Paeds Complete PDF

PAEDS: ALLERGY/ IMMUNOLOGY
Anaphylaxis
Symptoms and signs: (respiratory, cardiovascular, skin, GIT)
Swelling of the eyes and lips
Laryngeal oedema
Tongue swelling
Rash, Flushing
Vasodilation, Hypotensive fluid, adrenalin, antihistamine
Tachycardia
Wheezes(narrowing of the airway)  bronchodilator (Salbutamol) Ventolin 2.5 mg nebulizer for
children and 5 mg nebulizer for adult
Stridor (sign of upper respiratory obstruction)  Adrenalin 5 mg nebulizer
Shortness of breath, tachypnea  Oxygen 6-8 L (10-15 L) by mask
Abdominal pain, Nausea & vomiting
Itchiness antihistamine (Ranitidine and Promethazin)
Mild to moderate (swelling of lip without CVS and RS symptoms)

Swelling of tongue, hoarseness of voice, stridor, difficulty in breathing and persistent cough.
CVS: pallor, hypotension, loss of consciousness and collapse.
Skin: urticaria, itchy, angioedema, erythema.
GIT and pain, vomiting, diarrhea
Triggers: Bee sting, Peanuts, Eggs, Seafood, Vaccination, Latex, Antibiotics, Anti venoms
Antigen-antibody complex  Mast cell will burst out and secrete histamine  vasodilation 
swelling, tachycardia, tachypnoea, itchiness
Mx:
1. DR ABC
2. Adrenalin (vasopressor) 0.01 ml/kg (1:1000) IM 0.3-0.5 ml repeat every 5 minutes if there is no
response give IV infusion
3. Antihistamine 5 mg (children), 10 mg (adult)
4. Corticosteroid Hydrocotisone 500mg IV (adult), 8-10mg/kg IV (child)
5. Oxygen 6-8 L/min by mask
6. Bronchodilator Salbutamol continuous nebulised
7. Fluids IV fluid 20 ml/kg
8. Admit to hospital observe at least 4 hrs
9. Intubation
10. ICU
11. d/c with promethazine + prednisolone 50mg/d x 2 days
Biphasic reaction (20%) have relapse  to prevent recurrence  give IV or IM Hydrocortisone 100-
250 mg for adults (for children 2-4 mg/kg) single dose
Anaphylactic Action Plan

Educate how to use Epipen Remove the grey cap, hold it and stick the black side on the lateral side
of thigh until you hear or feel the click sound, leave for 10 seconds (can be over the clothes)
Remember to hold it in your palms but not to touch the ends of the pen.
Anaphylaxis kit
1. EPIPEN
2. Adrenalin inhaler
3. Antihistamine tablet
!
! 1!
Food Allergy And Atopic Eczema

A 9 month-old boy, now in GP for follow up. Yesterday he was in ED because of swelling of the lips,
vomiting, and skin rash followed by a meal. Now mother notices dry skin and rash over eye.
Task: Hx, PE, advice on Mx
Hx:
I understand your son was in ED yesterday, can you tell me what has happened?
What was the meal? Pancake (egg and flour)
Was it the 1st time?
How long it took him to develop the reaction?
How bad was the reaction? Apart from swelling lips, skin rash and vomiting, did he has SOB, wheeze,
stridor, tongue welling or loss of consciousness?
What did they do in the hospital? (Important to know if adrenalin been given or not)
How long did he stay in ED?
How is he now?
Dry skin rash: onset, progression with time, itchy or not. Is it reminding and relapsing. Any treatment
PHx and FHx of atopic eczema, asthma, hey fever or allergies.
BIND
O/E:
GA: rash (flexor folds + cheek, scratch mark ,oozing), swelling of lips & tongue, growth parameters.
blanching
Chest examination: wheeze
CVS: tachycardia,
Explanation:
After Hx and examination, your child is having 2 condition. Food allergy and atopic eczema.
For the allergy reaction yesterday is most likely due to egg. Food allergy is a very common condition
and it is also common for those who are allergic to one food to get another food allergy. Eg. nuts, fish.
Because he has positive family history, and current reaction, most probably he may develop severe
allergy to some food or medication.
Mx:
1. Don’t give the child any food what he’s allergic to. So we need to do skin test to find out what
food he is allergic to.
2. I will refer you to specialist for skin tests.
3. Skin test cannot be done now as it may show false positive reaction, we need to wait for 6 weeks.
Until that time don’t give the food I have mentioned.
4. I will give you reading material which will have a list of commonly allergic food.
5. Anaphylaxis action plan (3 copies)if you child has another attack of allergy
- Observe first for symptoms
- Locate the Epipen
- Call your local doctor
- If your child’s symptoms getting worse, give Epipen and call “000”
- If your child is on prescribed medication - give anti histamin, steroid.
Anaphylaxis : at least one reps symptoms + one CVS symptoms.
Eczema: most likely atopic eczema. Cause is unknown. But preventable. Apply skin moist after
shower, avoid overheating, no soap. Cotton clothing. Hydrocortisone cream. improve when older.
Is my child will be lifelong allergic? Allergy to egg most people grow out, but not peanut /sea food.
! 2!
Bee Sting
A 4 year-old boy presented to ED with bee sting. He’s wheezing and hypotensive (BP 60/40 mmHg).
Task: Manage the case.
Don’t ask Hx, rapidly assess ABC, then check VS

- Call for help  code blue (hypotensive)
- Give O2
- Salbutamol nebulizer (sometimes required)
- Adrenalin 0.1 ml/kg (1:10 000) IV or 0.01 ml/kg (1:1000) IM
- Put IV line give normal saline 10-20 ml/kg over 10 mins, (if no response, repeat 1-2) (bolus dose)
After each step check vital signs

If patient still unstable Repeat adrenalin every 5-10 minutes
If stable Give steroid (hydrocortisone 5mg/kg IV) and Antihistamine (Promethazine)
If pt still SOB  Salbutamol + Nebulize with adrenaline (5ml – 1 :10,000)
Tell examiner  I’d like to monitor VS, call the paediatric registrar to come and assess the patient.
If patient is not getting better  transfer to ICU for intubation
Keep!under!observation!for!at!least!12!hrs!(might!have!rebound!reaction!after!the!medication!wears!
out)!
Upon discharged, give steroid 3-5 days (1 mg/kg prednisolone)
Hx:
Ask father if this is the first time---yes
Any allergy to food, asthma, any eczema, hay fever?---no
Any family history of allergy?----no
Explanation:
It seems that your daughter has a severe allergic reaction to the bee sting what we call anaphylaxis.
This is a very serious condition, life threatening. Keep an eye on him, avoid exposure to bee. Try to
avoid going to areas that might get bee stings like under the trees. Let him wear long sleeves if he
needs to go. Install window screens at home.
Wear MEDI alert bracelet which states that she is allergic to bee sting.
I’ll give you anaphylactic action plan and anaphylaxis kit (epipen, hydrocortisone, antihistamine and
nebulize adrenaline)
Anaphylactic action plan

If a mild local reaction happens (Itching, Swelling of lips, Rash on the skin)  go to the GP and he
will give her antihistamine tablet
If she develops: Noisy breathing (laryngeal oedema), Coughing, SOB  give Epipen, then call “000”
Place the anaphylaxis action plan on the fridge so that everyone can see in case of emergency, educate
the family and educate the kindergarten teacher. I will send a letter to the kindergarten teacher about
her condition.
I’m going to refer your son to the allergic specialist who will do the skin test.
! 3!
TAKE HOME MESSGAES

1. ADRENALINE: 0.01 ml/kg IM (1: 1 000)
2. ADRENALINE: 0.1 ml/kg IV (1:10 000)
3. ADRENALINE: 5 ml via nebuliser (1: 10 000)
4. SALBUTAMOL: 2.5 mg (peds) via nebuliser
5. ALWAYS HAVE “DR ABC” APPROACH IF U SUSPECT ANAPHYLAXIS, DON’T ASK Hx

QUESTIONS INITIALLY
6. OBSERVE AT LEAST FOR 6 HOURS (IDEAL 12 HOURS)
7. STEROIDS: HYDROCORTISONE: 10 mg/ kg IV

PREDNISOLONE 1 mg/ kg on discharge PO
8. ANTIHITAMINE: PROMETHAZINE 10 mg IV + 10 mg PO on discharge

RANITIDINE 150 mg IV (? 3 mg/ kg)
APPROACH:
Hello Dr..
Tell me if the patient is stable hemodynaemically
Airway: Whats ur name? Speak or not?

Tongue swelling?
IF AIRWAY NOT PATENT, PT NEEDS TO BE INTUBATED, ALSO GIVE ADR
Breathing: distressed?
RR
Whats the O2 Saturation?
Wheeze?
Stridor?
Chest on auscultation
GIVE ADR, SALB as required
Circulation: pulse (tachy?)

BP (hypotensive)
IV Fluids resuscitation v v important.
GA: Rash
IV HYDROCORT, IV RANITIDINE, IV STEMETIL
ASK IF THE PATIENT IS STABILISED OR NOT.. IF NOT, CONT RESUSCITATION…
THEN, ask about the history…
Need for further Investigation by the GP in conjunction with Allergy specialist
! 4!
ASTHMA (PAEDS + ADULTS)
Asthma
Hx:
When is the diagnosis?
What medication is being taken?
How do you give Ventolin? (ask the Mother to show)
Frequency
Symptoms in between
Night symptoms, disturbed sleep (affect the growth of the child)
Exercise intolerance or activity
ICU admission
Triggers: smoking, pets, dust, exercise, infection, weather, seasons, occupation
PHx and FHx of Hay fever, eczema
O/E:
- GA: SOB, tightness of chest, cough, fast breathing, puffiness, ability to talk, cyanosis, chest
indrawings, level of consciousness; Growth & development
- VS: Oxygen saturation
Critical signs:
- Level of consciousness (Hypercapnia, Hypoxia Not enough oxygen to the brain)
- Silent chest
- Unable to talk
- Chest indrawings
- Oxygen saturation <92%
- Mental state: drowsiness
Mild or moderate symptoms:

- Shortness of breath, cough
- Able to talk in sentences
- Oxygen saturation >95%
Tx:
Reliever: given during attack
- Short acting beta agonist (SABA) – Ventolin/Salbutamol(bronchodilator)
Preventer: prevents inflammation
- Steroid
Symptom controller: act for a long time if symptoms not improved
- LABA – Salmeterol
- Anticholinergic – Atrovent/Ipratropium bromide (to prevent secretion)
- Aminophylin
Oxygen if O2 saturation<92%
Infrequent – attack during activities or every 6 weeks  Ventolin 2 puffs PRN
Frequent – every 3 weeks for <2 days/week (1 day or 2 days/week)  give reliever and preventer
(everyday 2 times) because there might be an inflammation  Ventolin 2 puffs PRN + Steroid 2 puffs
bd (in the morning and in the evening)
Persistent – affecting daily life and sleep  attacks >2 days or nights/week  Ventolin 2 puffs PRN
and Steroid 2 puffs bd + LABA 2 puffs bd (Combination of Steroid + LABA  Seretide 2 puffs bd)
Exercise induced asthma: give SABA 1 hr before exercise to dilate the airway.
! 1!
Infrequent episode Frequent episode Persistent

Duration >6-8 weeks < 6 weeks < 6 weeks
< 2 days/week > 2 days/week
< 1 night/week > 1 night/week
Symptoms mild more severe severe
No interval Interval symptoms
Treatment Ventolin short Ventolin short acting as needed Ventolin short acting
acting Preventer (steroid) Long acting beta agonist
2 puff in the morning Steroid
2 puff at night 2 puff in the morning 2 puff at
night
Intermittent Mild Moderate Severe Persistent

Day symptoms Day symptoms ≤ > once weekly Symptoms daily Daily symptoms
once a week
Night ≤2 month >2 Night symptoms Night symptoms > once a

symptoms night/monthly weekly week
Severe limitation of
activity
FEV1 ≥ 80% ≥ 80% 60-80% < 60%
Treatment Short Acting Beta SABA on need SABA on need SABA on need
Agonist (SABA) Inhaler Inhaler Corticosteroid inhaler ↑
as needed 2 puff 1 corticosteroid corticosteroid 2 puff in morning
min apart 2 puff in 2 puff in morning 2 puff in night
morning 2 puff in night LABA (long acting beta
2 puff in night LABA (long acting as needed 2 puff 1 min
beta agonist) apart
Mild Moderate Severe Critical

Mental state Normal Normal Agitated, irritable Drowsy, confused
Work of Minimal Slightly Increased Increased, exhausted
breathing increased
PaO2 sat > 95% 92-95% < 92% < 92%
Ability to talk In sentence In phrases In words Cyanosed, unable to
talk
Therapy Ventolin (reliever) Ventolin O2 100% Admit to ICU
6 puff < 6 year - 6 puff Ventolin puff O2 100%
12 puff>6year wait 20 min 6 puff 20 min Continuous nebulised
Assess after 20 - 6 puff 6 puff 20 min Ventolin Steroid
min wait 20 min 6 puff 20 min parenteral
Oral prednisolone - 6 puff Assess after 1 hour ---if not improved---
(preventer) wait 20 min Ipratropium bromide IV Aminophyllin
1 mg/kg Assess after 1 inh IV Salbutamol
for 3 days hour 4 puff <6 year If need, do intubation
Oral steroid 8 puff >6 year
1 mg/kg Oral steroid
1 mg/kg
! 2!
Acute asthma Mx:

Cyanosis, drowsy  Oxygen
Hypoxic (narrowing of airways)  bronchodilator (Ventolin)
Age < 6  6 puffs every 20 minutes  if not improving repeat 3 times (in 1 hour)  increase dose &
change the way of introducing the medication  if not improving the same procedure and add
Atrovent 4 puffs  if not improving give continuous nebulised salbutamol, steroid 1 mg/kg for 3 days
 theophylin, IV steroid, intubation
In all acute attacks give steroid
Before discharge, give general advice and Asthma Action Plan

- Avoid trigger factors
- Flu vaccination (infection is trigger factor)
- Remove pets from home
- Stop smoking around patient
- Vacuum bedroom everyday
- Good ventilation of bedroom (open window, sunlight)
- Regular changing of bed cover
- Avoid change in temperature
- Rinse mouth if using steroids
- Frequent monitor of growth & development if severe asthma
- Refer to paediatrician once or twice a year
- After all acute attack, follow-up with GP within 24-48 hours
- Action Plan leave 1 at home, 1 at school and 1 for carer
Action Plan (Asthma, angina, anaphylaxis, COPD, DM – hypoglycaemia)
CHILD ASTHMA ACTION PLAN

Name of child
Age
Name of Dr
Medication
- Reliever (Acute attack)
- Preventer (if asthma symptom not control  frequent and persistent)  Flexotide (contain
steroids), Seretide
If he start to have symptoms cough & wheezy  start Ventolin 4 puffs to see if wheezes improve, no
improvement  repeat
If continue and symptoms not improve, increase frequency of Ventolin
If not improving, add Prednisolone and see the GP
If anytime the child has respiratory distress (cyanosis, not able to talk, silent chest) call ambulance
000, continue therapy until ambulance come
If exercise-induced asthma  use Ventolin 30 minutes before exercise
ADULT ASTHMA ACTION PLAN

Peak Expiratory Flow (PEF)
1) If you’re well, PEF > 80% - usual therapy
- if you’re using Ventolin use Ventolin, if you are on preventer take preventer
2) If unwell
- PEF < 80% double dose of Ventolin and every ½ - 1 hour repeat PEF
- PEF < 60% double dose of Ventolin + Prednisolone and see doctor
3) PEF < 40%
- continuous bronchodilator and call ambulance 000 say “severe asthma attack”
4 – 4 – 4  4 puffs 4 breaths 4 minutes
! 3!
Age: 60; Sex: Male; Expected PEF 625 (PEV1)

If the result is 450 (PEV1)  450/625 X 100% = 72%
How many ways we give medication

- (MDI)
- Inhaler
- Mask
- Spacer
- Nebuliser
- Mouth piece
MDI (Metered dose inhaler): Shake it to make sure it’s not empty. Check it, make sure the Ventolin is
inserted and put it upside down. Remove the cap, take a deep breath in and out and put the MDI
tightly sealed around your lips. Press while breathing in slowly and hold for 10 seconds. After that
breathe out through your nose. Wait 1 minute and take another puff.
With spacer - press the nebuliser and take 4 breaths

For a child give spacer and mask (cover nose and mouth)
Clean/rinse the spacer with warm water & soap, dry with hair dryer.
The peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) is a person's
maximum speed of expiration, as measured with a peak flow meter, a small, hand-held device used
to monitor a person's ability to breathe out air. It measures the airflow through the bronchi and thus
the degree of obstruction in the airways. The value is affected by age, gender and height.
Zone Reading Description

A peak flow reading in the green zone
Green 80 to 100 percent of the usual or normal
indicates that the asthma is under good
Zone peak flow readings are clear.
control.
Indicates caution. It may mean respiratory
Yellow 50 to 79 percent of the usual or normal
airways are narrowing and additional
Zone peak flow readings
medication may be required.
Indicates a medical emergency. Severe
airway narrowing may be occurring and
Red Less than 50 percent of the usual or
immediate action needs to be taken. This
Zone normal peak flow readings
would usually involve contacting a doctor
or hospital.
! 4!
Asthma (Child / Chronic)

A 6 yo boy has brought to GP clinic by his mom because he has poorly controlled asthma.
Task: take further history, identify the pattern of asthma & discuss management.
Hx:
When was the first time he’s diagnosed with asthma?
What’s the Mx?---ventolin regular or prn
Who helps him to take the medication?
Can you show me how do you give him the puffer later?
Does he have any symptoms at the moment?
When happen, when did it start?
Any associated symptoms  flu, cough, cold, fever, allergy
Severity Qs:
- How frequently does he get asthma?
- How many days a week, how many nights a week?
- Is asthma affecting his sleep?
- What happened in between attacks?
- How is his activity exercise, does it affect his daily activity
- Has he ever been admitted to hospital for asthma ---YES  how many times
Is there anything that makes his asthma worse, like cold, smoke, flu, pets, dust, pollen?
Is he allergic to anything?
Triggering factorcold, perfume, dust, pollen, pets, smoking, weather changing, exercise
Growth & development
Immunization --- BINDS questions
O/E:
GA: mental state  confused, drowsy, lethargy, ability to talk, cyanosis, pattern of breathing (any
accessory muscle in breathing), growth chart
VS: SO2, pulse
Chest inspection, palpation, auscultation
Explanation:
Mrs X, I’d like to tell you:
1. about your child’s condition now
2. Risk factor and how to avoid it
3. I will teach you how to use medication
4. I will give you Asthma Action Plan to follow in case of emergency
5. You need to take your child for review by GP within 48 hours
Asthma is a condition which affects breathing tube due to narrowing of air tube. Due to spasm of
muscle of the tube wall and mucus secretion making it harder for air to flow through it. Common
condition. Prognosis is generally good. Many children improve when they get older.
Avoid triggering factors otherwise recurrence may happen.

If recurrent flu, give flu vaccination every year
Please put your pets outside the room
Please tell the father to smoke outside the room
Try to vacuum everyday if there is carpet
Change bed cover once a week
Open window for 1 hour everyday
! 5!
I’m going to give you Asthma Action Plan. Three copies, one put at home, one for the child
care/school and one copy for the carer.
Red flags: If severe attack occurs like severe shortness of breath, inability to speak, blueness of lip,
you need to call 000 or 112  and tell severe acute asthma.
How to use medications This is the puffer; Spacer; Mouth piece; Mouthpiece goes into your lips, no
air out.
Salbutamol (short acting ventolin)
Salmeterol (long acting beta agonist)
• After using steroid, rinse the mouth because of candidiasis
Before exercise 2 puffs 20 minutes before exercise
Give reading materials

GP follow up
Physician review yearly
Asthma (Child / Acute)

A 6 yo boy brought to the ED because of severe asthma not responding to home treatment.
Task: assess patient’s severity & manage accordingly.
Hx: (stable or not)

When did it start?
What treatment did you give him?
Did you use any steroid?
Is he able to talk?
Is it the first time he’s brought to the ED?
Has he ever been admitted to hospital for asthma? How many times?
When was the first time he’s diagnosed with asthma?
What’s the Mx?
Any triggering factor (cold, perfume, dust, pollen, pets, smoking, weather changing)
O/E:
GA: confused, irritable, agitated, drowsy, work of accessory muscle of chest, growth chart
VS: pulse, BP, T, RR, SaO2
Chest
Assess patient after 20 min  OK  sent home

If not  keep patient in observation room  for 4 hours  if patient need to be admitted or
discharged
Advice during discharged

Asthma Discharged Package
1)I’d like to tell you what’s the child’s condition, what are the risk factors
2)I’ll show you the inhalation technique
3)Asthma Action Plasma
- If this attack happen at home or at any time, you’ll give 1 puff 4 breaths (repeat 4 times
continous), you’ll to call the hospital 000 and say asthma attack
4)You need to take your child for review to the GP within 48 hours after hospital discharged
5)There’s some handouts
! 6!
Asthma In Infancy
David, 6 months old brought by his Mom to ED b/o coughing over the last 3 days. He vomited
occasionally with the cough.
Task: take Hx from Mom, ask examiner for PE finding, explain Dx & DDx, Mx plan.
Flu-like symptoms before

Hot to touch
GA: not pale, not unwell, not dehydrated
VS: temp 37.4, HR 100, RR 45, BP normal, O2 sat 93% at RA
Lung auscultation: bilateral expiratory wheeze, good equal air entry, no crepitation
Character of cough: whooping, croup

Strong family history ---Dad asthma as a child & has hay fever; child has eczema. Mom has eczema.
Repeated infections ---it happened 2 months ago & improved in 2 days
Signs of respiratory distress (coughing & runny nose)

- cyanosis
- nasal flaring (nose in & out)
- tachypnoeic (fast breathing)
- wheezes (bronchiolitis & asthma)
- tracheal tug
- accessory muscle
- chest indrawing
- intercostal & subcostal retraction
- abdominal recession
Hx
How long---2-3 days
Day & night or mainly night, nocturnal cough (asthma)---nocturnal
Dry or wet cough
Green nasal discharge
What type of cough? is it barking or croupy cough or cough cough cough and vomit or turn red at the
end of coughing (whooping)---No
Associated with fever, flu-like symptoms, wheezes, reflux---hot to touch, flu for 3 days, wheezy
Any past history of wheezes---2 mths ago wheezy but not bad like this time, he improved within 2 ds
Cough affecting his sleep
Drinking with milk or solid food, vomiting?
Any episode of choking
In bronchiolitis happy baby with wheezing
Preterm baby (bronchopulmonary dysplasia require surfactant)
Normal vaginal birth or not
PMHx and FHx of eczema, asthma, hey fever or other allergies.
6 months old, wheezy chest & history of eczema ---ATOPIC child
Most likely has asthma
Anyone smoking in the family---Dad & Mom
Other children healthy
Any contact with whooping cough person
O/E:
GA: Signs of respiratory distress; Growth & Development
VS: SaO2 92 % or less
Chest, heart, abdomen  in chest bilateral expiratory wheeze
! 7!
Mrs Smith, from history & examination, your child most likely has asthma, but it may be
bronchiolitis.
To diagnose asthma:
- If respond to Salbutamol
- Atopic
- Have family history of asthma
Start him on Salbutamol (Ventolin)

If the child with bronchiolitis respond to Ventolin, most likely he’ll have asthma later
Nocturnal cough, repeat episode, atopic, family history, wheezy  asthma

If improve with Salbutamol  asthma
It may be asthma. I need to admit to the hospital. If we decided to give him Salbutamol nebulizer 2.5
mg – 6 puffs by spacer
How will I use it?
Put the mask, shake the Ventolin, then press – let baby breath 4 times, press again until 6 puffs (1 puff
4 breathing)
If the child not improving  repeat after 20 minutes another 6 puffs by spacer
If still not improving  repeat
Three trials of Ventolin in 1 hour, if not improved  add Atrovent 250 mcg (repeat 3 times in 1 hour,
assess after each 20 minutes) and oral Prednisolone 1 mg/kg once daily (keep an eye on Oxygen give
3.5 L/min by nasal prongs)
- More oxygen, change nasal prongs by mask, give 4L/min

- Ventolin 2.5 mg every 30 min
- Stretch the Ventolin ½ - 1 hour
- If improving make it 1-2 hour, 2-3 hour then 4 hourly
- If stable from the 4 hourly, decrease O2 gradually
No improvement, admit to Paediatric and ask Paediatric team to assess

Ring the registrar
Discharge home
- Child is on 4-hourly Ventolin
- 24 hour with no Oxygen and stable
- Child start to drink & no signs of respiratory stress
At home 6 puffs :
- every 4 hours for 2 days
- every 6 hours for 2 days
- 8 hours for 2 days
- 12 hours for 2 days
! 8!
Asthma (Adult / Acute)

You’re in ED, a 25 year-old Thomas has been diagnosed with asthma. He has not been taking
medications for the past 6 months.
Task: assess the severity and manage accordingly.
Mild Moderate Severe

Talking Sentence Phrase Words
Pulse Rate <100 100-120 >120
PER (Peak Expiratory Flow Rate) >75% 50-75% <50%
Oxygen sat - - <90%
Central cyanosis - +/- +
Wheeze Variable Moderate to Loud Soft/(-)
FIRST, ask the examiner if patient is stable or not

Assess the severity
How do you feel right now
Do you a past history of severe asthma attack
Did you have a recent flu or cold?
Have you been exposed to a certain dust, allergy, pollen?
Did you take any exercise before the attack
What medicine are you on?
How’s your health in general?
PHx and FHx of eczema, hay fever
What’s your occupation?
O/E:
GA: level of consciousness, cyanosis, distress, SOB, cough, Talk in sentences, phrases, or
words
VS: T, PR, BP, RR, pulse oximeter
Chest: wheeze, ronchi, crepitation
Mx:
If mild, no admission
1) Inhaler ventolin 12 puffs with spacer or nebulized ventolin 5 mg
2) If patient is taking prednisolone orally, continue
3) If oxygen saturation is >90%, no need to take oxygen
4) If oxygen saturation is <90 %, give oxygen
Moderate, observe
1) Inhaler ventolin 12 puffs or nebulized ventolin 5 mg (every 1-4 hours)
2) Ipratropium bromide +/- 8 puffs
3) Steroid orally 25 mg (if able to take orally) or IV Hydrocortisone 250 mg
4) Oxygen if SaO2 < 90%
Severe, admit in ICU

1) Give oxygen
2) Ventolin (puffer/nebulizer) every 15-30 minutes if no response
! 9!
3) Salbutamol IV bolus dose

4) Ipratropium bromide by nebulizer
5) Steroid (IV/oral)
6) Aminophyllin
If patient is not responsive

- Chest X-ray
- Adrenalin
- Assisted ventilation (intubation)
Before discharge
1) Patient education about asthma, and how to use Ventolin, Peak Flow Meter
2) Asthma action plan
3) You need to review with GP after 48 hours
4) Need to continue steroid after discharge
5) Lastly monitor at home with Peak Expiratory Flow Meter
Asthma (Adult / Chronic)

A 25 year-old man, Thomas, presented to your GP clinic because of dry cough for 3 weeks.
Task: take further history, ask examiner for examination finding, and management.
Hx:
When did the cough start first? ---3 weeks ago
Any recent flu-like symptoms?
Was the cough all day & night? ---all the time
Have you produced any phlegm?  if yes  ask colour, odour, amount, consistency
Do you feel any SOB?
Any noisy breathing?
Do you have any chest tightness?
Temperature?
Any chest pain? ---slight chest pain because of cough
Any special time for you ---during winter
Triggering factor ---exercise, dust, flu
Smoking
Travel Hx
Contact with TB pt
PHx and FHx of asthma, hay fever, eczema
Has anyone in your family had a similar condition
Occupation  what do you do for your living
SADMA
Pets
Apart from this, do you have any other problem?
Anything that I miss that you haven’t told me?
O/E:
! 10!
GA: position, drowsy, distress or not, consciousness, breathing pattern, tell patient to cough
(dry or not), Any nasal flaring, cyanosis
VS: Pulse, BP, T, RR, SaO2
Chest:
- Movement of the lungs symmetrical or not,
- Accessory muscle movement,
- Wheeze (without stethoscope), ronchi (with stethoscope) in both lungs
Explanation:
You’re suffering most likely from asthma, but we need to do some tests for confirmation.
1)Spirometry
FEV1/FVC > 75% - normal  if less  asthma
We’ll give Ventolin to patient to check reversibility  1 puff 1 minute 1 puff  after 10
minutes  >15 % improved  asthma
If not improved  COPD (productive cough, occur every year)
2)Chest X-ray  if diagnosis uncertain
3)Challenge test  if uncertain diagnosis, occupational asthma, not responsive to treatment
4)Allergic test – RAST (Radio Allergo Sorbent Text)
Explanation:
Investigation has confirmed that you’re suffering from asthma.
It’s a common condition.
It’s an allergic disorder because some people are more sensitive to allergen.
Pathology of Asthma
- The whole wall tube secreting thick mucus
- The muscle wall becomes spastic
- The airway becomes thicker because there is no space
AIM OF MANAGEMENT
- Avoid triggering factor
- Minimise incidence of symptoms day and night
- No limitation of activity
- Normal pulmonary function >80%
! 11!
PAEDS: HAEMATOLOGY
HENOCH SCHONLEIN PURPURE (HSP)

A 4 yo boy presented to ED with his father c/o severe abdominal pain and limping, He also has skin
rash on buttocks and back of thigh. The child had URTI one week ago.
Task: ask investigation findings, explain diagnosis and management, answer father’s Qs.
DDx: ITP, PSGN
Hx:
Abdominal pain  pain Qs
Limping when did it start? Any specific site of pain?
Rash site, itchiness, blanching
Fever, joint pain, headache, vomiting
Appetite
Waterworks, color or urine (symptoms of UTI), joint painr/o PGNS
Bleeding from anywhere in the body?– gum bleed, hematuria, blood in stool
General health
Any concern about growth & development
Medication, allergy
Immunization
O/E:
Rash: non-blanching, oozing; Puffy eyes
Neck stiffness- absent
Ix:
FBE: WBC, Differential count, Platelets (to rule out ITP)
Urine: RBC, protein, cast
Stool analysis for blood in stool
U&E
Bleeding time
Coagulation time
Explanation:
Your son is most likely suffering from a condition called Henoch Schonlein Purpura. It is an
autoimmune disease, where person’s own body defence mechanism some times attacks the body cells
by mistake. What happened is that he has got antibodies in the body due to a previous infection. This
antibodies attack the wall of the blood vessels causing inflammation (vasculitis). It can affect
anywhere, but we’re more concerned about the skin (non-blanching rash), kidney (haematuria,
nephritis), and intestine (abdominal pain, intussuception, ileus, GI bleeding).
More common in boys between 2-8 years old.
Mx:
Admitt to hospital.
Paediatric registrar will see him and start on steroids which will help to decrease the duration of
illness, to decrease complications in kidneys and to relieve abdominal pain.
Urgent abdominal US to exclude complications such as overlapping of the intestine (intussuception),
slowing down of the gut (ileus), or bleeding in the gut as he has been complaining of abdominal pain
30% recurrence in the first 4 months after initial attack.

If there is no renal problem, follow-up in 6 months time check urine and blood pressure regularly
If there is renal problem, follow-up is for 1 year as the child can develop hypertension.
If the condition worsens, may need renal biopsy.
! 1!
PAEDS: HAEMATOLOGY
IMMUNE THROMBOCYTOPENIC PURPURA

A 3 yo Robert c/o widespread bruising of his skin for 2 days and small nose bleed yesterday for once.
He had flu-like symptoms 2 weeks ago. O/E, he is alert, numerous fresh bruises on trunk and limbs.
VS normal. No hepatomegaly or lymphadenopathy. Urgent FBE showed:
Hb 125 g% (100-146)
WBC 12000 (7000-14000), No immature cells, Differential count normal
Platelet 15000 (150000-250000)
Task: outline the provisional diagnosis according to blood result and discuss management.
DDx for child with fever and petechia:

- ITP
- Leukaemia
- Henoch-Schonlein Purpura
- Meningitis
DDx for child with bleeding:

- ITP
- Leukaemia
- Henoch-Schonlein Purpura
- Thrombotic thrombocytopenic purpura: primary-idiopathic, secondary-DIC, malignancy
- DIC (disseminated intravascular coagulation)
- Aplastic anaemia
- Infections - HIV
- Liver disease, malignancy
- Myelodysplasia
- Clotting factor deficiency
Explanation:
From exam and Ix it’s most likely your child is having immune thrombocytopaenic purpura. It is an
immune reaction. As your child had a viral infection 2 weeks ago, his body produced a substance
called antibody to fight against the infection. Unfortunately sometimes this antibody attacks our own
body tissues. In your child’s case the antibody is attacking the platelets.
Platelets help our blood to clot. Now as platelet cannot work well it's is causing bleeding.
It is usually a self limiting condition and most of the children recover within 4 to 8 weeks.
Tx : (admit as Plt < 20,000)

- Steroid (prednisolone) oral: severe bleeding and platelet count <50,000 or for all pt with <30,000
- Immunoglobulin if unresponsive to steroid, severe bleeding or platelet <20,000
- If fail, give thrombopoetic agent to stimulate the bone marrow to produce platelet
- If bleeding continues, he might need blood transfusion or platelet transfusion
- Finally, if chronic (6 months), consider splenectomy - need vaccination for pneumococcal organism.
Complication of ITP
- Intracranial bleeding
- Internal bleeding
- Adverse effect of steroid
Outcome (see AMC book case)

- >80% full recovery
- 10% can get chronic ITP  therapy splenectomy
- 10% outcome unsure
- If recurrence, look for other underlying cause like lupus
! 2!
PAEDS: HAEMATOLOGY
PANCYTOPENIA
A 3 yo boy came with father b/o tiredness, not eating well, T 39. Blood tests showed:
Hb 8 g/L (11 – 14)
WCC 2000 (5000 – 9000)
Platelet 20 000 (150 000 – 400 000)
Task: further history, discuss results of blood tests with father, outline the management plan.
DDx
- Fancony anemia
- Leukemia
- Lymphoma
- Multiple myeloma (not in children)
- Aplastic anaemia
- Myelofibrosis/Myelodysplasia of bone marrow
- Bone marrow infiltration from other tumour (metastasis)
- Chronic infection, TB, HIV
- Radiotherapy
- Exposure to benzene (petrol)
Hx:
How long has he been unwell?
Does he have any systemic illness?
Any bleeding from nose or anywhere else in the body?
Any recent medication?
Any allergy?
Family history of similar condition
Growth & Development
Immunization
Explanation:
He has a condition called Pantytopenia (Don’t jump to the Dx because it’s not the task and bone
marrow haven’t done yet. So just give DDx). In which all components of the blood are decreased.
It’s serious condition, needs further investigation  bone marrow
Refer to paediatrician & haematologist
Bone marrow  aspiration from iliac crest under general anaesthesia
Start antibiotic because he has fever
Steroid because he has thrombocytopenia and first-line therapy for leukaemia
If platelet < 15 000  platelet transfusion
Stem Cell
- ↓ Myeloid stem cell (bone marrow)
o ↓ RBC, ↓WCC, ↓ Platelets
- ↑ Lymphoid stem cell (bone marrow)
o ↑ Lymphocyte (immature)
! 3!
PAEDS: HAEMATOLOGY
Acute
- Myeloid  elderly
- Lymphoid  children
Chronic
- Myeloid
- Lymphoid
Leukemia is characterized by rapid increase of immature blood cell. This crowding makes
bone marrow not producing healthy blood cell.
Chronic leukemia is characterized by excessive built up of relatively immature white blood

cells. This can be accidentally discovered.
Aleukemic leukemia when there is not much WBC in the peripheral blood yet (all in bone
marrow).
Classification can be done according to the type of cell affected:

- Myeloid
- Lymphoid
Signs & Symptoms

- Bruise
- Infection
- Tiredness
- Anaemic Fever
Risk factors
- Family history (genetic)
- Viral infection (EBV – infectious mononucleosis)
- Down syndrome
- Exposure of radiotherapy/chemicals
Management
- Chemotherapy
- Radiotherapy
- Bone marrow transplant  only 30% compatible
Prognosis
5-year survival rate  85%
! 4!
PAEDS: HAEMATOLOGY
PANCYTOPENIA
A 3 year-old child brought by his father because of tiredness & high temperature.
Task: Hx, PE, & outline possible Dx & Mx.
Microcytic anemia  iron, Thalassemia

Macrocytic  B12, folic acid
Tiredness  usually means anaemia

Fever (leucopenia) + anemia  pancytopenia  ask for bleeding
Hx:
FeverWhen did it start? Have you checked it? How high? Continuous or not? Panadol?
Tiredness can you tell me more about it? (Lethargy, not playing, not happy, prefer to lie
down all the time)
Febrile case ---ask for system review for source of infection
Respiratory  any cough, SOB, wheezy chest, sore throat, runny nose, ear aches
GIT  appetite loss (is he off his food), N/V, abdominal pain, any change in the bowel habits
Urinary system  change in urine colour, smell, any pain while passing urine
Bleeding  easy bruising, bleeding from other sites like nose, gums, urine, stool
Any skin rash?
Abnormal movements or fits?
Any contact with any other child with similar condition?
Growth & development (growth velocity  comparing from previous) ---so far normal
Diet  what is he eating --- vegetarian families
Any past medical history
Is the child on any medication? --- Chloramphenicol might cause pancytopenia
Any history of blood transfusion?
History of blood diseases in the family
O/E:
GA: looking ill or well, pallor, multiple bruises of different ages, growth parameters
VS: T 39
LN: cervical lymphadenopathy,
Abdomen: no hepatosplenomegaly
I need to do some blood tests (FBE) to know what’s going on. 

