Condition 002 Breastfeeding/Bottle-feeding

 
You are a Hospital Medical Officer (HMO) in an antenatal clinic, seeing a 28-year-old woman for her
antenatal visit at 35 weeks of gestation. She wants to discuss infant feeding with you. She has heard a
lot about the benefits of breastfeeding, but her mother told her recently that babies grow better with
formula feeds. She is uncertain whether she should breastfeed or formula-feed her baby.
 
TASKS:
 Discuss the advantages and disadvantages of breast-feeding and formula-feeding with her.
 Outline the steps involved in safe formula-feeding.
 
APPROACH
 I appreciate that you came here to take advice regarding feeding your baby. I will explain to you
important concepts about both breastfeeding and bottle feeding. If you have any questions along
the way, just stop me anytime.
 Breastfeeding has its advantages both to the baby and the mother.
 For the baby:
 It protects against bugs for example, rotavirus and there is increased resistance of the
baby to infection, from immunological constituents in breast milk including
lymphocytes and antibodies
 It decreases the risk for celiac disease, and inflammatory bowel disease
 Babies who are breastfed, are protected from allergic reactions, as opposed to babies
who are formula fed who can have allergies from the contents of the formula.
 For the mother:
 It increases the bond between the mother and the baby
 It has less economic burden to the family
 it is available every time and you are able to feed almost whenever and wherever the
baby wants it without having to prepare formula, carry bottles around and without
problems with sterility
 It also helps in the weight reduction to pre-pregnancy state because when baby starts
suckling the breast, a hormone called oxytocin gets released which helps in bringing
the uterus size back to pre-pregnancy size
 It decreases the level of some hormones like cortisol in the blood thereby decreasing
incidence of mood disturbances after delivery in mother.
 It acts as a protective factor for breast cancer
 Exclusive breastfeeding can also to some extent act as a contraception
 At the beginning, you should breast feed your baby on demand until the baby gets adjusted
gradually within 48-72 hours. After that, you can feed her every 2-5 hours.
 However, if you are taking medications during breast feeding you need to contact your GP
regarding it, as some medications can go to the baby through the breast milk.
 If you are worried about a cracked nipple, there are some special classes at the hospital to prepare
the nipple during the last 2 months of pregnancy.
 Also, if you are working, you can still continue breastfeeding. You can express your milk and keep
the milk in fridge for 1-2days, 2 weeks in freezer and for 3 months in deep freezer.
  While breastfeeding is the optimal method of feeding the human infant, and that the majority of
mothers successfully breastfeed, a variety of reasons may prevent breastfeeding in practice,
including:
 illness in the mother
 failure to establish lactation, which may be hormonally based
 possible illness in the baby (e.g. cleft palate)
 prematurity, which requires the mother to express regularly to maintain her supply
 previous extensive breast surgery in the mother
 heightened anxiety in the mother
 If one of these conditions are present or if for some reason breastfeeding is unsuccessful, formula-
feeding is a safe and very effective alternative. Formulas are designed to contain the same
nutritional components as breast milk, but that exact reproduction is difficult as the concentration
and components of breast milk change throughout each feed to provide all the essential nutrients
the baby needs. In the morning it contains more water and towards the afternoon, it contains
more fat.
 However, there is no advantage of formula feeding over breastfeeding.
 In preparing bottle feeds, you need to remember the following:
 sterility in preparing the bottle feeds is essential
 Bottles should be washed clean with a bottlebrush to ensure that all residue is removed
 Bottles and teats should be stored in solution (Milton) to ensure continuing sterility, but the
bottles need to be rinsed free of this solution prior to use
 the fluid used to make the formula and to rinse the bottles should be cooled boiled water
 Each can of formula has explicit makeup instructions on the side of the can or packet and if
followed these will produce the exact required concentration. There is no place for any
added scoops, which can be harmful
 the day's requirements are best made up at the one time, although each feed can be made
separately. If the former, the day's feed should be stored in the refrigerator.
 only one day's feed at a time should be prepared in advance and each feed should contain
approximately 30 ml more than it is anticipated the baby may take, and any excess
discarded at the end of the feed.
 It is important for you to understand that weight gain is not the only criterion for success as excess
weight gain in the first 12 months of life may in fact be detrimental in later life.
 
KEY ISSUES
 Empathic answering of this young mother-to-be's questions.
 Recognition that she is uncomfortable with what her mother has told her but is seeking
reassurance and support for her own view which she feels is accurate.
 Satisfactory explanation of the advantages and disadvantages of the different methods of feeding.
 Candidates should know how formula feeds are prepared.
 
IMPORTANT POINTS FROM THE COMMENTARY
Ability to discuss impartially and accurately the relative merits, indications, contraindications and
techniques of infant feeding by breastfeeding and by formula-feeding is a requisite for all medical
graduates as outlined and is an area where good communication skills are paramount.
 
 
Condition 003 Advice on Neonatal Circumcision
 
A young couple, the wife pregnant with their first child, have come to see you in general practice to
discuss with you the place of routine neonatal circumcision if their baby is a boy.
 
TASKS
1. Discuss with the couple the perceived risks and benefits of the procedure.
 
