SHORT CASE SCRIPT FOR

PAEDIATRICS
AUTHOR:

CO AUTHORS: lain maciem

Script:

1. Cardiovascular system

I would like to end my examination by check blood pressure (in all for limb if suspect for coarc),
temperature chart and urine dipstick)

I have examined this patient (NAME), a (AGE) months/years old baby/boy/girl on the
cardiovascular system. On general inspection, the patient is lying/sitting on the bed (describe
what patient do). He/she looks well/ill and pink/cyanose. He/she is alert and conscious/ there is
spontaneous eye opening and she responds to surrounding. He/she looks
small/large/appropriate for her age but I would like to plot a growth chart to confirm. He/She is
syndromic baby as evidence by // There was dysmorphism or no dysmorphism seen such as (
hypertelorism, epicanthic fold, upslanting of the eyes, flat nasal bridge, low set ear,short stubby
fingers, clinodactyly . He/ she was in respiratory distress //or in respiratory distress as evidenced
by tachypnea with respiratory rate of (BREATH PER MINUTE), head bobbing, nasal flaring or
chest recessions seen. He/she is on oxygen monitoring with (95 %) oxygen saturation on (nasal
prog/face mask/intubation/room air) and nasogastric tube.

(sequence: hand-> face-> neck->chest)

On peripheral examination, the hands warm/cold and pink/peripheral cyanosis. There is no/
clubbing. Capillary refill time is </>than 2 seconds. There is no stigmata of infective endocarditis
such as splinter hemorraghe, janeway lesion and osler node. The Pulse rate was (BEATS PER
MINUTE), which is tachycardic or normal with regularly regular/irregularly irregular rhythm and
good volume// but with bounding in nature suggestive of (PDA). There is no/ brachiobrahcial or
radioradial delay and brachiofemoral or radiofemoral delay which suggestive of ( coarctation of
aorta). There is or no collapsing pulse.

Upon inspection on the face, there is / no conjunctival pallor or jaundice. There is or no central
cyanosis. On the neck, there is a raised JVP (older child).

On inspection of the chest, the chest is moved symmetrically with respiration. There is or no
chest deformity such as pectus excavatum/carinatum. There is or no surgical scar (median
sternotomy/lateral thoracotomy/infraclavicular scar/chest drain scar). There is precordial bulge
or visible palpation.
On palpation, the apex beat was shifted to or located at 5​Th​ intercostal space at midaxillary
line.)if knows with thrusting or forceful in nature). There is heave and palpable thrills at
(apex/tricuspid/left sternal edge/pulmonary or aortic region).

On auscultation, There is grade ___, PANSYSTOLIC/EJECTION SYSTOLIC/CONTINOUS/MID

DIASTOLIC/LATE DIASTOLIC murmur, best heard at __________(apex, lower left sternal
edges, upper left sternal edges /right upper sternal edges/infraclavicular), radiating to/not
radiating ____( axilla, back, neck) accentuate on inspiration on right murmur /expiration on left
murmur.

Or the first and second heart sound was heard and normal with no added sound.

On palpation of liver, there was hepatomegaly with liver palpable 2 finger breath below costal
margin. There was bibasal crepitation and pedal/sacral odema.

So my impression on this patient, this patient is having congenital/acquired cyanotic/cyanotic

heart disease and in failure could be due to //and my differential diagnosis are ___________.

Upper right sternal edge: Upper left sternal edge:

Systolic: Systolic:

1)ESM radiating to the neck: aortic 1)ESM and pink: Pulmonary

stenosis stenosis/ASD(+ fixed splitting heart
sound)/AVSD

2)ESM And cyanose,clubbing:

TOF/AVSD/Complex heart lesion

3)continuous murmur and below clavicle,

collapsing pulse: PDA

4) systolic murmur at along left sternal

edge radiate to back, (+brachiobrahcial or
radioradial delay and brachiofemoral or
radiofemoral delay) : coarctation of aorta

Diastolic:

-early diastolic: Pulmonary Regurgitation

 Lower left sternal edge Apex

Systolic: Systolic:

1) Pansystolic murmur: VSD, TR, AVSD 1) pansystolic: MR

2)Soft systolic murmur:innocent murmur

Diastolic:

Diastolic: 1)midiastolic murmur: MS

1)early diastolic+Collapisng pulse: AR

Congenital cyanotic heart disease:

1. TOF

2. Tricuspid atresia

3. Total Anomalous pulmonary venous connection

4. Truncus atriosus

5. TGA

6. Hypoplastic left heart syndrome

7. complex heart lesion

To summary:

Based on physical examination/ my clinical examination, this child is having

CONGENITAL/ACQUIRED ACYANOTIC/CYANOTIC heart lesion IN FAILURE/NOT IN
FAILURE most probably due to___ (best diagnosis of constellation of sign that project to this
diagnosis) as evidence of _____ OR and she/he is in failure as evidence of SMALL FOR
HIS/HER AGE/ TACHYPNIC/TACHYCARDIC/ DISPLACED APEX BEAT/GALLOP RHYTM/
HEPATOMEGALLY/BIBASAL CREPITATION and SACRAL/PEDAL EDEMA** uncommon in
children. My differential diagnosis would be ___(murmur at same timing, nature and location).