Result: Hb 8, WBC 2 000, Platelets 20 000, normochromic normocytic, any abnormal cells
(immature or blast cells)  in this case no abnormal cells
The blood result is bad, it showed pancytopenia which means the 3 important elements of the
blood are reduced, the Hb, white cells and thrombocytes. The white cells for defence or
immunity. If low cause infection. Red cells – anemia, tiredness. Thrombocyte low cause
bleeding. This can be due to a lot of reasons and your child needs further investigation. For
this, I need to admit your child to the hospital because the condition can be a serious one.
In ED he will be seen by a paediatrician.
! 5!
PAEDS: HAEMATOLOGY
Need further Ix: bone marrow examination (hip crest). Sepsis screening: urinary, blood
cultures and lumbar puncture (to see any CNS involvement), LFT, chest X-ray, abdominal
US,
Causes of pancytopenia:
1) Decrease production of blood cells
- Infiltration of the bone marrow like leukemia (Acute Lymphoblastic Leukemia – large
percentage of blast cells)
- Aplastic:
o Aplastic anemia (aplasia)
o Drug-induced like chloramphenicol, sulphonamide
o Megaloblastic anemia
o Congenital (Fanconi syndrome)
o Viral: EBV, HPV
- Acquired
2) Increased destruction/sequestration (hypersplenism)
Bone marrow is diagnostic.
General & Specific treatment:

- Antibiotics for leucopenia
- Blood transfusion (or iron supplement )for anemia
- Leukemia  chemotherapy
- Megaloblastic  folic acid, B12
My wife is away, do you want me to call her?

It’s a good idea if you call her because it can be a serious condition.
! 6!
PAEDS: CVS
HEART FAILURE
David, 7 weeks old brought by his Mom to ED because of coughing, wheezy and distress.
Task: Take history, examination, explain diagnosis & management.
Key issues
- Wheezes & respiratory distress are common presentation of CHF in paediatrics (not every wheezy
baby has respiratory problem), consider CHF for infant with tachypnoea, esp. in winter
(bronchiolitis season)
- Appropriate heart exam
- Pulse
- If BP increase in 1 limb, measure in 4 limbs
- Growth chart
- CXR shows a big heart
- Good management plan including admission, investigation, arranging therapy
- Paediatric cardiology consultation
Critical errors
- Didn’t consider Heart Failure
- Unable to understand that baby needs admission
O/E:
GA: alert, looks unwell, non toxic, fuzzy, moderate respiratory distress (mild intercostal retraction), a
little bit irritable, anterior fontanelle flat, not dehydrated, mucus membrane moist, sweating
Percentile – not gaining weight (under 3rd centile for his age), poor feeding
VS: T 37.2, HR 68/min, RR 70/min, SaO2 96%, BP 120/86 (N 80/60), Measure BP in 4 limbs (L arm
126/86, R arm132/92, L leg 69/41, R leg 63/49) , femoral pulse (use 2 fingers) very difficult to feel:
radio-radial, radio-femoral delay
Chest: diffuse wheezes & crepitation bilateral with intercostal retraction
Heart:
Abdomen: soft, non tender, active bowel sound, Hepatomegaly (liver 3 cm below the R costal margin)
Chest X-ray: Congenital heart disease
Explanation:
David has wheezy for a few weeks, bilateral crepitation, hypertensive different from upper and lower
limb, big heart and big liver, tired which suggest he has heart failure secondary to coarctation aorta.
Need to admit to paediatric ICU

Ix: CXR, ECG, blood test
Start on IV diuretics as continuous infusion & Dobutamine
Contact paediatric cardiologist
! 1!
PAEDS: CVS
INNOCENT MURMUR (AMC P49, 224, 666)

A 4 yo boy was seen by a doctor during holiday. A soft, cardiac murmur was heard. His parents were
asked to see the family doctor to decide if any further investigation needs to be done.
Task: Hx, Ex, explain the condition and Mx
Innocent Organic
Well-thriving Underweight
Exercise tolerance Good No
Chest Infection No Recurrent infection
Cyanosis No Yes
Murmur Soft mid-systolic Loud diastolic compartment
Changes with position Yes No change
respiration
Radiation or thrill No Yes
Hx:
- Qs regarding murmur
- Change in the colour of the lips
- Sudden stops when playing
- Eating, sleeping, excessive crying, shortness of breath
- BIND
- Family history of heart disease---his cousin has a hole in the heart, will this happen to her child
O/E:
GA: any dysmorphic feature, cyanosis, pale, growth and development
VS: normal (no palpitation)
Heart:
- listen – soft, vibrating in mid systolic grade II-VI,
- high pitched at the base of the heart,
- no palpitation, no thrill,
- changes with position & respiration
Explanation:
Your child has a condition called innocent murmur.
It’s very common in young children and >40% of healthy children may have it.
It’s caused by hyperdynamic circulation, his heart beating very fast because your child is growing.
Your child is thriving well, no recurrent chest infection, no cyanosis and tolerating exercise well. I’m
happy with the examination. There’s no signs suggest alternative diagnosis.
You child should be allowed normal activities.
If you’re concerned, I can refer you to a cardiologist.
! 2!
PAEDS: CVS
VENTRICLE SEPTAL DEFECT (VSD)

A 6 month-old baby was diagnosed with VSD by Echo. The baby is thriving well. She’s
eating well. Her growth is normal.
Task: Explain the condition and answer the questions.
How are you? How is your baby doing? How’s the situation at home?
We suspected Tom has a small hold in his heart and it has confirmed by ultrasound of the
heart (echo). The condition is called ventricular septal defect.
DRAW the heart There are 4 chambers in the heart. There is a hole between the ventricles.
We call the hole a defect.
It’s a congenital disorder in which there is a connection between the 2 chambers and there is
a flow from left to the right. It can be mild, moderate and severe. In Tom’s case, it’s mild
which is good news. Because it’s small and Tom is OK, we can wait until it’s closed by itself.
It’s good that her growth, sleep, apetite and development are good. All these are good signs.
What’s going to happen in the future?

When the heart grows, it will close or stay at the same size but will not get bigger. So our
management will be regular check-up, cardiologist will follow-up yearly. Your child should
have immunization, prophylactic antibiotics before dental procedure or surgery.
Next child having the same condition?

Not necessary
Is it passing from the mother?

There’s no specific reason
Red flags:
Signs of heart failure: cyanosis, shortness of breath, not gaining weight, not feeling well,
infection, swelling in the face.
It’s a treatable condition and leads to normal life.
These are some reading material for you. If you have any questions, write them down and I’ll
be more than happy to explain to you.
!
! 3!
PAEDS: DEVELOPMENTAL PROBLEMS
DELAYED WALKING—NORMAL VARIANT

Mrs Brown is worried about her son, 18 months old, who is not yet walking.
Task: take history, examination, diagnosis, management.
Milestones for 18mth walks well (gross), drinks from cup (social), build tower of 2 blocks
(fine motor adaptive), three words other than “mum” and “dad”
Hx:
What do mean by not walking?
Milestones(now and before) Sits with support; stands with support; Walks with support
Eye contact
Any progressing of activity / walking?
Pregnancy
- normal vaginal delivery or not
- term or preterm (could be a reason)premature
- assisted delivery?
- post partum jaundice
ChildcareDoes the child go to childcare? What kind of child care? How many children
there? What kind of activities do they do there?
Is mum working? How long do you spend time with him?
Dad? Any interaction between you, your husband and him?
Family settingcarpet? Timber floor? Marble?
FHx
O/E:
GA; VS; Growth parameter
Neurological exam – tone, power, reflexes
Hip exam, knee exammuscle atrophy, hip dislocation, deformity
Explanation:
From history & examination, I couldn’t find any abnormalities on his growth & development
apart from delay in walking. It could be a normal variant.
Mx:
Physiotherapy
Review regularly
CRITICAL EROR
Tell mom that the child has serious problem
! 1!
PLAGIOCEPHALY
David, a 9 month-old child with head oddly shaped.
Task: take history, examination, DDx, diagnosis & management.
Critical errors:
Failure to reassure of the diagnosis to the Mom
Over investigation
Hx:
What do you mean by oddly shaped? size is big, shape is abnormal
When did you notice it? Noticed 4 months ago and not improving
Vomiting (increase intracranial pressure)
Fits (epilepsy)
Mile stone Can he sit without support? Crawling?
Pregnancy antenatal check up, US, any infection, any medical illness
Birth history normal vaginal delivery, no vacumn
Resuscitation after birth?  no
Feeding, sleeping, growing, active
Any other concern about his growth and development?
General health
Any abnormal head / brain tumor in the family (familial)?
O/E:
GA: alert, active, smile, Any dysmorphic feature (mentally OK, no signs of Down syndrome)
VS: normal
Chest, heart, abdomen, genitalia: normal
Head: (photo provided)
- Can I feel the suture lines (?cranio-synostosis; ?premature closure of sutures)
- Anterior fontanelle (if tense, large  increase intracranial pressure)
- Head circumference (if small - microcephaly  chromosomal anomalies, fetal alcohol syndrome,
TORCH) (if big  hydrocephalus)
Height & weight
Hearing, vision & speech
! 2!
Explanation:
Everything from the history & examination is normal. It’s normal the shape of head like that.
Positional plagiocephaly (or positional molding of the head) is a disorder in which the back or one
side of an infant's head is flattened, often with little hair growing in that area. It's most often the result
of babies spending a lot of time lying on their backs or often being in a position where the head is
resting against a flat surface (such as in cribs, strollers, swings, and playpens). The flat spot on the
back or one side of the head is caused by remaining in one position for too long.
It can be caused by a condition called torticollis in which neck muscles on one side of the head
develop differently, causing the head to tilt to one side, but more commonly it happens in infants of
ordinary development who sleep in one position for long periods of time.
If head tilted to the right, face turned to the left  congenital torticollis
It’s not uncommon and not risky. Gradually it will improve
Mx:
- Active repositioning of the child's head while sleeping can be tried.
- He should have tummy time (give him sometimes sleeping on his tummy)
- Change the position of his cot
- Deal from the unaffected side (flat head) force the baby to turn  placing objects which attract
the baby's attention to lure them to turn their head the opposite direction of the flattened part may
work
- Send to paediatrician – craniofacial unit at Royal Children Hospital, they can give him a helmet
Prognosis for this condition is excellent and resolves in most cases before one year of age.
DDx: Craniosynostosis (premature closure of the suture line)

Another, similar condition called craniosynostosis occurs when bones in the skull fuse together too
soon. This is a much more serious condition that requires surgery.
To differentiate between plagiocephaly and craniosynostosis  X-ray of the head
! 3!
STUTTERING
A 4 yo boy came with his father c/o stuttering for the last 6 months. He was normal before but
developed it since he joined kindergarten. He gets this condition when he gets excited. Growth &
development normal.
Task: Take relevant history, exam finding from examiner, diagnosis & management.
Hx:
How long has he been having this condition?--started 6 mths ago when he went to kindergarten.
Any consultation?---no
Typesdifficulty to start a sentence, it was gradual
After he stuck with words, how’s his feeling?--embarrassed, anxious and can’t complete his speaking
How were your attitude, did you blame him, punish him?
Did you relate his condition with the environment around him?----since he attend kindergarten
Any recent change in the family like moving house, new sibling?--- has a 2 months old boy
I’d like to know his attitude at home. Does he speak with other family members?---before yes, but as
he has developed this problem, he started to withdraw himself?
When you ask him to speak in front of his new friends, does he agree to do that?
General health
Any problem with hearing or repeated URTI
growth & development
Immunization
Pt’s Qs:
Why did he develop stuttering?
What about his intelligence, will it affect him in future no relation between stuttering & intelligence
Types of stuttering
1. Your child has a period of silence and start to develop his speaking. He become normal
afterwards (difficult to start speaking) ----------<
2. Start to speak, develop a period of silence, start to speak and develop a period of silence again
(speaking normally, stuck with one word, then speaking normally) < ----- < ------
3. Prolongation of the same words …..unnnnnncle
4. Repeated words until he got the right word ……it it it…..
About 5% of the children can stutter. Percentage between boys and girls  3 : 1. After 9 years of age,
the improvement is very poor. 50-75% related to genetic problem.
Problem with a new place, new circumstances in the family like separation of parents, moving home;
speak in front of new people
Refer to speech pathologist. After 5 years the result will be affected by his age. The successful rate of
treatment 80-90%. We will require frequent visits. you & his Mom should be involved during the
treatment. We would also like to contact school teacher to inform about the problem. We need to
manage as a teamwork to overcome his problem.
Do and Don’t
- Praise him when he speaks fluently
- Listen to him, don’t interrupt him when he speaks. Just listen him carefully, don’t criticise him or
correct him or try to complete his words.
- Reassure him, give encouragement to him to speak
- Draw your attention to his speaking
! 4!
CEREBRAL PALSY
An 8 months old boy came with his father for 6 months immunization boost. His
immunization was delayed because of his grandma’s funeral. At the same time, the father
complained that his son cannot sit properly because of a curve on his back.
Task: Take history, ask PE findings, investigation then discuss with father.
Hx:
I understand that you have come for the immunization. You missed the immunization b/o the
grandma’s funeral, I’m sorry to hear about that. Before giving immunization, I’d like to ask
some questions regarding your child.
How is your baby now? Has he got any problem since the last immunization?----no
Bottle or breast feed?
How is his growth and development so far?---he cannot sit till now
Milestones Did he babble (2 months), smile and hold his neck (3 months)? Can he crawl (8
months)? Can he sit with support? Everything normal except cannot sit
Has he had any trauma to the head before?
Does anyone else in the family have similar problem?
Apart from this immunization, is his previous immunization up-to-date?
How was the pregnancy and all antenatal check-ups?
Has your wife used any medication during the pregnancy?---yes because of toxaemia
Was any abnormality detected at 18 weeks US?
How was the delivery, was it full term or any assistance required? – C Section
Birth weight (low birth wt is risk factor)
Did your child need any resuscitation?----yes APGAR score of 1 and 4
Is he on any medication?
Is he allergic to anything?
Do you have enough support at home? (If not  arrange for a community worker)
O/E:
GA: alert, active, playful, eye contact;
Growth chart (Ht, wt, head circumference)---at the lower limit
VS
ENT/Lymph Node
CVS/Respiratory/GIT
Genital areatestis
Neurological  muscle power, tone, reflex
Check the back for abnormal posture
Explanation:
From Hx & PE, most likely your child is having a condition called Cerebral Palsy. Have you
ever heard about this condition?
It’s actually a disorder of posture & movement due to defect or lesion of developing brain.
It’s not an uncommon condition (2/1000). Unfortunately it’s not curable and needs life-long
support and care. The exact cause is unknown. Lack of oxygen supply during delivery or any
illness after delivery can be a risk factor for this condition. In your case, your child needed
resuscitation after delivery, so this could be the reason.
! 5!
Mx
I’ll refer your child to a specialist for further assessment & investigation. He will assess his
hearing, vision, and detailed neurological assessment.
The disease will be dealt by a multidisciplinary teamGP, specialists, social workers,
physiotherapist, orthotics, occupational therapist, speech pathologist, and dietician. Sometime
nutrition is a problem, if child cannot do exercise he might be obese or if he cannot eat food
he will suffer from malnutrition. Some of the children might need surgery for a knee joint or
hip joint. The specialist will design special braces to improve function and support and
prevent any further deformity. Sometimes they need to be referred to the nurses and
psychologist for further assessment. When he goes to school sometimes they have a special
education teacher.
I can also arrange a social worker for you and Centrelink can help you financially.
Support group
Reading material
Follow up
(If there’s no risk factor foundgenetic counselling)
Complications:
Epilepsy (approx 50%)
Speech and language problems
Hearing deficits (approx 3-10%)
Visual problems (approx 40%): refractive errors, visual field defects and cortical visual
impairment, strabismus
Intellectual disability, learning problems and perceptual difficulties
! 6!
SPEECH DELAY
A 9 month-old baby came with parents because the baby couldn’t say any words. The baby
was seen by another GP a few days earlier. All findings were normal. Pregnancy and delivery
were OK. Body weight was normal. Immunization up-to-date.
Task: relevant Hx and manage the case. No PE required. Answer Qs from parents.
DDx:
Normal variation
Speech delay
hearing disorder
Autism eye contact, excessive crying, attach to a specific toys, FHx,
Hx:
Was it a planned pregnancy (because some medication may affect the baby  Gentamicin)
What about after delivery, any problem such as jaundice?
Since birth up till now was the baby well?---yes
What about his response regarding any loud sound around him?---sometimes he get scared
When you call him his name, does he turn his head?---yes
What about when you switch on the TV, does he pay attention?
Some games such as peek-a-boo, does he smile when you play with him?
How’s his motion, growth & development in general, does he sit by himself, does he stand
with help
How about his feeding, has he established solid food, does he grasp the food and feed himself
Does he hear noise and become alert to any sound
What’s the type of speaking does he have? ---babbling
Family history of speech problem---his grandma
Any medical issue like bowel problem, chest problem, UTI (general health)
Any URTI especially if complicated with otitis media or ear infection
Explanation:
Mrs Smith, speech and language problem are divided into 2 types:
- Receptive --the baby can’t understand your words
- Expressive – he understand but he can’t express his answer
Delay of the language or speech can be associated with other medical issue or it can be
normal variant. From the history, there is no issue that can lead to a speech problem.
Refer to an audiologistcheck his hearing (audiometry)
If you’re very concern I can refer you to a speech pathologist
I will follow her up. If you have some concern in the future, I can refer you to a paediatrician.
! 7!
HEARING PROBLEM IN 11 MONTH-OLD (AMC)

An 11 month-old child is suffering from hearing problem. Mother came to you and asked
what she needs to do for her son.
Task: take history and discuss manaement with the mother.
Parents concern – refer for audiometry
Hx:
From the notes, I understand that you are concerned about your son’s has hearing
Could you tell me what are you concerned about---community nurse told me
I appreciate that you have come to me and I will try to work out the problem
Past pregnancy history
- How was your pregnancy and antenatal period---good
- Did you take any medication during pregnancy---no
- Any infection (TORCH) during pregnancy
Delivery history
- Is your baby born at full term?
- How was your delivery?
- Any complication during and after delivery?
- What was your baby’s birth weight?
- Did he need any resuscitation after delivery?
- did he develope jaundice, infection, sepsis after delivery?---no
How is his past medical history, any ear infection, measles, mumps, meningitis?
Any trauma to the head?
Any discharge from the ears?
Any family history of hearing loss, mother, father, sibling?
Has he been admitted to hospital for any kind of condition?
Milestones
- When you speak, is he able to respond or move his head?
- When you turn on the TV & radio, is he able to turn his head?
- Is he scared of loud voice?
- When someone called his name, does he respond?---yes
- Can your baby speak any words?
- When was the first time he smiled?
- Can he sit without support?
Do you have any other concern about his growth & development?
Explanation:
From history, I found his growth & development all right, I could not find any abnormality,
but for confirmation I’d like to arrange for an audiometry testing for him and if abnormal,
refer him to an ENT paediatrician specialist.
For sibling too if there is any problem
If family history (+) refer for genetic study
What are the causes of hearing loss:

- Congenital sensory hearing loss depends on the type (50% hereditary from family and
50% non hereditary)
- Acquired
! 8!
PAEDS: IDDM
IDDM
Nadia, 14 years old, presented to you in your GP clinic to review her blood test results. She’s
an IDDM patient since 9 years of age. Her blood test showed that her HbA1c = 13.
Task: take history and explain your management plan.
Insulin twice a day

Skip meals
Sometimes feel tired
Control of your BSL is not good
Why are you not taking the medication regularly
Need to do urine dipstick
Needs to be re-educated for her diabetes
Mom is drug addict
Attending school anymore
Sexually active – had 2 emergency pills
Hx: (Confidentiality)
DM
At risk of self harm
Sexual health issues
Consider why her DM is not well controlled
Is she compliant with her insulin---no
What’s her diet
Access to money for extra food
Diagnosed with IDDM at the age of 9 years, the mother is IV drug user, she takes the
responsibility to manage her DM herself – she needs to be responsible for her illness
Adolescents have significant issues in DM, they are at risk of :
- insulin resistance
- eating disorder
- decrease compliance (not happy to take her medication)
Important to assess her moods and explore symptoms of depression
Appetite, concentration, enjoyment of activities
Stress at home
To score how they are feeling, to compare next time you consult her
Let’s talk about your mood, 10 is you feel life is fantastic, 1 not worth living, can you score
between 1 and 10
What number would you give yourself today
Have you been at the lower end 1-2
Have you any thought of hurting yourself
Actually hurt yourself –history of hurting herself (+)
Any plan to hurt yourself
! 1!
PAEDS: IDDM
How are you feeling at the moment

(Is she safe to leave your room or not)
If she has a significant risk of self-harm, involve the psych team
Physical exam may reveal evidence of self-harm which she will not disclose
HEADSS
H – Home
E – Education, Employment, Eating, Exercise
A – Activities
D – Depression
D – Drugs, Driving, Drink and Drive
S – Suicidal, Self harm
S – Sexuality, Spirituality, Safety, Sunscreen
Mx:
Admission to hospital for DM Mx, adjust insulin dose(Ask yourself if she’s safe to go home)
Diabetic education
Address the risk of psychological & social issue - involve psychologist
Education regarding sexual health issue
Further education at the hospital
She wanted her mom to be more involved in her health & life in general, need to ask her
Mom to come
Maintain regular contact with her
Social worker to be involved, dietician, mental health team, psychiatrist, adolescense
educator
Available resources
Explore the underlying of HbA1C
In your stomach you have a big gland which secretes insulin. The insulin is not enough
causing the sugar to become high, it can affect your eye (blind), BP, legs & circulation,
kidneys, heart and stroke
Re-educate about DM
Regulate the insulin (adjusting the insulin) with DM educator and specialist
Need to monitor BSL regularly
Eye check
Measure BSL with urine dipstick
Examine urine microalbumin
Take care of the foot
If <14 years old, need to have the parents or guardian consent

14-16 years old  grey area  patient can give consent if she’s mature enough to discuss her
issues, understand the implication & complication of treatment
>16 years old  mature enough to make decision without parent’s involvement
! 2!
PAEDS: IDDM
IDDM in child (AMC 27)

A 4 year-old boy Roger is admitted to paediatric unit. You’re an HMO. This is the first presentation
of type 1 DM. His general condition is satisfactory. He has already commenced insulin therapy and
has stabilised with good blood sugar control. His mother has asked you for more questions.
Other stem: A 4 year-old child with growth retardation, increase of thirst, passing a lot of urine, and
no other problem.
I understand……how do you feel about that

Do you understand what DM is -----give explanation, draw pictures
Anyone in the family has DM
It’s good that it was diagnosed early so that it can be managed in a better way
This will be managed by a multidisciplinary team
Don’t worry. This is a very common condition and mpst of the patients lead a normal life
Roger will need lifelong insulin injection.
Do you know what insulin is?
Usually insulin 2/d need to be given by a family member (in teenager and adult 4 times daily)
The specialist will decide the dose and follow-up will be done by GP
Blood sugar needs to be monitored twice daily with glucometer
The diabetes educator will teach you & your family member how to give the insulin injection
With practice and patience, even Roger can give the injection himself
DM can’t be cured but can be controlled
The specialist will decide the specific type and dose of insulin
Also, I’ll refer you to a dietician. He will talk about healthy diet. Usually he will need 3 main meals
and 2 snacks; Keep him away from junk food, fatty food
Diabetes education will instruct the school teacher and the school will be given phone numbers
Any new teachers should be informed
School camps
- Management is related to the confidence and experience of teachers
- A letter to the GP in that area (camping area) can be given explaining the insulin regime, BSL
- If the child is young, parent can attend the camp
Sleep over
- You should inform Roger’s friend parents about his condition
- It would be better if the place is close to your house so that you can go there and give the insulin
injection
HYPOGLYCAEMIA -----Critical error

- You should be aware of hypoglycaemia which means decrease of blood sugar level with
symptoms of abdominal pain, nausea, vomiting, drowsiness, dizziness, sweating
- If that happens, advise him to take jelly beans
- Also, you need to learn how and when to give Glucagon
Sports
- Play any sports, but before any active sport, insulin dose has to be adjusted and the reason is that
activity or exercise will utilise more glucose and decrease blood glucose level (decrease insulin
dose)
Any other questions

Do you want me to talk to other family members
Support groups  phone number and address
! 3!
PAEDS: ENT & RS
Allergic Rhinitis
A mother came with her 3 year-old child complaining that her daugter could not breath from
her nose. Mostly from mouth, recurrent URTI, nasal discharge, snoring at night, eczema.
Task: relevant Hx, ask for examination finding, arrange Ix, explain Dx & management.
Hx:
How long has she had this problem?
How frequent?
Any relation to any specific season?
Could you please describe about the discharge?
Any nasal blockage, unilateral/bilateral?
Itchy nose/eye?
Repeated sneezing? Cough, wheezing?
Does it affect her daily activities
Eczema  when was it diagnosed?
Any relieving or aggravating factors Pets, smoking at home
Family history of allergy
Hearing problem?
Pregnancy, delivery, development, immunization
O/E:
GA: dysmorphic features, adenoid face, open mouth
VS
Nose: nasal speculum Air passage, nasal mucosa (pale, water discharge)
Oral cavity, tonsil and adenoid
Ears
Lymph node
Neck, lungs, CVS and abdomen
Ix: FBC eosinophilia
Explanation:
Your daughter has a condition called allergic rhinitis.
The mucosal membrane in her nose become inflamed due to increase sensitivity to
environmental allergens. It may be pets, dusts, pollens.
Common symptoms  watery nasal discharge, sneezing, nasal congestion, itchiness
It’s a very common allergy in the family
I’d like to refer you to a paediatrician who will do some tests:
- Skin Allergen Test
- RAST (radioallergosorbent test)
We can use topical steroid, beclomethasone nasal spray to relieve symptoms
The best way is to avoid allergens regular vacuum cleaning every week, remove carpet if
possible, avoid contact with pets. Smoking is a risk factor.
RED FLAG  hearing problem
! 1!
PAEDS: ENT & RS
Common Cold
A 20 year-old girl presented with sore throat and runny nose.
Task: take relevant history, ask exam finding, discuss management.
Hx:
When did it start?
Did you take anything for it?
Fever, rash, cough, hoarseness of voice, N/V, diarrhoea, joint pain, skin color changed, did
you feel lumps in your neck or any part of your body? general malaise, body ache but no
joint pain.
Are you sexually active? How many partners? r/o HIV
Anyone at home has symptoms like you? partner has cold last week and is all right now.
You told me that you have antibiotics before, is that repeated Last 2 times I had for
tonsillitis and high fever.
When was that?  2-3 months ago
Between this attack were you ok?----yes
Have you travelled recently?---no
Are you on any medication?
Have you been diagnosed with any serious condition like hypertension?
Are you working?---yes
Does anyone in your work has the same problem---no
SADMA ---smoking can cause pharyngitis
O/E:
GA: looks tired, little bit dizzy
VS: T 37.8, P & BP normal
ENT: oral cavity  a mild pharyngitis, tonsil free, ear drum is normal, blocked nose
Neck stiffness
Any joint pain, arthralgia, lymphadenopathy, rash
Chest, heart, abdomen  all normal
Explanation:
Mrs Smith, from the Hx & exam you have a viral infection or common cold.
I can’t give you antibiotics because it doesn’t affect your condition.
I advice you to have a good rest, will give you medical certificate, try to sleep in good
amount, also you have to increase your fluid intake. You will have analgesics like
paracetamol. If you have some problems with your nose, there is a steam inhalation. Vitamin
C powder or tablet. Gargle.
Ix:
FBE
Monospot test  atypical lymphocyte (for glandula fever)
Complication: pharyngitis, otitis media, pneumonia, sinusitis
! 2!
PAEDS: ENT & RS
Viral URTI
Mrs Smith brings her 6 month-old daughter Sally because of fever, cough, runny nose.
Task: take history, examination, diagnosis & management.
DDx:
Viral URTI
Bronchiolitis
Pneumonia
Whooping cough
Hx:
Fever, cough, runny nose for 3 days, temp 38
No vomiting, decrease feeding, sleep – restless
Bowel motion (-) since yesterday
Pregnancy & delivery good
An only child, neighbour has cold
Goes to childcare twice a week
O/E:
GA
VS
ENT: ear red, runny nose
Chest: grunting, crepitation
- Inspection
o RR increase, grunting (pneumonia)
o Any wheezing
o Any stridor (croup)
o Any subcostal recession, intercostal muscle retraction
o Any hyperinflated lungs
- Auscultation : chest sound, crepitation
Explanation:
Risk of bacterial infection assessed by the following factors, indicate the child has a low risk:
- temperature not too high
- RR minimal increase
- Feeding relatively normal
- No vomiting
- Sleep well
- Wet nappies normal
Mx:
Conservative
Reassure mother
Make sure baby drinks well, Check wet nappies not decrease, sleep well not irritable
Panadol
Avoid sending to childcare for 2-3 days
If the baby appears sick, noisy breathing, refuse to drink, decrease wet nappies, high
temperature  bring back to ED
! 3!
PAEDS: ENT & RS
RESPIRATORY TRACT
Upper respiratory tract
- Sinusitis (rare)
- Pharyngitis
o Viral
o Bacteria (Streptococcus, Hib)
- Tonsilitis
o Viral – EBV, adenovirus, coxsackie virus
o Streptococcus group A
- Cold (coryza)
o Virus
 Influenza A, B
 Adenovirus (conjunctivitis, diarrhoea)
 RSV
 Parainfluenza
 Rhinovirus (sometimes)
 Human metropneumovirus (30%)
- Laryngotracheitis
o Parainfluenzae, coxsackie
- Ear
o Otitis media
 Streptococcus, moraxella, Hib
 Virus
Mastoiditis  meningitis
Children’s Eustachian tube is more straight, prone to infection after URTI
Tracheitis (stridor)
- Parainfluenzae, coxsackie, streptococcus, Hib, diphtheria
Bronchitis (coughing)
Bronchiolitis (wheezing)  <18 months old

- Virus - RSV, parainfluenza, influenza
Pneumonitis  inflammation of air cells

Pneumonia  inflammation + consolidation
! 4!
PAEDS: ENT & RS
Laryngomalacia
A 3 month-old boy came with his Mom as she is concerned about his breathing.
Task: take history, examination, Dx, DDx and management plan.
Hx:
What’s your main concern? Noisy breathing when cry, during bottle feeding; disappear
when sleep.
What do you mean by noisy breathing?
When did you start notice it? Noisy breathing since 1 month old
On and off or all the time?
What makes it better or worse?  after feeding or lying flat make it worse.
Any wheezing, barking cough, blue lips (cyanosis)?
Have you noticed if he stops breathing (apnoea) or rapid breathing?
Any signs of respiratory distress ---nasal flarings, supraclavicular retraction, tracheal tug,
intercostal or subcostal reatraction, tachypnea
Vomiting
Full term or preterm? Prolong labor? Resuscitation after labor?
Anyone smokes at home?
FHx of similar condition, asthma, SIDS? ---cousin died from undiagnosed illness
Gaining weight?
O/E:
GA, VS (HR 120/min, RR 35/min, BP 60/50), Growth chart
Chest, heart, abdomen
How is the noisy breathing like? ---mild stridor. When cries, noisy breathing start to increase
with Tracheal tug
Explanation:
The most likely Dx is laryngomalacia (weakness of the larynx). The wall of the larings is a
little bit immature, weak, and floppy. It’s congenital condition, no known cause.
Laryngomalacia is not common. But it’s the most common cause of stridor in infant.
DDx:
- Laryngeal web
- External compression from outside, LN, tumour (something pushed from outside)
- Vascular ring (blood vessels) around the laryngs or abnormal arteries (aberrant arteries)
The above condition usually present with moderate-severe stridor which needs further Ix.
Mild stridor wait and see. Usually improves after 6 mths of age, but some may take 12-24
months.
Chest X-ray can be done if there is a concern that the child may have other congenital heart
or pulmonary disease in order not to miss it.
Moderate and severe  further investigation
- Chest X-ray,
- Barium study of GIT may help to visualize the external compression because the notch
can be seen on the barium tract down the oesophagus.
- Bronchoscopy or laryngoscopy (camera)
! 5!
PAEDS: ENT & RS
Does he need tracheostomy? It’s not a routine procedure of laryngomalacia
Mild laryngomalacia is a benign condition, the indication for further investigation are:
- Significant increase of the work of breathing at rest
- Signs of respiratory failure manifested by requirement of oxygen
- Systemic features  failure to grow, developmental delay
! 6!
PAEDS: ENT & RS
Tonsillitis (AMC 77)

A 4 yo child was brought by his Mom because she noticed that the child is lethargic this
morning. There was a picture of swollen tonsils with a whitish material on the top.
Task: take relevant history, focus exam and management.