APPROACH
 I understand that you are here to discuss with me regarding the possibility of doing circumcision
for your child right after delivery. Can you tell me more about it?
 If it's okay, may I know how much you know about circumcision?
 As your GP, I am here to provide you a background of the procedure and why it is usually done.
Usually, many parents are unaware of the actual process of circumcision, and may ask this to be
done usually more as a ritual. As parents, I strongly advise you to consider the advantages and
disadvantages of this procedure before making a decision for your child.
 Explain what is circumcision (ILLUSTRATE)
o Normally, the tip of the penis is surrounded by a part of the skin called, the foreskin. This
foreskin serves as a protection of the sensitive tip of the penis called the glans. Circumcision
involves the removal of the foreskin to expose the tip/glans of the penis. It is usually done
under local anesthesia, or under general anesthesia if done after 6 months of age, and is
basically a pain-free procedure.
 Explain background of why circumcision is usually done
o As I mentioned earlier, it is usually performed on baby boys mainly because it is requested
by their parents, often for religious and cultural reasons.
o Generally, circumcision is not a routine procedure in newborn babies. Initially the foreskin
seems tight, but initially it frees up by the age of 5 years and it can usually be pulled back.
And when it can be pulled back, any debris or cheesy material present underneath the
foreskin may be gently washed away. And as a general rule, the foreskin should only be
retracted by its owner to prevent injuries.
o But in some cases, circumcision may be necessary for medical reasons, but this is quite
uncommon.
 STATE MAIN INDICATION
 In some boys the foreskin may be very tight, which leads to a very small opening
causing problems in passing the urine, and this tend to become prone to
swelling and infection. This is condition is known as phimosis, and when it does
not respond to conservative measures, circumcision is usually done.
 Explain advantages
o There are perceived advantages of routine circumcision of the newborns which include the
following:
 Reduced incidence of urinary tract infections, although routine circumcision is not
necessary to achieve this. Circumcision may assist those suffering recurrent UTIs and is
usually done at a later age.
 Minimizes the risk of subsequent development of penile cancer. However, infection by
a sexually transmitted infection, the HPV virus, is the major contributor in
 development of the disease. Cancer is still rarely seen in men who can retract and
clean their foreskin regularly
 There's divided opinion regarding its advantage in reducing the incidence of sexually
transmitted infections. But there is some evidence that suggest that the risk of HIV is
lessened by this procedure.
 Explain disadvantages and complications
o The recognized complications and disadvantages of this procedure include the following
 Hemorrhage, which is deemed to be the most common
 Infections, leading to septicemia, or infection in the blood
 Ulceration of the tip of the penis
 Injury to the urethra--the urine passage
 Too much skin removed leading to unsatisfactory cosmetic appearance
 Secondary phimosis
o But under the experienced hands of the specialist, these complications are very rare
 Explain ABSOLUTE CONTRAINDICATIONS TO CIRCUMCISION
o However, there are still conditions wherein newborn circumcision is not advised for a
patient. And in case these are present in your child, I'm afraid circumcision may not be the
best procedure for him
 Hypospadias and epispadias -- this is when the urethra, or the urine passage, is not
present at the tip of the penis. Rather, it is located on the other parts of the penis
(ILLUSTRATE)
 Chordee - a condition in which the head of the penis curves upward or downward
 Buried penis - a condition where the penis is partially or completely hidden below the
surface of the skin
 Sick infants, including jaundiced infants
 Family history of bleeding disorder, or known recognised familial bleeding disorder
possibility
 Inadequate expertise and facilities
 Do you have any questions so far?
 I have reading materials for you about circumcision, to give you more insight to this procedure.
 I hope this consult gave you more insight to guide you in making the best decision for your child.
Thank you very much.
 
KEY ISSUES
1. The ability to discuss in an unbiased manner the perceived advantages and disadvantages of
routine neonatal circumcision
2. Capacity to summarize that the recommendations of various national and international pediatric
and pediatric surgical associations, who have extensively reviewed the literature on the subject,
do not support routine neonatal circumcision
3. Critical error: none defined
 
IMPORTANT POINTS FROM THE COMMENTARY
 Many young parents are unaware of the issues involved about this procedure, as they request
circumcision without any information about the procedure
 Decision should be left to the parents after a full and accurate discussion.
 
 
Condition 004 Hearing impairment
 
You are working in a community health centre. Your next patient is a 10 month old female infant, baby
Helena, seen with her mother, who has been referred by the local child health nurse. The pregnancy and
delivery were normal. The child presented to the nurse six weeks ago for review and general screening
including hearing. The nurse was concerned that the baby has a hearing problem and wanted her
checked by a doctor. The child's parents have never had cause to worry about her hearing. She is the
third child in a healthy family and has been well apart from a few upper respiratory infections.
She is crawling, does not walk yet, but pulls herself up to standing beside a small table.
 
Initial examination findings
A busy infant girl who objects to being restrained by her parent. She babbles during assessment.
Otoscopic examination is normal. No abnormal physical signs are present on general examination. The
parents are puzzled at the need for referral and seek information about further investigation and
management.
 
TASKS
1. Ask the parent for additional relevant and focused history
2. Counsel the parent after you have obtained a further history
3. Explain possible causes of any suspected hearing loss to the parent
4. Discuss your plan of management with the parent.
 
APPROACH
 I understand from the notes that you have been referred here by the local childcare nurse for a
suspected hearing loss in your daughter. I am happy you've come, I am here to help you, but I just
need to ask a few questions, is that alright with you?
 Possible causes/risk factors for hearing loss:
o Is there a family history of deafness?
o Did you have any problems during pregnancy especially infections?
o Were there any health problems with the baby during or soon after birth?
o Was hearing test done after birth?
o Is the baby growing and thriving?
o Does the child have fever? Is she irritable? Pulls on ear?
 Assess for evidence of hearing loss:
o Does the baby respond to sounds, including loud sounds?
o Does the baby respond when called by her name?
o Does the baby turn towards the sources of the sounds?
o Does the baby respond to television?
 Assess for evidence of developmental delay: (child is 10 months)
o Do you have any problems with her growth and development?
o Do you have any concerns with her development as compared to other kids of her age?
 Counselling:
Hearing loss is common among pre-schoolers, and most cases are mild and transient and is usually
due to conductive hearing loss or a problem in the mechanical transmission of the sound in the
ear due to a blockage in the ear passage. The most common cause of hearing problems is a ‘glue
 ear’, which is a build-up of sticky fluid in the middle ear following middle-ear infections. The outer
ear can get blocked with things such as wax and foreign objects put in there by the child.
However in your child, she does not exhibit signs of infection, so this is quite unlikely.
Hearing loss can also be due to a problem in the nerve for hearing but it is far less common, but it
is important to detect it as early as possible. Possible causes for this include a genetic cause,
infections acquired by the mother during pregnancy like rubella, HSV, CMV, maternal diabetes, or
prematurity. If the child also acquired infections after birth such as measles, chicken pox, mumps,
it can also cause hearing loss in the child.
The distraction tests that were done to your child by the local health nurse is only a screening tool,
but it does not diagnose deafness. Usually, it is the parents who notice that there is something
wrong with the hearing of their child, however, it is important to follow-up this concern because if
there is indeed a problem, the earlier we diagnose this, the better. I am going to refer you to a
pediatric audiologist so that a formal hearing assessment by an audiogram can be done. I will give
you some reading materials about hearing problems in children for further insight. I will review
you after the audiogram is done. If we find a problem with the result of the test, I will refer you to
the specialist for further evaluation. If the results are normal, then I will review your child's
hearing and language development in about three months. I will give you reading materials for
further insight. Do you have questions at this point?
 
