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Pediatric OSCE A Guide for Medical Students (Dr Myo)

1. Neonatal jaundice
2. Protein energy malnutrition
3. Dengue hemorrhagic fever
4. Acute respiratory infection
5. Recurrent wheezing
6. Stridor
7. Cyanotic congenital heart ds
8. Acyanotic congenital heart ds (VSD)
9. Rheumatic heart ds
10.Acute diarrhea
11.Jaundice
12.Oedematous child
13.Pallor
14.Bleeding child
15.Fever with fits
16.Cerebral palsy
Take a history of newborn baby w NNJ
Initial approach
Introduce yourself, get permission from mother
HOPI
Onset
When was your baby born?
When did you start notice that the baby had jaundice?
(Preferably how many hrs after birth if it is in day 1)
Ddx different according to age of onset of jaundice.
How old is your baby now?
Is jaundice getting better or progressive?
Is the baby lethargic or irritable?
Does the baby cry with high pitch sound?
Does the baby feed actively?
Poor feeding can be a feature of early kernicterus.
Do you breast feed or bottle feed your baby?
Breast milk jaundice can cause prolonged NNJ.
Did the baby have any fits? If present, how frequent and how does it look like?
Convulsion is a feature of late kernicterus.
Any fever? its nature?
Fever may be d/t neonatal sepsis (one of the causes of NNJ).
Eg umbilical sepsis/omphalitis, staphylococcal skin infx
Did you notice any redness around umbilicus or discharge from it?
Did you notice any pustules, crusts or blisters over any part of baby?
Antenatal hx

Maternal illness
Do you (mother) have any febrile illness with skin rashes during pregnancy?
Viral infx eg rubella during 1st trimester may give rise to congenital infx that cause
prolonged NNJ.
Birth hx
What parity of this pregnancy? Any abortion or stillbirth?
Rh incompatibility causes jaundice in 2nd parity onwards.
ABO incompatibility causes jaundice in any parity.
Is the baby boy or girl?
G6PD def mainly in boys
How many hrs before delivery did mother start to have dribbling (PROM)?
Was there any fever or foul smelling discharge per vagina?
ROM>24hr before delivery => risk of perinatal sepsis in newborn
Other risk factors: maternal fever before or during labor & foul smelling vag discharge
Mode of delivery? Why?
Any instrumental delivery?
Any birth trauma?
Cephalhematoma is d/t difficult vaginal delivery and can cause jaundice.
Assisted instrumental delivery may indicate difficult labor which can lead to birth
asphyxia.
Did the baby cry immediately after birth?
Was the baby cyanosed?
Did the baby need any resuscitation?
Presence of birth asphyxia is a risk factor to develop kernicterus.
Is the baby born early/later than expected date?
Premature babies are more prone to develop NNJ and kernicterus.
Babys birth wt?
Family hx
Previous child with NNJ? Treated?
Jaundice d/t Rh incompatibility was more severe in 2 nd onward born babies.
Requiring exchanged transfusion indicates severe jaundice.
Blood groups of mother, father, baby?
ABO and Rhesus incompatibility if blood groups are different.
Summary
Baby John, 6d old boy was admitted for yellow discolouration of skin noticed on 4 th
day of age starting from face and now over abdomen. There was no history of lethargy and
irritability. He could suck well to breast milk and active. The baby was exclusively breast
fed and no feature suggestive of early kernicterus or sepsis.
The baby was born term via SVD at hospital with birth wt of 7lbs. there was no
history of PROM and no prolonged labour. He cried immediately after birth and could start
feeding with colostrums soon after birth. Blood group of both parents is O Rh +ve, babys
blood group was not known.
Pdx: physiological NNJ

Baby Mary, 3d old girl was admitted from yellow discoloration of skin noticed since
this morning which had spread over the abdomen. She was lethargic. Sucking was poor
and she was irritable. Both breast and formula milk were fed bcs mother thought her milk
production was poor.
The baby was febrile and mother also noticed foul smelling and redness around the
cord. She was the 3rd child of uneventful pregnancy. The baby was born term via SVD at
home by midwife. Mother had dribbling nearly one day before delivery and she was febrile
during labour. She was told that the liquor was dirty and foul smelling. Blood group of both
parents is O Rh +ve, babys blood group was not known.
Pdx: NNJ most probably d/t sepsis
Ddx
1. Physiological jaundice
2. Pathological jaundice
a. ABO incompatibility
b. Rhesus incompatibility
c. Sepsis (umbilicus, skin, septicemia, meningitis)
d. G6PD def
e. Prematurity
f. Birth trauma cephalhematoma
g. Prolonged NNJ (>14d in term, >21d in preterm)
i. Acquired infx
ii. Breast milk jaundice (dx of exclusion)
iii. Hypothyroidism
iv. Biliary atresia
v. Neonatal hepatitis syndrome
vi. Congenital syphilis
3. Complication kernicterus (spastic posture, high pitch cry, irritability, poor sucking)
Key points
HOPI
Yellow discolouration
Onset
Duration
Lethargy/irritability
Poor sucking
Breast/bottle fed
Fits
Fever
Discharge from umbilicus
Pustules on skin
Antenatal hx
Maternal illness
Birth hx
Parity
Sex