Remember  contact with family member, childcare
Hx:
When did this start?  unwell from yesterday, not active
Did you check his temperature?---no
Did you give him anything?---Panadol, didn’t help
Has he had any flu & cold symptoms in the last 2 days?---no
Any vomiting?---2 times
Diarrhoea?---no
Appetite ---he wasn’t well, just drink a little bit of juice, some snacks, but no proper meal
Any fever, skin rash, fit?---no
Has he c/o any joint pain?
Any rubbing of the ear / has he c/o ear pain?
Any change in his waterworks, any change in the colour?
Any other children at home? ---2 years old, she’s all right, no problem during the last week
Did he attend childcare?---yes
Did you receive any notes if anyone in the childcare has problem?---no
General health, serious medical problem since birth---no
What about you & his Dad---all right
Is he using any inhalers?
Any history of hospital admission?
Any difficulty when he moves his neck? (after 1 year old child)
What about his immunization?
O/E:
GA: pallor, flushing, toxicity, dehydration, nasal snuff, drowsy, active or inactive
Rash, lymphadenopathy, neck stiffness---no
VS: T 38.5, RR >20, pulse 100/min, BP normal
ENT:
- Ear – ear drum swollen, bulge, red ---no
- Oral cavity  pharyngs, tonsils (2 big large tonsils with pocket of pus, red tonsil,
pharyngs red), any exudate (not fixed but fluid runs), any ulcer, extra mass
Other system ---free
Ix:
Swab from the pus, nasopharyngeal
FBE  leucocytosis, inflammation markers increase
Rx:
Penicillin for 10 days (protection for rheumatic fever), paracetamol for fever
Admission if severe for fluids.
Complication: Glomerulonephritis; Rheumatic fever; Impetigo contagiosum
! 7!
PAEDS: ENT & RS
Peritonsillar Abscess (Quinsy)

ED setting. A 14 year-old girl comes with father complains of severe sore throat.
Task: Hx, Exam, Mx.
Hx:
Can you please tell me more about it?
Pain Questions
Do you know what type of pain? Dull, throbbing pain (abscess, can’t be sharp pain)
Associated symptoms: fever; is she able to drink, eat, talk? Has her voice changed? Any
difficulty in swallowing?
Any drooling of saliva (in younger children)
Is this the first time?
Anyone at home or in the school has similar conditions?
Her immunisation up-to-date?
Does she has a boy friend?
O/E:
GA: patient looks ill (act fast)
VS: T 39.5
ENT: pt can’t open her mouth  use local anaesthetic (lidocaine) spray wait for 1 minutes
Any redness, swelling, pus
Is the uvula in the normal position?
Any pus on the pharyngeal? Redness of pharyngeal wall and pus on it.
Tonsils? tonsils OK, R side tonsil pushed towards the midline
LN, neck stiffness, rash
Cardiovascular, Respiratory, abdominal exam
Explanation:
It’s a condition called Quinsy. It’s an abscess because of a bug called Streptococci
It’s a surgical emergency.
I will admit your daughter and call the ENT registrar for further management.
In the mean time start IV fluids and IV antibiotics like Ceftriaxone & Fluclox
The ENT registrar will excise & drain the abscess under general anaesthesia. During the
procedure, they will give a small cut on the abscess & drain it out
If don’t drain, it might cause:

- Systemic infection (Septicaemia - Toxic Shock Syndrome)
- Breathing difficulties (Aspiration Pneumonia)
She will have to stay in the hospital for a few days & continue oral antibiotics at home.
Peritonsillar abscess
Retropharyngeal abscess (can only be confirmed by laryngoscopy)
! 8!
PAEDS: ENT & RS
Posterior Triangle Lump (Lymphadenitis)

A 3 yo boy came with his Mother because mom found a lump in his neck and also she’s
concerned because her nephew is diagnosed with lymphoma.
Task: relevant history, ask examiner about examination findings, investigation, management.
DDx:
- Lymphadenitis Fever, previous URTI, tender, painful
- Lymphoma
- Cystic hygroma (unlikely for this age group, common in adult)  transillumination test
- TB
Hx:
When did you notice the lump?
Where is it?
Could you tell me more about this lump?
Is it painful? Tender? ---yes
Have you noticed any change in the size of the lump?
Any other lumps in the body? (in lymphoma there will be many lumps)
Any fever? Rash?
Has he got any recent infection?--- URTI 1 week ago
Is he active as normal?---active Appetite & Sleep, wt loss?
Any change of waterworks and bowel habits?
Do you have any concern about his growth & development---no, he’s all right
Immunization ---up-to-date
Have you travel recently or contact with TB patient?---no
Medication & allergy
O/E:
GA: active, no rash, no pallor, growth chart
VS: T increase, pulse, RR
Focus on the neck
- Inspection: size, site, color change, any discharge
- Palpation: size, shape, consistency (firm), mobility, tenderness, other lymph nodes
ENT: look for signs of infection
- any nasal discharge---no
- any redness of the throat---normal
Lung, Heart  auscultate, check for murmur  lung clear, heart no murmur
Abdomen: mass, organomegaly
Inguinal area: scrotal
Ix: FBE; Transillumination test; US
Explanation:
Maria, your son has a condition called lymphadenitis (Inflammation of the lymph nodes).
It’s a common condition in this age group especially after recent infection
It’s a self-limiting condition, it will go by time (for how long?)
It does not require any specific medication
Lymphoma is unlikely. I can understand your concern, you’re a very caring Mother. I’d like
to arrange some tests like simple blood test and US. We’ll meet within 1 week or when the
test results are back, we’ll discuss it further. If you still concern at that time, I can refer him to
see a specialist.
! 9!
PAEDS: ENT & RS
Recurrent Cough In Child

A 2 yo boy developed several episodes of cough over the last 6 months. No wheezing is
heard.
Task: take history, physical exam, diagnosis and DD.
DDx:
- Asthma
- URTI
- Tuberculosis
- Cystic fibrosis
- Croup (---usually occur up to the age of 9 months)
- Foreign body
- Whooping cough
- Chronic heart disease
Hx:
When exactly did the cough started?---6 months ago
Is it the first time?---on and off
How frequently does he cough?----monthly basis
Has he produced any phlegm? –no (dry cough)
Is it barking like a dog or is it cough and vomit? (whooping cough)
Is cough more during the day or night?---any time ( asthma early morning or late night)
Have you noticed any wheeze---no
Any fever, runny nose, vomiting, SOB, turn blue?
Who looks after your child? Foreign body (choking episode)? ----go to day centre
Do you have any carpet or pets at home?
Does anyone smoke at home?
Has he got any history of asthma or eczema?
Have you travelled somewhere recently?---(to exclude tuberculosis)
Any family history of asthma, tuberculosis, cystic fibrosis?
How’s his sleep, is it affected by cough?
How about drinking and eating habits?
How about waterworks and bowel motions?
How about your pregnancy, delivery, and after delivery was everything normal?
Is he having any allergies?
Is he on any medication?
Immunization
O/E:
GA: any SOB or any distress, any nasal flaring, any use of accessory muscle; growth chart
VS, ENT, LN CV & Abdomen--- all normal
RS: SOB, use of accessory muscle, nasal flaring; Tracheal tug; wheeze, crepitation, added
sound, reduced breath sound
Ix: FBE, ESR, CRP, CXR (inspiration and aspiration films), SaO2
! 10!
PAEDS: ENT & RS
Explanation:
From Hx & exam, your child has a condition called recurrent cough. It’s a very common
condition. The children who go to childcare usually develop URTI, 6-12 times in a year. As
children’s immunity is not very well developed, so they catch this infection. I cannot explore
asthma at the moment but in future if you notice any further symptoms, please bring back
your child for further check up. Then we can try Ventolin and see the result. The other
condition less likely is foreign body, tuberculosis.
! 11!
PAEDS: ENT & RS
Pertussis
ED setting. A 10-week old child came with c/o cough & runny nose for 1 week. Also had
fever and cold symptoms initially. Now baby is irritable, crying and coughing. Turned blue
and sometimes coughing is followed by vomiting.
Task: take a full history, examination and management.
Hx:
Cough Qs:
When did it start?
Dry or wet?
Is it the 1st time?
Type of cough: barking, any special sound, cough, cough and a big whoop
Is the baby turning blue?
Any vomiting after cough?
Rapid breathing or stop breathing
Is he feeding well, breast-feeding? Number of wet nappies normal or reduced (bowel
function)
Any siblings? elder brother 4 year old, well immunized
Anyone in the family has chest infection?  father has been coughing for a while
Any risk factor  smoking, pet  husband outside (that’s a good thing)
Whether the child is going to childcare or not
Antenatal history  full term
Baby has any problem after birth
Immunization up-to-date?
Explanation:
This condition is most likely pertussis, also known as a 100-day cough.
Caused by a bug which is a bacterium spreads by droplet infection.
I know that your child has had a dose of vaccine against this bug, but despite vaccination,
some children can have the infection as the immunity of the child is still developing and some
different strain of bacteria may be responsible for the infection.
But the good thing is that this is a less severe form of infection
Most important at this stage is to keep him in hospital for some time and observe how he
response.
Diagnosis is mainly clinical

The specialist may do some blood tests like FBE to check for lymphocytosis and
nasopharyngeal aspirate and culture to confirm it
We will give him some oxygen and Clarithromycine, which would help to reduce the spread
of the disease as it decreases the infectivity of the disease
Most important is that we have to notify the Department of Health Service as it’s a
communicable disease
Also we need to treat the contacts and the family members Clarithromycin
Try to keep him at home for 1 week after discharge from the hospital
In some cases child may have some complications like ear infection or lung problem like
atelectasis but this chance is very low
I’ll give you some reading materials
Another 2 shots of vaccine will strengthen his immunity
! 12!
PAEDS: ENT & RS
Croup (Laryngotracheobronchitis)
GP setting. A 9 month-old baby came with mom c/o noisy breathing and cough.
Task: history, ask physical finding from examiner, explain diagnosis & management plan.
Epiglotitis Croup Whooping Bronchiolitis

Organism H. influenza Parainfluenza B.pertussis RSV/Adenovirus
Physical Soft stridor , ±Stridor (seal) Cough cough Cough wheezing
Exam no cough, drooling barking cough vomiting
saliva not toxic
Treatment Ceftriaxon Self limiting Erythromycine ± O2
± Intubation ± Steroids 1 Clarithromycine ± ± IV fluid
mg/kg Admission ± Admission
±Adrenaline O2, steroid
±IV Fluid
Notify disease If FHx of asthma
Treat contact – give ventolin
clarithromycine 7 ds
Ix Neck X-ray Clinical Nasopharyngeal Clinical
(lateral) thrum aspiration – PCR
print sign FBE – absolute
lymphocytosis
Follow up All cases need to Review by GP After 24 hrs (GP
be /ED)
DDx:
Croup
Pneumonia
Asthma
Foreign body
Bronchiolitis
Epiglottis
Hx:
What do you mean by noisy breathing?
When did it start?
How’s the cough like? Cough, cough….followed by anything…vomiting, whooping
Any vomiting after cough?
Any difficulty breathing? Fever? Rash? Drooping? Fits?
Any skin colour changes during or after cough?
Do you think he’s active as before?
Is he irritable?
Is he feeding well?
Nappy/bowel motion
FHx of high fever, asthma, eczema
Any similar episode in the past?
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PAEDS: ENT & RS
How’s his general health?

Does he go to childcare?
Any sibling at home? Anyone at home has similar condition?
Pregnancy/delivery history
Immunization
Where do you live? If far away from the hospital, need to be admitted.
O/E:
GA: difficulty breathing, signs of dehydration, rash, growth chart
VS
ENT: ear or nose d/c, throat, LN
Neck stiffness
Respiratory examination
Inspection:
- Pattern of breathing, shallow breathing
- Cyanosis, chest retraction/recession
- Accessory muscle working
- Nasal flaring
- Symmetrical air entry
- Supraclavicular indrawing
Palpation  chest movement equal or not
Auscultation  stridor
Explanation:
Your son has a condition called Croup. It’s an infection of upper airway, usually caused by
virus (parainfluenza, RSV, Adenovirus)
It’s common in child’s age (6 months to 3 years)
Good prognosis and self-limiting
If it’s mild, it can be managed at home
Admit to hospital if severe
- stridor
- Decrease air entry
- Cyanosis
- Decrease level of consciousness: drowsy
Admission criteria
1. Drowsy – decrease level of consciousness
2. Irritable/inactive
3. Not feeding well
4. Increased work of breathing
5. Marked chest wall retraction
6. Nasal flaring
7. Stridor at rest
8. Apnoea
9. Sat O2 <93%
10. Chest wall recession
11. Age < 6 month regardless of severity
12. Mother can’t cope  distressed
13. Tracheal tug/grunting
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PAEDS: ENT & RS
Bronchiolitis (Happy Wheezing)

A 5 month-old boy brought to your GP clinic by his mother because of 2 days history of
fever, wheezing, and dry cough.
Task: take further history, ask for physical examination findings and manage the case.
Age < 1 yo, with cough, wheeze and fever  bronchiolitis (Respiratory Syncitial Virus)
Hx:
Cough
- Onset – when did he start coughing
- What is the cough like, sort of barking?
- Does he turn blue when he coughs (cyanosis)?
- Have you noticed a rapid breathing?
- Have you noticed his breathing stops at any time for a while (apnoea)?
Fever
- Have you measured his temp, how high was it? Continuous?
- Have you tried any medication or anything for the temp?
- Skin rash
- Any abnormal movements (fits) – staring, smacking lips
Appetite
- Is he feeling well, how is his appetite?
- Has he been vomiting? How many times a day?
- What time does he vomit, any special time?
- In bronchiolitis usually vomiting occurs after a cough
Urine output
- Is he wetting nappies normally?
- Have you noticed wetting nappies like before?
Bowel movement
- Have you noticed any change in his bowel movement, diarrhoea?
- How many times, what is the colour, any blood or mucus
How is his mood: crying a lot, sleeping well, more lethargic than before
BINDS
- Do you have any other children, how many
- Is this your only baby or do you have any other kids
- Was the pregnancy normal, delivered/born full term, normal or by SC
- Any problems after delivery
- Immunization up-to-date?
- How is his growth/development (for older kids ask milestones: smiling, sitting, crawling)
- Does anything like this run in the family?
- Have you had any medical condition like this in the family? Hay fever, allergy, asthma?
O/E:
GA: alert or not, rash
Growth Parameters  height and weight in normal percentile
Signs of respiratory distress
- Grunting
- Nasal flarings
- Tracheal tug
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PAEDS: ENT & RS
- Subcostal and intercostal recession

Hydration status
- Fontanelle (closure after 1-1.5 years)  depressed or not
- Sunken eyes
- Mucus membrane appearance  dry?
- Delayed skin turgor (pinch skin in abdomen and leave – normal is less than 1 minute; if
1-2 minutes  mild, moderate, if >2min  severe)
- Central & peripheral capillary refill time (central can be seen by putting hand in the chest)
VS
ENT: ear, nose d/c, LN
Chest: wheezes, widespread crackles, ronchi, nasal flaring, grunting
Heart and abdomen
Urine dipstick at this age, urine bag is not reliable (suprapubic aspiration not required).
Explanation:
After I’ve taken history and examination, it seemed that your child is most likely suffering
from a condition called Acute Bronchiolitis.
Which is a viral infection that is very common at this age.
It’s an infection of the little airways called bronchiolus by a bug/virus
The virus is most likely the Respiratory Syncitial Virus (RSV)
Usually acquired by droplets or close contact
Generally children with bronchiolitis have ….
Therapy of bronchiolitis depends on the severity mild, moderate, or severe  for mild &
moderate only needs oral fluids and monitor at home. If become severe go to ED.
Because the child is having breathing difficulties and SaO2 a bit low, I’m afraid that he needs
to go to the hospital because he will need O2.
What are they going to do at the hospital?
I’d like to refer him…
Send him to the hospital where they will do some tests such as nasopharyngeal swabs to
confirm the diagnosis.
No need for an X-ray because it’s clear from clinical symptoms
If not sure from history  need to check with X-ray

If localized crackles of the lung  pneumonia (widespread  bronchiolitis)
However at any time we’re not sure, we can do a chest X-ray
Therapy:
O2 and fluids, 75% maintenance (because of the risk of SIADH)
For mild cases

If the child is doing well, keep him at home, give plenty of fluids and monitor at home.
If at any time he develops shortness of breath, becomes tired, blue and lethargic, please bring
him to the ED.
Admission to the hospital  for very young age (less than 6 weeks).
Complications
Acute  pneumonia – viral or secondary bacteria
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PAEDS: ENT & RS
Long-term  asthma Usually children who get bronchiolitis and recurrent, may get asthma
or is more likely to get asthma when they get older especially common in family with allergic
history.
For dehydration  correct deficit and give maintenance
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PAEDS: ENT & RS
Transient Tachypnoea In Neonate

Intern at a regional hospital and just been called to the maternity unit to review a newborn
child whom the nurses have found to be breathing really quickly.
Task: take a short Hx from the nurse, ask for relevant PE, and provide a management plan.
1. Lungs
2. Heart: Congenital heart disease: cyanotic and acyanotic
3. Systemic problems  pyrexia (caused by infection)  GBS (check vaginal swab status)
 early and late onset (2 weeks after delivery), how long did the water break, any signs
& symptoms of infection; how many doses of antibiotics and when given.
4. Chorioamniitis
Hx:
Perinatal
1. Gestational age of child:
- Preterm (hyaline membrane disease caused by decrease of surfactant type 2 pneumocytes
 20/40; if born 33-34 weeks needs decrease the surface tension of alveoli – gas
exchange).
- Term babies  Transient Tachypnoea of the Newborn (TTN)  amniotic fluid in the
respiratory airway and not enough tension to breath it out  compensating and later
decompensate. Supplement oxygen .
- Post-term and term  Meconium aspiration  pneumonitis (chemical reaction, lungs
inflamed, lots of exudation, lungs hard to ventilate
2. APGAR score – any resuscitation done, any pneumothorax
Preterm baby (32 weeks), poor APGAR, given surfactant, bag & mask, decrease surface
tension  ventilator  burst alveoli  pressure from ventilator  pneumothorax
3. Mode of delivery Emergency SC, what’s the reason
4. Drugs: opiates  decrease respiratory of the child
Antenatal
1) Infection like fever, diarrhoea, vomiting during pregnancy (TORCH, toxoplasmosis, others
(hepatitis, HIV), Rubella, CMV, HSV)
Rubella can cause hearing defect, heart problems, brain, eyes, renal problems
CMV : calcification in the brain, blueberry muffin rash  Seizure, IUGR
HSV: brain  seizure
2) Drug; Smoking; Alcohol
3) Gestational diabetes; Hypertension (HELPP)
4) Trauma
5) Congenital Diaphragmatic Hernia
Post Natal
1) When was the child born
2) When did the tachypnoea start
3) When did the child pass meconium
4) Was the child feeding  aspiration  Trachea Oesophageal Fistula/ Oesophageal
Atresia; to detect something wrong  breastfeed/bottle fed, frequency, amount;
demanding 3-4 hourly, has poor glycogen reserve  10% dextrose.
5) How many hours they sleep (up to 21 hours)
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PAEDS: ENT & RS
O/E:
Vital Signs
RR: 40-60
HR: 120-160
Temp: 36-37
Sats O2: 98-100%
BP: low (cardiac output = Total Peripheral Resistance X HR) in babies HR high, so low total
peripheral resistance
GA
Pale: anaemia, constitution
Cyanotic: decrease partial pressure of oxygenation, increase partial pressure of CO2
Any respiratory distress
Chest
- Inspection: shape – deformities; movement; symmetrical (asymmetrical – one sided
pneumothorax or haemothorax); signs of distress: nasal flaring, intercostal recession,
subcostal recession, trachela tug
- Auscultation:
o breath sounds – vesicular ( bronchial breathing, crackles is snapping open and
close of the alveoli, wheezing – turbulent flow through a decreased diameter of
the small airways like bronchiole)
o heart sounds – murmur (turbulent flow)
HMD
Give inhaled surfactant – intubation, pushed the surfactant into the lungs
Pneumothorax
Intercoastal catheter (Heimlich pipe) in 4-5 intercostal mid axillary line
TTN
Oxygen via CPAP
Intubation ventilation
Move the child into nursery and observe.
If deteriorate
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PAEDS: ENT & RS
Cystic Fibrosis
You’re an intern in the paediatric ward. A newborn infant has been diagnosed with cystic
fibrosis through genetic testing.
Task: tell the parents about the diagnosis, explain the answer to the parents’ questions.
It’s a lifelong problem

Genetic disease, autosomal recessive, high prevalence in Caucasian
Problem in No. 7 chromosome, problems with transporting salts
CFTR (cystic fibrosis transmembrane receptor)
- defects in the chloride channel
- secretory glands/organs/tissues  respiratory, pancreas, sweat glands, genitalia, sexual
organs (testis)
Hx:
I’d like to tell you something about your newborn. You know we have done a genetic test of
your child and the result is came back.
Your child has some problems with the transporting salts
Failure to thrive
- sputum thick  repeated cough, infection
- digestion (malabsorption), not absorbing nutrients especially fat, fat soluble vitamin
- testis – semen – problem having kids
Involve respiratory physician, physiotherapist, dietician
Gutherie test – Day 3 of life  heel prick test

- Galactosemia
- Cystic fibrosis
- Phenylketonuria (PKU)
- MCAD, LCAD  fatty acid transport problem
- hypothyroidism
Neonatal period
- GI problem: meconium ileus, abdominal distension, feeding tolerance, bilious vomiting
Infancy & childhood
- Repeated chest infection: unusual pathogens – pPseudomonas aeroginosa, fungal
(aspergillous)
- Failure to thrive
Diagnostic test
- Sweat test  gold standard investigation rather than genetic testing
- Genetic test  as different genetic variant can’t test all  first, test common defect then
the less common
Respiratory
Decrease viscosity of secretions causing thick mucus  repeated infection  bronchiectasis
Therapy with:
- Mucolytics
- Hypertonic saline for the dry mucus
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PAEDS: ENT & RS
- Removal by postural drainage

- Physiotherapy
- Antibiotics for the repeated infections
- “tune ups” weekly or 2 weekly IV antibiotics in hospital  instead of 5 infections  3
infections if give antibiotic prophylaxis
- Anti fungal
INVESTIGATION
- Sputum culture
- Bronchoscopy and lavage
- Culture of lower respiratory tract secretions
To assess lung function  spirometry
Gastrointestinal tract
Pancreatic insufficiency
- Fat and fat soluble vitamin deficiency due to malabsorption
- Enzymes: pancreatic enzyme  Creon
- Replace Vit A D E K
- NaCl salt tablet replacement
- Dietary supplementation, high calorie drink to fight against infection, to compensate
energy get from fat
Definitive therapy
Respiratory  lung transplant
Related liver disease  liver transplant
O/E:
Hands  clubbing, cyanosis (peripheral)
Nose  nasal polyps
Mouth  central cyanosis
Chest
- hyperinflated chest
- accessory muscle in case of respiratory distress
- posture of child
- look for scar  chest drain, mediasternal surgery
- vocal fremitus  hyper resonant – bronchiectasis, hypo resonant – mucus secretions
- decrease air entry (secretions, consolidation)
- crackles thick mucus
- wheeze  decrease diameter of bronchioles
Gastrointestinal
Newborn – distension due to meconium
Liver increase in size  sometimes jaundice skin, sclera
Nutritional status  fat stores – abdomen & gluteal region
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PAEDS: ENT & RS
Cystic Fibrosis Counselling

A couple came to your GP clinic. They have a 2 yo daughter, who has recurrent chest
infection and recently diagnosed with cystic fibrosis. Now she’s pregnant for the second child
and wants to know the future of her first and second child. You’re a senior medical officer.
Task: explain the nature of the disease progression, medication of cystic fibrosis. The
possibility of the second child problem and how to detect.
I know that you are concerned for your daughter and current pregnancy regarding cystic
fibrosis. CF is an inherited disorder and not uncommon.
It affects the mucus secreting glands in the air pipe known as the bronchial tree and the gut
and sometimes the reproductive system.
The mucus gland produces abnormally thick and sticky fluid.
In lungs it can cause repeated chest infection. These infections can cause more serious
condition like scarring of the lungs known as pulmonary fibrosis and this can lead to heart
problem known as cor-pulmonale.
In gut, there is no adequate enzymes to digest the food, so it can lead to malnutrition.
Unfortunately, if reproductive system is affected, it can cause infertility.
Usually, the disease is diagnosed within the first 6 months of life and maybe within the first
few days.
After delivery did your daughter have any problem? Did she pass meconium.
Mx:
For the chest infection, we need to use antibiotics repeatedly depending on the culture of the
sputum. She might need antibiotics on daily basis for long time.
She might need regular chest physiotherapy.
She will need to be followed up at a paediatric chest unit.
Sometimes in severe cases, lung transplant might be required.
She will need to have influenza vaccine yearly and pneumoccoccal vaccine 5 yearly.
Growth retardation is very common in this kind of children.

Unfortunately the majority of patients will reach up to 3rd or 4th decade of life (30-40 years
old). This condition is very common. 1 in 2500 people are diagnosed with CF.
For the second child

CF is an autosomal recessive genetic disorder.
If both parents are carrier, there is a 25% or 1 in 4 chances of getting the disease in every
pregnancy.
We can do the genetic testing intrauterine like chorionic villus sampling (CVS) at 11-12
weeks of pregnancy or amniocentesis at 15-16 weeks of pregnancy. But they have some risks
of miscarriages.
For CVS 1.5% chance of miscarriage, for amniocentesis 0.5% .
After this test, you can decide to continue the pregnancy or to terminate it. It's your decision.
Being in Australia, there is more hope as there is a lot of support for financial and
psychological problem. There is the CF foundation. If you contact them they will help you.
I will give you reading material and follow you up.
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PAEDS: ENT & RS
< 15 weeks of pregnancy  dilatation and evacuation

>15 weeks medical termination
Tests for CF
Immunoreactive trypsinogen (IRT) test – screening
Sweat test is diagnostic
Heel prick test/Gutheri test
! 23!
PAEDS: ENT & RS
Chronic Otitis Media

A 5 yo girl with recurrent otitis media was treated with Amoxycillin 3 times in 6 weeks.
Child has snoring and mouth breathing history. They came with another relapse. PE tympanic
membrane bulging, red, child is febrile. Mother wanted to know alternative treatment.
Task: advise about treatment options.
Unfortunately, your daughter has another recurrence of otitis media (infection of her ear),
she’s febrile and ear examination showed infection. We need to start course of antibiotic.
Your daughter needs antibiotic, but now longer course than before, we need to treat the
infection because it may lead to some complications such as:
- Infection can go to the brain
- Infection of surrounding bones
Is your child immunized up-to-date?
Ix: swab for culture, hearing test
Short term treatment:

- Ear wash with Povidone iodine 5% solution. Put the solution in the 20 ml syringe with
plastic tube in suction kit and put into the ear, 2-3 times/day
- Chemoprophylaxis with Amoxycillin or Cefaclor orally for 6 weeks continuously (swab
for culture & sensitivity)
- r/o external otitis
Long term management: Consider flu and Pneumococcal vaccination
Risk factors
- Childcare – we don’t recommend kids with chronic otitis in group childcare, any
possibility to keep her at home
- Smoking may affect your daughter’s condition
- I will refer your daughter to the paediatrician & ENT specialist because your daughter has
some problems with nasal breathing & snoring, we need to check her tonsils & adenoids
(lymphatic tissues around oral & nasal cavity). Usually it’s function is to protect against
infection but if enlarged it will cause difficulty in breathing & affect ear infection. It’s a
risk factor for otitis media.
- Your daughter needs hearing test (audiometry)
- Speech & language evaluation (by speech pathologist) may be affected by recurrent
infection
Possible surgical options

- Tympanostomy tube or GROMMET  tubes to make better connection between inner &
outer ear for a better drainage (draw a picture)
- If tonsil & adenoid enlarged: Tonsilectomy & adenoidectomy
Regular follow-up
CRITICAL ERRORS
- Hearing test
- Speech & language assessment
- Check tonsil & adenoids
! 24!
PAEDS: ENT & RS
Recurrent Otitis Media

David is 18 months old presented to you with pain on his right ear.
Take: Hx. Examine David and explain Dx and management plan.
Classification:
- Acute otitis media < 6 weeks
- Recurrent otitis media >3 episodes with complete recovery within6 months
- Chronic suppurative otitis media
- Glue ear  Otitis media with effusion(fluid collection) without infective symptoms
Hx:
Pain Qs
When
How frequent
PHx of similar infection – sinus, lung infection, and pneumonia – autoimmune – Ig A
deficiency or (think of cystic fibrosis)
What was the treatment
Feeding bottle Flat position of the child when bottle feeding also can cause otitis media
Smoking in the family
History of hay fever, rhinitis
Non indigenous or not
Explanation:
Hearing is OK but has chronic frequent otitis media  start antibiotics for a few months and
refer to specialist because may need Grommets put the tube in the middle ear – rupture the
membrane for suppuratives otitis media with effusion (pain relief, fever decrease when the
membrane is ruptured) – change the Grommets after 6 months, help with drainage.
Can he swim?
If he can keep his head above water, he can swim. Or he can put ear plug or nasal plug.
Tx:
- Aboriginal child: have high frequency of otitis media with complications  give A/bs
- Non indigenous
<2 yrs (can’t express himself and have high risk of complication) give antibiotics;
>2 yrs – give Panadol for 48 hours, observe, if not improve  antibiotic
- If Mom is worried, child is 3  review in 48 hrs not improving, give antibiotics
- Any concern of Mother  refer for audiometry and ENT review
Amoxycyllin 20-40 mg/kg/day

If body weight 14 kg  14 X 30 = 420 mg  give 125 – 125 – 125 mg for one day
Commonly otitis media is caused by bacteria rather than virus, usually caused by
Streptococcal pneumonia, Haemophylus influenza, Moraxella catarrhalis
Acute attack  give antibiotics and followed-up in 2-3 days
If recurrent  >3 episodes in 6 months  6 weeks of antibiotics (cotrimoxazole)test

hearing and refer for ENT opinion for further assessment and Grommets
! 25!
PAEDS: OPHTHALMOLOGY
ORBITAL CELLULITIS
David 5 year-old came with his Mom to you complaining of puffy swollen left eye.
Task: Hx, ask examiner about examination finding, order investigation and explain
diagnosis.
T 38, HR 80, RR 30, BP 100/65, O2 Sat 99%
Unilateral puffy eye DDx:

- Insect bites
- Conjunctivitis
- Allergy
- Trauma
- Periorbital cellulitis
- Orbital cellulitis
Bilateral puffy eyes DDx:

- Allergy
- Bilateral conjunctivitis
- Nephrotic syndrome
- PSGN (post streptococcal glomerulonephritis)
Hx:
Since when was the puffy swollen eye started?
Gradual onset or acute? ---gradual over the last 3 days
Any sticky eye or eye discharge? What’s the colour of discharge?
Any red eyes, watery eyes?
Any trauma to the eye recently? post traumatic eye swelling
Any complain of pain, itchiness, blurred vision or diplopia (double vision)
Oedema anywhere else? (generalized oedema  nephrotic syndrome)
Any sore throat, fever, rash, joint pain  r/o Rheumatic fever & glomerulonephritis
Any recent Hx of infection Flu-like symptom (sore throat), any
sinusitis (ethmoid sinusitis: predisposed to orbital cellulitis), ear infection, skin infection
Any vomiting, eating, sleeping, urine output, active or lethargic
O/E:
GA: lethargic or pale, swelling anywhere else  Glomerulonephritis
VS: If BP normal (if 140/85 for 5 year-old  hypertensive think of PSGN)
Chest, heart, abdomen---normal
Eye exam:
- Look for Proptosis
- Check for visual acuity and ophthalmoplegia
- Periorbital  swelling of the eyelid due to trauma, allergy, infection, insect bite; NO
Proptosis, NO decrease in visual acuity, and NO ophthalmoplegia
- Orbital  infection on the eye and around the eye, usually from the ethmoid sinuses;
proptosis, decrease of visual acuity, ophthalmoplegia
! 1!
Tx:
- Mild  Augmentin
- Moderate  IV Flucloxacillin
- Severe  IV Flucloxacillin + Cefotaxime
(if not sure of the severity  Moderately severe periorbital cellulitis)
Orbital cellulitis is a paediatric emergency  can result in significant complications

including blindness, cavernous sinus thrombosis, meningitis, subdural empyema, and brain
abscess and ethmoid sinus abscess.
These complications have become rare in the antibiotic era, but the potential for sight- or life-
threatening complications makes prompt diagnosis and early treatment important  require
CT and ENT consultation to drain the abscess (could be ethmoid sinus abscess which should
be drained)
The orbital septum divides the soft tissues of the eyelid (preseptal space) from those of the
orbit (postseptal space). Periorbital (preseptal) cellulitis occurs anterior to the orbital septum
and results from trauma, contiguous infection or primary bacteremia among young infants. In
orbital cellulitis, the infection is localized posterior to the orbital septum and usually occurs
as a complication of acute or chronic sinusitis.
Patients present with sudden onset of fever, proptosis , restricted eye movement, and swelling
and redness of the eyelids. It is usually caused by a previous sinusitis. Other causes include
infection of nearby structures, trauma and previous surgery.
Orbital cellulitis  pain with eye movement, restricted eye movement and proptosis
Needs admission to hospital for further assessment, it’s an emergency situation.