KEY ISSUES
 Appropriate history relevant to deafness.
 Counselling with reference to early definitive screening for hearing.
 Providing appropriate level of support and reassurance.
 
CRITICAL ERROR
 Failure to refer for specialist assessment (audiogram) for definitive diagnosis.
 
IMPORTANT POINTS FROM THE COMMENTARY
 Proceed from the cue of 'possible hearing loss' to assess whether other evidence, such as failure
to turn to sound, is present to support this diagnosis
 Inquiry regarding features suggesting associated developmental delay is appropriate
 Given a working hypothesis of possible hearing loss, features in the history which could be
causative, such as maternal illness in pregnancy, perinatal problems such as jaundice or drug
administration, should be evaluated
 The importance of early diagnosis and treatment of significant hearing deficit in this age group
make referral for definitive diagnosis mandatory despite no other concerning features being
present
 
 
Condition 005 Counseling a family after SIDS
 
You work in general practice. You are counseling the family of a four-month old male infant who was
rushed to the emergency department of the local hospital the day before but was dead on arrival. The
provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a
coronial autopsy.
 
You had seen him for the first time two months previously, with his single mother, when he was thriving
and developing normally and had commenced immunisations. Two days before his death, you saw him
again, this time with mild upper respiratory snuffles which were causing minor difficulties with
breastfeeding. However, over the next two days, he apparently improved, and his mother had advised
you that he appeared normal and fed well from the breast just prior to his death. You are unaware of
any suspicious circumstances surrounding the death.
 
The family members have attended to seek details of why the baby died and why an autopsy is
necessary. The spokesperson for the group is the mother's sister, the aunt of the infant. The mother is
also present, but is too distressed to ask any questions herself.
 
TASKS
1. Answer the questions of the aunt relating to the death of the infant
2. Counsel the aunt and family
 
APPROACH
 I am so sorry to hear about Andrew's death. Please take my deepest condolences. I can imagine
how this must be very hard for you and for your family. I understand that you are all here to
discuss the occurrence surrounding his death, and why an autopsy is necessary. I will do my best
to answer any questions or concerns you may have with regard to this.
 We can’t understand why Andrew has died!
o I'm so sorry to hear that. As of now, we are still doing our best to identify the specific cause
of his death. However, at this point It seems that most likely the cause of his death is what
we call as Sudden Infant Death Syndrome (SIDS), or commonly called as "cot-death". This is
a major cause of death for infants under 1 year, and this is often seen in infants at about
four months of age, and sadly there are no certain causes are known to predispose anyone
of this condition. Usually there is a need to exclude other possible causes, such as a severe
infection, which is unlikely in Andrew's case because his snuffles were not warning signs that
suggest a an overwhelming infection. Other conditions, such as metabolic and genetic
causes also need to be excluded. And that is why in any cases of sudden or unexplained
death, just as in Andrew's case, the police and the coroner must be notified to assist us in
identifying the cause of his death.
 Why do the police have to be involved? Do they think my sister killed her baby?"
o I can see that you are getting very upset during this difficult time. But let me reassure you
that we don't mean to let you feel that way. Nobody suspects your sister to harm her child.
The police are here to assist the coroners to help identify the cause of Andrew's death. BY
law, they are required to interview all the people concerned, including you, me, and the
doctors in the hospital, to provide information to the coroner. Let me reassure you that all
 police officers and coroners who work with SIDS cases are specially trained to conduct their
work in a manner that will provide comfort to the family.
 Why does he have to undergo an autopsy?
o There is a need for an autopsy in all cases of SIDS to identify the cause and to exclude other
possible causes of his death. It is a medical examination of the body and organs, and it is
usually performed on the next working day after the child's death. It is performed like a
surgical operation, by a very experienced pathologists and will ensure care in the manner of
the proceeding with the examination. In order to identify the cause of SIDS, they will have to
remove tiny tissue samples from the body in order to examine it under the microscope, and
they might also send it for chemical and microbiological analysis. Do you understand so far?
 When will we get further information and results of this/ When can we arrange a funeral?
o Usually the full results of the autopsy will be available after 6 weeks from the day of the
procedure. However, I can try to find out the initial findings after the autopsy has been
performed. Nevertheless, the coroner's office will contact your sister at a later date to
provide further information regarding the full results. I will follow him up.
o The coroner usually decides if an inquest needs to be held, but with SIDS this is generally not
necessary. Once the autopsy is complete, you can arrange his funeral. A social worker can
assist you in arranging his funeral. If you wish to see or hold Andrew after the procedure, I
will try to arrange for this as well
 We feel so alone. Is there anyone we can talk to about this?
o I can imagine how distressing this must be for all of you in the family. As of now, what I can
offer you are these contacts of SIDS support groups which can help you get through this. The
support groups often hold meetings with other bereaved parents, and hopefully you can
think about taking part of it. I am here to help you too. Please don't blame yourself (to the
mom) because you are not responsible for Andrew's death. It is not related to his mild
infection and medical treatment of the snuffles will not change the outcome.
 CLOSING
o Again, please don't blame yourself as this is not your fault. We are all here for you to assist
you and support you in this whole process. I will arrange another review with you to check
up on your situation, and also follow-up the coroner's office to confirm the diagnosis. I will
contact you immediately once I have the results of the autopsy. Do you have any other
concerns?
 
KEY ISSUES
 Appropriate empathetic explanation
 Ability to explain the involvement of appropriate authorities and support groups
 Offering to arrange for continuing follow-up, contact, and support with the family
 
CRITICAL ERRORS
 Failure to display empathy in counselling
 Failure to recognise and explain need for coronial notification and autopsy

IMPORTANT POINTS FROM THE COMMENTARY

 Empathy in communication
 Knowledge of legislative requirements
 ALL UNEXPLAINED DEATHS must be reported to the coroner and the police must take statements
  The caring practitioner will offer to liaise with the coroner on behalf of the parents, and in this way
is often able to receive preliminary reports if the coroner is agreeable to them being released.
 Offer to keep contact with the grieving family until confident that this tragic event has been
accepted.
 
 
Condition 020 DM Type 1
 
A nine year old boy, Roger, is admitted to the pediatric unit to which you are the HMO. This is his first
presentation of insulin-dependent Type 1 diabetes mellitus. His general condition is satisfactory, not
requiring intravenous resuscitation, and he has already commenced insulin therapy and has stabilized
with good blood sugar control.
As the ward HMO, his mother has asked you for further information about his ongoing care in relation to
his diabetes from now on.
 