To investigate, I would like to sent for:

1. Chest xray to look for cardiomegaly, plethoric/oligaemic lung/ shape of heart if any.

2. ECG to look for sinus tachycardia,left/right axis deviation or any heart block

3. ECHOcardiogram to look for location, size of cardiac lesion and assess haemodynamic
circulation.

To manage this patient:**depends on what diagnosis and pts condition

a)supportive

1. give oxygen supplementation via Nasal prong or face mask, to maintain spo2 over 95% or
intubation of respiratory failure

2. restrict fluid,

3. monitor vital sign, I/O chart, daily weight

3. Nasogastric tube feeding, refer dietitian to increase caloric intake

B)Specific:

4. anti failure medication such as furosemide, spironolactone later can give captopril->digoxin if
severe

5. give antibiotics of there is infection

C) LONG TERM: sbe prophylaxis ( VSD, PDA )

 2. Developmental Assessment (DA)

*keep in mind, we want to guess the developmental age of patient and also find the possible
cause of delay in this patient (find clue from inspection)
*always start with general inspection and then can proceed with what the patient is doing right
now and start with possible age that patient can do then proceed to what he can do next

Sequence: general inspection-> vision and fine motor->hearing->social + hearing and speech
*throughout the assessment->gross motor-> neonates proceed to primitive reflex (6: rooting,
palmar grasp, ATNR, moro,galant, stepping

Script:

I have examined (name) , a (age) years old baby/infant/boy/girl who appeared well/sick and
cooperative throughout my examination. // *if patient is crying or stranger anxiety need to
explain also .eg ( who is crying throughout my examination, although it was difficult to examine
him/her, i would like to present my findings, dr. ---introduction

On general inspection, he/ she was alert and conscious // if neonates and infants can mention
there was spontaneous eyes opening and he/she responded to the surroundings (she has
stranger anxiety, she has a social smile) . He/she was lying on the bed with no abnormal
posture seen and actively moving all of his/her limbs (explain what pts doing during general
inspection-posture and movement) // she was lying on the bed in scissoring posture//
generalised flexion of upper limb and lower limb (general abnormal posture that can be seen).
There was also paucity in movement seen (explain abnormal movement-twisting
movement,slow repetitive movement if fingers (athetosis) or tremors). He/she looks
small/large/appropriate for his/her age and His/her head looks proportionate to his body/larger
than body however i would like to confirm by plotting on the growth chart.
There were no dysmorphic features seen// there were dysmorphic features seen such as
hypertelorism/epicanthal fold/upslanting of the eyes,flat nasal bridge/low set ears that
suggestive of down syndrome. ( if unsure what syndromes type, just explain the finding and
mention that “ i am not sure which syndrome is, therefore i would like to send for karyotyping
and consult genetician to know the type of syndrome”).
-NOT TO FORGET : just explain any abnormalities that we found throughout the examination
such as she looks cyanose, and there were median sternotomy scars that may suggest
postoperative cardiac lesion. (because this could be the cause of developmental delay)*always
find the cause!!.

(example of 15-18 months infants already on sitting position), always explain what patient can
do first, then what he cannot do)

For gross motor assessment, he was sitting unsupported on the bed, he can lean forward to
pick up toys then progress to crawling, standing unsupported and walks well by himself with a
broad base gait and squats to pick up toys. He was unable to run safely to avoid obstacles and
jump on feet together. Therefore, developmental age for gross motor was 15-18 months old.
**if the child is not cooperative, so can present like this “ from what i’m able to see, she was
sitting unsupported however i could not demonstrate whether she can crawl, standing
unsupported or holding on furniture, and walk. Therefore, developmental age for gross motor
was about 6-9 months old.

For vision and fine motor, he was able to reach out for toys, he is able to pick up small beads
with immature/mature pincer grasp, hold the cube with palmar grasp/ mature pincer grasp, bang
two cubes together, transfer cube to another hand when another cube is given, built a tower of
3, put the cube into the cups. He holds the pen with palmar supinate grasp and can draw
spontaneous scribbles. He enjoys picture books and turns to a few pages at a time. However,
he is unable to build a tower of 5 and bridge of 3, imitate a train , draws circular or vertical lines,
or recognizes any details in a picture book. Therefore, developmental age for vision and fine
motor is 15-18 months old.