Needs Paediatrics, ENT & ophthalmology review
Urgent CT and other routine blood test
Start on IV Flucloxacillin & Cefotaxime
Review for intracranial spread-- may cause blindness
Prognosis and treatment

Because of concern for spread of infection, patients must be admitted to the hospital to
receive . Complications include and
. Abscess formation is another complication and may require surgical drainage.
Orbital cellulitis is considered an ophthalmological emergency.
Critical error:
- Unable to diagnose orbital cellulitis
- Failure to admit
If child is hypertensive, eye exam normal, has puffy eyes  take urine exam, urine dipstick
GA, VS, Chest Heart Abdomen, Urine dipstick  haematuria +++ (coca cola urine)
Send for urine analysis  red blood cell cast (erythrocyte cast)
Oedema, haematuria & hypertension  Post Streptococcal Glomerulonephritis
! 2!
SQUINT (STRABISMUS)
GP setting. A 12 months old girl presented with Mom as Mom noticed her R eye is turned in.
Task: explain to Mom the diagnosis, how it happen & what’s your plan.
There are groups of muscle controlling the eyes. Incordination of the 6 muscle of the eyes 
caused squint  Failure of the 2 eyes to look together lazy eyes
There are different types of squint

1. True squint – always present  constant
2. False squint – pseudo  problem of the eye lids shape (distance between the eye)
3. Alternating squint – change between the 2 eyes
4. Transient squint – for short period of time normal
5. Latent squint – appears only on some condition like fever, fatigue, stress
It’s common.
Cause: different types, can be muscle, nerve, cranial nerve, brain
Risky  If not corrected the true squint before 6 years of age will lead to permanent lazy eye
(amblyopia)
MxPersistent squint needs refer to ophthalmologist and optometrist
If the treatment early (before 6) the result is excellent. After the age of 7, it’s too late to save
the vision of the lazy eye, it will be permanently lost. Better at 1-2 years of age.
Surgery  micro surgery, correcting the muscle balance
Cover the good eye with patch (unacceptable for this age  use eye glass). Enforce the lazy
eye to focus.
True squint cannot correct itself. The child doesn’t grow out of the squint. Do the surgery as
soon as possible.
At any age with constant squint or >6 months old with any squint
should be referred.
Refer all children with squint or suspected squint to ophthalmologist.
- Allow early detection and preventing amblyopia.
- Detection of other anomalies like cataract or retinoblastoma.
Examine the child with red reflex suspected with squint. White reflex need to refer.
All the children with first degree relative with a squint should be seen by the ophthalmologist
by the age of 3 and 3.5. Even if there is no squint as they may have other eye problem.
! 3!
PAEDS: GIT & GUT
Recurrent Abdominal Pain

A 8 yo boy has recurrent abdominal pain since he was 4. The problem was getting worse
when he was in his class with a male teacher and now the teacher has gone, his pain is getting
better but sometimes still has some pain. All results of the investigations were negative.
Task: talk to mom, give her your diagnosis and management. Explain the different between
organic and non-organic
DDx:
- UTI
- Constipation
- Lactose intolerance
- Coeliac disease
- IBS
Hx:
Pain Qs  localized (non-organic); Panadol sometimes but doesn’t help a lot
Did your son wake up at night because of pain?
Did you find any relation with food or milk?
Associate symptoms  N/V, fever, headache
Bowel habit diarrhoea, constipation (fecal loaded, mass in colon: enuresis, encoporesis)
Any blood or mucus in his stools?
Had he been diagnosed with anaemia before?
Has he followed any special diet?
What about his appetite?
Do you think he is underweight? Gaining wt or not?
What about his waterworks, any problem, any burning, any urgency
Is he free of pain in between attacks? (non-organic pain---free in between)
Is he happy at school?
Any bullying in school?
How’s his school performance?
How about his attitude in general?---he’s a good child, if not for the pain
What about during weekends does he have pain?---sometimes
How’s situation at home?
Are you happy family?
Does he have any sibling?---one brother
How’s his relationship with his brother, his dad and you?
Any one at home has similar condition?
O/E:
GA, VS, ENT, LN
Abdomendistension, mass, tenderness
Inspection of genital area and anus fissure, hernia
Explanation:
From Hx and PE I couldn’t find anything wrong with your child. It’s most likely he has
what’s so called non-organic (dysfunctional) abdominal pain. I want to assure you that his
health is fine and has no problem in his tummy.
! 1!
PAEDS: GIT & GUT
It’s not a severe condition but his pain is real. Our mind is connected to the body, so if he is
scared or stressed, he show it in the form of pains especially tummy pain. Try to understand
his needs, not to overload, identify the type of stress he has. Also if he has some problem
with his school teacher, try to meet & talk to his teacher.
Give him analgesia and try to reduce his stress. Try to distract him when he has the pain.
Encourage him to do more activities and give him good balance diet
We can keep a diary for him diary to fine what time exactly he has the pain and what cause it.
I’d like to order some Ix to r/o any organic cause

- FBE, ESR/CRP
- Urine analysis and culture
- Stool for microscope and culture
- X-ray (or US) of abdominal to find out if there is any fecal retention or not
As you’re concerned, I can refer him to a paediatrician for a specialist opinion. Please don’t
worry, he will be fine and in fact he will grow out of it with time.
Warning signs and follow up.
Site of pain
- Organic  not peri umbilical
- Non organic  most common occur in umbilical or just around (central abdomen)
Radiation
- Organic  radiates
- Non organic  no radiation
Wake at night
- Organic  yes
- Non organic  no
Associated with pain

- Organic  vomiting
- Non organic  nausea and rarely vomiting
Between attacks
- Organic  unwell
- Non organic  well
Body weight
- Organic  weight loss or failure to thrive
- Non organic  no weight loss, just anxious
! 2!
PAEDS: GIT & GUT
Gastroenteritis
Jimmy, 4.5 years old boy was brought in by his Mom because since yesterday afternoon he
has been having diarrhoea & he has vomit a couple of times.
Task: take a relevant history, examination, discuss diagnosis & management.
A 4 month-old baby came to your GP clinic with his Mother. He has a mild dehydration, low
grade fever and diarrhoea.
Task: take history, examination finding and management.
DDx:
Viral gastroenteritis
Bacterial gastroenteritis
Appendicitis
(Infections UTI, meningitis, ear infection)
UTI
Hernia
Hx:
Could you tell me when did it start? Started since yesterday, 5 motions & today 7 motions.
Which one started first, fever or diarrhoea? T was 37.8.
DiarrhoeaFrequency, color, consistency, smelly, any mucus / blood (mucus but no blood)
Associated symptomsany vomiting, tummy pain
Is he crying more than usual?
Feeding Qs: breastfeeding ,bottle feeding, solid food, any new food? Appetite?
Urine outputhow many nappies? smelly wet nappy?
Sleeping
Level of consciousnessIs he alert? Is he active?
Any concern about his growth & development?
Immunization
Is he full term or premature?
Any previous illness like that
Is he the only child at home?
Any member of the family has this problem?
Who’s taking care of your baby----me
Childcare Anyone there get diarrhoea
O/E:
GA Pale, jaundice, Level of consciousness: active, happy, flushed
Level of dehydration - mucous membrane, skin turgor, capillary refill, cold hands and feet,
sunken eyes or tears, fontanelle, (Check GP for mild, moderate and severe)
Growth & development chart ---normal
VS: T 37.8, pulse 90, normal BP, RR
Chest, heart normal
Abdomen: distension, tenderness, rigidity, organomegaly
Inspect anal area: redness (frequent motion), rash
Genital area
! 3!
PAEDS: GIT & GUT
Explanation:
From the Hx & PE, your child has gastroenteritis. This is an infection of the bowel by virus
or bacteria. The most common cause is Rotavirus.
From the virus, it doesn’t mean that you have not taken care well of him.
Healthy people can transfer this virus to your son.
If bacteria, it comes from contaminated food (even fly can cause it).
There is no need for treatment, but we need to provide him with plenty of fluids to prevent
dehydration. Keep & continue breastfeeding. Also we will add gastrolyte or ORS solution;
this is the solution which will compensate the minerals and salt lost in the motion. We have 2
ways to give this to your baby.
1. 50 ml of Gastrolyte (don’t mix with lemonade, only use water) every 15 minutes
2. Every time he give watery motion, give him 200 ml of Gastrolyte in addition to
breastfeeding.
If my baby doesn’t like the Gastrolyte, I have to offer him other fluid like cordial, lemonade,
normal sugar in normal amount of water (to increase the fluid intake).
If bottle feeding
- No bottle feeding  use gastrolyte, lemonade or cordial
- Second day bottle feeding but with half strength formula (eg 1 spoon with 30 ml of water
 give 1 spoon with 60 ml of water)
- Fourth day start with normal strength of milk but with simple food
If baby has taken solid food

- Stop first day
- Second day give solid food less carbohydrate or less fat
- Give boiled rice, boiled potato, plain biscuit, plain bread
For fever give Panadol
Hygiene Wash hands after change nappy
Review in 6-12 hours, may refer
Excluded from others until 24 hours from the last bout of diarrhoea or vomiting
Dont give antibiotics even blood or mucous found in stool.
Warning sign
If diarrhoea increases up to 10 times, seek help
If vomiting persists
If he develop severe abdominal pain (raise his leg, excessive crying)
If fever start to increase or deteriorate
If child start to be floppy, not reactive or unconscious
! 4!
PAEDS: GIT & GUT
Gastro-Oesophageal Reflux
4 week-old baby, breastfeed, he’s vomiting all over him after feeding. He put on weight 1 kg since
birth and has no other symptoms. Mother wants to know if she could change him to bottle feeding.
Task: relevant history and management.
Baby vomiting DDx:

- after each feeding  Pyloric Stenosis, reflux
- other possibilities  UTI, meningitis, infection, intususception
- duodenal atresia (> 2 weeks old)
White vomiting: reflux, pylorostenoiss

Green vomiting: duodenal atresia, malrotation
White & Green vomiting: Meningitis, GE, oesophageal atresia, intussusception
Weight gain in babies

0 – 4 months old  750 grams/month
Hx:
I know you’re here because your child has been vomiting after each feed, could you pls tell me more?
Is the vomiting forceful (projectile) or not?
After each feeding or not?
What color and what amount?
Any lumps in his abdomen after feeding (exclude pyloric stenosis)
When does he feel hungry again?
Any family history of pyloric stenosis or similar condition?
Do you have any concern for his growth and development?
Is he a happy child?
Does he sleep well during the night?
Any cough, SOB or noisy breathing?
Explanation:
Most likely the child has a condition called gastro-oesophageal reflux. It happens when the food in the
stomach overflows back to the oesophagus (gullet) and baby vomit milk after feeding. This is a
common condition. Babies are usually comfortable and thrive. Gaining weight well, no other
symptom. It will gradually improve with time especially after solids introduce. Most cases clear up
completely by 10-12 months of age. We recommend in this case :
- frequent, small feeds
- elevate the head of the cot to 10-20 degrees
- propping up baby after feed
Also sometimes we offer thickening of the food, we have a medication called Gaviscon which you
can buy in a pharmacy. Take half of a teaspoon mix with 120ml of formula in the bottle. If breast
feeding, give after feeding.
About the bottle feeding, there is no difference between breastfeeding & bottle feeding. It won’t
prevent the reflux. The most important thing is small, frequent feeds.
I’d like you to follow my advice for a couple of days and please come back for review in 3-4 days.
(If mother is concern, refer for ultrasound to exclude pyloric stenosis.).
In severe cases in which it couldn’t be controlled by conservative treatment, we may use medications.
I may refer you to the paediatrician for a second opinion. He may give medication (omeprazole).
! 5!
PAEDS: GIT & GUT
Giardiasis
A 3 yo child came with mother to your GP clinic c/o diarrhoea for the last 3 weeks.
Task: take Hx, ask for examination finding, diagnosis & management.
DDx of Chronic diarrhoea:

- Giardia (recent travel, childcare)
- Irritable bowel syndrome
- Antibiotics
- Coeliac disease
Hx:
When did it start? 3 weeks ago
How often? 4-5 times a day
Character of the stool: profuse, smelly, explosive, watery and excessive flatulence (flatulence due to
mild absorption of fat), pale (mild absorption)
Does the stool float on water? Difficult to flush?
Any blood or mucus in the stool?  no
Any nausea, vomiting, fever, tummy pain?
Any change in the diet recently?
Any travel recently?
Does he go to childcare or kinder? (common in playgroup children)  Yes
Any other family member has similar problem?  sibling, 2 weeks ago, stop by itself.
Anyone in the family has a special diet?
Any medication recently especially antibiotics?
Any allergy?
Growth & Development any wt loss recently?
Immunization
O/E:
GA: pale, active, signs of dehydration
Abdominal exam: tenderness, mass, distension, rigidity, organomegaly, bowel sound
Urine dipstick
Explanation:
From Hx & examination, it looks like your child has some infections of giardia which is a kind of
protozoa. However I’m not sure, it could be also due to some bacteria like Salmonella, E. coli or other
diseases like coeliac disease, lactose intolerance, toddler’s diarrhoea and inflammatory bowel disease.
I’d like to order the stool microscopy, culture and sensitivity to confirm this. What we look for in the
stool: cyst, parasite, ovum, tropozoids. We also need to do coeliac screening, but first we’ll wait for
the stool exam result. To confirm giardiasis we can do duodenal fluid aspiration and analysis
Giardia causes atrophy of the duodenum.
Tx:
- Start immediately Metronidazole tablet 30 mg/kg daily for 3 days or Tinidazole 50 mg/kg single
dose.
- Main transmission is contaminated water
- Less likely is contaminated food and person-to-person
- Maintain the hygiene.
- Transmission through the fecal-oral route. Wash your hands after toilet and before handling food.
- Clean the toilet seat
- Bring the stool for examination
- I’ll see your child in 3 days time to see how’s he going
- If diarrhoea persists, treat the whole family
! 6!
PAEDS: GIT & GUT
Congenital Hypertrophic Pyloric Stenosis (AMC 127)

1-3 weeks old boy is brought to you with vomiting repeatedly.
Task: examine and explain management.
DDx:
o Congenital Hypertrophic Pyloric Stenosis
o UTI
o Obstructive hernia
o Intestinal obstruction
o Meningitis
o Gastroenteritis
o Reflux
o Volvulus
o Duodenal atresia
Features of Pyloric stenosis:

o Projectile vomiting
o Non billous
o Immediately after feeding
o Child is hungry and crying after vomiting
o Feeding test done and on positive  olive shaped mass above umbilicus
o Common in boys, firstborn, weeks old
o Complication: Hypochloremic hypokalaemic metabolic alkalosis
Hx:
When did he start vomiting?
How many times?
Contents / Colour of vomit Fresh milk like or processed milk
Is it forceful?
Relation of vomit to feed? How long after the feeding?
Associated with crying
Before vomiting does the child cry?
Does he draw legs up while crying?
Have you noticed any change in motions?
When was his last bowel emptying?
Does the child feel like eating according to you?
Do you think he has lost wt?
Any abdominal distension
Did you feel any mass or swelling in the abdomen?
How’s the appetite (very hungry after vomiting)
Any fever?
Any cough, shortness of breath, noisy breathing, turning blue  to r/o aspiration
How many nappies changes per day?
Any color change / smells in the wet nappy?
Ask about obstetrics and birth history
Any post natal problems on admission
FHx
! 7!
PAEDS: GIT & GUT
O/E:
General examination, check for dehydration and rest
GIT  check for distension
Peristalsis: reverse peristaltic wave seen from left to right
Check hernial orifices
Genitalia
Palpate for mass, diff to feel, olive shaped mass
Ix:
FBE
ABG (every 6 hours)
U&E
Urine examination
US for confirmation  hypertrophy of pylorus is diagnostic
Explanation:
From history, this condition is called Congenital Hypertrophic Pyloric Stenosis. It’s a
SURGICAL EMERGENCY (assess signs of dehydration)refer to hospital immediately.
Draw pylorus --- this is the end of the feeding pipe and it thickened
Nil by mouth (stop breastfeeding now) – need surgery; IV line start fluids
We have well trained & skilled paediatric surgeon and anaesthetics. In hospital they will do:
- Try feeding Observe where the peristalsis is going from (LR)
- Clinical diagnosis 100%
- Confirm with US by paediatric surgeon
- (If still not confirmatory then we will give gastrograffin and check  string sign
- Nasogastric tube (decompression of the distended stomach)
- Blood test: ABG to assess electrolytes, U & C, acid base balance
- Nil by mouth, Fluid  Half normal saline, half dextrose
- Check urine output and assess to add potassium Hyperchloremic hypokalemic metabolic
alkalosis
- Skilled paediatric surgeon – Ramstein pyloromyotomy (split the thickened pylorus)
- Child may feed immediately after or within an hour after surgery
- After 24 hours can go home
- Prognosis is very good
- More common in males and firstborn
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! 8!
PAEDS: GIT & GUT
Testicular TORSION
GP setting. An 8 / 18 yo boy c/o pain in the right groin area. He vomited twice when he was riding a
bicycle, he got the pain & this happened 2 hours ago. Previously healthy.
(can come with R illac fossa pain)
Task: take a relevant history, do the physical exam & management.
DDx:
Trauma
Torsion
Adductor tendinitis
Strangulated inguinal hernia
UTI
Ureter colic/stone
Adhesion (small bowel obstruction  ask previous surgery)
Hx: haemodynamically stable?

Do you want me to give you a pain killer?
How did it happen?
Any trauma, any abdominal pain, fever?
Any history of previous abdominal surgery?
Any mumps, family history of mumps
Any swelling in your tummy, swelling in the groin area?
Vomiting  how many times
(If 18 years old)
Are you sexually active? r/o
How many partners?
Any other medical problem
O/E:
GA: ill, pale, any distress, any signs of dehydration
VS:
Abdomen: any tenderness, organomegaly, any mass, bowel sound
Groin: tenderness, any swelling, mass (hernia)
Scrotum: tenderness, swelling, mass, redness, position of testis (horizontal) the right testis not
palpable, very tender
Explantion:
Your son has torsion of the testis, it means the testis in the right side is twisted. The risk is the
decrease of blood supply to the testis. This is a surgical emergency. If <6 hours from the onset, the
outcome is better.
Refer call the ambulance
During the surgery, if the testis is found dead, they need to take it out. They will take the consent from
you. But in your condition, it’s only 2 hours, the outcome is good.
Even if the testis needs to be taken out, the fertility will not be affected because you have 1 testis.
They will fix both testes because there is a higher risk that the other one will be affected
(orchydoplexy).
Ix: if Doppler U/S available that’s fine, but my concern is not to waste time, immediately take to the
theatre  no use of ultrasound.
! 9!
PAEDS: GIT & GUT
Tongue Tie (Ankyloglossia)

You are a paediatric HMO. The midwife asked you to see David who is just born and has
tongue tie (tight tongue).
Task: counseling
Congratulations!!! Is it your first baby?

The midwife told me that your baby has a problem with the tongue, when did you first
notice? How do you feel about this?
David has a condition called tongue tie. It is a condition in which the tongue is normal but it
is attached to the oral cavity by a small muscle we called frenula. In this case the frenula is
short. The cause is unknown
I will also check for other congenital abnormalities.
Symptoms: they may not be able to protrude the tongue fully out of the mouth. Cannot touch
the roof of the mouth. May not be able to move sideways to the corner of the mouth.
Tongue may look flat or square instead of pointing.
This will not affect his feeding, however, sometimes there may be some problems with
speech. Rarely problem occurs with feeding.
As it is not a progressive disease we will wait and see. If you’re concerned, I can offer you to
see a paediatric surgeon for second opnion.
If everything goes well we will not do anything.
But if you are concern and if there is any complication or any problem with breastfeeding or
speech, surgical intervention can be done.
It is a very small and quick procedure. It may or may not need local anaesthesia.
<12 weeks surgery  no need for anaesthesia
>12 weeks need local anaesthesia
It can be cut with a scissor and no complication is usually seen.
If you find feeding difficulty or speech problem please come back to me and I will refer you
to a paediatric surgeon for appropriate management.
Refer to speech pathologist after surgery.
!
! 10!
PAEDS: GIT & GUT
Vulvovaginitis
A 3 yo girl presented with mom c/o vaginal discharge for the third time. She had recovered
spontaneously before but now she’s complaining of pain when passing urine.
Task: Hx, Exam, Mx.
DDx: (d/c in paediatric)

Vulvovaginitis
Foreign body
Child Abuse
Pinworm
DM type 1  Candidiasis
UTI
Hx:
Discharge Qs:
Type: thick (candidiasis) or thin (trichomoniasis)
Amount (copious  large or stainy)
Colour
Smell  foul smelling  foreign body
Any blood seen in the discharge
Itchiness
Fever, frequency of urination, colour, smell
Toilet trained
Bedwetting
Any change from the previous
Pain or soreness down below
Drinking more water than usual (rule out DM)
Is it possible that she’s left unattended or unsupervised? (r/o foreign body or child abuse)
Do you think that she may put something in her private area (foreign body)
Who looks after the child – at home, go to day care
Any rash or bruises all over her body
Does she scratch her bottom  perianum excoriation (pinworm)
Have you changed her soap recently (allergy)
Swimming (wet)
How is her general health DM?

Any concern of her growth and development?
Any family history of asthma, allergy or eczema?
Is she on any medication?
Does she have any allergy?
Is her immunization up-to-date?
O/E:
GA: Growth chart, especially body wt, rash, bruises
VS
ENT
Focus on abdomen
! 11!
PAEDS: GIT & GUT
- Inspection: any mass, distension, rash, scratch mark (for allergies)

- Palpation: organomegaly, mass, tenderness
- I’d like to inspect the perianal and genital area
- I’m looking for discharge, any redness, any swelling, scratch marks
Urine dipstick  can be normal
Ix:
Urine analysis – microscopy & culture
Discharge profuse – take a swab
Explanation:
Most likely inflammation of private area called vulvovaginitis.
Quite common in this age group (2-8 years). Usually resolves spontaneously.
In this age there is lack of estrogen and the skin of the vulva (the soft genital area that
surrounds the vagina) and vagina is thin and poorly developed and is susceptible to the action
of bugs from the skin and the anus.
I’d like to do a urine microscopy & culture.
Risk factors:
- family history of allergy & eczema
- bubble bath, bath salts
- nappies
- wet swimming suits
- overweightdribbling of urine
- Lack of hygiene
It’s not a serious condition. We will be able to manage it.

- Attention to good hygiene is the first line of treatment
- Avoid bubble bath
- Soak the child’s bottom in a warm, shallow bath containing half a cup of white vinegar or
bicarbonate of soda (baking soda)10 grams to 10 litres of warm water
- Use cotton underwear, loose clothing
- Soothing creams 3 times per day zinc & castor oil cream or any other nappy rash cream
- Teach good toileting practicetell the child wipe the bottom from front to back to avoid
the infection.
If this doesn’t work, we can refer her to a paediatrician.
Reading material.
Review in a few days time.
Red flags painful urination, excessive scratching, heavy or bloodstained d/c

!
! 12!
PAEDS: GIT & GUT
Duodenal Atresia
You’re an HMO in a rural hospital. A young woman who has had a normal vaginal delivery
with 1 day old baby came back after discharge as the baby has greenish vomiting afterwards.
The baby did not pass meconium. Plain X-ray of abdomen done & attached.
Task: explain X-ray finding. You’re allowed to take history if needed. Explain the condition.
Hx: before I explained the X-ray, may I ask several Questions

When did the baby start to vomit?
How many times so far?
Has the baby currently been passing wind?
Is the abdomen distended?
How was the pregnancy, were there any problem?
Any antenatal check up done, any abnormality detected?
Delivery
Any family history of cystic fibrosis?
Are you here alone today? Do you have any other kids at home? Do you have any help at
home? If you need any support, we can send support from the local council for you
Explanation:
From the X-ray & symptoms of greenish vomiting, it’s most likely your child has a condition
called duodenal atresia which may involved another part called ileum. Other causes could be
- Malrotation or volvulus
- Your baby did not pass meconium and this may raise another differential diagnosis which
is meconium ileus with possible cystic fibrosis or meconium plaque
- The least can also be Hirschsprung or imperforated anus
! 13!
PAEDS: GIT & GUT
This condition is a medical emergency and serious, please do not feed your baby. Your baby
will be admitted & reviewed by the local surgeon who I believe will refer your child as soon
as possible to a tertiary hospital which can be arranged by the NETS or PETS (Neonatal or
Paediatric Emergency Transfer Service).
A small tube called nasogastric tube will be passed from your baby’s nose, and this is to
suck the secretion from his stomach, to decompress the stomach. At the tertiary hospital with
special neonatal facilities your baby will be under the care of an anaesthetist & paediatric
surgical team who will perform an urgent operation if decided. Your child will be supported
by intravenous fluid, so don’t worry about feeding him. Please don’t feed him now and
after the operation until you’re told so.
In the future if your child have any severe abdominal pain or severe vomiting, please go
back to the hospital as soon as possible. I’m more than happy to give you any other
information if you have any other concern.
Qs asked by the patient

1. Is it a serious condition?
2. Can I go with my baby to the hospital?
3. Can I feed my baby now?
4. How will my baby be fed?
5. My baby is too small to have this operationthis team of surgery, they’re doing such
operation more frequently, so don’t worry about your child’s age.
6. Will my baby have problems in the future?  post operative adhesion, severe obstruction
7. My breastmilk is leaking I know that you’re ready to feed, this will be decided later
until the child is stabilised. If you have any milk leakage from your breast, a nurse will
teach you how to use the breast pump to express the breast milk. In all the hospital there
is a lactation nurse who is well-educated.
To note that if the case is in a rural hospital  usually needs referral to a tertiary hospital
!
! 14!
PAEDS: GIT & GUT
Foreign Body Ingestion

A 3 year-old child presented to the ED after swallowing a board pin. The child is now fine.
Task: relevant Hx, PE, order necessary Ix. Advice mother regarding appropriate Mx.
Hx:
1. Could you please tell me what happened? ----encourage the mother to talk (Don’t worry,
everything is under controlled, I’ll do my best to get the best outcome for your child,
please calm down and tell me what happened? )
2. At what time did it happen? ---one hour ago
3. What kind of pin is it, sharp? How big is it?
4. Are you sure that he swallowed it, is there a possibility that he might just throw it away?
5. Any shortness of breath? Any cough? Any change in colour and difficulty in breathing?
6. Any vomiting, did he drink or eat after it happened?
I know it’s very difficult for you especially looking after children at this age, it would be a
good idea to put the board pins away.
Ix: X-ray showed the abdominal area where the pin is above the navel
Explanation:
This is the X-ray of your child
I have good news for you…as you can see, the pin has passed the narrow places which are
the gallet and the stomach. The pin is in the small gut, it probably will pass itself within the
next 10-12 hours.
Social history --- asking the mother when giving the reading material
Whom do you live with?
Any other children at home?
Do you have difficulties coping with your children
Is this the first time to happen?
If you’re not coping, I can arrange for a social worker or nurse to come and help you out with
your children  day care
Where do you live? Do you live far from the hospital?
If not sure the location of the pin in the X-ray  I’m not sure if it’s in the stomach or small
intestine.
If the pin is in the gullet Admit
If the pin is in the stomach  I might want to keep the patient in the hospital for observation,
and do serial X-ray (2-3 hours later) to see if the pin is moving or stucked
If it’s in the small intestine, and you live near the hospital, it will pass by itself. I’m going to
discharged you home. Any problem bring him in. There’s a tiny possibility of perforation 
nausea, vomiting, abdominal pain, fever, excessive crying, drowsiness, not sleeping well &
not feeding
!
! 15!
PAEDS: GIT & GUT
Circumcision (AMC 3)
A 28 yo primigravida, 35 weeks of pregnancy, presented ask about newborn circumcision.
Task: counsel patient regarding circumcision and answer her questions
Hx:
Congratulations.
My understanding you’re in my room to speak about circumcision
How much do you know about that? Cut the foreskin of the penis.
There are some reasons people want to have the procedure done
- religion
- your believe
- runs in the families
There are medical indications:

1) If the opening of the foreskin is tight, very narrow opening (phimosis), child suffer during
wee, can’t pass the urine. But we can deal with it without circumcision if it’s mild. We can
give Betamethasone 0.05% cream, hold the foreskin squeeze some cream several times a day
for 14 days and may improved.
2) Paraphimosis
There is a contraction ring on the head of the penis.
Retract the skin, push it back, try to push it forward again; if it stuck, the surgeon can push it
back again, in the expert hand can be pushed back to normal.
3) Infection of the undersurface of the foreskin – balanitis

But may treat it with 2 courses of antibiotics
4) Frequent UTI
May be indication but we need to deal with it with medication and investigate, may be has
reflux (investigate with US) or abnormalities in the ureter, exclude first before we do the
circumcision
Does it carry any benefits?

Research said it has some benefits:
- Decrease HIV, Penis ca, cervical Ca in the partner,
- Increase the sexual pleasure
Not sure if it’s correct or not. In reality it’s not confirmed by Australian research
The disadvantages:
- Infection
- Bleeding
- The surgeon can amputate the penis (partial or complete)
- Leave a scar
- Deformed penis
- Pain
- The risk of general anaesthesia
! 16!
PAEDS: GIT & GUT
Contraindication
- Congenital anomalies: hypospadias (the opening of the urethra is on the underside of the
penis) or epispadias if the opening is upper or below
- Patient with haemophilia
When I should do it?

- When the child is out of nappies
- Australian College of Physician said it’s unwise in the first weeks of life
The operation is best performed in hospital under general anaesthesia; the patient is at least 6
months of age.
It’s your decision, discuss it with your husband and parents

I’m happy to invite them to discuss in details
In Australia it’s not indicated, not encouraged but we respect your believe.
Not cover by Medicare.
!
! 17!
PAEDS: GIT & GUT
Congenital Adrenal Hyperplasia

A 5 days old presented to ED with Mom because she’s not drinking well and started to vomit.
Task: Hx, ask the examiner about the examination finding, order Ix, explain Dx & Mx.
DDx:
Infection
Reflux
Cow milk intolerance
Pyloric stenosis
Biliary stenosis
Pyloric & reflux  vomit, drink (demanding)

Congenital Adrenal Hyperplasia  refuse to drink & lethargic
5 day-old child with frequent vomiting, potassium high  Congenital Adrenal Hyperplasia
Potassium low  pyloric stenosis
Hx:
No problem during pregnancy
Antenatal care
Full term or premature
Delivery at home  no baby check & no immunization (Ask why home delivery)
No resuscitation, cry immediately
Mom has fever at the day of labour
PROM, ascending infection after birth  think of neonatal meningitis
Infection  any fever, skin rash, flu-like symptoms (coughing)
Breastfed – how often  perhaps over feeding

What’s the colour of the vomiting, is it green and projectile – bile stain
When he vomit, does it throw far away?---NO
Is she demanding?
How’s her sleep?
Bowel action, how often, frequent, how many times, watery, smelly, mucus, blood
Baby can have one bowel action after each breastfeeding (increase bowel reflex but not
diarrhoea)  healthy, gaining well
Is it related to food or not---not related to food or breastfeeding
How often after you feeding her
Could be reflux  did the baby scream, unsettled, drawing legs up, arching the back
Family history of cow milk or lactose intolerance
Are you using any medication at the moment?
O/E:
GA: unwell, very lethargic, dehydrated, depressed anterior fontanelle, some darkness of the
skin in the axilla & in the groin (skin fold), rash, LN
VS: temp 36, HR 162, RR 38, BP 60/35 (hypotensive), O2 Sat 93%
Chest & heart normal
Abdomen soft, lax, no mass, bowel sound (+)
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PAEDS: GIT & GUT
Genital exam: abnormal, ambiguous  clitoromegaly, labioscrotal fusion

Urine dipstick: Ketones (++); Nitrite (-); Leucocyte (-); No blood
Feeding test: Mom breastfeed the baby and look at the baby’s tummy to see if there is a mass
Ix:
FBE: Hb 220 (150-200); WCC 9000 (3000-9000); Platelets normal
ABG: Na 124; K 7.5; Urea, creatinine normal; CO2 10 meq/L (15-27); O2 sat normal
Bilirubin normal
Indication for admission to hospital

How much is she drinking (25% or less than usual  admit)
How much urine---nappies is it 25% or 50%
Do you know anything about CAH

Draw kidney & adrenal gland Adrenal gland secretes corticosteroid & sex hormones
Your daughter has problem with this gland, it’s congenital
There’s some abnormalities in the gland
It’s not common
We will try our best to fix it
It still carries some risks: vomiting, dehydration, abnormal genitalia, long term treatment with
steroids carry a risk
Need more investigations

Refer to paediatrician, endocrinologist, plastic surgeon
Mx:
- Give fluids
- Cortisone replacement – IV corticosteroids (on replacement cortisone treatment all her
life)
- Correction surgical treatment for her genitalia
Breastfeeding & Mom is eating diary product (full cream milk, yoghurt, cheese)  to check
if baby has cow milk intolerance  tell Mom to stop taking diary product  baby improve
! 19!
PAEDS: GIT & GUT
Neonatal Jaundice (Conjugated)

You’re an HMO2 in paediatrics department and one of the midwives rang you and said that
there is a 3 days old baby has jaundice. Jaundice occurred at the end of the 2nd day. Total
bilirubin 400, indirect (unconjugated) 330, direct (conjugated) 70
Task: Take Hx from mom, PE findings, order Ix, Dx & DDx to mom & management plan.
Unconjugated Conjugated
ABO incompatibility Biliary atresia
Physiological jaundice Galactosemia
Haemolysis: RBC (G6PD def, Pyruvate Neonatal sepsis (unconjugated &
kinase deficiency), hereditary spherocytosis conjugated)
Breast milk Hepatitis
Hypothyroidism
Hx:
How was the pregnancy? Any medical issue like thyroid disease, DM?----No
Full term or preterm baby (up to 36 weeks), how many weeks?----38 weeks
After how many hours was the delivery?
Any instrumental delivery? Cephalo haematoma (vacuum extraction) can cause jaundice
Any resuscitation, cry immediately after delivery?
Do you know his APGAR?----No----We’ll check it.
Breastfeeding or bottle fed?
He sleeps well?  Baby start to be sleepy from yesterday (before he cries, but now I need to
wake him up for feeding)
Any fever, skin rash, vomiting, lethargic  septicaemia, or hypothermic
Urine color---red tea (coca cola), red colour urine (indicate hemolysis)
Stool color---clay / white or dark colour?---clay (some elements of obstruction)
FHx of blood disease or liver disease?
Roots of the family: from which country ---Greek, Egyptian, Italian ----G6PD
Blood group  ABO or Rh incompatibility
Any other sibling, if there is any disease in the eye?  galactosemia
O/E:
GA: Body wt; Head circumference
Level of jaundice  extensive, upper chest, upper abdomen;
The way he cry  high-pitched cry, irritable  something serious;
Lethargic, alert, moving limbs or not;
Any dysmorphic features (chromosomal abnormalities);
Skin rash
Fontanelle
VS: BP, feel femoral pulses  if no femoral pulses, ask nurses for BP in 4 limbs
Auscultation: chest, heart sounds, murmur
Abdominal exam: soft, relax, distended, any organomegaly, bowel sound
Genitalia
Test hips for clicky sounds
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PAEDS: GIT & GUT
Explanation:
I agree your child has jaundice but from Hx and exam I don’t know what’s the cause.
The Red Blood Cell contains Hb which consisted of iron and globin. Iron goes to the storage.
RBC is 70 days. Globin goes to the liver where it’s changed and discharged through the
kidney.
There are two types of jaundice, indirect and direct. The difference is water insoluble and
water soluble. Indirect (unconjugated) is water insoluble and direct is water soluble, the body
can get rid of it (soluble one) to the kidney.
Which is more risky?