TASK
1. Answer the queries the mother has, related to the ongoing care of Roger's diabetes.
 
APPROACH
 I understand that Roger has been diagnosed with an insulin-dependent Type 1 diabetes mellitus
and he is now on insulin therapy. I know that this might be quite distressing or upsetting for you,
but do not be too stressed, I am here to help you. Do you have some questions about this?
 Will he need insulin injections each day from now on?
o Yes, Roger will need life-long injections of insulin, because in his condition, there is
absolutely no production of this hormone in the body that is why we need to give it to him
externally. There are different types of insulin, rapid acting, short acting, intermediate acting
and long acting insulin. At this time, he will need twice daily insulin injections which consists
of a combination of a short-acting insulin and an intermediate-acting insulin so that his
blood sugar can be controlled for the whole day. You should remember to assist Roger in
taking the right amount and right frequency of insulin injections and not to miss his meals so
that his blood sugar level will not drop to very low levels. However, if at any time he
experiences dizziness, shaking, sweating, nervousness or a rapid pulse, these may be signs of
a low blood sugar level. He should immediately take in at least 15 grams of a quick acting
carbohydrate such as some glucose tablets or high-sugar options like candy, or fruit juice or
non-diet soda to help stabilize his blood sugar and reduce symptoms. Within 15 minutes, he
should feel better. If he doesn't get better, he could take another 15 grams, but if he still
doesn't improve, you should bring him to the ED for further management.
 Who is going to be giving Roger's insulin from now on?
o It is best if you and your husband and if possible an older sibling can assist Roger in giving his
insulin injections. Do not worry about this because the Pediatric unit staff and educators will
ensure that you will be educated on the proper drawing up and administration of insulin
before discharge so you would be confident to do it at home. Also if necessary, or if you
need further assistance, we can also arrange help for you at home from the district nursing
service after discharge.
 How do I assess the day to day control of his diabetes?
o Roger's blood sugar levels will need to be monitored several times daily by a glucometer
(show details of glucometer to the parent). These levels are usually assessed before each
meal and before bed at night. This will allow us to be able to review the blood sugar levels
and to recognize if adjustment in the insulin dosage is required depending on the trend of
his blood sugar levels over several days.
If the blood sugar levels are persistently high, or if Roger will be unwell for any reason, we
could also test his urine for ketones which will tell us that Roger's body is not able to use
 glucose for energy, and the insulin might need adjustment. [In normal states these ketones
will be completely metabolised so that very few, if any at all, will appear in the urine. If for
any reason the body cannot get enough glucose for energy it will switch to using body fats,
resulting in an increase in ketone production making them detectable in the blood and
urine.]
 What do I need to do about his school?
o The school should be notified about Roger's condition. After his discharge, the ward diabetic
educator will be with you to visit Roger's school so that relevant school staff can be
instructed and educated about possible complications that Roger might experience while in
school, most importantly if he experiences symptoms of a very low blood sugar level, and
how to detect and manage it. You should also take every opportunity to review these
important aspects of care with the school staff and ensure that any new staff are made
aware of Roger's condition. We could also give the school a list of phone numbers which
include your number, your GP's number, and the hospital/children's ward number, so that
they could contact you if needed in cases of an emergency.
 Will he be able to go to school camps? What should I do about them?
o The aim of our treatment and education program is to allow Roger to live as normal a life as
possible, and he should be encouraged to participate in all school activities and social
activities. However, some arrangements should be made prior to allowing Roger to attend
the school camp. If it would be possible for you, you and your husband or any one of you
can attend the camp as camp parents so that you could also supervise Roger while he is at
camp. However, if this is not possible, his teacher can be educated about Roger's condition
and its management so that you would be confident and comfortable with the teacher's
knowledge in looking after Roger. If the camp would be situated in a distant town, I would
also provide a letter for the local medical practitioner explaining Roger's diagnosis and
providing details of his insulin regimen, blood sugar levels and telephone contacts.
 He went to his first sleepover party a few weeks ago — could he still go on these now?
o Yes, as I mentioned, our aim is to let Roger live a normal life as possible. He should be
encouraged to participate in social activities such as this. However, it is better if Roger will
be staying in the home of a family whom you know very well so that a frank informative
discussion on the management of Roger's condition can be done. Also, it is better if the
sleepovers are done in a home close to your home, if not in your own home, so that if
necessary, you can come over and do the blood test as well as give the insulin in the evening
and the next morning until Roger is old enough and reliable enough to do these by himself.
 Can he play sport?
o Of course. I would like to assure you that there is no reason why Roger cannot play most
sports. However, you should remember that his insulin dose needs to be adjusted prior to
partaking in the sport since there would be increased glucose metabolism with physical
activity. But again, I would like to emphasize that we should allow Roger to lead a normal
life and enjoy activities as much as possible.
 Do you have any other queries at this point? I would give you some reading materials about
Diabetes for your further insight. When he gets discharged, I will also give a letter to his GP so he
can regularly follow you up.
 
KEY ISSUES
 Ability to answer the specific questions of the parent accurately and sensibly
 
CRITICAL ERROR
 Failure to discuss symptoms and treatment of insulin-induced hypoglycaemia

IMPORTANT POINTS FROM THE COMMENTARY

 The scenario is designed to assess both the knowledge of the topic and the candidate's ability to
provide accurate information in a reassuring manner to a parent who is trying to cope with a
diagnosis, which to most parents is initially devastating and upsetting.
 The emphasis in many of the answers should be allowing the child to lead as normal a life as
possible, so that school and social activities should be maintained wherever possible.
  
 
 
Condition 030 Jaundice in a breastfed infant
 
Baby Helen is brought to see you in a general setting, as her mother is concerned about her continuing
jaundice. Helen is now two weeks old and was born at term by easy vaginal delivery weighing 3.7kg.
APGAR scores were 9 and 10 (at 1 and 5 minutes respectively).
 
She became jaundiced in the neonatal period starting on day three. Investigations then revealed no
blood group incompatibility, both mother and baby being group O positive and no red blood cell
(including enzymes) abnormality. The infant was treated with phototherapy for two days. Since
discharge from hospital at eight days of age the jaundice has persisted and the mother is concerned.
Baby is feeding well from the breast. Current weight is 3.9kg.
 
