo)
8) 15 compressions : 2 breaths
9) Repeat for 5 cycles or approx 1 min.
Possible questions:
1) If after your 5 cycles no one has come to your assistance what do you do? Ans: carry the
infant to help.
2) If help has arrived before the 5 cycles what do you do? Ans: continue CPR while they set
up leads for cardiac electrical monitoring
3) You have three leads (red, white and black) where do you position them on the patient's
chest? Ans: white (right 2nd intercostal space), red (lower left) & black (left 2nd
intercostal space).
4) After setting up your cardiac monitor, you see a flat line on the screen, what do you do?
Ans: DOUBLE CHECK lead positioning, contacts and attachment to the device.
5) Name the parts of the bag and mask, including point of attachment for oxygen input.
Mask - ambu bag - reservoir - oxygen inlet
6) How do you make up a 1 in 10 000 solution given that adrenaline comes in a 1 in 1000
solution? Ans: Pull up 1ml of the 1 in 1000 solution and add 9ml of normal saline to the
mix.

Know shockable and non-shockable rhythms, and the protocol for each.

Non-shockable rhythms:
Asystole, pulseless electrical activity
- 0.1 ml/kg in 1 in 10 000 solution adrenaline IV/IO.
- Re-administer every 4 mins.
Causes:
4H’s 4T’s
Hypoxia, Hyper/Hypokalemia, hypovolemia, hypothermia
Tension pneumothorax, toxic, tamponade, thromboembolism.

7) Immunization
 Dose Age Vaccine

1st 2 months Hib/HepB/DPT, inactivated polio, pneumococcal

2nd 4 months Hib/HepB/DPT, oral polio, pneumococcal

3rd 6 months Hib/HepB/DPT. oral polio, pneumococcal

12 months MMR, Yellow Fever

Booster 18 months DPT, oral polio

Booster 4-5 years MMR

Booster 10-12 years Tetanus Diptheria (adult)

2018 Immunization Schedule from Dr.Balkaran

Dose Age Vaccine

1st 2 months DPT/HepB/Hib, inactivated polio, pneumococcal

2nd 4 months DPT/HepB/Hib, oral polio, pneumococcal

3rd 6 months DPT/HepB/Hib, oral polio, pneumococcal

12 months MMR, Yellow Fever

Booster 18 months DPT, oral polio, pneumococcal

Booster 2 years MMR

Booster 4-5 years DPT, oral polio

Booster 10 -12 years Tetanus Diptheria (adult)

HPV
10 - 15 yrs = 2 doses; > 15 yrs = 3 doses
1st 11 - 12 +

2nd + 2 months

3rd + 6 months

For a patient with HbSS;

 Dose Age Vaccine

2 + years Pneumococcal 23, Meningococcal

6 + months Seasonal Influenza

Therefore if asked, to list the vaccines that an 8 year old girl is expected have:
1st, 2nd, 3rd dose of HepB/Hib/DPT, pneumococcal, inactivated polio x1, oral polio x2.
MMR, Yellow Fever, Booster of DPT, oral polio, MMR

8) Nebulizer

1) Identify components involved in set up. ie. Mask, gauge, oxygen tubing,
humidifier/christmas tree, respule, and oxygen tank. Assemble
apparatus…
2) Attach gauge to oxygen tank. “Ideally I would use a wrench to tighten it.”
3) Screw on humidifier with yellow screw thingy or attach the christmas tree to the oxygen
tank.
4) Attach oxygen tubing to the anterior aspect of the humidifier or to the christmas tree.
Assemble respule…
5) Out of all solutions given I would choose the salbutamol and insert the appropriate dose.
(0.03 ml/kg plus the remaining 1-3ml in normal saline or 5mg if > 5 years old, 2.5mg if < 5
years old)
6) I will insert the diffuser and screw on the cap.

7) Connect oxygen tubing to the underside of respule and choose appropriately sized mask…
One that fits snuggly around the child’s nose and mouth.
8) Turn it on to high flow oxygen ie 10-15L/min. (Mthope PED uses 6L/min)
9) Put mask over child and ask parent or guardian to keep it in place.

At this point I’d want to warn the parent of some side effects of the salbutamol including
tachycardia, hyperactivity and tremors.
_____
Note: nebulized SABA is usually combined with oral prednisolone 1-2mg/kg (max 40mg). If
ineffective consider… IV hydrocortisone, inhaled ipratropium, IV
SABA/aminophylline/magnesium sulphate.
9) Peak Flow Meter

1) Identify equipment in front of you as a peak flow meter… ie peak flow meter +
disposable mouth piece (cardboard) or reusable mouthpiece (plastic).
2) To assemble apparatus….. Insert mouthpiece
3) To use apparatus…
…..
1)I want you sit upright or stand.
2)I want you to zero the cursor.
3)Take a deep breath in, form a complete seal around the mouthpiece with your lips.
4)Blow as hard and as fast as you can.
5)The cursor will move to a value, I want you to note that value and repeat the process two
more times.
6) Record the highest of the three values.
This will be reviewed with the doctor either in clinic or in an emergency setting.
……
4) Now it is your turn to demonstrate what I’ve just shown you.
_______
In the emergency setting, peak flow is used to determine the severity of the attack.
Moderate PEF > 50% (best)
Severe PEF 33%-50% (best)
Life-threatening PEF < 33% (best)

10) Metered Dose Inhaler

1) I will discharge my patient with a metered dose inhaler/reliever device and spacer.
2) Show patient parts of MDI… Cap, mouthpiece, canister with medication. You woud want
to check the medication name and expiration date.
3) Show patient parts of the spacer… Cap, mouthpiece, whistle, space for inhaler
4) Show the patient how to use the device…
……….
1) shake device a few times
2) Prime device by giving one spray away from everyone's face.
3) Insert MDI into spacer.
4) Press canister then let child take 10 slow breaths in and out
 5) Once that is finished… Repeat step 4. Note if whistle sounds while breathing, they’re
doing it to hard/fast so encourage to breathe more slowly.
6) Any questions? Ask patient to demonstrate.
………
5) Care for the device…
MDI: 1) It is important to have a 2nd canister at all times in case the current one runs out.
2) Remove canister and put in a bowl of water, if it floats horizontally it means that the
canister is near empty. If stay vertical, it means that it still has some way to go again.
Spacer: 1) Once use is complete, take it apart and rinse in warm soapy water and leave to air dry.
Do NOT use towel or paper towel on the device.
…………
6) Any questions?
7) Thank you very much for your time.

Reliever/blue inhaler- Salbutamol

Side effects: tremors, hyperactivity, tachycardia
Preventer/Brown inhaler- beclomethasone
Side effects: most common - oral thrush

Note what's controlled, moderately controlled and uncontrolled.

11) Prescription Writing

12) Development
Learn based on pictures in illustrated