The unconjugated hyperbilirubinemia can cross blood brain barrier and causes kern icterus.
The conjugated is risky too
Both carry some risks
The blood test will help us differentiate if it’s indirect or direct.
I need to order some tests

- FBE
- Blood film  look for spherocytes, blood smear
- Blood group for the baby and mom if not known from the history
- Total bilirubin direct and indirect
- Coombs test direct and indirect
- Urine test for microscopy, culture, sensitivity and reducing sugar (galactosemia)
If the direct bilirubin is high, we need to order some tests
From the Ix your baby has a condition called conjugated hyperbilirubinemia, it’s
uncommon. There are a lot of causes which are:
- Biliary atresia: the indirect bilirubin goes to the liver, by enzyme it becomes direct
bilirubin, go to the biliary system which is not developed
- Galactosemia a metabolic disease
- Sepsis
We need to order more tests:

Liver enzyme and liver US
Septic work: blood culture
TORCH – congenital infections
I need to ask the paediatric consultant, perhaps we will involve the metabolic consultant if it’s
(galactosemia stop breastfeeding, use special formula), and surgical consultant if biliary
atresia for liver transplant. If sepsis give antibiotics and follow up. Multidisciplinary team
will be involved.
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PAEDS: GIT & GUT
Neonatal Jaundice (Unconjugated)

You’re an HMO and you have a 1 day infant with jaundice seen within the first 24 hours. Full
term vaginal delivery, birth weight 3.7 kg, sucking well. No other significant findings.
Task: Investigation & Management.
Hx: Congratulations, you must be very thrill with your newborn. From the notes I understand
that your baby has jaundice
1. When did you first notice it?
2. Where did it start?
3. Where has it progressed to?
4. How’s the baby doing? Irritable, drowsy/active(bilirubin level is very high  emergency)
5. Breastfeeding or bottle feeding? Feeding well? ---hydration status
6. Fever, diarrhoea, vomiting
7. How many wet nappies? Color?
8. Has the baby passed stools  colour and smell?
9. How was the pregnancy? antenatal care? Any infection, any drugs taken?
10. Are you aware of your blood group? Mother blood gr O (+), baby A (+), father A (+)
11. How was the delivery? Any instrumental delivery?
12. Did you have any fever just before, during and after the delivery?
13. Full term or premature?
14. Has the child got any bruises? – cephal haematoma
15. Do you know whether the neonatal screening test has been done?
16. Any family history of bleeding disorders, liver disease, similar condition?
Neonatal screening  Heel prick test:

- Cystic fibrosis
- Hypothyroidism
- Phenylketonuria
- Galactosemia
O/E:
GA: jaundice (icteric distribution), active, drowsy, dysmorphic features (Down syndrome),
Birth weight, Head circumference  cephal haematoma
VS
Any lymph node enlargement
Rash
ENT exam
Systemic review : Respiratory, CVS, Abdomen
Explanation:
Because of jaundice within the first 24 hours, it is pathological. You’ll have to stay in the
hospital for a few more days. We’ll do some Ix to find out the cause like:
- FBE and blood film (to check for anemia, microspherocyte)
- Mother’s blood group, baby’s blood group
- Direct Coombs test shows hemolysis
- Baby’s Hb level
- Thyroid function test (baby)
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PAEDS: GIT & GUT
- Urine culture
- Serum bilirubin level (total, unconjugated)  244  phototherapy
Explanation:
Your son has got a condition called haemolytic jaundice. It’s b/o ABO incompatibility, the
baby’s and the mother’s blood groups are not compatible together. There is some interaction
between them and hence the jaundice.
Quite common in first born child (Rh incompatibility is common in the next born).
There is increase level of unconjugated bilirubin.
It’s risky because the unconjugated bilirubin can cross the blood brain barrier deposit in the
brain that can cause neurological damage (kern icterus) and can also cause deafness.
Treatment phototherapy & monitoring
Your baby will be kept under lights except feeding time. His eyes are covered for protection.
It’s done in the same room where the mother is.
Phototherapy may cause black and green loose bowel motion.
Excellent prognosis.
Continue breastfeeding.
Refer to the paediatric registrar.
I understand you want to go home, but it’s very important to treat him. It’s a dangerous
situation, if unconjugated bilirubin will cross the blood brain barrier – Kern icterus (only
unconjugated cross the blood brain barrier)
Need to admit phototherapy
Call paediatric register
Not resolving, values increasing  exchange transfusion
Follow up in 6 weeks
Audiometry has to be done later because of the risk of deafness (done at 6 weeks).
May have developmental problems  assessment
There are 4 cases in AMC:

Conjugated jaundice (Haemolytic)
Physiological jaundice
Breastmilk jaundice
Galactosemia
Obstructive jaundice (Conjugated bilirubin) DDx:

- Biliary atresia
- Choledocho cyst
- Hepatitis
- Galactosemia
Neonatal jaundice
- Haemolytic
- Breastfeeding
- Obstructive
Newborn jaundice (physiological)  liver not mature  unconjugated bilirubin to the liver
 unconjugated bilirubin increase in neonatal period
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PAEDS: GIT & GUT
Red Blood Cells are metabolised in the spleen  Unconjugated bilirubin  goes to the liver
and metabolised by the enzymes  conjugated bilirubin  bile duct  absorbed in the
intestine and circulation  color of urine & stool
Differentiate between physiological & pathological jaundice

Unconjungated bilirubin increase  no color change in urine & stool
Conjungated bilirubin increase  pale, dark stool
Any increase of bilirubin within 24 hours is always PATHOLOGICAL

Unconjugated bilirubin (liver immature)
Haemolytics  ABO incompatibilities
1. Mother + Baby blood group
2. Direct Coombs test
3. Serum bilirubin
4. FBE  Haemoglobin increase
5. Blood film
6. Treatment: unconjugated bilirubin > 150 micromol/L  start phototherapy
7. Hb < 110 gram/L  Exchange transfusion
Physiological Jaundice
1. Appears 2-4 days (7 days)
2. Usually resolves within 2 weeks (14 days)
3. Range of bilirubin <220 micromol/L
4. Prolonged jaundice if >14 days and bilirubin >220 micromol/L
5. If bilirubin >220 micromol/L  rule out infection, hypothyroidism, RBC enzyme defect
6. If prolonged jaundice but the investigation results are within normal limit (<285
micromol/L)  baby breastfeeding  breastfeeding jaundice
7. If bilirubin is >285 micromol/L  give PHOTOTHERAPY
USG  biliary atresia

CT  choledochocyst
Prolong jaundice (>14 days, >220mmol/L), need to r/o infection, hypothyroidism, RBC
enzyme defect (G6PD) before Dx breastfeeding jaundice.
For Breastfeeding Jaundice if bilirubin >285  phototherapy
For physiological jaundice

Bilirubin >260  Phototherapy
Bilirubin >340  Exchange transfusion
During phototherapy, the eyes and genitalia need to be covered.
SE of phototherapyblack and green loose motion dehydration
! 24!
PAEDS: GIT & GUT
Inguinal Hernia + Umbilical Hernia

A 5 month-old baby was brought in by his father because he found a lump in the groin area.
He developed another lump in his belly button.
Task: talk to the father about management.
Hx:
He has two lumps in his body. Could you tell me where they are?
Which one did you find first? ---the inguinal one
When did you find it?
Can you return them back after they come out? yes
Is there any factor which makes it more prominent?
How about the one on the belly button?
Explanation:
Your son has two lumps, we call them hernia. Hernia occurs when there is a weak point in his
tummy or inguinal area. When there is an increase of abdominal pressure like crying,
coughing, the swelling will become more prominent. Sometimes, there is no cause and it is
congenital.
There are 2 types of hernia.

The one in the inguinal area – inguinal hernia
In the belly button – umbilical hernia which can resolve by itself within 12 months. We are
not worried about this hernia as it has a wide opening so bowel obstruction is unlikely.
But down below which is the lump in the inguinal area, it needs treatment as the
canal/opening is narrow and there is high risk of strangulation. It can affect the testicular
vessel and cause testicular ischaemia.
< 6 weeks – refer in 2 days
< 6 months – refer in 2 weeks
< 6 years – refer in 2 months
I’ll refer your son to the paediatric surgeon for the inguinal hernia. Regarding the umbilical,
the specialist will wait for spontaneous resolution or do the operation together with the
inguinal one.
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PAEDS: GIT & GUT
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PAEDS: GIT & GUT
Incarcerated Hernia
A 5 month-old baby came to GP clinic with Father b/o sudden onset intermittent screaming
with a few episodes of vomiting. Older brother has got recent onset of gastroenteritis.
Task: take history, examination, diagnosis & management.
DDx:
- Intussusception
- Small bowel obstruction
- Volvulus- malrotation
- UTI
- Gastroenteritis
- Meningitis
- Pyloric Stenosis – 3-6weeks
Features of inguinal hernia:

- Groin lump
- May cause intermittent pain & discomfort
- Common in premature infant and boys
Incarcerated – irreducible, still reddish color signs of inflammation (just occur)

Strangulated – bluish color blood supply has been cut off (longer time)
Hx:
When did it start?
Is it improving or worsening?
Is it happen previously or first time?---first time
How many times did he vomit?---2-4 times
- Amount
- Color
- Smelly or not (foul smelling?)
- Content (blood, food)
- Projectile or not
How’s the bowel motion?
- Amount
- Smell
- Blood
- Color
When he cry does he turn blue or draw up his legs?
Any fever? Any rush?
How’s his feeding?
Breastfeeding or bottle feeding? Have you introduced any solid food
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PAEDS: GIT & GUT
Any lumps in the body?---one lump on the right lower tummy (inguinal area)
Waterworks – how many times do you change his nappies – foul smelling?
Any tummy distension
BIND – birth, immunization, nutrition, growth & development (Common in premature boys)
Medication allergy,
O/E:
GA: Very irritable, mildly dehydrated, Growth parameter
VS: P 100, RR 30, T
Neck rigidity
ENT
Heart & lung
Abdomen: distension, mass, tenderness, guarding rigidity, bowel sound (obstruction)
Inguinal orifice – scrotum (testis)– mass on the right inguinal ring – size, shape, site, color of
the skin  reddish
Reducible or irreducible ---irreducible
Rectal – inspection (?PR red current jelly)
Urine dipstick
Explanation:
From history & examination, most likely your son has a condition called incarcerated hernia.
Hernia is a protrusion of the covering of the bowel (gut) or part of the bowel through a weak
point in the tummy wall. It is irreducible, that means it can’t go back inside the tummy.
Mx: (medical emergency)

I’d like to refer him to the hospital to be assessed by the paediatric surgeon.
Nil by mouth, IV fluid and they will do surgery as soon as possible.
He will reduce the hernia back and put it in the original position.
Surgical intervention as soon as possible for:

- irreducible hernia
- infant
If reducible hernia: 6-2 rule
! 28!
PAEDS: GIT & GUT
Coeliac Disease
(Iron deficiency anaemia /failure to thrive in child)
An 18-month old boy came to your GP clinic with his mother after a holiday. The child has
flu-like symptoms and look very pale. Blood test showed hypochromic microcytic anaemia.
(another case: mom is concerned he is not gaining wt as expected, pregnancy normal)
Task: check growth chart, take history, explain about the result and management plan.
Hx:
Pregnancy/delivery history
Twins
Feeding pattern
How long was he breastfed
Introduction of solid foodWhen solid was introduced? What kind of solid food?
Stool: bulky, smelly, greasy, not flushing, flooding
Eating well? Playing well like other children?
How is his growth & development
Immunization
Any medical problem
Any allergy
Explanation:
I suspect he has celiac disease, auto immune enteropathy triggered by ingestion of gluten
(main source: wheat, grain, oat, barley, rye), in genetically susceptible individual.
This autoimmune reaction can lead to flattening of bowel wall resulting in malabsorption of
vitamins and minerals.
Ix:
1. Stool exam fat
2. FBE
3. U & E r/o renal failure
4. Serological (coeliac) screening: if negative, do sweat test to r/o CF
- Antiglutin antibodies
- Antiendomisial antibodies
- Transglutaminase antibodies
5. Duodenal biopsy villous atrophy (ask pt to continue normal diet, if biopsy (-) while on
normal diet, need to do 2 more biopsies; if 3 biopsies are normal but still highly suspect
coeliac disease, can do genetic test)
6. Genetic test  there are 2 types of genes detected now.
Mx:
Short term 
Long term  life-long gluten-free diet. If patient can stick on diet, can lead a normal life
Complications  GIT lymphoma, IDA
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PAEDS: INFECTIONS
Febrile Convulsion With Speech Delay (AMC 31)

ED setting. A 14 month-old boy came after an episode at home the previous evening. His
parents explain that he has been unwell all day with a high fever (40 degrees) and while he
was being cuddled he was staring and did not respond to his name. They noted that his body
twitched all over for several seconds and the whole episode lasted for 60 seconds. He then
went off to sleep and slept for the rest of the night. Examination findings: he’s alert,
neurological exam normal, he has low grade fever, and signs of URTI.
Task: further Hx. Explain your diagnosis and give management plan.
Important things to ask in Hx:

Birth history, birth trauma (rule out epilepsy)
Any head injury
Developmental history
FHx of epilepsy and febrile convulsion
Hx:
When did this happen?
Is it a generalised fit all over the body or only on one side?
Who witnessed the fit?
How long did it last?
Any urination/defecation/tongue bite during the fit?
Is this the first time?
Any head injury?
Any recent infection with high temperature? How high was the temperature?
Does he have any flu-like symptoms like coughing, runny nose; or rubbing ears?
Wet nappies?
Is he feeding well? Sleeping well?
Any FHx of similar problem or epilepsy?
Any concern of his development?---speech problem.
Other milestones like walking, social interaction
Do you have any other child? How is the child?
Birth history
Immunization
Explanation:
Your daughter had a febrile convulsion. It’s a common reaction to fever in young children,
fro 6 months to 6 yrs of age. About 3 in every 100 children will have a fit form a fever and it
tends to run in families. The fever is caused by an infection, usually a viral infection. A
simple viral infection would give an adult a heavy cold, but in children, if can cause high
fever. The growing brains (immature) of little children are sensitive to fever, and when the
normal brain activity is upset a fit can occur.
Febrile convulsion is a benign condition, does not usually cause brain damage or epilepsy.
Most children are absolutely normal later on but about 25-50% will go on to have another
seizure.
30% chance of getting the febrile convulsion in the first 24 hrs. So you need to keep an eye
on him. If he has a high fever, undress him, give him Panadol, and tepid sponging.
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PAEDS: INFECTIONS
Only 3% will lead to epilepsy in the high risk group: family history of epilepsy, prolonged
convulsion for more than 10 minutes, focal element and any abnormal development before
the seizure. 1% for those without FHx, the same as general population.
If he has a fit, place him on his side, chest down, with the head turned to one side. The
primary concern is to keep his airway open. Undress him to keep him cool. Then call your
GP or Ambulance ASAP. Even if the fit stops, have your child checked.
Red Flags:
- if the fits last >10 minutes
- any focal element to the seizure
- any abnormal neurological behaviour in the child prior to the seizure (like vomiting,
severe headache, slurred speech)
- any family history of epilepsy
CALL the ambulance or go to ED immediately.
Review in 24 hours.
If mother is very concern, can refer to paediatrician.
Recurrence Give Diazepam rectally, admit.
If focus of infection identifiedIx as appropriate for focus, send home and review by GP
If not focus of infection identified FBE, blood culture and urinalysis.
If suspect meningitis give antibiotics, full septic work up including LP
For the speech delay, refer to check hearing and to a paediatrician or to the speech
pathologist.
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PAEDS: INFECTIONS
Meningococcal Septicaemia (AMC 114)

A 2 yo boy is brought by his parents to a GP clinic in a small country town, 50 km from the
city. The child has become lethargic & febrile for the last 4 hrs. He has had a mild URTI for
the last 3 days. Now he has high fever, uninterested in food, irritable and has very cold skin.
He’s an only child of healthy parents. O/E, he looks unwell, has a fine, non specific macula
petechial rash on the trunk & legs. The skin is cold and pale especially over the extremities. T
40, RR 48, pulse 150, BP 90/60 mmHg. Neck stiffness not apparent.
Task: explain the diagnostic possibilities, outline your management plan. Picture is given.
Meningococcal septicaemia fever + pallor + macula petechial rash (in the trunk & limbs)
(Infection of the blood, not the brain)
Hx:
How long has he been ill?
When did it start?
Is it a continuous fever or it comes and goes?
Any associated symptoms like vomiting, diarrhoea, rash, cough, ear rubbing, fits?
Any medication? Did it help? ---Panadol, didn’t help
Anyone in the family has similar condition?
Eating, sleeping, waterworks and bowel habit
Any travel history?
Childcare
Difficulty in breathing
Any change in the skin colour
Allergy to any medication especially Penicillin
Immunization
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PAEDS: INFECTIONS
O/E:
General appearance
Alert and active?
Temp, HR, RR
Rash?
Capillary refill, hydration status
Fontanelle
Neck stiffness
ENT- ears, throat, enlarged tonsils?, enlarged LN?, eye examination
RS, CVS, Abdomen
Explanation:
Your son has a blood infection called septicaemia. It’s most likely caused by a bug called
meningococci. The bugs enter the body, spread through the blood all over (this can be caused
by Neisseria meningitides or Haemophylus influenzae). May be he caught this infection from
previous illness.
1) I will give antibiotics IV Cefotaxime (if unavailable, use Benzyl Penicillin)

2) I’m going to take the blood for blood culture
3) I’ll start IV fluids
I’m going to call the ambulance and transfer him urgently to the hospital. He will be seen by
the Paediatricians, they will do some more investigations such as:
- FBE (WCC), U & E, ESR, CRP
- Urine culture & sensitivity
- Chest X-ray
- Blood cultures
- Lumbal puncture
If meningococcal infection confirmed, give Benzyl Penicillin 4 hourly for 7 days.
Prophylaxis treatment to the family

I will give antibiotics to household contacts within 24 hours Rifampicin / Rifampin 12
hourly for 2 days. (SE: color urine, itchy, affect OCP, upset GIT)
Cefotaxime IM for pregnant / breastfeeding lady, and sever liver and renal disease
Also I have to notify this disease to DHS.
IMP POINTS:
- rash
- notifiable disease
- antibiotics for contacts- Rifampicin
- Full septic work up including LP
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PAEDS: INFECTIONS
Meningitis
A 32 yo man presented to ED & you’re an intern there. He has headache since yesterday.
Task: take history and examine, investigate & manage.
DDx:
Migraine
Tension headache
Subarachnoid haemorrhage (very sudden – eg. coughing)
Space occupying lesion
Meningitis
Hx:
Pain Qs Onset, site, characteristic, radiation, aggravating (coughing, straining, light)
Timing: morning?
“Is this the worst headache you have ever had?” r/o SAH
Recent flu-like illness, fever, rash, neck pain / stiffness
N/V, photophobia, visual changes, sensory or altered sensation, weakness r/o migraine
Joint pain
Any recent head injury
Any contact with a sick person
Any SOB, palpitation, chest pain (could be pneumonia)
Any past medical history, surgeries
SADMA
Social history: stress, what do you do for a living, whom do you live with
O/E:
GA: conscious level, Skin rash
VS: pulse, BP, T (hypotension, bradycardia raised intracranial pressure)
Signs of meningitis:
- Fundoscopy
- Neck stiffness
- Kernig sign (is done by having the person lie supine (flat on the back), flex the thigh so
that it is at a right angle to the trunk, and completely extend the leg at the knee joint. If the
leg cannot be completely extended due to pain, this is Kernig sign)
- Brudzinski’s sign
Heart, lungs, abdomen
You’re most likely suffering from meningitis, an inflammation of the covering of the brain.
Mx
- Take blood for blood culture & blood tests (FBE, U&E, ESR & CRP, BSL)
- Give Ceftriaxone (age >55 Ceftriaxone + Ampicillin), change later when get culture
 Benzyl Penicillin or Cefotaxime for Haemophylus influenzae
- Admit, call registrar LP (if there is no increased intracranial pressure)
- If shock  admitted to ICU & resuscitation
- If meningitis is confirmed and pt develops seizure  Brain CT
- Notify to Health Authorities
! 5!
PAEDS: INFECTIONS
- Prophylaxis for family members with Rifampicin (or Ciprofloxacin – but Ciprofloxacin is
only for adults)
Extra points:
- If in ED  CT and LP and Bloods (FBE, Culture) and Antibiotics
- If in country  bloods, Antibiotics and ambulance
- Benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) IV, 4-hourly
- OR amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 4-hourly.
Brudzinski's sign of meningitis
One of the physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck
stiffness causes a patient's hips and knees to flex when the neck is flexed.
! 6!
PAEDS: INFECTIONS
Chicken Pox
An 11 year-old girl came to your GP clinic with Mom c/o fever and skin rash since yesterday.
Task: take history, examination, management.
Hx:
When did the fever start? Did you check her temperature?
Any chills and rigors?
When did the rash start? (Usually fever first and rash after 2 days)
Where did it start first?
How did it spread?
Can you describe the appearance of the rash? (macule  vesicle)
Are they itchy?
ChestCough, noisy breathing, shortness of breath?
GIT & urinary tract Nausea, vomiting, waterworks and bowel motion
CNS  any headache, neck stiffness, photophobia, does bright light bother her?
Any similar condition at home, school or past?
Is she generally healthy?
Immunisation up to date?
O/E:
GA : ill,
Rash: vesicle with erythematous base, some area of macular stage, most are vesicular stage
VS: pulse rate increased, T high
Neck stiffness
ENT examination : runny nose, sore throat , LN
Respiratory, heart normal
Explanation:
Your child is having chickenpox. Diagnosis is clinical, no further test is needed.
It is caused by a virus called Varicella Zoster.
It is a common airborne infection and transmitted by air. It's contagious.
Usually the child has fever for 1-2 days and the rash appears.
As it is a viral infection, it’s a self-limiting condition, so all she needs is supportive treatment.
She needs to rest, give fluid, Panadol for fever, and Calamine lotion and soothing cream, if not relieve
give antihistamine for itching. It's advisable to avoid scratching. Daily bathing, and avoid rubbing.
Acyclovir or VZIG is only given to immunocompromised child.
Acyclovir is usually given only if present within 72 hours after the rash.
Don't send to school for 1 week.
Why does she have this although she’s immunized?

Immunisation can prevent only 80% of the infection. However, immunisation can prevent the severe
form of disease. After getting the infection, immunity is lifelong.
(Immunisation: 2 doses 1st dose at 12-18 months, 2nd dose at 4-6 years (school entry)
Complications:
Secondary bacterial infection (skin lesion and pneumonia)
Encephalitis
Thrombocytopenia
Aseptic meningitis
If >12, contact <3 days, consider immunization
! 7!
PAEDS: INFECTIONS
Septic Work Up
A 4 week-old baby presented with fever without focus.
Check
Fontanelle
Eyes
Ears (otoscope)
Nose
Mouth: sore throat - swab
Skin rash
Lung examination – chest X-ray
Urine suprapubic aspiration – urine culture
IV – blood culture
LP – CSF (Just a fine needle going through the lower spine to collect the sample of
cerebrospinal fluid for examination, it will not cause pain to the baby. It’s a routine
procedure. It looks awful for you but we will minimize the trauma. We will give local
anaesthesia and cream. LP will only take 2 minutes, it will give clear picture if there is any
bug present.
No procedure without risk, but we need to compare the benefit & risk
Why need LP to be done?

The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a case of
suspected meningitis, since there is no other reliable tool with which meningitis, a life-
threatening but highly treatable condition, can be excluded. Young infants commonly require
lumbar puncture as a part of the routine workup for fever without a source, as they have a
much higher risk of meningitis than older persons and do not reliably show signs of
meningeal irritation (meningismus).
Medical personnel perform lumbar punctures and test the cerebrospinal fluid to detect or rule
out suspected diseases or conditions. CSF testing looks for signs of possible infection by
analyzing the white blood cell count, glucose levels, protein, and bacteria or abnormal cells
that can help identify specific diseases in the central nervous system.
Most lumbar punctures are done to test for meningitis, but they also can determine if there is
bleeding in the brain, detect certain conditions affecting the nervous system such as Guillain
Barré syndrome and multiple sclerosis, and administer chemotherapy medications.
Chest X-ray to the baby – what effect the radiation has to the baby
One X-ray is harmless, very high sensitivity to detect pneumonia, very minimal radiation
without long term harm, the only one to show us any abnormality in the lung.
! 8!
PAEDS: NEUROLOGY
ABSENCE SEIZURE / PETIT MAL IN CHILD

A grandma with a 9 yo boy came to your GP clinic c/o her grandson’s school performance is
going down. He sometimes goes out of the world and stares and feel out of the world.
Task: take history, diagnosis, management.
DDx:
ADHD
Separation Anxiety
School bullying
Epilepsy
Provoked seizure
For any epilepsy, ask:

- head injury
- fits
- infection/meningitis
- febrile convulsion
- family history of epilepsy
- tumour
Hx:
How can I help you? I received a letter from the school
How is the situation at school?
Any stress at school? Any new thing happened at school? (new teacher, new activities)
How is the situation at home? Any stress? Parents divorced, father married other woman.
He was upset initially then OK, stays with his father now.
What do you mean by go out of world?  While playing he suddenly stops and stares for a
few seconds and he can’t remember anything. After that, he’s fine.
How is his general health?
Any medication?
Who looks after the child?
Has he had any head injury?
Any fit due to high temperature when he was young?
Has he ever had meningitis?
Have you noticed any fit or seizure?
Any family history of epilepsy?
Birth history  preterm or term
Any problem during pregnancy, delivery or after delivery
Immunization
Explanation:
From the Hx, it looks like your grandson has a condition called Absence Seizure. It’s one
type of epilepsy, common in children from 4 years to puberty. In this condition, child
suddenly stops the activity and stare. They become motionless. They have jerky movements
in face, finger and eyelid. They also have chewing or lips smacking.
It last for 5-10 seconds.
! 1!
PAEDS: NEUROLOGY
Outcome is good with treatment.

Most of the children grow out of it, sometimes it leads to generalised seizure in adulthood
(5%). I need to confirm the diagnosis. I’m going to refer your grandson to a specialist and he
will do EEG as a confirmatory test.
Also we need to do some basic test like: FBE, BSL, U & E (sodium)
If the Dx is confirmed, he will be put on medication. The first line medication is

Ethosuximide or Sodium valproate, the specialist will decide.
SE of Ethosuximide is nausea, vomiting, ataxia, diarrhoea, and headache.
SE of Sodium valproate  hepatotoxic. He need to take the medication regularly.
He’ll be followed-up by me and the specialist.

He needs to wear Medi alert bracelet.
Need to take a good balanced diet.
School teacher should be informed. If you like, I will inform the school teacher.
We can arrange a family meeting if you like.
Also there is an epilepsy support group.
I’ll give you some pamphlets to read.
! 2!
PAEDS: NEUROLOGY
MIGRAINE
Mother with her 10 yo daughter c/o recurrent headache. Her parents have Hx of migraine.
Task: relevant Hx. Ask examiner about examination findings and discuss Mx with mother.
DDx:
1. Migraine
2. Tension headache
3. Brain tumour
4. ENT infection (otitis media, etc)
5. Visual problems
6. Psychological issues/component
7. Meningitis
Hx:
Migraine Frontal, usually one side radiation
- Location of pain: unilat/bilat
- Time of start  diurnal variation (day or night)
- Aggravation/triggering factors  food, stress, school, bullying
- Severity on scale of 1 – 10
- Radiation of pain
- Associated symptoms like vomiting, flu-like illness
- Duration of pain
- Any pain-relieving medication taken, did it work?
- Does light bother her?
- ENT infection
- Eye check
Brain tumor
- Appetite
- Weight loss (any significant)
- Any unusual smells
- Sensation before headache
- Projectile vomiting
Tension headache (Unilateral, temporal)
- Condition at home
- Bullying (what are the relationship with teachers/friends)
- Relation with partner or daughter
- Relation with other siblings
- Financial problems
Explanation:
From the Hx and examination, it’s most likely that your daughter is suffering from migraine.
It is a common condition, especially when child has strong family history.
In majority of cases it’s mild. It does not carry any risk of neurological deficit.
If it happens again, put her in a dark and quiet room.
Avoid any kinds of activities such as watching TV, reading books.
I’m going to give a simple analgesic  paracetamol.
If it does not control her migraine, I will give her Ergometrine and Sumatriptan.
For brain tumour, let me assure you the symptoms are totally different.
! 3!
PAEDS: NEUROLOGY
Warning signs  drowsiness, visual problem (blurring), severe headache, severe vomiting,
child becomes more irritable, affect daily activities  see me or go to ED
Review in a week.
There are some reading materials for you.
Tension headache Explanation:

I’m happy with the exam. It’s most likely tension headache. It’s not a serious condition and
we can manage it.
Tension headache is mainly due to stress or
Due to the stress at school, bullying at school or family stress, she’s having this type of
headache.
This stress is not due to organic condition like brain tumour. You know that our body and
mind are interconnected.
Stress will express in many different ways of body function and can come with other
problems such as stomach pain.
In your daughter’s case, she’s having a headache.
I believe once we treat the stress, the headache will subside.
I’m going to talk with your child and find out if there are more problems or stresses.
I want to refer her to a child psychologist (for cognitive behaviour therapy; psychiatrist 
with medication). The psychologist is an expert, he will teach her how to overcome her stress.
We can make a family meeting, or you can spend more time with her.
You can take her for a holiday.
If you’re too busy, I will arrange for a social worker.
Examination
• Do a thorough neurological examination, including examination of visual acuity and fields,
eye movements, optic fundi, coordination and gait. Measure head circumference and blood
pressure.
• Auscultate the skull for intracranial bruits; palpate over the sinuses, cervical spine and teeth.
• Assess the child’s growth and pubertal status; inspect the skin for neurocutaneous stigmata.
464 www.rch.org.au/clinicalguide
Management of migraine
• Reassure the child and parents that migraine is not usually a serious condition.
• In an acute attack, all that is usually required is trigger avoidance, stress management and
the early use of paracetamol 15 mg/kg per dose orally, 4 hourly (max. 90 mg/kg per 24 h).
NSAIDs (e.g. ibuprofen 2.5–10 mg/kg per dose (max. 600 mg) oral 6–8 hourly) can also be
useful. The role of sumatriptan in childhood is not yet clear. In children with severe
vomiting and oral agents are not tolerated, metoclopramide and chlorpromazine can be
used.
• Prophylactic therapy for those with severe or frequent attacks is best used in consultation
with a specialist. Propranolol or pizotifen are commonly used. Sodium valproate,
cyproheptadine, verapamil, clonidine and amitriptyline can also be effective in some
children.
• 2/3 of children cease having attacks but 50% of these have recurrences in adult life.
! 4!
PAEDS: NEUROLOGY
INCREASED INTRACRANIAL PRESSURE

(MEDULLOBLASTOMA)
A mother of 10 yo child come to GP clinic with complaints that her daughter has headache.
Task: take history from the mom, examination, DD, management.
DDx:
Migraine
Medulloblastoma  increase intracranial pressure  admit to hospital (emergency case)
Tension headache  stress at school
Meningitis
Sinusitis (ask ENT)
URTI: pneumonia, sinusitis
Hx: (haemodynamically stable or not?  Severe headache painkiller)

When, where exactly, sudden/gradual? headache for 10 days, constant, on the back of head
Character of pain: travel anywhere like neck or shoulder
Any associated features:
- nausea, vomiting, dizziness vomited twice yesterday, once today
- fever, cough, runny nose (to rule out URTI – sinusitis)
- Any rash, neck pain or neck stiffness (meningitis)
- flashes of light or ringing in the ears, double vision, blurring of vision (aura for migraine)
- loss of consciousness, fits
Any headache / vomiting in the morning? wakes up with severe headache
Any head injury or trauma no
Any stress at school, is she enjoying going to school (tension headache)
Any stress at home, how’s her relationship with parents / siblings happy family, no sibling
Any family history of migraine  no
Immunization
O/E:
GA: alert, drowsy, any distress, rash
VS: BP 140/90, T, RR decrease, p 75
Eye exam:
- PEARL normal
- Fundoscopy  papillary oedema (increase of intracranial pressure), disc swollen, margin
indistinct (not clear), engorged retinal vessels
- Eye movement (intracranial nerve involvement, nerve 3, 4, 5)
- Any diplopia, nystagmus
ENT: any discharge, nose clear, throat (enlarged tonsils, any redness), sinus tenderness
Neck stiffness, LN
CNS: cranial nerve examination, gait, cerebellar signs all normal
Office test: urine dipstick, BSL
Explanation:
It seems that your daughter has an increased pressure around the brain (in the skull/ head which has
been showed in the test called fundoscopy. This is most likely due to growth in the part of the brain
(back of the brain). I don’t mean to scare you but I need to call the ambulance, transfer your daughter
to the hospital to be seen by the paediatric neurologist. They will perform the investigations, CT brain
scan, MRI and some blood test. After confirming the diagnosis probably they will give her some
medications to decrease the pressure in her head and she may need to go for surgery. But this will be
decided by the specialist. (SPIKES protocol. THIS IS A BAD NEWS FOR PARENTS)
I will follow up her after discharge from the hospital. Please don’t hesitate to contact me anytime.
! 5!
PAEDS: NEUROLOGY
BRAIN TUMOR – POSTERIOR FOSSA

Nadia, 3 years old, came with a 10-day history of vomiting.
Task: history, examination, explain DD, investigation, final diagnosis and management plan.
Positive findings:
Vomits food she eats, forceful but non projectile, non bile, early vomiting in the morning
Not related to diet, eating & drinking well
Twice vomiting per day
Normal stool
No rash, no coughing
She’s still playing but a little tired with decreased energy
She did not eat anything outside
No history of allergies and not on any medication
The child is quietly looking at you & her mother
Moist mucus membrane, not dehydrated
BP 100/70
Abdomen not distended, bowel sound normal
Capillary refill 1 second
More sleepy, very tired
Lebanese background
Growth & development normal
DDx:
- Gastroenteritis
- UTI
- Meningitis
- Malignancy - brain tumor
- Allergic to food
- Infection
- Constipation and fecal loading (abdominal X-ray)
- Reflux
- Food poisoning
- Drugs
- Metabolic condition (DKA?)
- Toxins such as spider bite, snake bite, or poisoning
- Non specific – cyclic vomiting
- Migraines
- Surgical causes appendicitis, bowel obstruction
! 6!
PAEDS: NEUROLOGY
Hx:
Vomiting for 10 days (if viral infection usually only for 7 days)
OPEN Q: tell me more about the vomitting.
- What is the content
- How often: 3-4 times/day
- Color
- Projectile or not (throw far away up to the wall?)  any increase of intracranial pressure
– brain tumor, meningitis
Duration: how long has he been vomitting?
Onset: how did it start?
Did he have any other illness at the same time?
Progression: has it been progressively getting worse/ improving/ no change?
Aggravating factors:
Any food?
Travel history?
Anyone in family sick? Especially gastro?
Relieving factors
Lying down quietly..
Any medications that help..
Associated symptoms:
Fever, cold, runny nise, cough? (sinusitis)
Rash, headache, blurred vision, fits? (meningitis)
Headaches, flashing lights? (migraine)
Dysuria, frequency, change in colour? (UTI)
Polydypsia, polyphagia, wight gain/ loss + bad odourous breathing? (DM- DKA)
Abdo pain, constipation, blood in stool? (obstruction/ intussuseption)
Diarrhoea, family members same problem? (gastro)
Is he eating and drinking ok?

Is he alert and interactive?
Any family history of tumour, especially at young age?
How has the growth of the baby been? Development ok?
Immunisation up to date?
Any pregnancy or birth complications?
Any medical problems?
Allergies to food or medications?
Ix:
FBE, pancreatic enzymes, CRP, ESR, Blood culture, Chest & Abdomen X-ray, USG
abdomen and kidney, CT Brain
! 7!
PAEDS: NEUROLOGY
Explanation:
Prolonged vomiting (>10 days) is pathological, I need to investigate further
Order CT under sedation  presence large 3 cm brain tumor in posterior fossa
(Posterior fossa tumor – there is no headaches, papilloedema or any neurological deficits)
From the CT, I’m sorry, we discover accidentally your child has brain tumor. It’s not
common in paediatrics. Many brain tumor in paediatrics has excellent prognosis, it has good
outcome. Heavily dependent on the nature of the tumor, has spread or not, damage the
adjacent tissue (surrounding area)
Need admission to hospital Peadiatric oncologist review + Neurosurgeon will be involved
Can use:
- Ondansetron (Zofran) waffer (biscuit - melt easy on the top of the tongue)
- Use it for tumor & chemotherapy
! 8!
PAEDS: NEUROLOGY
PROVOKED FIT
Jason, a 14 year old boy who has a fit immediately after an injury when playing football
(collide with another boy in the head and fell to the ground & had fits) was brought to your
GP practice 45 minutes after the seizure. There is no relevant PMHx. FHx included 2 teenage
sisters who are well. The full PE is negative.
Task: Hx from his Mother (3 mins), Ix (explain reason), Mx
Hx: (First time, all body shaking, vomiting, weakness afterwards)

What was the nature of the injury?
Was there any loss of unconsciousness?
Witnessed or not?
How long did he have the fit? (If fit > 2 minutes  cause cyanosis, brain damage)
Did he wet himself?
Can you describe me the seizure? Start from one part of the body (Jacksonian) or not.
Unilateral, bilateral, symmetrical or not (the type of fit tonic clonic)
Can you tell me his appearance after the recovery?
Did he vomit? Did he look pale? Any c/o headache?
How long did he take after recovery to be aware of his surroundings?
Any similar events before?
Before the fit, any preceding illness, any infectious disease and fever?
Any recent infection?
Any previous health problems?
Any recent history of trauma apart from this?
What about his school performance before?
Any behavioural / personality changes recently?
Any sleep deprivation or changes recently?
Any headache or visual disturbance recently?
SADMA Any illicit drugs, non prescribed medications
Family history of epilepsy?
O/E:
GA: any other injuries especially to the scalp
VS: T
Neck stiffness
Ix:
FBE
U&E especially sodium & calcium
Serum glucose
Urine dipstick: any infection
Send urine for drug screening
! 9!
PAEDS: NEUROLOGY
Scalp X-ray
Any neurologic deficits  possibility of CT scan but in young age only if there is a need
Chest X-ray (for any trauma)
LFT
ECG if the seizure is repeat or if the specialist decided to do (Hocum, arrhythmia)
Mx: Referral to neurologist is mandatory.