Examination findings
The baby was active and clinically normal apart from the jaundice when you saw her yesterday. You
arranged investigations as set out below. The mother has now returned with the baby to discuss the
results and your advice about treatment.
 
Investigation results
Serum bilirubin Total: 250 umol/L

Conjugated Less than 10umol/L

Neonatal thyroid screening Normal

Urine culture Sterile

Full blood examination normal

 
TASKS
1. Obtain any further necessary history you require. You should not take more than 2-3minutes to do
this.
2. Discuss the results of investigations with the mother.
3. Explain the diagnosis to her and advise about future management
 
APPROACH
 Congratulations again on becoming a new mother. Helen is a very beautiful child.
 I understand that you are concerned about Helen's skin, and is here to discuss Helen's lab results
with me. But before we talk about it, is it alright if I ask you a few clarifying questions to help me
assess her further?
 HISTORY
o Is she your first baby? How is her general health so far?
o Well Baby Questions
 Is he crying too much, sleeping too much or difficult to wake up?
 How is he feeding? How many feeds has he been taking for the past few days?
 After every feed, did he produce a wet nappy? How many wet nappies have you
changed so far? Any changes? Is it foul smelling?
o Rule out sepsis and conjugated hyperbilirubinema symptoms
  Any fever, rash, vomiting, and lethargy?
 Have you noticed any fast breathing? Has he been breathing harder than the usual?
 What's the color of his stools and urine? Has it turned dark or pale colored?
o Did she have a heel prick test done?
o Mother
 How is your general health so far? Are you taking any medications? Do you smoke,
drink alcohol, or engage in recreational drugs?
 Do you enjoy your motherhood so far?
 DISCUSS INVESTIGATION RESULTS
o There can be several factors that could have led to the yellowish skin color of your child, and
medically we call it as jaundice, that is why we ran some investigations to identify what is
causing this. Infections can be ruled out as the full blood examination and urine culture tests
turned out to be normal. Thyroid conditions can also be ruled out because the thyroid
neonatal screening turned out to be normal as well. However, we can see here that the
serum total bilirubin is increased. Bilirubin is a pigment in the baby's blood which is usually
absorbed by the body in the gut. However, in some conditions there seems to affect its
absorption, making it accumulate and deposit in the skin and some organs, causing it to
manifest as a yellowish tinge in the skin. There can be several causes of it--like a blood
disorder or anything that causes obstruction in the part of the gut which tend to prevent
this bilirubin absorption. In your baby's case, the conjugated bilirubin is low, which means
we can easily rule out the conditions causing obstruction in the gut, and point our diagnosis
towards the blood-breakdown related or absorption causes of jaundice.
 DIAGNOSIS AND FUTURE MANAGEMENT
o However, based on the history and examination findings, most likely she has a condition
called, breast milk jaundice. Have you heard about it? Sorry for the medical terms but let me
explain the condition to you. There are some factors within the breast milk that increases
the absorption of the pigment in the blood called bilirubin in the baby's gut, and
accumulation of this pigment then causes the yellowish tinge in your baby's skin. It is a
benign condition and does not require treatment. I can tell this because your baby is gaining
weight well, feeding well, and active, and she has normal physical examination findings
except for her yellowish skin. Just as your baby is still developing, her organs are also still
adjusting to the milk that you give her, and in time as she grows more, she will then
eventually be able to metabolize/digest/use this pigment and subsequently the yellowish
tinge of her skin will disappear.
o There is nothing wrong with your breastmilk, and you can continue breastfeeding. It can
persist for as long as three months of age, but the baby will remain active and gain weight.
We can confirm the diagnosis by temporarily suspending breastfeeding for 24-48 hours
which results in the fall of the bilirubin levels in the body. After which, the breastfeeding can
be continued.
o During the time of this temporary suspension, please express your breastmilk in order to
maintain lactation. I can refer you to the lactation nurse who can teach you more about this
method.
o However, if you will see that the jaundice is progressing, where it already includes her palms
and the soles, or if she becomes overly sleepy or irritable, or if not feeding well, please
report back immediately so that we can check her again.
o I will arrange regular reviews with you to check for Helen's progress.
o Here are some reading materials that I can give you to give you more insight to your child's
condition and about breastfeeding. Do you have any questions?
 

 
KEY ISSUES
 Establishing that urine and stools are of normal color
 Accurate interpretation of important pathology results
 Reassurance to the mother that her milk is not harmful to her baby
 Accurate explanation of the possible causes of jaundice and logically excluding other important
diagnoses
 
CRITICAL ERRORS
 Not appreciating the significance of predominant unconjugated hyperbilirubinemia and insisting
that the baby has biliary atresia or hemolytic disease
 Insisting that the breastmilk is unsatisfactory for the baby and recommending permanent
cessation of breastfeeding
 
IMPORTANT POINTS FROM THE COMMENTARY
 Jaundice very common affecting at least 50% of full term babies, and a significantly higher
proportion of premature infants
 Physiological Jaundice
o Adaptation process to the extrauterine life that takes some days to mature
o Resolves by end of the first week in term infants
o Up to 10 days to a fortnight in preterms
o Usually appears on day three on term infants, and late day two in preterms
 Pathological jaundice = appears within 24 hours of life
o Hemolytic process (ABO incompatibility) = most common cause
 Hereditary spherocytosis
 G6PD
 RH isoimmunization - usually known prior to birth due to screening
 Prolonged jaundice
o Conjugated vs unconjugated = determined by blood levels
o Breast milk Jaundice = unconjugated, but should only be considered as a diagnosis by
exclusion
 CLIN FEAT (MUST BE ASKED IN HISTORY)
 Babies are breastfed, thriving, gaining weight well
 Bowel motions and urine are normal in color
 PE is entirely normal except for jaundice
  Benign, requires no treatment except explanation and support
 Breastfeeding SHOULD NOT BE INTERRUPTED, although it is usually interrupted to
confirm diagnosis
 This is rarely necessary and tends to give a wrong message to young mothers
that their breast milk is harmful to the infant
 Cause is unknown, but it is thought to be due to a factor in the breast milk that causes
increased enteric absorption of bilirubin.
 Jaundice may persist for up to three months, but baby thrives and remains well
 
 
Condition 031 Convulsion
Benjamin, a 14 month old boy has been brought in to the hospital Emergency department by his parent
following as episode at home the previous evening. His parent explains that he had been unwell all day
with a high fever (40C), 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 60
seconds. He then went off to sleep and slept for the rest of the night.
 