PROM
Mode of delivery
Term
Birth wt
Birth asphyxia
Birth injury
Family hx
Previous jaundiced baby
Blood groups
Age
(month
s)
04

Gross
motor

Fine motor/vision

Hearing and
speech

Social behaviour

Head
control

Responds to sound
Cooing

Social smile (6w)


Recognizing mother

57

Rolls over
Sit with
support
(6mo)
Crawls/cree
ps (910mo)

Eyes follow an
object/follow mum
face
Grasps a rattle or
rings when placed in
hand
Reaches out to an
object and hold it
with both hand
Transfer and mouths
Points with index
finger

Turns to voice

Put solid food into


mouth

Bi-syllables
(mama, baba)
Responds to own
name
Distraction hearing
test
Turns to sound of
name
Understands
several words

Waves bye bye


Play peek-a-boo

Utters 3 or more
words
Points to ear, nose,
mouth
Complete
sentences
Knows own name

Indicates toilet
needs
Follows simple
command
Can remove
garment

Knows full
name,sex,age
Normal speech

Dry throughout day

12

Pulls to
stand
Stands
without
support
Walks
holding
furniture
Climbs
onto chairs
Runs

A good pincer
Casting

24

Climb stairs
(2
feet/step)

36

Climbs on
alternate
feet

Tower of 6 cubes
Imitates vertical
stroke
Turns book pages
singly
Copies a circle
Matches 2 colours

18

Scribbles
Builds tower of 3

Drinks from cup


Indicates wants
Claps hands (play
pat-a-cake)
Wary of strangers

60

Riding
tricycle
Bounce &
catch ball

Copies triangle

Speak fluently
Name 4 colours

Chooses own friends


Dress with
supervision

Dengue hemorrhagic fever (DHF)


? yo child presented with ? days history of fever and +ve Hess test.
Initial approach
Introduce and get permission
HOPI
Cover main clinical presentations of DF and its complications
Fever:
1) Severity, peak, duration of fever
2) Differentiate other possible causes of high fever
How many days fever?
Continuous/intermittent/remittent fever?
Low/high grade fever?
a/w evening rise in temp/chill&rigor?
a/w vomiting/diarrhea?
a/w skin rash?
Fever associated symptoms
Bleeding manifestation d/t low plt count/DIC in critical period.
Sudden massive ICH p/w severe headache, altered sensorium, vomiting
Any gum bleeding, epistaxis, coffee ground vomiting, rashes (petechiae), subcutaneous
bleed, black tarry stool?
Abdominal pain d/t shock/acute liver enlargement/massive ascites
Central/RUQ/LUQ pain?
Shock features
Does the child become restless, loss of interest to surrounding, more sleepy, cold clammy
extremities, oliguria?
Sx of encephalopathy
Headache, projectile vomiting, convulsion, irritability, restless, altered consciousness?
PMH
More prone to develop dengue shock syndrome if have past h/o dengue like fever
Any previous h/o DF, hospitalization (IV infusion, blood transfusion)
Environmental hx
Cover water container/tanks at home?
Regularly exchange water from vases?
Any place near house whr mosquitoes bread?
Good water drainage nearby house?
Use mosquitoes repellent?
House well ventilated?
Use mosquito impregnated net?