The management of tonic clonic seizure is observation and investigation
There is still debate that unprovoked first seizure should have anti convulsant. After the first
unprovoked, there is 50% rate of recurrence within 6 months
For provoked seizure, most neurologist will not give anti convulsant. They prefer to do
EEGIf the initial EEG shows spike and wave pattern, there is a room for prescribing
anti convulsant.
Give encouraging prognosis

Educate how to deal with seizure
Avoid restriction in work & play
Avoid alcohol and smoking
Adequate rest and sleep (sleep deprivation will provoke seizure)
Avoid the word epilepsy (because it’s the first fit)
Give encouraging prognosis
Indicate the nature of the seizure & anticonvulsant unlikely to be prescribed for the 1st attack
Lifestyle
Medication:
If medication needed  monotherapy is preferred, change to another drug if unsatisfactory,
do not use 2 anticonvulsants
- Sodium valproate (Epilin) 500 mg daily for 1 week, then 500 mg bd for 1 week and can
be increased to 2.5 g daily (5 tablets)
- Carbimazole (Tegretol)
- Carbamazepine 100 mg oral per day increase to 200 mg bd
- If seizure persists, Phenytoin (Dilantin) 50-100 mg up to tds (3 times daily) is advised.
Monitor blood level for Phenytoin.
- Rivotril (Clonazepam) can also be used
Pt’s Q: The percentage of recurrence?
! 10!
PAEDS: ORHOPAEDICS
Irritable Hip (Transient Tenosynovitis)

A mother came to you because her 6 year-old son has pain in the right knee and limping.
Task: Take history, exam findings from examiner, diagnosis and DD, management.
DDx of limp in childhood:

Acute
- Irritable hip (has previous cold  reactive arthritis), has fluid around the hip joint
- Septic arthritis (fever)
- Osteomyelitis (fever)
- Fracture
- Haemarthrosis
- Henoch-Schoenlein Purpura (history of bleeding disorder)
Subacute
- SCFE (overweight, before puberty, 10-13 years of age)
- Malignancy (tumor and leukemia)
- Juvenile rheumatoid arthritis
Chronic
- Perthes disease (smoke in the family, has irritable hip previously)
- Chronic SCFE
- Development dysplasia of the hip
- Cerebral palsy
Hx:
Can you tell me more about it ---he has been having pain for 3 days & limping for 1 day
Radiation – other joints involvement
Type of pain –aching
Severity – can he walk or not? Bear wt or not?
Aggravating / Relieving factor
Any other associated symptoms like fever?  r/o septic arthritis, osteomyelitis
Any previous cold or viral infection? r/o HSP
Any rash, abdominal pain?  r/o HSP
Is this the first attack?
Any previous joint problems?
Any bleeding disorder? r/o haemarthrosis
Any loss of weight, loss of appetite? r/o tumor
Any trauma?
How is his general health?
Immunization
Does anyone in the family smoke? r/o Perthes’ disease
O/E:
GA: normal, alert, ill; Growth chart
VS: T
Chest & heart & abdomen
Right knee
- Compare both sides
- Inspection: gait, redness, swelling, deformity, bruises, scar
! 1!
PAEDS: ORHOPAEDICS
- Palpation: T, tenderness, effusion, pain in the lower end of femur, tibia tuberosity
- Limitation of movement
Right hip
- Limitation of movement  internal rotation & abduction
 Pain in legs
- Examine genitalia
- Examine both hips and knees
Ix:
FBE, ESR (<20), CRP (<8)
X-ray of the hip and knee
US of the hip  shows fluid in the affected joint
Explanation:
From the examination, I found the R hip joint has pain and movement limitation, most likely
irritable hip. It’s a reaction to the viral infection he had last week. Don’t worry too much, it’s
not a serious condition but to confirm the diagnosis, I will order US of the right hip.
The main DDx is septic arthritis, it’s a bacterial infection of the joint and it’s a serious one.
Although I don’t think it would be, I want to do some blood tests and refer him to a
paediatrician for a second opinion to exclude it.
The other DDx is Perthes’ disease in which the blood supply to the head of the thigh bone is
reduced or cut off. To exclude this, I will arrange X-ray.
If irritable hip is confirmed, all we need to do is just supportive treatment like bed rest, pain
killers, crutches, not to allow him to stand with his right leg. Simple analgesia. This condition
usually settles within 7 days without any consequence.
Review in a week.
 If the child has ADHD  I want to admit him because he needs complete bed rest &
observation. The more the child can rest, the quicker the recovery. Pts may have a relapse
if they increase their activities too quickly.
It will be difficult for you to look after him alone at home.
! 2!
PAEDS: ORHOPAEDICS
Osgood-Schlatter Disorder
A 12 yo boy c/o R knee pain for the last 3 months. Pain worse after playing football.
Task: Hx, PE, Dx and Mx.
DDx:
Trauma: Fracture
Osgood-Schlatter Disorder
Bone tumor
Slipped Capital Femoral Epiphysis
Hx:
Pain Qs
What makes the pain better or worse? Occurs after sport, strain exercise
What kind of sports do you do usually?
Any swelling in the joint, hotness
Limitation of movement, limping
Any temperature/fever?
History of trauma in the leg
Any symptoms like loss of appetite, wt loss, tiredness, lethargy
How’s your health in general?
FHx of bone tumor
O/E:
GA: in pain or looks healthy, BMI
VS: T
Focus on the right knee and right hip (r/o SCFE)
LOOK – gait, swelling, deformity, redness, scar
FEEL – local tenderness, swelling, change of temperature, joint effusion
MOVE – restriction of active or passive movement
(Positive findings: Swelling over tibial tuberosity below the knee joint, tenderness, redness,
limitation of movement, no infection, no effusion)
Explanation:
After Hx and PE, I think you’re suffering from a condition called Osgood-Schlatter Disorder
but I have to confirm with an X-ray to exclude tumour and fracture.
The X-ray has come back and confirmed that it’s most likely O-S D (bone fragmentation at
tibial tuberosity, widening of epiphysis), tumour and fracture are r/o.
It’s a sport-related injury, due to repeated pulling of the patella tendon on the immature tibial
tubercle. This friction effect causes inflammation.
It’s common in male, aged 11-16, being overweight, rapid bone growth.
It’s a harmless and self-limiting condition, but usually takes 6-18 months to heal.
I’d like to refer to an orthopaedic surgeon for therapy which consists of:
- Rest - stop the sport, I know that it’s your favourite game but you have to stop for a while
to prevent pain and allow healing. (no running, cycling and football)
- Icepacks + analgesic  for acute pain
! 3!
PAEDS: ORHOPAEDICS
- Compression (warm) and heat packs  provide relief after the acute phase settles
- Physiotherapy: He will arrange for a physiotherapy and gradual return to physical
activityquadriceps exercises involving stretching can promote healing.
- No plaster, no steroid
- If not responding, surgery might be neededremove the irritating piece of bone
! 4!
PAEDS: ORHOPAEDICS
Perthes’ Disease
A 5 year-old child presented to the ED with a history of limping, left hip & knee pain. He
can’t put weight on his lower limb.
Task: take history, exam finding & manage.
Hx:
Pain Qs
Trauma
Any recent infection (transient synovitis)
Swelling around the knee (Osgood-Schlatter disorder)
Full term or premature, birth wt low birth is a risk factor
Anyone smokes in the family
Immunization
General health
Growth and development
O/E:
GA
VS
Lower limb, start from the right hip / knee, compare both side
Movement: internal rotation & abduction restriction on the affected limp, all the movement
restricted
Genitalia
Ix:
X-ray
Bone scan: helpful in the early stages before the signs are clear on X-ay (order by specialist)
Urine  Microscopic Culture Sensitivity
Inflammatory marker  CRP, ESR
Explanation:
Perthes’ Disease is a condition in which there is decrease of the blood supply to the head of
the thigh bone.
It’s more common between 4-8 years old (2-12 yo), more in males. 20% bilateral.
The exact cause is not known. Could be related to trauma, diet, genetic, recurrent synovitis,
and passive smoking.
Refer to orthopaedics. (All Perthes’ disease and SCFS need to refer to orthopaedics)
Also I’d like to give him some pain killers & refer him to physio to do exercise who will
teach him what kind of exercise will help him.
This is a self-limiting condition lasting for 1 or 2 years. The main treatment is to decrease the
activity and close observation.
Complication: Osteoarthritis
! 5!
PAEDS: ORHOPAEDICS
Red flags: Not improving; Deteriorating; Fever, nausea, vomiting (septic arthritis); Any
swollen; Abnormal position of the leg
Give reading materials
! 6!
PAEDS: ORHOPAEDICS
Septic Arthritis
ED setting. A father brought in his 3 year-old daughter complaining of fever for 1-2 days, not
walking for a few days, ill-looking. Pain on her right knee, not eating well.
Task: take history, ask for physical examination, give diagnosis & manage.
Hx
- How long she’s limping?
- Start sudden or gradually?
- Is it the first time? yes
- Any history of trauma?
- Any fever now / any infection recently?
- Can she walk now?
- Is she complaining of pain? Pain Qs
- Any swelling of the joint? R knee swollen
- Is it painful on touch? yes
- Any bleeding disorder ( to exclude hemarthrosis)
- Family history of bleeding disorder?
- Any rash on her body? (Henoch-Schoenlein Purpura)
- Immunization if not, HIB(influenza) vaccine should consider
- Growth and development
- Water works  colour change of urine (microscopic haematuria)
- Bowel activity
OE:
GA: irritable, looks very ill, check for rash, bruise
VS: T 39
Knee exam: the child won’t let you to touch.
Inspection: swollen, red, any sign of injury, any d/c, any change of colour
Palpation: temperature  warm
Examination of hip, knee and ankle
Ix: (Septic work-up)

FBE, ESR, CRP, Culture (blood, urine, fluid from the involved joint), X-ray, US
Explanation:
Your child is suffering from a condition called Septic Arthritis
- Admit to the hospital
- Blood test: FBE with differential, WCC increased, ESR (>20-30), CRP, Urine, Blood
culture
- Plain X-ray of the joint or affected knee often normal, just to r/o trauma
- US (to differentiate with and irritable hip  fluid is more visible than X-ray)
- Aspiration of the knee urgently and wash out with flucloxacillin (will be done by
orthopaedic consultant or paediatrician)
- After orthopaedic consultation  if diagnosis not clear  bone scan
- Give analgesic
- IV antibiotics (Consult with orthopaedic team first)
- IV fluid
- Elevate and immobilise limb
! 7!
PAEDS: ORHOPAEDICS
 Most common caused by staphylococcus aureus with flucloxacillin

Cover should be broaden for neonate up to 1 month & children who have no HIB vaccine
If child is not immunized – haemophylus influenzae and other negative Gram organism
Uncomplicated acute haematogenous septic arthritis & osteomyelitis – give IV antibiotics

until sign & symptom improved – inflammatory marker improved (CRP, ESR). Disease
usually treat for 3-5 days (1 week). Switched to oral for 14 days. Total course of antibiotics
should be minimal 3 weeks.
Any complication like symptoms >14 days, any change of chronicity on plain X-ray (bone
destruction), any underlying disease, child has any other problem, delayed response to
treatment, penetrating injury  continue treatment of IV antibiotics to 7-14 days then oral
antibiotic  total duration 4-6 weeks
! 8!
PAEDS: ORHOPAEDICS
Slipped Capital Femoral Epiphysis

GP setting. A 10 year-old son came with Father complaining of right thigh pain.
Task: take history, diagnosis, management.
DDx:
- SCFE
- Perthes disease
- Irritable hip/transient
- Osgood-Schlatter disease
- Septic arthritis
- Osteomyelitis
- Trauma, fracture
- Henoch Schonlein Purpura
Hx:
Where? – in both knee and hip
Can he walk? Any limping? Can he bear weight?
Any history of trauma?
Any recent flu-like symptoms? (irritable hip)
Does he feel feverish? (septic arthritis)
Any stiffness of joint?
Did it happen before? (Perthes)
General health
BIND
Any significant medical, surgical condition
Any family history
Social history
Medication, allergy
O/E:
GA: ill, BMI – high, Growth chart, rash
VS: T, PR, BP
ENT, LN, chest, heart
Lower limb exam both hip & knee:
 Look – abnormal posture, gait (unable to walk, limping), swelling, redness, lump at tibial
tuberosity, signs of trauma, deformity
 Fell – temperature, tenderness
 Move – active, passive (all movement of the hip restricted due to pain)
Inguinal areahernia orifices, LN
Ix:
X-ray of hip & knee
- AP, Lateral, Frog view for hip joint
- AP, Lateral for knee joint
FBE, ESR, CRP
Explanation:
From history & examination, most likely your son has SCFE. (can be both side)
Our hip joint we call socket hip joint which allows free movement of the legs
In young people, there is a growth place between the head and neck of thigh bone
This growth plate allows the child to grow
! 9!
PAEDS: ORHOPAEDICS
Some children who are tall, overweight, active might have head of femoral slips from its place
affecting the growth plate
If untreated, initially it might be cut off blood supply to the head of the thigh bone which leads to the
death of the head of thigh bone, called avascular necrosis
It leads to some long term complications, restriction of growth, arthritis of bone
Mx:
Refer to orthopaedic surgeon as soon as possible who will arrange surgery
He will fix it with pin.
The surgeon will discuss all the procedure with you before doing the surgery
General measures: Rest; Painkiller; Crutches
After surgery he needs to be followed-up by physical exam & X-ray
Can I go home now?  No, you need to see the surgeon as soon as possible
What is the best option for therapy? Surgery
Are you sure the knee is normal? Yes, on physical examination the knee is normal
! 10!
PAEDS: ORHOPAEDICS
Developmental Dysplasia Of The Hip (DDH)

A young mother brings her 8 weeks old girl to your GP clinic because one of the nurses
found asymmetrical hip creases.
Task: Take further History, Physical Examination, advised on the Management.
Hx:
Did you or the nurse notice the asymmetrical hip creases first?
Have you noticed any asymmetry while changing nappies?
Is your child moving both her legs normally?
Is she crying if she moves one of her legs or when changing nappy?
How is your baby’s general health?
Is she your first child?
Was she full-term or premature?
Was she delivered normally or by operation? by CS (a risk factor)
Why by CS? breech presentation (another risk factor)
Was there any problem after delivery?
Does anyone in the family suffers from hip problems?
Is she feeding well?
Is she putting on weight?
Does she have any vomit?
Is she wetting nappies normally?
How about her poos or bowel motions, any change, diarrhoea?
How about you? Any problems after delivery, are you coping well with your child after CS?
O/E:
GA, growth chart, VS, systemic review
Hip exam:
Remove nappy, look for the asymmetry, then do screening test
Ortolani test - dislocating the hip, Flex both knees 90 degrees, do full abduction
Barlow test - relocating the hip, adduction positive if there is click or clung sounds.
Ortolani Test (steps 1-5) Ortolani test is performed by abducting the infant’s hip and assessing for a
clicking sound. This test is used to detect the posterior dislocation of the hip. A positive Ortolani’s
sign is noted when a clicking or distinctive “clunk” is heard when femoral head re-enters the
! 11!
PAEDS: ORHOPAEDICS
acetabulum. Ortolani maneuver is performed before 2-3 months of age. The maneuver is done in early
infancy because after 2-3 months the development of soft tissue contracture prevents the hip from
being relocated, thus, no clicking or clunking sound will be assessed in children with congenital hip
dysplasia.
Barlow Test (steps 6 and 7) Barlow test is performed by bringing the thigh towards the midline of
the body. Feeling of femoral head slipping out of the socket postolaterally, is considered as a positive
Barlow’s sign.
The Ortolani test is then used to confirm that the hip is actually dislocated.
Procedure
1. Lay the infant in a supine position and flex the knee to 90 degrees at the hips. Proper position of
the infant ensures accurate results.
2. Hold the infant’s pelvis with one hand to stabilize it during manipulation.
3. Using the other hand, place the middle fingers over the great trochanter of the femur and the
thumb on the internal side of the thigh over the lesser trochanter. Placing the fingers in this
manner allows easy abduction of the hips.
4. Slowly and gently abduct the hips while applying pressure over the greater trochanter. The femur
is pulled forward while the greater trochanter is used as a fulcrum.
5. Listen for a clicking or clunking sound while performing step number four. Normally, no sound is
heard. A clicking or clunking sound is a positive Ortolani’s sign and it happens when the
femoral head is re-entering the acetabulum.

6. With the fingers in the same position, assess the infant for Barlow’s sign. Hold the hips and knees
at 90 degree flexion while exerting a backward pressure (down and laterally).
7. Slowly and gently adduct (bringing the thigh towards the midline) the hip. Note any feeling of the
femoral head slipping. Normally, the hip joint is stable. The feeling of the femoral head slipping
out of the socket postolaterally is a positive Barlow’s sign.
Explanation:
Your daughter might have Developmental Dysplasia of the Hip which needs to be confirmed.
The better way to confirm at this age is by doing US, after 6 months X-ray is helpful to make
the Dx.
DDH is a condition in which there is underdevelopment of the femoral head.
The head of the femoral is smaller than normal, easily dislocated.
Exact cause unknown.
Risk factors:
- who are born by Caesarian Section or
- Breech delivery or
- premature
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PAEDS: ORHOPAEDICS
- baby girl or
- with a first family history
Complications: if untreated will lead to

- Delayed walking
- Limping
- Shortening of the leg
- May develop early osteoarthritis changes in the head
Treatment depends on the age:

Very young, very good time, easily treated with a splint
Abduction splint (within the first 6 months)  Pavlik harness
After 6-18 months  Hip spica (from belly button to the leg for a few months)
After 18 months  prefer surgery
! 13!
PAEDS: ORHOPAEDICS
Osteomyelitis
A 5 year-old boy was brought by his father with a temperature of 39 degrees and pain in the left tibial
head, just below the knee.
Task: Take history, ask for investigation, manage.
Osteomyelitis means an infection of bone, which can either be acute (of recent onset) or chronic
(longstanding). Bacteria are the usual infectious agents. The two likely access methods are by primary
infection of the bloodstream (including secondary infection via the blood following an infection
somewhere else in the body), and a wound or injury that permits bacteria to directly reach the bone. In
adults, the pelvis and the spinal vertebrae are most vulnerable, while bone infections in children tend
to target the long bones of the arms and legs. Without treatment, the infection and inflammation block
blood vessels. The lack of oxygen and nutrients cause the bone tissue to die, which leads to chronic
osteomyelitis. Other possible complications include blood poisoning and bone abscesses. Treatment
options include intravenous and oral antibiotics, and surgical draining and cleaning of the affected
bone tissue.
Symptoms of osteomyelitis include:

• Localised bone pain
• Reduced movement of the affected body part
• The overlying skin may be red, hot and swollen
• The overlying skin may contain pus
• Spasms of associated muscles
• Unexplained weight loss
• General malaise
• High temperature
• Excessive sweating
• Chills.
Events that can cause osteomyelitis (from trauma or blood)

Bones are infected by blood-borne micro-organisms. In most cases, the micro-organisms are bacteria
such as Staphylococcus aureus, but fungi can also cause osteomyelitis. Some of the conditions and
events that can lead to osteomyelitis include:
• Bacteria introduced during bone surgery.
• Bacteria introduced by trauma to bone.
• Infection of bone fractures.
• Infection of prosthetic implants (such as an artificial hip joint).
• Infections elsewhere in the body that reach the bones via the bloodstream.
• A primary infection of the blood (septicaemia).
Risk factors
• Long term skin infections.
• Inadequately controlled diabetes.
• Poor blood circulation (arteriosclerosis).
• Risk factors for poor blood circulation, which include high blood pressure, cigarette smoking,
high blood cholesterol and diabetes.
• Immune system deficiency.
• Prosthetic joints.
• The use of intravenous drugs.
• Sickle cell anaemia.
• Cancer.
Acute osteomyelitis
! 14!
PAEDS: ORHOPAEDICS
• Haematogenous osteomyelitis - primary infection of the blood or infection from somewhere else
in the body is delivered to the bone via the bloodstream. Children are at increased risk. The
bacteria are drawn to areas of rich blood supply, which is why the infection tends to target the
growing parts at the ends of the long bones.
• Direct inoculation osteomyelitis - bacteria are delivered direct to the bone tissue via surgery or
trauma.
Chronic osteomyelitis
An acute attack of osteomyelitis can lead to chronic osteomyelitis, characterised by dead areas of
bone. This condition can fail to respond to treatment and recur for a long time. In many cases, chronic
osteomyelitis is polymicrobial, which means more than one infectious agent is involved.
Complications
Some of the complications of osteomyelitis include:
• Bone abscess (pocket of pus)
• Bone necrosis (bone death)
• Spread of infection
• Inflammation of soft tissue (cellulitis)
• Blood poisoning (septicaemia)
• Chronic infection that doesn’t respond well to treatment.
Diagnosis methods
• Physical examination
• Medical history
• Blood tests (FBE: high leucocyte, ESR high)
• X-rays (non specific)
• Bone scan
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Bone tissue biopsy.
Treatment methods (depends on the severity)

• Hospitalisation and intravenous antibiotics Flucloxacillin IV and oral until 6 weeks
• A long term (four to six weeks or more) course of antibiotics, either oral or intravenous.
• Pain-killing medication.
• Surgery to clean and flush out the infected bone (debridement).
• Treatment for underlying cause, such as diabetes.
• Replacement of the infected prosthetic part, if needed.
• Skin grafts, if necessary.
• Amputation, in severe cases.
• Lifestyle changes, such as quitting cigarettes to improve blood circulation.
Long term outlook

Acute osteomyelitis is easier to treat than chronic osteomyelitis. The earlier the diagnosis and start of
treatment, the better the outlook. If dead and diseased tissue needs to be surgically removed, the bone
regenerates in a matter of weeks. Prevention of acute osteomyelitis includes proper management of
wounds, and prompt medical attention for infections.
! 15!
PAEDS: ORHOPAEDICS
SCFE Perthes Transient Osgood- Developmental

synovitis Schlater Dislocation of the
Syndr Hip (DDH)
Age 10-15 4-8 4-8
(years)
Obesity Normal Nomal
Limp Limp Limp
Pain Pain Pain
Restriction on Internal rotation, All range
internal abduction, All of
rotation, all movemen
movements t
restricted
X-ray Lateral/AP AP Normal Up to 9 months
(25% bilateral) X-ray Ultrasound then X-
(Ultrasou ray
nd 
effusion)
PE Examine Hip will be short, hip
genital crease & thigh crease
(testicle will not be at the
torsion) same level
Ortolani & Barlow
test
Therapy Pin - 6 months Pavlik

harness
- 6 -18 months Hip
spica
- >18 months surgery
Associated with Bone Complication
smoking & transient growth is Delayed walk
Synovitis, Loss of faster than Short leg
blood flow to femoral the OA of the head
head quadriceps
Femur not in correct muscle
position
Flattened femoral
head
! 16!
PAEDS: BEHAVIOURAL
ADHD (AMC 32)

6 yo boy came with Mom as Mom received a letter from school saying that he is not doing
well at school.
Task: Take history from Mom and counsel her regarding her son’s condition.
ADHD:
2 places: at home and at school
2 behaviours: attention and hyperactivity disorder for >6 months, onset before 7 yo
Hx:
My understanding that he’s 6 years old and he has a performance or behavioural problem
according to the letter from the school.
What did they told about him at school?---agitated, not listening to teacher, aggressive, not
easy to deal with, jump the school fence
Since when  >6 months ago
When did he start school? r/o Separation anxiety at home
Attention Qs (6 criteria):
- Can he give you attention---not really, he’s always distracted
- If he gives you the attention, can he maintain it?---not long
- Can he concentrate on doing one task?---no, even when he plays, sometimes he jump
- Does he like to do homework?---no, he dislikes homework
- Can he finish his task---no
- Is he forgetful?---yes
Hyperactive Qs (6 criteria)
- During dinner when you’re eating together, can he sit still?---he never sit still, always
jumping
- In the supermarket, can he wait for his turn in a queue?----he can’t
- Is he talkative?---yes
- Does he interrupt others?---yes
- Is he a noisy boy?--- noisy and excessively use his hands
Any concern about his vision or hearing?
FHx of ADHD or other psychological problem?
Medication
School bullying
Situation at home
O/E:
Developmental percentile chart
Assessment of eye, hearing, neurological
Ix: Serum lead test
Explanation:
From the history & exam, even if he’s OK at home, your child has query behavioural
problem, it may be ADHD, ODD (Oppositional Defiance Disorder), Asperger syndrome. We
need to do behavioural & cognitive assessment with a specialist.
We can arrange Family meeting if you agree.
Send questionnaire to the school teacher
! 1!
PAEDS: BEHAVIOURAL
Protect his self esteem, praise for good behaviour, no physical punishment, be close to him,
insist on having his full attention, keep him away from dangerous environment
Medication lifelong: Dexamphetamine (Ritalin), methylphenidate  GP can’t prescribe
If Mom ask about the advantage of preservative-free diet  tell her that eliminating certain
food is ineffective, but if given medication should use it.
! 2!
PAEDS: BEHAVIOURAL
Poor School Progression

An 8 yo boy came with his mother complaining of slow progression at school recently.
Task: take relevant history, manage the boy.
DDx:
School bullying
ADHD
Absence seizure
Hearing and vision problem
Child abuse
Stress
General health problem
Hx:
It’s very important to find out the cause because it can easily affect your child’s performance.
Reassure confidentialitypls tell me anything you think might relate to this issue.
What do you mean by slow school progression?
When did it start?
Did you talk to his teacher?
School bullying
Is he happy at school?
Does he have a lot of friends?
ADHD
Any change in his behaviour?
Any noisy or interruptive behaviour?
Is it very hard to keep his attention?
SeizureAny funny face or hand movement or jerking?
Has he ever had his hearing or vision checked?
Have you ever been concerned about his growth and development?
Family situation
Are you on a stable relationship?---no
Any problem with your recent partner?---no but with the previous one
Does your son get along well with your new partner?
Do you have any stress in your life?
Any financial issue?
Does your partner work?
Any stress at work for you or your partner?
Explanation:
There are a lot of reasons that might affect your son’s school performancestress, school
bullying, viral infection, hearing or vision problem, developmental problem. I’d like to talk
with your partner separately then we’ll arrange a family meeting. And I’d like to talk to his
teacher. I’d like to refer your son to check his hearing and vision. After that we need
paediatrician’s opinion.
If there is a marriage problem  marriage counsellor.
If financial problem, we’ll arrange with Centrelink and inform social worker.
! 3!
PAEDS: BEHAVIOURAL
Failure To Thrive (Cow’s Milk)

18 month-old girl drinks about 2 litres cow’s milk everyday and loss 1.2 kg in the last 2
months. She’s below the 3rd percentile in her growth.
Task: take relevant history and talk to the mother.
DDx:
1. Fussy eater
2. Failure to thrive
3. Coeliac disease (problem with the bowel)
4. Cystic fibrosis
Hx: (<3 yrs ask for pregnancy, delivery, development period. >3 yrs depends on the problem)
Was the pregnancy planned?
Any medical issue during pregnancy / delivery?
Birth weight of Jessica
Was she breastfeeding?
How about now? What does she normally eat? 2L milk/d
How about solid food?  hardly
Any vomiting? Abdominal pain? (crying with hands up, not sleeping well)
How’s her sleeping?
What about bowel motion? (diarrhoea - how many times, colour, how’s the stool look like;
constipation – how many days)
Water works – wet nappies and dirty nappies
Immunisation
Family issue – child abuse or neglect Supporting family, any other children
O/E:
GA: fine, pale, Growth development chart (ht, wt, head circumference)
VS; Systemic review abdominal distension?
Ix:
FBC + iron study, LFT, TFT, BSL, Ca + Phosphorus study, Stool and urine analysis with
microscopy and culture, coeliac screen
Explanation:
From examination your daughter has Failure to Thrive. She has not been offering food
suitable for her age and development. Huge amount of milk does not give her chance for
other food because she feels full. The result of this huge amount of milk, decrease the iron
intake for her.
Mx:
No more than 500 ml milk per day for her age, it’s about 2 cups a day.
Change cow milk to formula. Fortified formula especially for iron def anaemia, offered a
good amount of iron.
Offer variety of food; try to make the time of feeding a fun/entertaining time (Finger foods),
don’t punish him; Juice is not good; Try to offer her some meat, from the beginning, minced
meat, some fish in a sample way; Also give her egg yolk which is full with iron; Dry fruits
! 4!
PAEDS: BEHAVIOURAL
Cow’s milk can cause microscopic bleeding in her bowels, loosing of the iron through the
gut.
I will prescribe syrup form iron for her put in a small cup and use straw. Without staining
her teeth
Iron supplement will give the stool a bit darker and for some children cause diarrhoea.
Will do some investigation and repeat after 2-3 months (follow up)
Until something abnormal I will refer to the paediatrician.
! 5!
PAEDS: BEHAVIOURAL
Fussy Eater
Father brings a 2.5 years old boy to your GP clinic as he’s not eating well.
Task: Take history, examination and investigation.
DDx:
Hx:
I can see from your notes that you’re a bit worried of your son’s eating habits.
Can you describe me his a full day diet? He eats everything like biscuits, fruits, veggies but
struggled to feed him.
Do you think he drinks too much milk? 1-2 bottles/day
Is he an active child?
Does he have good relationship with other friends?
Do you think he has other tantrums or do you find him to be too stubborn?
What about his general healthtummy pain, diarrhea
Birth  delivery full term, vaginal, birth weight 3 kg
Immunization status
Growth and Development is consistent with other children of his age?
Anyone in the family on special diet?
Any recent stress at home, any financial trouble?
Does he go to childcare?
Who looks after him, is there enough support or family help?  we will organize a social
worker
O/E:
GA: actively playing, Growth chart past and present  within normal range
VS, ENT, Systemic exam
Explanation:
We have this growth chart which help to monitor the child’s progress and in your child’s case
it is well within the normal range.
I can understand your concern about your son.
This condition we called fussy eating. It’s very common in this age group. Children have
some fear of new food, neophobia. Initially they refuse but later on they finally develop a
taste for it.
Actually as the child’s age increases due to rapid growth, the requirement for food also
increases.
There can be various other causes like:

- Coeliac disease
- Cow’s milk allergy
But his appeared to be less likely in this case, as everything is normal. But we can organize
some tests for him like FBE, Urine test, Stool test.
I noticed a bit frustrating at times but patience with kids is the key to success. There are
general principles to follow:
! 6!
PAEDS: BEHAVIOURAL
- Try to give food at fixed time like in the childcare because the child will realize when
they are hungry and will demand for food
- Try making eating time, fun time finger food
- Involve him while having food on dining table, like serving
- Avoid being harsh towards him
- Give the food for eating and not for rewarding or punishing
- Milk is OK but limit it to 500 ml/day
Reassure, follow up and reading materials.
! 7!
PAEDS: BEHAVIOURAL
Shaken Baby Syndrome

A GP refers 10-month-old Charmaine, to your ED for dehydration and a change in her level
of alertness. According to her mother's boyfriend, she had been crying in her crib before she
was noted to throw her arms in the air for appro. 5 mins and then breathe irregularly. She
vomited once and continued to cry inconsolably on the way to the GP clinic. The GP
performed an abdominal X-ray and interpreted it as possible constipation. She has had
multiple episodes of nonbloody, nonbilious emesis on the way to ED. There is no recent Hx
of diarrhea or change in bowel habits.
Task: further Hx, PE, Ix, discuss the Dx and Mx whit the examiner, explain the Mx to the
family
HOPC: Charmaine was recently diagnosed with an upper respiratory infection and has
received several doses of acetaminophen over the last few days. Her symptoms have included
fevers, runny nose, and raspy cough. Before this occurrence, her breathing had been normal
and without increased effort. She had been feeding well earlier today. She is currently taking
no prescription medications and has no reported allergies. Her immunizations are not up-to-
date; she only received immunizations at 2 months of age. She lives at home with her mother,
her mother's boyfriend, and her 2-year-old brother.
According to her mother's boyfriend, she had been crying in her crib before she was noted to
throw her arms in the air for approximately 5 minutes and then breathe irregularly. He took
her to the local GP, she vomited once and continued to cry inconsolably before she arrived at
the urgent care center. An abdominal radiograph was performed at the urgent care center and
interpreted as consistent with possible constipation, but it was otherwise unremarkable. She
has had multiple episodes of non bloody, non bilious emesis on the way to the ED. There is
no recent history of diarrhea or change in bowel habits.
PHx.: normal pregnancy and delivery, not breast fed, always on formula milk, development at
40th percentile.
FHx.: NAD
SHx: lives with her 21 year old mother, a brother of 2 years age and mother’s boyfriend of 6
months who is unemployed. The family lives on social security. No family support from her
or his parents.
O/E:
Charmaine appears drowsy and somnolent, is lying motionless, is not making eye contact or
engaging in other social interactions, and is not crying. She vomits several times during the
evaluation.
Vital signs: BP 100/55, P 90, RR 12, SaO2 100% on RA, T 37.3
Her pupils are equal and 5 mm in diameter; they are measured at 3 mm in response to light.
The anterior fontanel is flat. A small, 5-mm, purple bruise overlying the left maxilla is noted.
Two lacerations on the inferior mucosal surface of the upper lip are identified that line up
with the upper incisors. The lungs are clear to auscultation and the heart sounds are normal.
The abdomen feels soft and appears non distended and non tender. Bowel sounds are present.
The neurologic examination reveals diffuse hypotonia.
! 8!
PAEDS: BEHAVIOURAL
Investigation:
• FBE: Hb 9.7 g/dL, WCC 18.4
• Ophthalmologic examination: revealed bilateral retinal haemorrhages extending into the
periphery and intraretinal haemorrhages of the macula were noted in the left eye, with
possible choroidal rupture.
• Computed tomography (CT) scanning of the head shows bilateral subdural hematomas
outlining bilateral cerebral convexities, with hyperdense blood noted in the left frontal
lobe.
DIAGNOSIS: “SHAKEN BABY SYNDROME” or “abusive head injury