Examination findings
Benjamin is alert and normal neurologically. He has a low grade fever and sings of an upper respiratory
tract infection.
 
TASKS
1. Take any further history to ascertain the most likely cause for this episode.
2. Explain your diagnosis and subsequent management to the child's parent.
 
APPROACH
 I understand form the notes that you are worried about Benjamin because he had a twitching
episode last night. Can you tell me more about it?
 Okay, I understand that he also had been unwell all day with a high fever, he had a period of
staring and unresponsiveness, then the twitching episode came which lasted for about a minute,
but he seems to be better now.
 Is this the first time this kind of episode happened? Has he ever had this episode without the
fever? Did you notice any abnormal behavior before the twitching episode happened? Was it a
generalized twitching episode? Did he have any injury to the head?
 Well Baby questions:
a.Mental state of the baby: has he been really irritable, or has been hard to wake up?
b.Eating/Drinking: has he been eating and drinking fine?
c. Wet nappies: Has he not been producing wet nappies for the last 8 hours? (very
dehydrated), change in the number of wet nappies?
 Rule out risk factors for epilepsy:
a.Birth history
i. Antenatal: what was your age when you had your child? Did you have any
infections or any medical condition during pregnancy? Did you take any drugs or
medication, or had any trauma?
ii. Delivery: was he a term baby? What is the mode of delivery? What is the reason
for the mode of delivery? Did he require resuscitation or did he cry immediately
after birth?
iii. Postpartum: did he spend any time in special nursery? Was heel-prick test
done?
b.Developmental history
i. How do you think he is growing compared to kids of his age group? Are you
concerned about his development when you compare him with kids of his age
group?
c. Family history
i. Do you have a family history of epilepsy? How about a family history of febrile
convulsions?
  Closure
a.Immunizations: Is the immunizations up to date?
b.Nutrition: is he breastfed or bottle-fed? When did you start weaning? Any concerns
about it?
c. Social history: Does the child have any siblings? Do they have the same symptoms? Any
family member with the same problem?
d.Medications: Do you give your child any medications?
e.Allergies: Does he have any allergies?
f. Past history: Does he have any previous medical or surgical illness?
 From the history, most likely the episode that happened last night is a simple febrile convulsion.
Do you have an idea what this is? A febrile convulsion is a fit or seizure caused by a fever. They are
caused by a sudden change in your child's body temperature and are usually associated with a
fever above 38°C. Almost always, the fever is caused by a viral infection, which would usually
manifest as an upper respiratory tract infection in adults, but in children, their brain is immature
so it is susceptible to effects of high fever. This is a common reaction to fever in children, about 3%
of the population have a seizure associated with fever. This condition commonly runs in families,
as in your case wherein your sister had episodes of febrile convulsions in her childhood.
During a febrile convulsion, your child will usually lose consciousness, their muscles may stiffen or
jerk, and your child may go red or blue in the face. The convulsion may last for several minutes but
when the movements stop, your child will regain consciousness but will probably remain sleepy or
irritated afterwards.
Remember that during a convulsion, there is nothing you can do to make the convulsion stop. The
most important thing is to stay calm and don't panic. Place your child on a soft surface, lying on his
or her side or back. Do not restrain your child and do not put anything in their mouth, including
your fingers. Try to watch exactly what happens, so that you can describe it to the doctor later and
time how long the convulsion lasts. Do not put your child who is having a convulsion in the bath.
After the first twitching episode, there is a 30% chance of recurrence especially in the first 24
hours. Do not give your child any medication, except Panadol for the fever along with tepid
sponging to bring the fever down.
Do not stress yourself, this is generally a benign condition and the convulsions do not cause brain
damage nor cause an increased risk for subsequent epilepsy.
However, if the convulsion lasts more than five minutes or your child does not wake up when the
convulsion stops or if your child looks very sick when the convulsion stops, please see your GP
immediately or go the ED. Do you have any questions at this point?
 
KEY ISSUES
 Appropriate questioning and history-taking.
 Appropriate education and reassurance.
 Advice on preventive measures.
 
CRITICAL ERROR
 Suggesting on the strength of this episode of a brief febrile convulsion that he has epilepsy.
 
IMPORTANT POINTS FROM THE COMMENTARY
 The dominant cue is the recognition of the change in sensorium in this child while he has a high
fever. Pattern recognition leads to the likely diagnosis and should allow the candidate to make a
definitive diagnosis.
  The scenario tests not only knowledge of a common condition, but also skill in being able to
impart a logical explanation in language that the parent can understand without causing alarm. It
also requires reassurance and confidence in the diagnosis.
 While epilepsy may be raised as a possibility, the clinical features at the time, the normal
appearance of the child when examined and absence of risk factors, make this highly unlikely at
this stage. The candidate should therefore recognise this as a simple febrile convulsion with an
excellent prognosis.
 A simple febrile convulsion is a common condition and candidates must be aware of risk factors
that would suggest an alternative diagnosis of epilepsy should be considered: prolonged
convulsion lasting greater than 15 minutes; a focal element to the seizure; a family history of
epilepsy; or abnormal neurological behaviour in the child prior to the seizure. Any of these
features would throw doubt on the diagnosis of simple febrile convulsion. None of these features
is present in this child and hence the diagnosis is clearly most likely to be a simple febrile
convulsion.
 
 
Condition 032 Loud and disruptive behavior of a 6-year
old boy
 
You are seeing a 6-year-old boy, Jonathan, for the first time with this mother, who complains how active
he is. He is in his second year at school, and his teacher has commented that he is disruptive and loud in
class.
 
TASKS
1. Take a focused history from the mother to determine the possible causes for the child's
presentation
2. Indicate to the mother your probably diagnosis and a brief plan of management.
 