Family & social hx


Did neighbours, siblings or classmates have similar illness?
Drug hx
Meds that could precipitate GI bleed and previous fluid mx (preadm) are valuable to
further mx in hospital.
Aspirin, NSAIDs, IV line, ORS
Severity of DHF b/o clinical hallmarks of bleeding & plasma leakage
Grade I: only +ve tourniquet test
Grade II: +ve tourniquet test w spontaneous superficial bleed
Grade III: shock
Grade IV: profound shock w unrecordable BP/pulse
Cerebral palsy
_yo child p/w delayed milestones.
I understand that ur child is not developing very well ie unable to walk or speak, may I ask
u more about this?
HOPI
What are the developmental problems that youre worried about and how long have you
noticed?
Developmental milestones
Other areas of developments eg other gross and fine motor, hearing n speech, vision etc
Abn movement & posture
Strange mvs and postures unlike other kids.
Any stiffness of body or limbs?
Hands fisted all the time?
Associated problems
Fits
Frequency, duration, character (generalized/partial), a/w fever, impaired consciousness
after fits
Repeated chest infx and h/o aspiration during feeding?
Difficulty in feeding? (liquid/solid)
PMH
Previous h/o meningitis/encephalitis/head injury
Previous hospitalizations when, how freq, reasons
Birth hx
CP<2yr
Child p/w delayed milestones. Perform PE to get dx.
General condition
Well conscious & alert
Interested to surrounding & respond to name, sound, regard to mothers face

Measure head size/occipitofrontal circumference (OFC) largest measurement of 3 times


Microcephaly Intrauterine infx, birth asphyxia, permaturity
Macrocephaly hydrocephalus
Birth 35 cm
3mo 40 cm
6mo 43 cm
9mo 45 cm
1yr 47 cm
2yr 49 cm
3yr 50 cm
5yr 51 cm

start at left temporal above eyebrows around head occiput

Anterior fontanelle (AF) open/membranous/alr closed


Posture
Opsithotonus
Decerebrate
Decorticate
Scissoring/spastic
Tiptoeing
Movement
Observe for ms twitching, myoclonus, tonic spasm, choreoathetoid mv (post kernicterus
CP)
Limbs
Hand fisting
Spastic limbs
Deformities
Joint contractures
Windswept deformity
Released scars
Casting/orthoses/splints
Ms wasting disused atrophy, poor nutrition, generalized wasting
Tone
Spasticity
Rapid buildup of resistance during 1st few degree of passive mv and then as the mv
continues sudden lessening of resistance (clasp-knife spasticity)
Dyskinetic
d/t damage to extrapyramidal tract, fluctuating ms tone n involuntary mv (athetoid slow
writhing, chorea sudden jerky)
Uncooperative child observe spontaneous mv of limbs
Deep tendon reflexes
Plantar response
Clonus

Trunk 180 turn/ 180 motor assessment


Supine position
Assess posture
Grasp reflex
Head control/head lag
Pull to sit
Spine curvature
Sit w support
Sit wout support
Pull to stand
Stand w support
Stand wout support
Ventral suspension
Truncal tone
Head raised above horizontal line or nt
Forward parachute
Downward parachute
Prone position
Head raised against floor or not
Return to supine position
Moros reflex
Asymmetrical tonic neck reflex
1 yo child is lying on bed. He is conscious, interested to surrounding & responds to
stimuli and mothers voice
------------------------1d old baby, Mother claimed no changes in urine or stool colour, urine was normal with no
staining of ?, no fever, lethargy or change in ?of baby, temp, blood gp mother o baby x
know, full term, svd, uneventful antenatal and postnatal history, h/o NNJ physiological in
2nd child, resolved 3rd d, no h/o kernicterus, neonatal death, anemia, g6pd def. no maternal
illness or iu infx, drug
Phototx
Conscious, x lethargic/dehydrated, x hypotonia, x dyspnea or cyanosis, no sign of sepsis,
no arching of back, no petechiae purpura or ecchymosis on body, no abd distension
Summary:
4d old malay baby, mother noticed yellow discolouration of sclera and face that ? on the
3rd day, still feeding well, breast fed immediately after birth, h.o nnj in prev child, currently
phototx, bilirubin normal.
Physioloigical
3d of birth
No h.o anemia, ..
G6PD normal
Blood gp same

Other causes of jaundice in newborns


high risk bcs inc rbc mass 17g/L
high rbc turnover short rbc lifespan
liver immaturity
inc ?
Preterm
Birth trauma cephalhematoma inc rbc breakdown hyperbilirubinemia
Polycythemia big baby/infant of diabetic mother
Exaggerated physiological jaundice (x pathological jaundice)
Normal physiological jaundice starts on day 2-3 and peak on day 4-5 and resolve after 710d of life
Tx: ? screening, if needed phototx
basic ix: mother n baby blood gp if indicated (d1 jaundice=onset of jaundice within 24hr),
G6PD status, blood C&S, FBC, peripheral blood film to check for anemia hemolysis & ? test
for hemolysis
Pathological jaundice = onset of jaundice within 24hr of birth
Hemolytic jaundice (prehepatic)
G6PD def
Blood gp incompatibility
Infx
>2w in preterm = prolonged NNJ