SLMC GC

Institute of Pediatrics and Child Health

RESIDENT’S ORAL EXAMINATION
Oct 2019

M.W., a 5 year old male, was taken to the emergency room carried by his father
with a history of intermittent high grade fever (up to 39°C) accompanied by
watery, foul-smelling stools since 5 days PTC. He was given paracetamol
suspension 1 tsp every 4 hours which would only temporarily lyse the fever.

1. What other information would you like to ask the father?

Acceptable response:

- Ask questions to elicit further information regarding the child’s illness – how
often fever recurs, paracetamol preparation, etc.

Upon direct questioning, the examiner shall provide the following information:
- Character and frequency of stools – watery, foul-smelling, non mucoid, non
blood-streaked, occurring 5x a day, approximately one-half regular glassful per
episode
- Vomiting – none
- Abdominal pain – generalized
- Cough and colds – none
- Other medications – none
- Urine output – none in last 8 hours but previously adequate
- Personal Health History – admitted last month for one week for pneumonia at
provincial hospital; subsequently improved
- Family History – unremarkable; no other member presently ill
- Drinking water – comes from deep well but boiled 5 mins for consumption
*If the examinee requests specific information beyond those presented, the
examiner may answer using his/her own input as long as it remains related to
and is within the limits of the case and its train of thought

Unacceptable response:

- Proceed to physical examination

- Ask questions unrelated to the case

Pertinent PE:

HR=142/min RR=24/min T=39.2°C BP=72/40

HEENT: sunken eyeballs, dry lips and mucosa, no tonsillopharyngeal
congestion, no neck nodes
LUNGS: equal expansion, no retractions, clear breath sounds
HEART: tachycardic, regular rhythm, no murmurs
 ABD: flat, hyperactive bowel sounds, grimaces on generalized palpation, no
masses noted, no organomegaly
EXTREMITIES: fair skin turgor, weak peripheral pulses

2. What other information would you like to know?

Acceptable response:

- Perform complete PE

Upon direct questioning, the examiner shall provide the following information:
- NEURO – drowsy but fairly arousable, can answer direct questioning when
aroused, no meningitic signs, normal cranial nerves, normal reflexes
- central pulses – fair
- capillary refill – 4 seconds
- cool upper and lower extremities
*If the examinee requests specific information beyond those presented, the
examiner may answer using his/her own input as long as it remains related to
and is within the limits of the case and its train of thought

Unacceptable response:

- Does not perform a complete PE

- Proceeds to next section

3. Can you make a preliminary diagnosis at this point?

(Note: The diagnosis at this juncture should more or less point to the final diagnosis:
AGE with hypovolemic vs. septic shock)

4. What diagnostic procedures, if any, would you like to order?

(Note: It should be stressed to the examinee that ordering and awaiting diagnostic
work-up should NEVER take precedence over starting appropriate and timely
therapeutic action based on initial history and appropriate physical examination)

Acceptable response:

- Order appropriate diagnostic procedures

Upon direct questioning, the examiner shall provide the following information:
- CBC: Hb 10.2 Hct 29.8 RBC 2.8 WBC 23,800 St 6 Segs 86 Lym 8 Plt 80,000
- Na=124mEq/L K=2.8mEq/L Cl=108mEq/L iCa=1.3 Albumin=24g/dL
- Liver enzymes normal, PT=15.2secs / control=12.2secs, PTT=54.6secs /
control=20.5secs; RBS=69mg%
- Urinalysis: dark yellow, sp gr 1.025, ph=6, RBC 0-1/hpf, WBC 3-5/hpf
- Stool exam: watery, brown, foul smelling, RBC none, pus 5-7, no ova/parasites
*If the examinee requests specific information beyond those presented, the
examiner may answer using his/her own input as long as it remains related to
and is within the limits of the case and its train of thought

Unacceptable actions:
 Unacceptable response:

- Not requesting for at least the above laboratory exams

- Requesting for an exam that is not essential to making a diagnosis or to
establishing a therapeutic decision (i.e., ordering a chest x-ray or cranial CT)

4. Using all the available information, what is your diagnosis now?

Acceptable response:

- Diagnosis: Acute Gastroenteritis, with severe signs of dehydration

-depressed level of consciousness, dry mucosa, sunken eyeballs, decreased
urine output, weak pulses, hypotension
- Septic Shock, cold shock, uncompensated
-Septic shock: hyperthermia, cold extremities, depressed level of
consciousness
-Cold shock: cold extremities, cap refill>2 secs, weak pulses
-Uncompensated: BP not within normal range for age (sys BP=age x 2+70)
- Electrolyte imbalance
-Hyponatremia, hypokalemia, hypocalcemia

Unacceptable response:

- Not recognizing the basic diagnosis of Acute Gastroenteritis, severe signs

- Not recognizing Septic Shock
- Making a concomitant diagnosis of UTI
- Making any other diagnosis that the examiner deems unacceptable

5. What step-by-step therapeutic actions would you take to manage this

patient?

Acceptable response:

-Recognize decreased mental status and perfusion

-Perform ABCs of resuscitation
-Airway – maintain patent airway; provide 100% FiO2 via face mask to
all patients in shock
-Breathing – ascertain proper ventilation; adequate tidal volume /
respiratory rate
-Circulation – establish venous access using large bore peripheral line or
intraosseous access;
- push 20cc/kg Plain NSS or LR over 5 to 10 mins; titrated to
clinical monitors of pulses, BP, urine output, cap refill, neuro status
- may repeat boluses every 20 mins up to 60 to 80cc/kg total;
some patients require higher amounts so monitor breath sounds and
CXR for signs of congestion
Acceptable response (cont’d):

Fluid-responsive: Vital signs and level of consciousness improves, (+) urine

output > transport to PICU and manage other problems (electrolyte
imbalance, hypoglycemia, anemia, infection, hypoalbuminemia,
coagulation defects)
(Note: The examiner may opt to proceed further depending on the examinee’s
competency or lack thereof, to give additional merit if necessary)

Fluid refractory shock: establish central venous access; start inotrope therapy
with dopamine
Dose: 5-10mcg/kg/min
Preparation: Multiply 6 x wt (kg) = ___mg of dopamine in 100 ml D5W;
continuous infusion at 1 ml/hr = 1mcg/kg/min

Fluid refractory-dopamine resistant shock: start epinephrine for cold shock or

norepinephrine for warm shock
Dose: 0.1-1.0mcg/kg/min
Preparation: Multiply 0.6 x wt (kg) = ___mg of epinephrine or
norepinephrine in 100 ml D5W; continuous infusion at 1 ml/hr =
0.1mcg/kg/min

Catecholamine-resistant shock:
At risk of adrenal insufficiency (history of CNS abnormality or chronic
steroid use)
- Give hydrocortisone, 1-2 mg/kg for stress, and up to 50 mg/kg
for shock, followed by same dose as a 24 hour infusion
Not at risk of adrenal insufficiency
- No need to give hydrocortisone
- try vasopressin (0.04 to 0.08u/kg, or higher)

Refractory shock:
Consider ECMO

Unacceptable response:

- Does not recognize decreased mental status and perfusion

- Does not perform ABCs of resuscitation emergently or, if performed, is not in
proper sequence
Airway – does not provide 100% FiO2
Breathing – does not monitor breathing for adequacy
Circulation – pushes less than 20 ml/kg fluids per bolus, pushes each
bolus over more than 15 minutes or uses glucose-containing fluids; does
not monitor clinical response
- Does not or is reluctant to start inotrope, wrong dose or computation
- Uses epinephrine for warm shock or norepinephrine for cold shock
- Does not suggest hydrocortisone or vasopressin for catecholamine-resistant
shock