APPROACH
 I understand that you are here with Jonathan as he has certain behavioral concerns in school. Can
you tell me more about it?
 HISTORY OF PRESENTING CONDITION (MIX WITH SOCIAL HISTORY)
o What do they mean about being "active, disruptive, and loud"? What exactly is his
behavior?
o Since when was he noted to be this way?
o Is this kind of behavior only observed in school or is it also noted in other places as well?
o When did he start school for this year (rule out separation anxiety at home)
o Is he bullied in school?
o What interventions has been done in the class? How did Jonathan respond to it?
o How is his academic performance?
o ATTENTION QUESTIONS
 Can he give you his full attention when you call him?
 If he gives you this attention, can he maintain it for a long time?
 Can he concentrate on what he is doing?
 Does he like to do homework?
 Can he finish his task?
 Is he often forgetful?
o HYPERACTIVITY QUESTIONS
 Can he stay still on his chair when you eat a meal? Or can he stay still on his chair
when asked to?
 In the supermarket (or other scenarios), can he wait for his turn when in a line?
 Is he talkative?
 Does he often interrupt others when other people are talking?
 Is he sleeping well? How many hours does he sleep in a day?
 Do you think he is aggressive towards other kids?
o HOME SITUATION (add confidentiality statement if patient is initially uncooperative)
 How is he at home? Who does he live with? How is his relationship with others? How
is the relationship of the family members to one another?
 Are there recent changes in your home situation?
 How about you and your partner, how is your relationship with one another?
 Can you say that you are a generally a happy family?
o R/O DDX
  Any concerns about his vision and hearing? Has he ever done any formal vision or
hearing assessments?
 Any episodes of staring blanky or day dreaming?
 How is his general health? Any previous history of trauma to the head, fever, cough,
colds, ear pain?
o BINDS
 BIRTH: Any complications during your pregnancy with him? Have you taken any
medications during your pregnancy with him (r/o meds that may cause deafness in
utero)? Any concerns during his delivery? Was a hearing test done on him?
 Immunisations up to date? (if not, I will arrange another review with you to address
this issue)
 Nutrition: Does he often eat meat, green leafy vegetables, nuts, fruits?
 DEVELOPMENT: Do you have any concerns about his growth and development
compared with other children? At his age, can he speak full sentences and express
himself thoroughly?
 Social History*** (already asked)
o Any previous history of other medical or surgical illnesses? Does he take any regular
medications? Does he have any allergies?
o Any family history of a similar problem, behavioral, or mental health problems? Medical or
surgical illnesses?
 EXPLANATION AND FURTHER MANAGEMENT
o From history, it seems that most likely your child has a behavioral disorder. The condition
which most commonly presents this way is Attention Deficit Hyperactivity Disorder or ADHD.
I still need to confirm it that is why I will refer him to the specialist for further assessment.
They will consider checking his vision and hearing, and they might consider doing something
called psychosomatic testing best done by a specialist child psychologist. They will send
questionnaires to the family and to the school to try and figure out that he is exhibiting this
behavior both in school and at home. This might take several months of observation and
assessment of your child before a certain behavioral condition is diagnosed. But do not be
stressed about this, as we will continually provide you support, and arrange regular reviews
with your child throughout the way.
o Once it is confirmed, he will be started on behavioral modification therapy. These are
classroom strategies to help with his learning and improve his concentration span. The
specialist might also consider starting him on medications to stimulate the areas in the brain
for impulse control and concentration (RITALIN, methylphenidate). These medications may
have certain side effects like nausea, vomiting, rash, but the specialist will taper the dose
which is appropriate to the weight and age of your child to minimize the occurrence of these
side effects.
o We have a lot of support available for you and your family. If you need one, I can refer you
to a counselor/centerlink/etc.
o For now I will also arrange basic blood investigations for him just to rule out other possible
causes of this change in behavior, which would include an FBE, UEC, ESR/CRP. I will arrange
another review with you once the results are available. If he ever develops nausea,
vomiting, headache, ear pain, please report back to me so that we can check him again.
Here are reading materials that I can share with you to give you more insight about your
child's condition.
o Do you have any questions?
 
KEY ISSUES
 Obtaining a logical and focused history to exclude various possible causes for Jonathan's behavior
 Showing empathy with the parents' frustration
 Having a clear approach to the management plan
 
CRITICAL ERRORS
 Coming to a premature conclusion of ADHD and recommending stimulant medication, without
having explored the history for other causes
 
IMPORTANT POINTS FROM THE COMMENTARY
 Important history points
o Past history
o Current developmental status
o Family and school situation
 Monitoring progress OVER SEVERAL CONSULTATIONS may be required to give a positive diagnosis
of ADHD
 Majority of children presenting this way have MAJOR FAMILY DYNAMICS PROBLEMS
o However, the current scenario is designed to indicate that a diagnosis of ADHD is by
EXCLUSION of all other causes for this symptom
o Stimulant medication is NOT THE IMMEDIATE TREATMENT NEEDED
o The doctor is often under great pressure to prescribe these medications at first visit and this
should be resisted
 No specific tests available to make a diagnosis of ADHD
o Diagnosis is made from the pattern of behavior, confirmed by psychometric testing
o Parents often already arranged this prior the consultation, and often tried a variety of
exclusion diets which may be helpful, but overall are not
 Support parents when they are trying exclusion diets if they are keen to institute them, but you
should monitor progress and make a critical appraisal as to the success or otherwise of this
treatment and support the parent accordingly.
 
 
 
 
Condition 049 Heart murmur
 
You are working in a general practice. A 4-year-old boy has been seen with his mother. He was taken to
another doctor with a cold whilst the family were on holidays and a soft cardiac murmur was heard. His
parents were asked to bring him to see the family doctor, to decide if anything further needs to be done.
His general health and exercise tolerance are excellent and he is on the 50th centile for height and
weight. He has never been cyanosed. There is no history of heart disease in the immediate family but a
cousin had a hole-in-the-heart operation. His parents feel he has no concerning symptoms. On
examination you have confirmed a soft vibratory mid-systolic murmur (grade 2/6) located between the
lower left sternal edge and the apex, which varies with respiration. Full physical examination is
otherwise completely normal. You have finished your history-taking and examination and are about to
discuss things with the child's mother.
 
TASKS
1. Explain your diagnosis and further management to the child's mother.
 