Abusive head injury/trauma (AHT), sometimes referred to as "shaken baby syndrome," is the
most common cause of death resulting from child abuse. The majority of cases occur in
infants less than 1 year old. Head injury among infants in this age group is often the result of
abuse and the mechanism of injury, although much debated, is usually thought to be
significant forces generated from angular deceleration with or without impact. Many children
with AHT also have a clinical history or findings consistent with prior maltreatment. Crying
is thought to be a trigger for many cases of AHT and prevention efforts are directed toward
caregiver response to colicky babies and crying infants.
The diagnosis of AHT can be difficult to establish; the clinical presentations may be
nonspecific, children are often too young to give history, and witnesses and confessions are
rare. The reasons for seeking care in children include seizure, breathing difficulty, apnea, and
apparent lifelessness. A history of trauma is often lacking. Approximately 30% of children
with AHT may be missed on the initial presentation. Common misdiagnoses include viral
gastroenteritis, sepsis, and accidental head injury. A history of injury mechanism
incompatible with an infant's developmental stage or degree of force required to inflict severe
injury may raise the suspicion for AHT. Common symptoms at presentation are often the
result of acute brain injury (ie, lethargy, decreased level of consciousness, vomiting, apnea,
hypotonia, and seizures).
The physical examination findings may include evidence of soft tissue injury, particularly
swelling or bruising; however, the absence of bruising or other evidence of trauma neither
excludes injury nor abuse. Funduscopic examination should be performed in any child
suspected to have abusive head injury, preferably by an ophthalmologist with sufficient
pediatric experience to determine the significance of any identified injury. Retinal
haemorrhages are a hallmark finding in abusive head injury, and they are present in a
majority of children who carry the diagnosis. They may be unilateral or bilateral and involve
1 or more layers. Not all retinal hemorrhages are the same with respect to their significance in
predicting an abusive mechanism. The most specific pattern of retinal hemorrhages is
numerous hemorrhages involving several layers of the retina and extending to the periphery.
No pattern of hemorrhages, however, is pathognomonic for abuse. The mechanism of retinal
hemorrhages is unclear, but the leading theory is that they are caused by vitreous traction on
the retina during acceleration/deceleration. Lasting visual impairment in those children who
survive AHT is common.
CT scanning is an essential part of the initial workup of suspected head trauma. CT scanning
can also be helpful as a screening neuroimaging study in children with suspected abuse. Even
without clinical examination findings of brain injury, a significant number of abused infants
will have important findings on neuroimaging. Unilateral, bilateral, or parafalcine subdural
haemorrhages are the most common radiologic finding in infants with AHT. Subdural
haemorrhages of mixed attenuation have previously been considered as evidence for repeated
head injury, with hyperdense components of the haemorrhage associated with injury
occurring in the past 48-72 hours and hypodense components representing older injury
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PAEDS: BEHAVIOURAL
occurring more than 3 weeks prior to the scan. Hyperacute bleeding or the mixing of blood
and cerebrospinal fluid (CSF), however, can produce mixed-density lesions from a single
injury.
Additional supportive evidence for child abuse is obtained through a skeletal survey. The
presence of previously healed fractures in infants is strongly suggestive of chronic abuse.
While the cause of subdural hematoma in association with retinal hemorrhage will most
commonly be abusive head injury, a differential diagnosis for these findings must be
considered. Coagulopathies have been associated with retinal and intracranial hemorrhage in
infants, including haemophilia, vitamin-K deficiency, and disseminated intravascular
coagulopathy. Retinal haemorrhages in these disorders are typically confined to the posterior
pole, and the nature of the bleeding problem can be detected by laboratory tests.
Further conversations with the mother revealed a history of physical abuse at the hands of her
current boyfriend. The Department of Children and Families (the regional department
responsible for addressing issues of child safety and potential abuse) assumed immediate
temporary custody of the patient and of her older brother. Testing for conditions that mimic
the signs of abuse was completed, and no sign of other medical illnesses was found. The
patient was discharged 12 days after admission and has had follow-up visits with
neurosurgery and ophthalmology. She is currently living with her second foster family and is
noted to have persistent developmental delay. Her retinal findings have improved and her
foster parents have not noticed any evidence of visual impairment.
Mx:
• Obviously admission to hospital
• Reporting to the appropriate child protection authority
• Managing the cardio vascular (fluids) and neurological (?seizures) situation
! 10!
PAEDS: BEHAVIOURAL
Adolescent Management
A 15 year-old girl came to see you because her parents were concern that she was very thin.
Task: take history, explain to patient your management.
(You know being a teenager is difficult because so many pressures at home, at school, people
keep telling you things. Parents controlling, you ask for money, they don’t give, can be very
difficult)
Confidentiality I’m not going to tell other people, anything you tell me is confidential
unless
Normalize the feeling Quite acceptable you feel this way
Be non judgemental I’m not judging you at all
Close-ended Q Do you go to school regularly
Not interrogation but conversation

1. Are you happy how your parents are interrupting at the moment
2. How is your feeling about your parents?
3. Why do you fight a lot, what do you fight about
4. A lot of times, different between parents & children….
5. You still need your parents at some extend, you need money, but this phase will pass very
soon
6. Think what’s the patient thinking, see from their perspective
7. How come other people see them having a problem
8. Has anybody told you that you have a problem?
9. What about your friends, do you socialize with them?
10. What sort of problem do you think you have?
11. Why do they think that?
12. (How other people see her instead of how do you see yourself)
13. Do you like exercising? What exercise do you do? Do you go out for a run?
14. How about having meals with your family?
! 11!
PAEDS: BEHAVIOURAL
Irritable Baby (Crying Baby)

A young mother came with her 6 week-old baby as the baby has been crying a lot. She visited
another GP 2 wks ago & was consoled that her baby was normal. She came for a 2nd opinion.
Task: take history, exam findings, explain diagnosis and management.
DDx: same as infantile colic

- Colic >3hrs/d, at least 3 days/week
- Irritable baby respond to cuddle
- Cow milk allergygive formula other than cow milk
- Reflux
- Not enough milk
- Lactose intolerance bloating, diarrhea, anal excoriationgive lactose-free formula
- Intususception / Volvulus / Bowel obstruction
- Hernia
- UTI
- Otitis media
Hx:
What’s worried you at the moment? ---the baby is crying a lot.
Could you please describe the episodes of crying per day?
When, night or daytime?
How long does it last?
Is she breastfeeding or bottle-feeding?
Is the crying related to food /feeding?
Do you think the baby is hungry or does he have enough food?
Any vomiting?
What do you do when the baby starts crying, change nappy? Cuddle? Any response?
Is there any pallor/drawing up of legs with the episode of crying?
How many wet nappies a day? Was it smelly?
Bowel habit, diarrhoea
Does he pass a lot of wind?
Sleep well?
Is she your 1st child?
Any complications during pregnancy / delivery / post partum?
Full term or premature? Birth wt?
Social Hx including mother’s mood:
How do cope with her?
How’s your mood? Have you been feeling depressed?
Do you have enough sleep?
Do you eat regularly, how’s your appetite?
Energy level
With whom do you live with?
Do you have good support, any financial problem?
O/E:
GA: distressed/alert/lethargic; Signs of dehydration; Signs of trauma
Growth chart: height, weight, head circumference
! 12!
PAEDS: BEHAVIOURAL
VS: T, HR, RR, O2 Sat

ENT
Chest, Heart
Abdominal  inguinal mass (hernia), genitalia
Explanation:
After examination, let me assure you that your baby has no problem. He’s growing well,
gaining weight and no abnormality detected.
This is your first baby and you have enough experience and support
It’s a common condition; we called it “irritable baby”
Usually occur at the age of 6-8 weeks esp. during evening time
This condition will improve spontaneously without any intervention
It’s not your fault, and the baby is fine. Sometimes it can be related to DDx
What I would suggest you is that sometimes the coffee intake of mother may cause this
condition. So if you could reduce or stop coffee intake.
Also you need to reduce your stress.
I’d like to arrange a family meeting with your husband.
Is there any chance that your mother could come & help you, ask her help for a wk or 2 wks.
Respite care can be arranged by us if you need a break.
A social worker will come and contact you.
If you have any concern, come back again to see me, I’m here to help you.
Advice: To write a cry diary

Time of crying
Related to food
Response – what you do and Child’s response
I’ll review in a week time, please come back with the diary.
! 13!
PAEDS: BEHAVIOURAL
Infantile Colic
A young female came with her 8 week-old baby as he is crying all the time.
Task: take Hx, ask examiner about exam findings, tell the patient diagnosis and management.
Hx:
Could you tell me more about her crying?
How many hours she’s crying a day? ---3-4 hours a day, >4 days a week
Does she respond to something like cuddle while she’s crying? ---no
Is there any specific time of crying? Afternoon and evening.
Any special features like drawing up legs, any vomiting, diarrhoea, frothy diarrhea?
Any vomiting or diarrhoea?
How’s her feeding? Bottlefeed or breastfeed?
How frequently do you change the nappy
Did you notice any change in the nappy? Color? Smells?
Fever, cough, noisy breathing?
Full term or premature?
Mode of delivery.
Any postnatal problem of baby or mother?
How do you cope with your new baby?
Any support at home?
If patient is depressed, ask depression Q.
O/E:
GA- alert, ill, lethargic, irritable; Growth parameter; Head circumference
VS; ENT ; Chest, heart, abdomen, hernia orifices and genitalia
Explanation:
After examination and history, it seems that your baby has a condition called infantile colic.
It's common condition at this age group.
Some babies are excessively sensitive to internal factors like - hunger, over tiredness and
environmental factors such as noise, overheating.
But it usually settles when your baby reach 3-4 months of age.
There are some general measures like:

- Adjust room temperature, comfortable heating
- Frequent feeding
- Reduce noise
- Rocking the pram
- Patting, warm bath and massage.
If it exists after 4 months we need to exclude other causes from DDx.
Also we need to give support through mother child health nurse, family, friends.
And I would like to review within 1-2 weeks time. And regular follow up.
! 14!
PAEDS: BEHAVIOURAL
Suspicion Of Sexual Abuse

25 yo Mary came with her 4 yo daughter Nadia. She complained that Nadia has some rash in
the genital area. This rash has been there for 6 wks and is getting worse. Mary is divorced &
looking after her daughter. At the week-end Nadia goes to visit her Dad but last week she
refused to visit her Dad. Mary suspected Nadia has been sexually abused by her ex-partner.
Mary is living with Nadia and her new boyfriend, David.
Task: counselling Mrs Smith about her daughter condition, focus history and examination
and management.
Hx:
When did you notice the rash?
Is it the 1st time?
Rash Qs
Abnormal behaviour recently like nightmares, screaming, oss of appetite or wt loss, sleeping
Start to wet herself even though wet-trained and toilet-trained before
Sexual play on her genitalia
Any recent trauma? Recent injury in genital area.
Hx of recent travel  parasite from the back passage (worms)
Underwear cotton, recent change, How often does she change underwear?
Skin rash (eczema) or nappy rash, change shower gel
UTI symptoms
Childcare
Relationship with her dad
O/E:
Should perform careful general examination of the child’s body to search other signs of abuse
including oral and genital area, without labia traction (bleeding from ear), cigarette marks
Observe the general emotional of the child
Detect any abrasion – bleeding, bruises
Urine dipstick
If child is 14 year-old, STD check in the household
Explanation:
From Hx & Exam, I respect your concern that your child may be as you said sexually abused
by her dad or somebody else.
But it could be just normal skin or nappy rash, easy to be treated with corticosteroid.
But because of your concern & my medicolegal responsibility for the child, I have to notify
the Department of Human Service (or a Child Protection Agency & Police) now.
They will talk with you, Nadia & David. They may do some tests. Hope everything will be
OK
Because of the stress, a refer to the paediatric psychologist will be better for Nadia
(Calm down….I’m not accusing you…it’s my responsibility to ….

My job is to put your child in a safe environment for a non-accidental injury, will admit to the
hospital)
! 15!
PAEDS: BEHAVIOURAL
Burns On Palms (Child Neglect)

David, 18-month old child was rushed to your GP clinic by his Mom because he has put both
of his hands on a hot oven door 10 minutes ago and has blisters to both palms.
Task: immediate first aid and request the dressing, discuss with Mom about the Mx plan.
Panadol or Nurofen liquid for pain

Immunization complete except for 18 months
No Allergy
For this case, not need to refer to ED
1)Mention child abuse / neglection

signs of non accidental injury, bruise, cigarette mark
2)Assess the depth of the burns
3) Immediate first aid  running cold water for 20 minutes
4) One of the issues is to incise the blister

Fluid – inactive fluid & create pressure, inhibit the circulation and acting as culture media 
hence the recommendation is to release the blister fluid
5) There are 2 types of dressings:

- Daily dressing  SSD (Silver Sulphadiazine) cream – topical, provides antimicrobial &
anti inflammatory, required daily change
- Acticoat which can be left in place for 7 days, every now and then make it wet with water
(pain and burning sensation will disappear) keep it moist
Superficial burn with erythema  skin moisturiser
Major issue in burns are:

- Scar (contracture)
- Infection
! 16!
PAEDS: BEHAVIOURAL
Temper Tantrum – Head Banging

A mother came to your clinic c/o her 2.5 yo son hits his head frequently against the wall.
Task: take a history, exam finding from the examiner, manage the case.
Hx:
How long has he been having this problem?----1-2 weeks
How many times a day he does it?---10 times
Any specific time?
Can you describe a typical episode for me?
Is he ok in between episodes?
Did you notice any bleeding or bruises on his head?
Activity, appetite, sleeping
How’s his general health chronic diseases, fits, hearing and vision
Growth & Development milestone (walking, speech, ...
Pregnancy and delivery, full term or premature
Did his brother have similar condition when he was younger?
Any recent change of his life moving home, new sibling, start childcare, separation of
parents
Situation at home single parent, any support, financial issue, mother’s mood
O/E:
GA: healthy, happy boy, conscious; any dysmorphic features, Growth chart (ht, wt, head)
Developmental examination (gross motor, fine motor, language, personal-social)
VS, ENT, Chest, heart, abdomen ---normal
Explanation:
From the Hx & Exam, it’s most likely he has Temper Tantrum. This is a type of behavioural
disorder in children, especially in toddlers (16 mth-4 yr). The behaviour includes head
banging, stamping or kicking the feet, throwing things, shouting or screaming, breath
holding, or rolling on the ground. Tantrums are more likely to occur if the child is tired or
bored and feels angry or frustrated.
There is usually no risk to self harm except perhaps bruising to the forehead.
Reassurance that this is a self limited problem and will settle over time.
Mx:
• Avoid reinforcing the behaviour with excessive attention, actively ignore the behaviour
• Don’t punish the child
• Talk about strategies to reduce the noise nuisance factor by placing the cot away from
walls (less rattling) or place a mattress on the floor.
• “Tire” the child out before going to bed and possibly restrict the time in bed.
• Time out – Tell him, John stop it, I will leave the room and come back in 10 minutes.
You have to stop your action. Ignore him.
• Distract him, when he start to do this action, give him 1 toy or come with you to do
something, playing football, gardening, open TV or DVD.
• Helmet
• May need support from family crisis services or community health centre, including
parenting group, counseling etc. Assess Mary’s degree of depression and isolation! Invite
Mary to see you on a regular basis for follow-up and support as well
! 17!
PAEDS: BEHAVIOURAL
Autism
A mother came with her 3 yo girl. She was concerned about the child and the childcare career
was also concerned about her destructive behaviour which is different from her 5 yo sister.
Task: take full developmental history, explain diagnosis and management.
Autism (Emotional, behavioural and speech disorder)

Isolated, no emotion, typical features
Little emotional like to mother
Concentration on 1 toy
Resist in changing routine
Speech problems, delayed milestone no bubbling by 1 yr; no single word by 16 months
Growth and development problems
Learning problem
Usually need only minimal sleep
Difficult to diagnose before 2 years
Associated with tuberous sclerosis
Smiling  2 months
Turning from prone to supine  6 months
Sitting  9 months
Standing with support  10-12 months
Walking  1-1.5 years
Speech & language  1 year=1 word; 2 years= 2 words; 3 years= 3 words
Any child with behavioural abnormalities or learning disability

- Questionnaire to parents and teachers
- Ask if heal prick test and hearing screening test done when born
- Vision and hearing testing
- Help of psychiatrist
- Check for endocrine disorders
History of pregnancy
- infections
- full term or premature
- post natal problems – jaundice, meningitis
Hx:
Could you pls tell me what do you mean by destructive behaviour?
Why exactly you & the childcare teacher are concerned?
Why do you think she looks and behave different from others?
Has she had any hearing and vision test done? Any abnormal result?
How was the pregnancy? Any infection? IUGR?
Full term or premature?
Any problem during delivery? Any prolonged labour?
Has she required resuscitation after born?
Any Hx of prolonged jaundice or meningitis?
Does she look abnormal compare to other kids?
Does she smile?
! 18!
PAEDS: BEHAVIOURAL
When did she smile first?

When did she start sitting, walking?
Can she talk? Total number of words
Can she grasp a pen and write?
Does she react with other family members, friends?
Does she keep an eye contact with you when you talk to her?
Does she become upset if you change her routine?
Does she have any repetitive behaviour?
Does she have any preoccupation with any specific toy?
How about her sleep? Any abnormal sleeping problem, head banging?
Any Hx of head trauma?
Any Hx of fits, epilepsy?
Any other concern?
Immunisation
General health
Any FHx of similar condition or mental retardation?
Home situation
Explanation:
From the history, your child has a developmental behavioural disability, with impaired social
interaction & communication. It can be the type of autistic spectrum disorder.
I need to refer you ASAP for further assessment by a specialist.
Paediatrician will also arrange Ix to exclude fragile X syndrome, chromosomal analysis to
exclude other genetic disorder.
If diagnosis is confirmed, he’ll be managed by a multidisciplinary team: pediatrician,
paediatric psychologist, GP, counselor, nurses.
There is lot of support from myself, paediatrician, autism association of Australia, social
worker, and centrelink.
This condition has no medical treatment, but autistic child need to have regular medical
check up as they will not complain of anything.
They have a high risk of epilepsy and OCD
The child will not grow out of this problem and they may face problem and get worse during
adolescent period and especially during sexual development.
There is some degree of mental retardation and most of them need lifelong support.
Therapy
- Behavioural and speech therapy
- Psychiatric counselling
! 19!
PAEDS: BEHAVIOURAL
Speech Delay (Hearing Loss Or Autism)

A Mother of 18 month-old child came to GP clinic concerned that her daughter is not
speaking well.
Task: take history from the Mother, most likely diagnosis and further management.
Hx:
I know you have a concern about your daughter. Can you please tell me more about that?
What do you mean by bubbling, any words? Bubbling but not speaking
When did she start bubbling?
When did she start smiling, sitting with support, standing with support?
When was she able to walk?
Do you have any other children? How old are they? 5 yo son, he’s good.
Does she play with her brother?
How is her interaction with other children?
Does she has eye contact with you, respond to her name?
Does she turn her head towards sound such as TV?
Does she resist any change in the routine?
Is she attached to any particular toy?
Does she have excessive crying? (sign of autism)
Any repetitive behaviour example head banging?
Any formal hearing or visual testing been done?
How was the pregnancy? Any infection? IUGR?
Full term or preterm?  preterm and admitted for 3 weeks in the hospital
Any problem during delivery? Any prolonged labour?
Has she required resuscitation after born?
Any Hx of prolonged jaundice or meningitis? need phototherapy
Any other significant medical condition, admission to hospital?
Medication and allergy
Who looks after her?
Immunization
How is the situation at home?
Ask detailed birth history
Growth & percentile chart
Dx:
From the history it seemed that your child has speech delay. The most likely cause that need
to be ruled out is hearing problem. So I’d like to refer you to :
- An audiologist for formal hearing
- For visual testing
- Paediatrician for further assessment
- Speech pathologist for speech development
I’d like to see you after the test being done and give you some written materials.
Is it autism?
It could be autism but it is very early to say. We need to do more tests and assessments to
confirm the diagnosis. Paediatrician will do further assessment & investigation.
There are a lot of support groups for autism.
This will usually be managed by a multidisciplinary team.
! 20!
PAEDS: BEHAVIOURAL
Child Abuse (AMC p 636 )

A 23 yo lady presented to ED with her 6 months old child who had bruises over the left cheek
and she’s crying for a long time. She’s worried that the child might have a bleeding disorder.
Task: take further history, ask for PE finding and advise on the management.
Hx: to exclude organic disease and to know the social circumstances behind
When did you start noticing the bruise on the cheek?
Bruise anywhere else?
Is it the first time you noticed this bruise?
Have you noticed any easy bleeding from the gums, nose, or from anywhere else?
How did the bruise happen? Spontaneously or after a trauma
Has your child have any fever? (to exclude pancytopenia, leukemia)
Systemic review: cough, noisy breathing, feeding, vomiting, wet nappy, abdominal
distension, bowel motion
PMHx: Any medical condition in the past?
Is he the first child?
How was the pregnancy, was it planned or not?
Was it a full-term or premature?
Delivery normal or not
Any problem after delivery?
Immunization
Who looks after the child?
Do you have any support?  no
HEADDSS
Any issue of violence at home?
Is your partner, his biological father?
Any health issue with you or your partner, any mental illness problems?
O/E:
GA, Growth parameters (emotional abuse  not feeding the baby well)
VS
Full survey of the child from the head to toe:
Skin examination – signs of abuse: Start with the hands, fingers (bruises, burns, scars)
Face, head (fontanelle), recurrent shaking of the baby
Eyes – possible pallor, jaundice, haemorrhage; Funduscopy
Examine the mouth
Examine the frenulum of the tongue (injured b/o smacking to the mouth – squeeze to face)
ENT and lymph nodes
Chest – inspect for any swelling, rib fracture, listen
Abdomen – organomegaly, possible bleeding
Genitals
Upper/Lower limbs - deformities, reduced movement of R limb (spiral fracture of the femur)
Suspicion of non-accidental injury  finding of broken leg

- Admit
- Treat accordingly
- Notify health authorities(Victorian infancy paediatric medical service)
! 21!
PAEDS: BEHAVIOURAL
Explanation:
After I examined your child, apart from the bruising, there might be a broken bone on the
thigh. For this reason, we need to admit your child to the hospital to do some further Ix.
Also to look if there is any disease behind
- FBE
- Coagulation profile
- Full X-ray
- Bone scan
- Take photos to document
Because the nature of the injuries don’t go well with the mechanism described.
I’m very concern about your child’s health and safety as to me the injuries I’ve seen or the
lesions do not correlate well with the mechanism behind it.
It’s my legal obligation to notify the health authorities to assess your child.
Do you think that I’m harming the child?

I’m not saying that. Our priority is the safety of your child and I know you also want him to
be treated.
! 22!
PAEDS: BEHAVIOURAL
Breath Holding Attack

A 2 year-old boy brought by his Father to your GP clinic. His son’s finger jammed on a car
door. He screamed, cried for a while, hold his breath for a few seconds and he became blue.
Now his son is OK but quite difficult to examine him.
Task: relevant history, probable diagnosis and management.
Hx:
Can you please tell me what happened exactly?
Did he turn pale or blue during that time?
Did you notice any jerky movements of the body?
Did he become stiff?
Did he wet himself?
Any uprolling of the eye?
Did he lose consciousness?
What happened before the attack?
How long did this breath holding attack last?
Was he drowsy or difficult to arouse after this?
Is this the first episode?
Is he a difficult child or stubborn?
Any FHx of similar problem?
How is his appetite and diet (sometimes in IDA  breath holding attack can occur)
Any medical problem, surgery or hospital admission in the past?
Immunization
Birth history
Explanation:
From the history, it seems that your son had breath holding attack which is a part of the
temper. It’s one of the types of behaviour disorder in children especially toddlers who protest
for frustration. It means a dramatic reaction to temper. So it happens when babies or children
crying or frighten or upset have had minor accident and have gone into minimal shock. The
children will cry, catch their breath, hold it without breathing. This is not done on purpose. It
may look scary for you, usually ends in about 30-60 seconds. In some cases they will lose
consciousness. When this happens, the body automatically kicks and then start breathing
again. Some cases are also associated with iron deficiency anemia, so we’re going to do a
blood test to check the iron level. It’s common between children age 6 months to 6 years,
peak in 2-3 years. It can happen often as several times a day. There’s no evidence that breath
holding attack has harmful effect in the brain. So I’d like to reassure you that this attack is
self-limiting, not harmful, not associated with epilepsy, not causing intellectual disability.
It’s important to maintain discipline and resist spoiling the child. Avoid incidence not to
frustrate the child, stay calm and watch him till the spell is over. Don’t put anything into the
child’s mouth not even your finger to clear the airway and don’t shake the child because that
may cause more injury.
Something to look out during or after the attack:

- Confusion
- Drowsy
! 23!
PAEDS: BEHAVIOURAL
- Shaking
- Stiffness
- Or the attack last > 1minute
 need to bring the child to hospital or GP
! 24!
PAEDS: PUBLIC HEALTH
Immunisation Advice (AMC 75)

A 6 week-old baby was brought by his Mother to your GP practice.
Task: advice on immunisation and answer parent’s questions.
In Victoria, the routine vaccination:

- Birth: Hepatitis B
- 2 months : DTP, IPV, Pneumococcus, Hib, Hepatitis B, Rotavirus
- 4 months: DTP, IPV, Pneumococcus, Hib, Hepatitis B, Rotavirus (same as 2 months)
- 6 months: DTP, IPV, Pneumoccocus, Rotavirus
- 12 months: MMR, Hib, Meningococcus, Hepatitis B (only give to premature baby)
- 18 months: Chicken pox
- 4 years: DTP, IPV, MMR
IPV (inactivated polio vaccine); Hib (Haemophylus influenza)
Influenza can give to infants>6 months if they are at high risk.
Immunisation is very important to prevent certain diseases. It’s the primary prevention. It stimulates
immunity in child against certain diseases by injecting the same bugs that causes the disease. But the
bugs are weak, they cannot produce the disease, they stimulate the immunity. Vaccines are given at
certain times and need more than one dose for complete protection. After introduction of vaccine
programme, lots of diseases are eradicated which can be fatal. The vaccine is not 100% protective,
child can still get the infection but in a milder form. If the child is not vaccinated and he gets the
infection, it will manifest as a serious problem.
SE: Fever and swelling, tenderness and redness in the local injection site.
For fever, give Panadol 30 minutes before injection (especially for DTP)
Contraindications?
- Immediate severe anaphylactic reaction with vaccinationAdren
- Encephalopathy (within 7 days of previous DTP vaccine)
There are certain conditions that can postpone the vaccine:

- Fever >38.5 (fever is not a contraindication)
- Any major illness (especially if you feel that the child is unwell)
CD for live vaccine(MMR, Chicken pox): Immunocompromised child (HIV, under chemotherapy)
If the baby is allergic to egg, it’s not a contraindication, the vaccination will be given under
supervision
The injection site:

- <12 months old  anterior lateral aspect of the thigh
- >12 months old  deltoid or thigh
Catch up immunisation (If missed one injection)

- If he missed vaccination at 4 months, give it at 5 months and 1 month later give the routine one.
- You can give the missed one now and one month later give the routine which should be given.
! 1!
Baby Check
You’re an HMO in O & G Dept. The midwife asked you to examine Tom, a 3 days old boy.
Task: take focus Hx, examine the baby and give the final result to the mum
Hx:
Congratulations, is it baby boy or girl? Is it your first baby?
How are you coping with your baby?
Is the baby preterm or full term?
How was the delivery? NVD or Caesarean?
Any complications after the delivery?
Is he bottle-fed or breastfed?
How was the pregnancy? Antenatal check up
Examination:
1. Inspection activity, facial feature, asymmetric, red reflex
2. Half expose Listen to the heart sound (S1, S2, may has S3; any murmur)
i. Listen to the lungs (upper and lower lobes)
ii. Listen to the bowel sound
3. Full expose
Limbs: Check the limbs movement (power, tone: hold both hands, life baby up )
Head: fell anterior suture line; Anterior & posterior fontanelle
Mouth: Sucking reflexuse little finger to suck into the mouth; Rooting reflexopen mouth
Pulse: feel brachial pulse to see if symmetric or not
Abdomen: use 1-2 fingers do deep palpation; use thrum and index finger to check umbilicus
Femoral pulse: use index finger to check inguinal area
Genitalia: feel if the testes in scrotum or not
Hips: Ortolani & Barlow test
Low limbs: deformity; planter reflex
4. Turn the baby around to check the spine.
5. Reflexes
Moro reflex: support the neck, when baby is not crying, drop it he spreads his arms, pulls his
arms in, he cries (10 seconds)
Asymmetric tonic neck reflex (ATNR): external rotate the shoulder normal before 6 wks
6. Head circumference, weight, height
He has no dysmorphic features at all

He’s moving his all limbs
There’s no respiratory distress; His lip is pink, no sign of cyanosis
Before baby cries, I need to listen to his heart & lungs with my stethoscope
Fantastic! Heart rate is very good, no murmur, no abnormal sound
Respiratory rate is fine
Lung auscultation  good air entry, I have not found any crepitus nor wheeze
Let me feel his liver and spleen, there is no organomegaly, beautiful, there is no enlargement of liver
nor spleen
Abdomen is soft
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Head
- Anterior & posterior fontanelle normal
- Suture line is good, no over riding / overlaping
- Eye – I will check red reflex – normal
- Nose
- Ears look good, there is no abnormality
- I will check later with otoscope
- Mouth  No cleft lip or cleft palate, Sucking reflex good
Genitalia
- Testis in Scrotum I can feel it
- No hernia, no hydrocele
- Put 2 index finger on femoral arteries to check femoral pulse – equal and regular
- Umbilicus should be clean and dry
- Ortolani & Barlow test
- Put thumb in front and other fingers at the back and hear the click sound
- Nails of hands & foot are good, no abnormality
- Muscle tone and power normal
Put baby facing down in your palm

- Check the spine
- Head is the same line on spine and there is no spinal deformity (run finger down on the
spine), there is no abnormal hair
- Anus is patent
Check truncal tone (with 2 index fingers let the baby grasp and lift the baby, with the rest of the
fingers hold the baby’s hands) – very good
The Moro reflex, also known as the startle reflex, is one of the infantile reflexes – transfer the baby
from one hand to another
The reflex is initiated by pulling the infant up from the floor and then releasing himhe spreads his
arms, pulls his arms in, he cries (10 seconds)
Height and weight, head circumference – all normal
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HOPC: First child, normal pregnancy and uncomplicated vaginal delivery on term. Spontaneous
crying and breatheing. APGAR score of 8 at 1 minute and 10 at 5 minutes.
PHx.,FHx.: unremarkable ( especially no genetic or familial diseases)
SHx: married, school teacher, non smoker, no alcohol or drugs, NKA
NEONATAL EXAMINATION:
The examination should be carried out with the baby undressed in the presence of the mother(and
father if there).Observe the infant’s general appearance, posture, movements, behaviour, colour and
exclude any characteristic disorder (e.g. Down syndrome)
HEAD AND NECK:
1. swelling, haematoma (boggy swelling present from birth, cephalohaematoma which is
subperiosteal and limited by suture lines, usually does not require any treatment. Subaponeuritic
/ subgalealhaematoma is more extensive and can lead to hypovolaemia and often is a neonatal
emergency!).
2. abnormal shape (premature fusion of sutures, craniosynostosis)
3. head circumference (micro / macrocephaly)
4. clefts of lip and /or palate
5. periauricular sinuses
6. swellings, cysts or sinuses in the neck (thyroid, branchial cleft malformations)
7. the eyes (cataract etc.)
CHEST:
1. respiratory rate (35-60), central cyanosis, nasal flaring, costal recession (laboured breathing)
2. cardiovascular: peripheral pulses, auscultation of the heart
ABDOMEN:
1. anterior abdominal wall defect (exomphalos, gastroschisis), a simple paraumbilical hernia does
not require treatment at this stsage.
2. abdominal distension (?enlarged organ, intestinal obstruction, atresia, Hirschsprung’s disease)
3. umbilicus should be clean and dry
4. genitalia: patency of anus and especially testicular position
HIPS: for congenital hip dislocation (Ortolani and Barlow test)
BACK:
1. myelomeningocele (spina bifida, hairy patch or lipoma on lower back)
2. sacrococcygeal teratoma
SKIN AND MUCOUS MEMBRANES: Mongolian spots (blue-black pigmented areas),
Urticaria, heat rash, milia (white pimples)
NEUROLOGICAL ASSESSMENT:
1. spontaneous movement: frequent
2. posture: flexed arms, extended legs
3. upper limb tone: resists lifting of arms
4. lower limb tone: resists hip abduction, popliteal extension
5. truncal tone: attempts to straighten back when lifted prone
6. tendon reflexes: brisk, some clonus common
7. Moro (startle) reflex: abduction and extension then adduction and flexion
8. Response to objects: fixes and follows bright lights
9. response to sounds: quietens or startles
MEASUREMENTS: weight, length and head circumferen
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SIDS (AMC 5)
GP setting. A 4 month-old male infant has rushed to the ED but was dead on arrival. The
provisional Dx was SIDS and coroner autopsy was arranged. You have seen him 2 months
before for immunization purpose, and you have seen him 2 days before death for
URTI/snuffles and improved the following day. You were not aware of any suspicious
situation. She’s a single mother, she & her sister are coming to see you
Task: counsel the family & answer their questions.
Common cause of death in infants (0-12 months), peak is 4 months of age.