**Do crude hearing test if <6m old by shaking the rattles, but more than 9m do distraction test
For hearing and speech, (present hearing/receptive first the speech/expressive),
Upon a distraction test, he was able to turn his head to sound at same, above,below and central
to the ear level. He responds to his name, understands no and bye-bye, and understands and
obey simple commands. He also give toys upon requested.[ receptive speech]
For expressive speech, he speaks 2-3 meaningful words in phrases such as mama nak susu,//
he speaks in jargon words but he knows 1-2 words with meaning and points 1-2 body parts.
However, he is unable to tell a story, name familiar objects and pictures, tell his gender and age
or name any colour. Therefore, developmental age for hearing and speech is 15-18 months old.

For social and behaviours, initially he has stranger anxiety, but subsequently he enjoys playing
with me. He throws the toys when given but not frequent (or any repeated casting). He can find
hidden toys and give toys upon request. He can drink from the cups without assistance and use
the spoon well. However, he is still wearing diapers// he is not toilet trained yet, and unable to
wear shoes or cloth by himself. Therefore, developmental age for social and behaviour is 15-18
months.

Based on my clinical assessment, this child had a normal developmental assessment with a
development age of 15-18 months and it corresponds to his current age// Based on my clinical
assessment, the developmental age for this child is 15-18 months (tp dr ckp age budak ni 3
thun) Which is not correspond to his current age. My impression, this child is having global
developmental delay which affects all 4 domains and the most probable cause is _______(eg:
down syndromes)**causes based on pts condition and findings. My differential diagnosis would
be ________.
 3. Abdominal Examination

I would like to complete my examination by examining pt’s cervical lymph nodes, checking pt’s
diapers (to look for any abnormalities of stool or urine such as loose stool, blood, foul smelling
urine, colour of stool and urine) and taking blood pressure (especially if there are signs of
nephro pathology - AGN).

On general inspection,
Pt looks well / unwell / jaundiced / cachexic lying flat supported with one pillow, pt is alert and
conscious to time, place and person // ​if neonates and infants can mention there is spontaneous
eyes opening and he/she responded to the surroundings (she has stranger anxiety, she has a
social smile),​ not in respiratory distress // in respiratory distress evidenced by RR of ___ and
___. Pt is attached with _____. Pt’s head is proportionate to body and pt’s size is appropriate /
small / large for age, however, I would like to confirm by plotting on a height and weight growth
chart. There is no dysmorphic feature seen // there are dysmorphic features seen such as
hypertelorism / epicanthal fold / upslanting of the eyes, flat nasal bridge / low set ears that are
suggestive of Down’s Syndrome. (if not sure of type of syndrome, just mention the dysmorphic
features seen; ​there are dysmorphic features seen such as ___)​

On peripheral examination,
Hands were warm and moist, not pale. There is no clubbing, koilonychia or leukonychia, CRT is
less than 2 seconds. Pulse rate was normal/tachycardic with _ beats/min regular rhythm good
volume. There is BCG scar present on left deltoid.

Upon head and neck examination,

(If below than 3 year old) There is no sunken anterior fontanelle. There is no jaundice,
conjunctival pallor, sunken eyes/periorbital edema, puffy face. Oral hygiene is adequate, no
coated tongue or dry lips, angular stomatitis.

On general inspection of abdomen,

The abdomen moves with each respiration and is not distended // distended (mention more
towards which side or generalized) with centrally localized umbilicus (unless if it is deviated), no
surgical scars noted (if any, mention type of scar), dilated vein or visible pulsation.

On palpation,
The abdomen is soft and non-tender (if hard and tender, mention which quadrant and
characteristic of tenderness);
Upon deep palpation, there is presence of hepatomegaly measuring __ cm below costal margin
with smooth surface and regular margin, and splenomegaly measuring ___ cm (from left costal
margin midclavicular line to the tip of spleen) with smooth surfave and regular margin with
positive Traube’s space (10 - 12th intercostal space) on percussion.

Liver:
 - Right hypochondrium
- Moves downwards with respiration
- Cannot get above
- Not ballotable
- Dull to percussion

Spleen:
- Left hypochondrium, enlarges towards right iliac fossa
- Moves with respiration
- Cannot get above
- Not ballotable
- Dull to percussion
- Splenic notch if palpable

There are no ballotable ​kidneys.

- In lumbar region
- Moves with respiration
- CAN get above
- Ballotable

On percussion,
Shifting dullness was positive.

On auscultation,
There is no renal bruit and normal bowel sound was heard.

*Also, check for any ankle edema, especially if patient has ascites or any edema. (in nephrotic
sx)

In summary,

Investigation;

Management;