Incidence has decreased from 1/500 to 1/1000 because of increase awareness.
Cause  not found, that’s why coroner autopsy is needed to study more and prevent.
Risk factors Prevention
Sleeping prone positione Sleep supine with no pillow
Artificial feeding (formula or bottle Breastfeeding
feeding)
Passive smoking Stop/avoid smoking in the baby
surrounding
Hyperthermia (cover baby with blankets) Do not overheat (do not cover head), no
more than adult covering required
Parental narcotic drug use Nothing else in the cot
Extreme prematurity < 32 weeks
Intercurrent viral infection
Monitor can be used but will not prevent SIDS.
Why is the coroner and police officer notified and baby autopsy?
Because doctor usually do not find any cause, he was brought dead to the hospital, suspicious
or not, it’s required by law to notify cases where we don’t find any cause of death. We have
to do examination of the baby. We will take some tissues from the baby, experienced
pathologists will examine the tissue under microscope and find out what cause so that we can
prevent it in the future.
If you want, I can ask the coroner and police officer to ask for the result. I will contact you
and have another appointment as soon as I find out the result and so that you can arrange for
the funeral of baby Andrew.
Give written material and tell her about SIDS Foundation, a support group with people who
had a similar situation, they can share their feeling.
Lactation suppression for the mother
Follow up
If mother is depressed, you can give short acting anti depressant but not more than 2weeks.
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Refugee Child
A 2 yo boy, a Sudanese refugee, came with his Dad as the local community worker asked his
Dad to see you regarding his health issues. They arrived to Australia 2 months ago. They
have been through a traumatic time in the refugee camp for the last 5 years.
Task: counsel dad about his son’s management issues and answer his questions.
For refugee child I-BINDS-MEN
I’m not from the government and not from the immigration service, I just want to talk to see
if there is any health problem that I can help. (Make sure that the father can speak English
first Need verbal approval from Dad if a translator is required. )
- Parental concerns
- Check immunization status from the beginning
- InfectionTB screening, Symptoms of parasitic infection & malaria
- Nutritional status & growth (including iron def, vit D, bone health, vit A def)  any
concern  refer to dietitian
- Dental issues
- Concerns about development, vision, hearing
- Mental health issue  refer to paediatric psychology
- Previous severe/chronic childhood illness or physical trauma  check for G6PD,
Thalassemia  treat family members
- Issues arising from resettlement in Australia
Hx:
Pre-term or term pregnancy
How was the delivery, who did the delivery?
Any problem after the delivery
Feeding, prolonged breastfeeding, not good quality of solid food
Ear infection, urine infection and asthma
Any concern regarding physical development, hearing, vision, speaking, language---normal
Dental issues, any problem with his teeth  dental assessment
Any serious illness in the family such as tuberculosis, blood disease (Sudanese G6PD,
Thalam)?
Vaccination status, any documentation
Mental health assessment for Dad and child in future (psychological assessment)is the
child active?
Growth, nutritional, developmental assessment
Social issuesFinancial situation; Housing; Centrelink; English class
O/E:
GA pale, jaundice, signs of rickets, Growth development
VS
Dental
ENT + Lymph nodes
Chest, heart, abdomen
Genitalia
BCG scar in deltoid region or lateral aspect of elbow (in African patients)
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Ix: Screening Test

Infectious disease
- hepatitis B serology
- TB screen
- schistosomiasis (urine & serology)
- Malria screen
- STI and HIV screening in sexually active adolescents
- Faecal specimen for paracites
Assessment of TB in the child

- Investigate with Mantoux test and chest X-ray
- Blood test  Quantiferon gold test, TB interferon assay  differentiate between positive
Mantoux (BCG) from latent TB
Nutritional screening test

- FBE and film
- Ferritin
- Iron study
- Vitamin D (fatigue, tiredness may be caused by vit D deficiency can be treated with vit D
tablets for 3 months)
- Vit A
- Calcium
- LFT, RFT
- Parathyroid hormone (if clinical rickets)
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PAEDS: RENAL
Enuresis (Bed-Wetting)
A 4 yo boy bed wetting at night. He’s dry during day time since he was 2.5. Urine test (-).
Task: take relevant history for 1 minute. Outline your management.
4 elements can cause secondary enuresis:

- stress in the family or at kinder
- bowel action, constipation or diarrhoea, if constipation how long
- any history of DM (drinks too much water)
- UTI
Hx:
I read that he has bedwetting problem. Could you tell me more about this?
Has he been dry before?
How frequent, every night?
What’s the colour of the urine?---normal
FHx of similar condition , DM, UTI?
Are you a happy family?
Does he go to childcare? When did he start? Is he happy there?
Bowel habit? Constipation?
Is he the only child at home? How old? Has his sibling had similar condition?
Does he drink a lot of water during daytime?
What about his growth and development, weight, height?
O/E:
GA: any abnormal or dysmorphic feature, height and weight
VS: BP (some defect on anti diuretic hormone can cause BP problem)
Neurological exam: spina bifida (can cause enuresis), vertebral function
Exam external genitalia: to exclude hypospadia
Long history of constipation  do rectal exam to see fecal mass
Ix:
Urine analysis, culture  glucose
Routine radiological exam IS NOT NEEDED unless there is a neurological defect
Explanation:
Your child has a condition called enuresis. It refers to bed-wetting at night at a time when
control of urine could be reasonably expected.
Bed-wetting at night is common in children up to the age of 5. 50% of 3-yr-olds have bed-
wetting, 20% of 4 yr-olds & 10% of 5 yr-olds. It is considered a problem if regular bed-
wetting occurs in children 6 yrs and older, although many boys do not become dry until 8 yrs.
It tends to be more common in boys and seems to run in families.
Bed-wetting after a long period of good toilet training with dryness is called secondary
enuresis. The cause can be psychological, in a small number of cases there is an underlying
physical cause, such as urinary tract abnormality, DM, UTI.
Causes: There is usually no obvious cause, most are normal in every respect but seem to
have a delay in the development of bladder control. Other causes are
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PAEDS: RENAL
- Bladder defect (bladder not maturely developed – delay controlled can be up to 8 years).
If the bladder has small capacity or sensitive (even for a small amount of water – try to
get it out).
- Genetic predisposition---father has this problem at the same age (autosomal dominant) 
problem in arousal status, does not wake up when the bladder is full
- Insufficiency of anti diuretic hormone ---BP
- Psychological issue (not a predisposing factor but as a consequence) because of the
bedwetting & he start to develop some issues eg he can’t sleep over at his friend’s house.
Advice:
- Don’t blame or punish him
- Encourage
- No need to stop him drinking after dinner
- Don’t wake him up during the night to go to toilet
- Use a night light to help him to the toilet
- Try to using special absorbent pads beneath the bottom sheet rather than a nappy
Mx:
We can wait and see for a while. If there is no improvement
- Try the alarming system (can borrow the system from Royal Children Hospital) for at
least 12 weeks  a clip will be attached on the child’s underwear, 1 drop of urine can
start the alarm. The child will wake up and go to the toilet.
- If doesn’t help, stop for 3-6 months
- Then give another try for 12 weeks
- If doesn’t help  refer to paediatrician because GP cannot prescribe Vasopressin nasal
spray
- Follow up in 2-3 weeks after we start the alarm system.
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PAEDS: RENAL
Hemolytic Uraemic Syndrome

A 18 months old presented with 3 days history of vomiting, diarrhoea & fever.
Task: Take history, exam, investigation, Dx/DD, management.
DDx:
- Gastroenteritis
- HUS
- Intususception
- Infection (Shigella, Salmonella, Campylobacter)
- Malignancy
Positive finding:
Vomiting started first, not related to food, contains blood today.
Frequent diarrhoea (5-6 times/day) with blood mixed stool, watery
Lethargic, pale, mildly dehydrated, not drinking and eating
T was 39 yesterday but 38 today Panadol didn’t help
HR 120, RR 27, BP 92/77
FBE  Hb 80 (anaemia), WBC 17 (neutrophilia), Platelet 50 (thrombocytopenia)
Electrolyte  Sodium 132 (low), K 5.8 (high), Creatinine 188 (high)
Urine and Stool culture (-)
Urine analysis blood (++), large proteinuria
Gastroenteritis + mild dehydration + lethargy  HUS (anaemia, thrombocytopenia, uraemia /

abnormal RFT)
HUS is uncommon, is a diagnosis to be considered in any child presented with diarrhoea

(pale, anemia, proteinuria, hematuria, thrombotic thrombocytopenia purpure), especially
when a child has severe diarrhoea but only mild dehydration, or does not pass urine (oliguria
or anuria) after appropriate rehydration treatment
Fluid replacement aggressively may give fluid overload.
Treatment:
Admit. Refer to paediatric nephrologist.
Despite infective origin, antibiotics is not effective. (E. Coli infection)
Monitor renal function
Most of the cases self-limiting, some cases peritoneal dialysis may needed
Hypertension & proteinuria common
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PAEDS: RENAL
UTI
David is 1 year old, he’s not feeling well, he has fever over the last 2 days. His mother noted
that his urine is very smelly.Urine bag positive infection.
Task: immediate & long-term management.
Urine bag or mid stream urine with container cannot be used as it’s highly contaminated
Immediate treatment
I need Suprapubic aspiration urine sample  urine microscopic culture & sensitivity
(Feed baby 30 mins before, lower abdominal crease, local anaesthetic, guided by US)
If failed the 1st time because there was no urine, do it again  if fail again  catheter
Blood tests: culture, electrolyte.

Consider LP.
Antibiotics: Amoxycillin or Keflex, Trimethoprim, Augmentin

Amoxycillin 24-40 mg/kg
Weight 10 kg  400 mg
5 X 400/125  5 ml tid
For 5-10 days
Trimethoprim 4-6 mg/kg/day bid
Long-term treatment
1) Every child (esp. < 4 yo) with first UTI should have a renal US  40% has renal tract
abnormalities  to see reflux, obstruction
2) MCU  micturating cystourethrogram (invasive procedure, done by specialist)

- if child < 1 year
- there is obstruction
- hydronephrosis
3) DMSA scan (Mega scan)  Dimercaptosuccinic acid

- 2-4 years after the last UTI
- to detect chronic pyelonephritis (scar on kidney  renal injury)
VUR (reflux)  prophylactic antibiotic until reflux is treated surgically
Prophylactic antibiotic for high risk VUR (vesicoureteral reflux)

- frequent UTI
- child < 1 year
- strong family history of VUR
Investigate brother & sister with renal ultrasound  50% of sibling may have VUR
Patient education  voiding, micturition

(?Another case need to explain to the mum how to do voiding cystourethrogram)
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PAEDS: RENAL
Dark Urine (AMC 76)

A father brought his 7 yo son because the son passed dark urine for 2 days. He also brought a
jar of urine.
DDx:
- Post streptococcal Glomerulonephritis (occur 2-3 weeks after infection)
- IgA nephropathy (within 1-2 days after infection, more common in adults)
- Liver problems, hepatitis
- G6PD deficiency
- Henoch-Schoenlein Purpura
- Trauma
- Drugs (iron, Rifampicine)
- Food – beetroot, blackberry
Hx:
From the notes, I see that your son has problem with urine.
When did it start?
Did this happen suddenly?
Is it constantly the same colour throughout the day?
Has he passed water more frequently or less frequently?
Has he complained of pain while passing water?
Any problem with his kidneys previously?
Any recent infection like skin or throat infection?---skin infection
When did he get? ---3 weeks ago
How was it treated?
Did he have any problem with his liver?
Abdominal pain, skin colour changes
Any joint pain, any rash
Any blood disorder
Is he on any medication, recent use of medication? (Rifampicin, Sulfanamide, Quinine)
Any recent intake of beetroot, blackberries?
Have you noticed any eye puffiness, facial puffiness, leg swelling
Has he c/o headache, shortness of breath, any fits? High BP
FHx of similar condition r/o G6PD
Immunization
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PAEDS: RENAL
Post Streptococcal Glomerulonephritis (PSGN)

Infection of kidney after 2 weeks of sore throat or skin infection caused by antigen-antibody
complex (immune reaction). Bacteria in the body decreases the body complement level of
C3-C4 which causes damage to glomerulus.
Skin infection & sore throat  treat with antibiotics  to prevent PSGN
Risky?
Let me assure you >95% of this case recover completely with no complication. Excellent
prognosis with treatment
In the future will he be hypertensive, renal damage & renal failure?  NO.
IF NOT TREATED, then it may carry the risk of :
- Hypertension (is a risk by itself).
- Nephritic (hypertension, oedema, haematuria) can change to nephrotic
(hypoalbuminemia, proteinuria, oedema)
- Renal failure
- Heart failure
- Pulmonary oedema
- Acute can become chronic GN
Post streptococcal GN (overweight, swollen knee)
MANAGEMENT
Admission to hospital for further investigation:
- FBE
- RFT
- ASO (Anti Streptolysin O)
- Complement level C3 and C4 (hypocomplement level) will become normal after
treatment
- If persistent hypocomplement level  up to or more than 6 months normal  reconsider
diagnosis  renal biopsy
Admission
Antihypertensive medication
Antibiotics +/-
Restriction of fluids
No need for steroids in post streptococcal
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PAEDS: DERMATOLOGY
ERYTHEMA TOXICUM NEONATORUM

(Normal baby rash)
A 5 days old boy presented with Mum as Mum noted that he has skin rash all over his body.
Task: Take Hx, ask exam for findings, Dx, DDx, Mx.
DDx
Viral infection (Herpes simplex)
Varicella
Neonatal sepsis
Listeria infection
Miliaria rubra
Erythema toxicum neonatorum (also known as toxic erythema of the newborn) is a harmless
red rash that appears on the skin of newborns. This rash goes away on its own and has no
symptoms. It has often been likened to the appearance of a fleabite on the skin. Erythema
toxicum is an very common rash that does not require any treatment, as it will
spontaneously go away in 5–14 days. The cause of this rash is unknown. The name toxic was
named in the 15th century---because of the extensiveness.
Hx:
Rash Qs: when and where, any contact with similar rash, any fever, vomiting, diarrhoea, any
lumps, feeding, sleeping, is the baby irritable?
Risk factors: How was the pregnancy? How was the delivery? Full term or premature;
Maternal fever, Premature rupture of membrane; Bottle feeding or breast feeding
(Focus the history on age at onset of the eruption, absence of systemic signs (eg, fever,
irritability, lethargy, mucocutaneous involvement), or maternal history of herpes
simplex/varicella viral infection, bacterial pyoderma, or candidiasis)
O/E: papulovesicular rash. absence of mucosal, palmar, or plantar involvement.
Explanation:
Mrs Smith, your child has a normal baby rash.
Very common, Cause unknown
Not risky at all, no complication, excellent prognosis.
Self limiting condition, no treatment required, resolved within 2 weeks after birth.
Papulovesicular rash, within the lesions there is eosinophilia.

Lab study not indicated. Investigate only if you feel the child has fever, lethargic, vomiting
Diagnosis clear clinically
Gram stain from the rash ---eosinophil mainly (A Tzanck smear or Gram stain performed on
intralesional contents is essential for diagnosis. Inflammatory cells are present, with greater
than 90% eosinophils and variable numbers of neutrophils)
If suspecting neonatal sepsis ---septic work up
http://emedicine.medscape.com/article/1110731-overview
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PAEDS: DERMATOLOGY
NAPPY RASH
5 months old boy has rash on his buttock. Mom is worried because this is the 1st time she noticed it.
Task: Take a history, examination finding from the examiner, diagnosis & treatment.
DDx:
Contact dermatitis
Psoriasis
Bacterial infection
Zinc deficiency (ask for nutrition  feeding)
Hx:
When and where did the rash start first?  The rash started 2 days ago as red spots. On the second
day started to increase in size & spread to the front & back of scrotum.
Is it the first time?
Are there any rash anywhere in the body?  no
Itchy? the baby started to be irritable
Have you tried any cream or medication on it? cream but didn’t help
Any associated symptoms like fever, coughing, runny nose?
Any recent diarrhoea? he has bouts of diarrhoea for 2 days but improved by himself
How many times? 6-7 times/day
Any medication, esp. antibiotics
Feeding; Sleeping
Have you changed his shower gel, shampoo, body lotion for the last 2 weeks?
Have you changed his nappy brand?
Anyone at home has similar condition?
Recent travel Hx
PMHx and FHx of eczema or allergies?
If age > 6 months  ask teething process  decrease immunity
Who’s looking after the baby? Does he go to childcare?
O/E:
GA: Healthy, irritable; VS: normal
Rash: Erythematous lesion in the gluteal & perianal region, little bit scaly, some lesion collect
together. Satellite lesion (clue for fungal lesion).
Any regional lymph node enlarged (infection)
Systemic exam: chest, heart, abdomen
Explanation:
From Hx & exam, it’s most likely he has a condition called Nappy Rash. This rash specifically
appears in the area of the nappy in the gluteal region and in front as well. It’s a very common
condition. It can be caused by
1. The moisture or wetness of the nappy
2. Irritation from the urine  ask how frequent did she change the nappy?
3. Wetness & urine are good culture for fungus infection  candida
It’s not a risky condition but it may irritate the baby.
I will take a swab from the skin just to confirm candidal infection.
There is a specific cream called miconazole (nystatin), anti fungal cream.
And you can take some precautionary measures to help him to get better soon.
1. When change nappy, dry the skin carefully, put barrier cream to prevent from moisture & fungus.
2. Try to change the nappy more frequently.
I’d like to see him in 2-3 days, if there is no improvement, add corticosteroid cream  Kenacomb.
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PAEDS: DERMATOLOGY
ROSEOLA INFANTUM (SIXTH DISEASE)

Marina, 5 month old, has a fever over the last 4 days, her mom brought her to the clinic
because she found some rash on her back and abdomen.
Task: History, exam finding, diagnose, treatment.
DDx:
Measles
Septicaemia
Meningitis
Drug reaction
Hx:
Fever Qs: (can you tell me a bit more about the fever, like when did it start, how severe it was?
When did the fever start? 4 days ago
Have you checked her temperature? What was the highest reading? 40 degree C
Did you give her any medication? Panadol did help a bit.
Any other symptoms like runny nose, cough, wheezing? to r/o URTI
Any vomiting, diarrhoea?
Appetite, sleep
How often did you change his nappy?
Did you find any lumps in the body? ---lumps in the neck.
Any fit? Any abnormal movement or loss of consciousness? (If older child can ask if lost
control of bladder) 10-15% have febrile convulsion.
Rash Qs: (relationship with fever is important)

When did the rash start? Found accidentally in abdomen and back today
Where did the rash start?
Can you describe roughly how does the rash look like? fine, red spots
Previous skin problem?
Anyone at home has similar condition?
Any history of allergy in the patient and the family?
Who’s the carer, does the child go to kinder, childcare?
Immunization?
O/E:
GA: ill, drowsiness,signs of dehydration, level of consciousness (alert)
VS: T 38, BP normal, RR normal, pulse little bit increased
ENT: redness on pharynx (pharyingitis) with intact ear drum, blocked nose,
Lymph nodesenlarged in neck
Rash: red flat top macule or papule distributed all over the chest & abdomen and the back.
Some of the lesion has a halo, a whitish circle around the lesion. Blanches when pressed.
Chest: no ronchi,
Heart normal, abdomen free
Explanation:
From the hx & examinaion, she has what’s called Roseola Infantum. It’s a common
contagious viral infection in babied and young children aged 6 months and 2 years. It is
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PAEDS: DERMATOLOGY
caused by a virus from the human herpes group, type 6 (belongs to Herpes Simplex family,
but doesn’t cause any ulcer).
The virus is spread from person to person by droplets from the nose or mouth travelling
through the air or by direct contact. The tiny droplets of fluid are expelled when an infected
person talks, laughs, coughs or sneezes. If people touch these droplets and then touch their
own noses or mouths they can become infected. The incubation period (time from contact to
the appearance of symptoms) is 9-10 days and it is most infectious before the symptoms
occur (i.e before the baby has fever).
It’s characteristics with high fever of 4-7 days, fever subside, rash start to appear. It can cause
swollen lymph gland in the neck. The rash is bright red and spotted, started from the trunk
(chest, back) and arms, usually sparse on the face and legs. It disappears within 2 days.
The infection usually runs a mild course but the high fever sometimes can trigger febrile
convulsions.
Rare complications: inflammation of the brain and its covering (meningitis) and hepatitis.
As soon as the rash appears, the child gets better. Still contagious until rash disappear.
Diagnosis is uncertain, by exclusion.
Mx:
Most of the time, Roseola does not need any professional medical treatment.
• Paracetamol can be used to help reduce the high temperature if your child seems
uncomfortable or irritable
• Offer the child lots of drinks (water, flat lemonade or clear broth) to keep them well
hydrated during a fever
• If you are still breastfeeding, breast milk can also help prevent dehydration
• Antibiotics are of no use and cannot treat roseola because it is a virus
You should see your family doctor if:
• Your child is lethargic (very sleepy, hard to wake)

• Your child will not drink
• You cannot reduce your child's temperature
• Your child has a convulsion (a fit) that lasts less than five minutes
Call 000 immediately if:
• Your child has a convulsion that lasts more than 5 minutes

• Your child does not wake up after a convulsion
• Your child seems very sick after the convulsion
http://www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=11173
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PAEDS: DERMATOLOGY
ATOPIC ECZEMA
A 11 months old girl has rash over her cheeks and cubital fossa. She keeps scratching over the last 2
nights. She developed swelling on her lips and eyelids after eating egg a few weeks ago. She was not
taken to the hospital or GP because the condition settled in a few hours.
Task: obtain relevant Hx & explain what is the most likely Dx and manage the case.
Start from the first year of age and positive family history of allergic condition  atopic eczema
Hx:
I read from the notes that Sally has rash and also had some reactions to eggs before. Is she all right
now? She developed rash 2-3 days before.
Where are the rash?  some red spots in cubital fossa and rough rash over her cheeks
Does anywhere else in the body have the rash as well?
(Other distribution can be  Gluteal, groin or nappy area, back of the knee, arm)
Is that itchy? Yes, she couldn’t sleep well.
Have you noticed similar rash before?
Have you noticed anything make the rash better or worse?
Did you notice any reaction or rash with any type of food other than eggs?
Did you change her shower gel, shampoo or body lotion recently?  No.
Do you have any pets at home? in the neighbour’s home
Do you have carpet at home? in some area…. How frequent do you clean it?
What it the material of lounge covering? Fabric or leather?
Does anyone at home smoke?
Has she had allergic attacks other than last time?
FHx of eczema or allergies?
Other than the reaction to egg, did she has other allergic attacks in the last 11 months?
How’s her general health?
Is she on any medication?
Immunization
Explanation:
Your daughter has a skin condition called eczema. It is a very common condition and affects about
5% of the population. It is not contagious. No particular cause has been found. It can run in the
families like some other condition such as asthma, hay fever and skin sensitivities, we call it atopic
eczema.
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PAEDS: DERMATOLOGY
It usually starts in infants from any age, but often before 12 months. It tends to improve from 1-2
years, but some may last until puberty or even adulthood.
There are 3 stages:
1. Start from 2 months – 2 years old the child can improve
2. 2 years – 12 years  not improving, worse
3. Adulthood eczema
It’s not a dangerous disease, but infection can occur form scratching.
What are the things I have to avoid?

- After playing in the sandpits  wash
- Dust, especially dust mite
- Detergents with fragrant
- Woollen and rough clothes  cotton clothes, put cotton before wool
- Smoking
- Pets
- Carpet, sheepskin
- Teething (decrease immunity) can aggravate but not the obvious cause
- Stress and emotional upset
- Foods like cow’s milk, fish, eggs, wheat, oranges and peanut (not definite rule)
Treatment
- Soothing the skin  use normal body lotion, body cream  after shower, put a layer of soothing
lotion 3-4 times daily on the affected part
- Avoid soap and perfumed products
- Avoid rubbing and scratching (use gauze bandages with hand splints for infants)
- Wear light, soft loose clothes such as cotton clothing
- Avoid dusty, dirty conditions and sand, especially sandpits
- Corticosteroid skin  use hydrocortisone (least potent) cream for face only because it’s less
potent; for body (more potent) use Elocon (betamethasone)
- Wet dresses  for extensive case, admit to hospital for 1 day, the nurse educate the mother how
to use it. Bind the affected part with wet dressing (soaked first with water).
- Zinc & tar combination  for chronic cases, alternate the corticosteroid with this. Corticosteroid
must not be used for a long time.
- If the eczema is infected  give systemic antibiotic (penicillin or amoxicillin)  take swab for
culture; give antiseptic lotion to clean the skin and put corticosteroid cream
Skin Patch Test

Leave for 24-48 hours
Results are graded into  A B C
A = means Absolute  Avoidance of the substance
B = medium  use substance with some limitation
Serum Allergy Test (for asthmatic, allergic rhinitis, eczematous)

3 panels include: food, metals, some type of oils
Results graded in A B C
Allergy is an immune response. Allergies are an overreaction of the body’s immune system to a
specific part of a food, usually a protein. These proteins may be from foods, pollens, house dust,
animal hair or moulds. They are called allergens. The word ‘allergy’ means that the immune system
has responded to a harmless substance as if it were toxic.
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PAEDS: DERMATOLOGY
PINWORM
A 3 yo girl came with her Mother c/o scratching her bottom always.
Task: take history, PE, management.
DDx:
Pinworm
Vulvovaginitis
Foreign body
Eczema
UTI
Child abuse
Hx:
When did it start?  2 days ago.
Is this a first time? Six months ago had the same problem
Any scratch marks around the bottom?
Where exact the itchiness is? Is it around the anus or around the vagina?
Any D/C down below?
Any rash?
Any family member has a similar problem?
Who’s looking after her? Does she go to childcare?  childcare
How was the child’s general health?
How’s her appetite? (can get anorexia, irritability and feel unwell )
UTI How’s her water work? Did she c/o pain while passing urine?
Foreign bodydo you think she might have put something into her private area
PMHx and FHx of eczema or allergies
Immunization
Social Hx
Explanation:
From the history, the child has infection/infestation of pinworm. This is common condition in school
children. Pinworm is a tiny white worm. The eggs enter the body in contaminated food, hatches into
worm in the gut. The adult female worm during the night time lay egg in the anus. The worm + egg
provokes irritation & itchiness. During the scratching, egg goes under the nails. When the child
sucked the fingers or eat food with unwashed hand, the egg enter the gut and the cycle repeated.
Diagnosis mainly clinically. To confirm this, put an sticky tape around the anus at night time. In the
early morning remove the tape and give to the GP who will observe it under the light.
Mx: Hygiene
Hands should be washed before handling food and after toilet. Cut the nails short
Child should wear pyjamas rather than night gown
Take shower before going to school.
Beddings should be washed with hot water.
Vacuum everyday the house if possible, and clean the toilet seat
Medication:
Albendazole or Mebendazole single dose, after 2 weeks, one more dose.
Ointment or lotion for the anal irritation.
Because it’s a second episode, we need to treat the whole family members.
<10 kg – 50 mg Mebendazole
>10 kg – 100 mg Mebendazole
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PAEDS: DERMATOLOGY
HERPES SIMPLEX STOMATITIS

A Mother came with a 2 yo boy to your GP clinic who has been refusing to take food all day.
He has ulcer in his mouth.
Task: relevant history, examination, explain diagnosis to Mother and management.
DDx:
Drug reaction
Immunodeficiency
Trauma or mouth burns (abuse)
Hand mouth foot disease
Signs & symptoms:

Blister in the mouth & tongue
Reduced food intake
Difficulty swallowing
Fever may occur before blister
Pain in mouth
Swollen gum
Ulcer in the mouth
Hx:
Could you tell me more about your son’s condition?
Has it happened before?
Does he feel feverish?
Any drooling, vomiting, diarrhoea?---no
Have you noticed any rash anywhere else in the body? ---no
Has he taken any newj me dication?---no
Has he reduced wet nappies?-no
Anyone in the family with similar condition?
Is the baby going to childcare, anyone in there have the similar problem?---no
Any recent infection?  had flu 1 week ago, now temperature normal
Any significant medical condition in the past?---no
Any possibilities of burns in the mouth?---no
How’s his growth & development?
Is his immunization up-to-date?
Any medication & allergy?
O/E:
GA: look for rash (palms & soles – Kawasaki), consciousness and dehydration
VS: Pulse, Temp, O2 sat, RR
Eyes: any red eye, discharge, conjunctivitis, ulcer (complications from mouth to eyes)
Mouth: soft palate, gum, tongue ---ulcer inside the mouth everywhere
ENT: any discharge from ear
LN, neck stiffness
Chest, Abdomen, Inguinal area
Rash
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PAEDS: DERMATOLOGY
Explanation:
One kind of viral infection we called herpes simplex stomatitis.
Not uncommon, mainly seen in young children caused by herpes virus.
How did he get this?

As it’s a viral condition, it’s transmitted like flu
Doctor, what will you do now?

As it’s a viral infection, no need for antibiotics, it goes away with time (self-limiting
condition) usually takes 5-10 days.
We’ll manage Kevin symptomatically like:
- Analgesics  Lidocaine gel put inside the mouth as often as he needs to reduce the pain
so that he can drink; Panadol syrup
- Needs to drink more fluid than usual
- If child is able to drink, send patient home
- If not, admit to hospital and need to rehydrate
- Can be treated with Acyclovir
Can my baby go to childcare?

Not until all the ulcers go away, usually 7-10 days
Ask if other family members affected or not  need to separate personal things like plate,
cup, towels
RED FLAGS:
- If child is lethargic, reduce intake of fluid, reduced no of wet nappy, vomiting, headache,
fits/seizure, any new rash in body  go to ED immediately
Complications:
- Dehydration
- Herpetic keratoconjunctivitis
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PAEDS: DERMATOLOGY
SCARLET FEVER
A 6 yo girl came with fever and rash on the upper trunk. The rash is rough bulbar.
Task: take Hx, exam, diagnosis.
DDx:
Kawasaki
Meningitis
Roseola
Infectious mononucleosis
Measles
Toxic Shock Syndrome (TSS)
Drug eruption (allergy)
Tongue is inflamed, enlarged, covered with red bulbar  strawberry tongue (before that
white coat tongue)
I read that Jessica has rash and fever

Which one started first? fever first for 2 days
Have you checked the temperature, was it high? 38.5
Did you give her any medication? Repeated Panadol, improved a little bit
When did you notice the rash? After 2 days, the rash started to appear started from the face,
neck chest, axilla, groin (the creases area) and become generalised. She had a circumference
pallor around the mouth
Any PHx or FHx of allergy?..no
Does she have cough, runny nose like common cold?…..yes
What about her waterworks?
Any diarrhoea, constipation?
What about her appetite, drinking, eating? (White coated tongue, fever & constipation--typhoid)
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PAEDS: DERMATOLOGY
Is she alert, active? When she had the fever she likes to sleep
Drowsy? ….no. Now she started to improved, a little bit active than before because the fever
subside, she’s annoyed from her rash
Any cream on the rash?….body lotion but doesn’t help
Is she on any medication?……no
Immunization up-to-date?….yes
Any family member with this condition?….no, she’s an only child
Does she go to school?….yes
Any notes from school that this condition occur in school?…..no
O/E:
GA: alert, active, drowsy, pale, flushed
VS: temp 37.6, BP normal, RR normal
What is the description of the rash?….coarse (sand paper rash)
ENTOropharyngeal tract….red pharyngs with red oedematous enlarged tongue
Perioral pallor
LN
Explanation:
Mrs…..your daughter has what’s called Scarlet Fever, it’s a disease caused by bugs causing
common cold and flu like symptoms. Because of the toxin produced by bugs, she has
characteristic rash & red tongue (inflammation of the tongue) after 2-3 days from the
common cold. She can get this bacteria by droplet infection or by direct contact.
The white coated tongue peeled off and turned into the red swollen tongue.
The rash usually start from the creases of the body like neck, armpits and groins. Afterwards
it becomes general. After 3-4 days from the rash appeared, it will start to fade, skin
desquamate, peel and normal within one week.
I will give her Penicillin for 10 days.

- Under 10 years  250 mg bid for 10 days
- > 10 years  500 mg bid for 10 days
She can go to school after 24 hours taking the antibiotic.

Droplet infection: if there is any other child in the house, needs to be away from Jessica.
Risky?
She will continue the antibiotic until 10 days, if not, she can have complications such as:
- Local cellulitis
- Otitis media (ear)
- Rheumatic fever (heart)
- Glomerulonephritis (kidney)
Cream for soothing the rash
Follow up
Reading material
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PAEDS: DERMATOLOGY
SCABIES (AMC)
A 3 yo boy c/o itchiness and rash on right hand for 1 week.
Task: history, examination & management.
Rash Qs:
- When
- Where
- Spread anywhere else
- Can you describe the rash, itchy or not
- Any history of previous rash, eczema, asthma, hay fever
- Any contact with somebody with similar rash
- History of travel– stay in a bad hygiene hotel
- Anyone in the family has similar problem
- FHx of eczema, asthma, hay fever
Hx:
Since when did he have the rash?
Where did it start? Is it present anywhere else?
Can you describe the rash for me?
Is it itchy?
Are you aware of anything that makes it better or worse? Worse by heat
Does it interfere with sleep?
Any recent use of new cosmetics, soap, or any detergent?
Any history of fever, runny nose or flu-like symptoms recently?
Any PHx or FHx of eczema or any allergies?
Does he go to childcare / kindergarten?
Are you aware of anyone else suffering from the same condition?
Anyone in the family with the same symptoms?
Travel history summer vacation to the mountains 3 weeks before they notice the rash
Detailed sexual history if adult
Do you have any concern about his growth & development?
Explanation:
Your child is suffering from a skin infection which is called Scabies. Have you heard of it
before? It’s caused by a mite called Sarcoptes scabiei.
It causes a characteristic lesion which are burrows, severe itchiness or pruritus, papules,
vesicles
There is different variants and this one affects human being. The variant in dogs & cats are
unable to reproduce in human, but can cause transient dermatitis in human.
The sites: palms, soles, axilla, umbilicus, groin, web spaces, genitalia
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PAEDS: DERMATOLOGY
It’s highly contagious and spreads through close contact (including sexual contact)
It can affected the entire household especially if overcrowded.
The female mite burrows beneath the skin in order to lay eggs which hatches into mites
The mite antigen in excreta causes the rash
Itching can cause secondary infections. Superinfection can cause impetigo.
We will do one Ix just to confirm the diagnosis which is the skin scraping from the lesions
Ix: Skin scraping  under microscopy  mites, ova, scybala (fecal debris)
Mx: the condition is not serious, although very uncomfortable, it can be treated.
1. Application of Permethrin cream 5 % to (Lyclear) apply for the whole body except face
including the nails & genitalia  leave overnight then wash out thoroughly in the
morning
2. Hypersensitivity reaction can occur; drug of choice for infants >2 months. For pregnancy
can be used but class B (need to use or not).
3. Repeat the Permethrin in 1 week if severe
4. Benzyl benzoate is another option
5. If infected, start oral antibiotics. Antihistaminic & topical antibiotics may be used if
infected
6. Avoid hot baths and scrubbing, gently rub
7. All clothes & linen that have been in contact with patient, wash in hot water & machine
dried
8. Carpet & vacuum bag should be disposed
9. Examine other member of the families, treat family members asymptomatic or not
10. (Avoid intimate or sexual contact  for adults)
11. Patient re-examined in 2 weeks to see if the treatment is effective
If cannot make the Dx

I’m not sure if it’s eczema or scabies
I’ll try Elocon cream, if no improvement then we’ll think of scabies
Try steroid if 1-2 days not improving, I’ll treat for scabies
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PAEDS: ALLERGY/ IMMUNOLOGY

Mild to moderate (swelling of lip without CVS and RS symptoms)

Anaphylactic Action Plan

Food Allergy And Atopic Eczema

Task: Hx, PE, advice on Mx

Anaphylaxis : at least one reps symptoms + one CVS symptoms.

Task: Manage the case.

Don’t ask Hx, rapidly assess ABC, then check VS

After each step check vital signs

Upon discharged, give steroid 3-5 days (1 mg/kg prednisolone)

Anaphylactic action plan

TAKE HOME MESSGAES

2. ADRENALINE: 0.1 ml/kg IV (1:10 000)

3. ADRENALINE: 5 ml via nebuliser (1: 10 000)

4. SALBUTAMOL: 2.5 mg (peds) via nebuliser

5. ALWAYS HAVE “DR ABC” APPROACH IF U SUSPECT ANAPHYLAXIS, DON’T ASK Hx

6. OBSERVE AT LEAST FOR 6 HOURS (IDEAL 12 HOURS)

7. STEROIDS: HYDROCORTISONE: 10 mg/ kg IV

8. ANTIHITAMINE: PROMETHAZINE 10 mg IV + 10 mg PO on discharge

Airway: Whats ur name? Speak or not?

Circulation: pulse (tachy?)

IV Fluids resuscitation v v important.

IV HYDROCORT, IV RANITIDINE, IV STEMETIL

ASK IF THE PATIENT IS STABILISED OR NOT.. IF NOT, CONT RESUSCITATION…

THEN, ask about the history…

Need for further Investigation by the GP in conjunction with Allergy specialist

Mild or moderate symptoms:

Infrequent – attack during activities or every 6 weeks  Ventolin 2 puffs PRN

Infrequent episode Frequent episode Persistent

Intermittent Mild Moderate Severe Persistent

Night ≤2 month >2 Night symptoms Night symptoms > once a

Mild Moderate Severe Critical

Acute asthma Mx:

In all acute attacks give steroid

Before discharge, give general advice and Asthma Action Plan

Action Plan (Asthma, angina, anaphylaxis, COPD, DM – hypoglycaemia)

CHILD ASTHMA ACTION PLAN

ADULT ASTHMA ACTION PLAN

4 – 4 – 4  4 puffs 4 breaths 4 minutes

Age: 60; Sex: Male; Expected PEF 625 (PEV1)

How many ways we give medication

With spacer - press the nebuliser and take 4 breaths

Zone Reading Description

Asthma (Child / Chronic)

Avoid triggering factors otherwise recurrence may happen.

Before exercise 2 puffs 20 minutes before exercise

Give reading materials

Asthma (Child / Acute)

Task: assess patient’s severity & manage accordingly.

Hx: (stable or not)

Assess patient after 20 min  OK  sent home

Advice during discharged

Flu-like symptoms before

Character of cough: whooping, croup

Signs of respiratory distress (coughing & runny nose)

Start him on Salbutamol (Ventolin)

Nocturnal cough, repeat episode, atopic, family history, wheezy  asthma

If still not improving  repeat

- More oxygen, change nasal prongs by mask, give 4L/min

No improvement, admit to Paediatric and ask Paediatric team to assess

Asthma (Adult / Acute)

Task: assess the severity and manage accordingly.

Mild Moderate Severe