APPROACH
 I understand that you are concerned about your son as a soft cardiac murmur was heard on
examination by the other doctor. Is it alright if I confirm some information with you?
 When you took him to the doctor when he had a cold, did he also have fever at that time?
 Are there any problems with his growth and general health?
 Is he able to perform his activities well and able to tolerate exercise?
 Did he ever had episodes where his skin turned blue?
 Was he ever diagnosed of a heart disease?
 Is there a history of heart disease in the family?
 From the history and examination, most likely the extra heart sound or murmur that is heard on
your child is what we call an innocent murmur.
 A heart 'murmur' is a sound heard when listening to the heart with a stethoscope. It occurs
between, or in addition to, the normal 'heart sounds' and results from some turbulence ('eddies')
resulting from the flow of blood through, or close to, the heart. Murmurs are sometimes
described as "whooshing noises" produced with each heart beat.
 Whilst some murmurs can indicate the presence of a heart abnormality, the commonest murmurs
are not due to any heart problem at all. These so-called 'Innocent murmurs' are detected in many
normal children. They result from minor turbulence in the flow of blood, which occurs in entirely
healthy children and even in adults. 
 This is most likely because there are no concerning signs and symptoms present in your child. He is
within the normal growth percentile, his general health is good, he is able to tolerate exercise
well, he had no previous episodes of turning blue, and his physical examination is all normal. Also
the characteristics of the murmur that is heard which are soft with no diastolic component, varies
with respiration and is only heard on part of the chest all points more to a functional or innocent
murmur.
 During that time that you took him to the doctor while he was having a cold and fever, the
murmur was easily detected because innocent murmurs are often rather louder, and hence more
easily detected, during an illnesss associated with a raised temperature (fever). As the heart works
harder when the body temperature is high, this makes the turbulence in blood flow increase and
the murmur is louder.
  If you would prefer, I could arrange for a chest x-ray and ECG which is unlikely to show any
abnormality which may be reassuring for you.
 If you would still prefer, I could also refer you to the specialist who might consider doing an
echocardiography.
 
KEY ISSUES
 Ability to assess confidently the features of an innocent heart murmur.
 Avoidance of unnecessary extensive investigation.
 
IMPORTANT POINTS FROM THE COMMENTARY
 Cardiac murmurs in young children are very common. It is estimated that careful auscultation
under ideal circumstances will detect an innocent soft murmur in over 50% of normal four-year-
olds. Hence medical facilities would be overwhelmed if all of these murmurs were referred for
specialist assessment.
 Primary care physicians should be confident in distinguishing innocent functional murmurs from
those that are associated with an organic heart lesion.
 Rheumatic fever in our community is unusual these days unless practising in areas where large
numbers of Aboriginal or Torres Straight Islander peoples are treated.
 So the usual task is to differentiate an innocent murmur from one due to an organic heart lesion,
most likely of congenital origin.
 
 
Condition 074 Neonatal Jaundice in the first day of life
 
You are asked to see an infant, Jessica, born 24 hours ago, for jaundice. She is the first child of a healthy
mother, whose pregnancy was normal. Delivery was at term, by a midwife, and was uneventful. The
infant weighed 3700 grams at birth. Jaundice was noticed soon after birth, within the first 24 hours. The
infant has been sucking well at the breast. The mother wants to go home as soon as possible.
 
Examination Findings
The infant is clinically jaundiced but otherwise well and active with no hepatosplenomegaly or other
abnormal physical signs
You have obtained all relevant findings on history and examination.
 
TASKS
1. Ask the observing examiner for results of any investigations you consider necessary
2. Advise the parent on diagnosis and management
 
APPROACH
 Congratulations on having your baby. What a beautiful baby girl!
 I understand that you really want to go home right now, and that your Obgyn may have said that
you could immediately go home after your delivery. However, I am just really concerned about the
progressive change in Jessica's skin color since she was born. Have you noticed this yellowish tinge
in her skin? In some cases, this could be a sign of certain conditions that we need to catch earlier
on to be able to treat it well to avoid life-threatening consequences for the child. That is why we
ordered some investigations to identify certain conditions that could explain this. Will it be alright
with you if I go check on the results of her blood works first, just to ensure that everything is okay
with her, and then we'll see how we can manage Jessica from there?
 Examiner, I would like to know the results of the following investigations: Blood typing with RH
typing for both the mother and the child, Direct coombs test, Full blood examination, peripheral
blood smear, total bilirubin and conjugated bilirubin levels
o INVESTIGATION RESULTS
o
Mother's blood Group O Rh positive

Infant's blood Group A Rh positive

Direct coombs test Strongly positive

Infant's Hb 170g/L

Blood film/Peripheral blood smear Microspherocytes

Bilirubin (Total) 250 umol/L

Bilirubin (Conjugated) 6 umol/L at 24 hours

o Feedback from biochemist: this is abnormal, but below the range at which exchange
transfusion is indicated
 ADVISE ON DIAGNOSIS AND MANAGEMENT
 o I got her blood results back, and based on history and examination and these results, it
seems that most likely Jessica has got a condition called ABO INCOMPATIBILITY. Sorry for
the medical jargon, but let me explain this to you.
o [ILLUSTRATE] The red blood cells in our blood got a special protein in their surface called
antigens, and we have special proteins in our body called antibodies which help fight off
infections. Your blood group is O positive, and in people with O+ blood group, they have no
antigens in the surface of their RBCs, whereas they have ANTI-A and ANTI-B antibodies
which are the proteins that fight off against infections or foreign RBCs. Your baby has got A+,
and it has A antigen, and ANTI-B ANTIBODIES. Now sometimes during the third stage of
labor or during delivery, there is silent exchange of blood between the mother and the
baby, Now since you got antibodies (Anti-A) which reacted to the baby's antigens (A
antigens), that lead to the breakdown of the RBCs of your baby, leading to the accumulation
of a pigment which causes Jessica to become jaundiced.
o Unfortunately, this is a serious condition, because if it is left untreated, this pigment can
damage the baby's brain, leading to long term neurological deficits, hearing impairment,
learning disabilities, and mental retardation, a condition called kernicterus.
o I'm afraid that you may not be able to go home right now, as she needs to be admitted in
the hospital to receive urgent treatment to avoid all these complications. I will refer her to a
specialist who order a treatment called phototherapy, where we will keep Jessica under a
special type of light which will help in excreting this pigment from the body through her
urine and feces. It can be done in a room where you can also stay in the hospital so that you
can conveniently feed her as well.
o There are some side effects of this treatment, first is retinal and genital damage that's why
we are going to cover her eyes and her genitals while we do the treatment. The second
complication is dehydration, that is why we will make sure she's under the lights only when
she's sleeping, and not during feeding. Third, green colored stools may be noted, which can
suggest that the treatment is working and that she's removing the pigment from her body
already. It
o If this treatment is given immediately, most babies recover well from the condition, and it
has an excellent prognosis.
o We'll continuously monitor her pigment levels (bilirubin levels) in her blood. If this levels
keeps going up despite this treatment, we'll consider other treatment modalities called
exchange transfusion, where we will try to exchange the baby's blood with a fresh blood.
o I can only imagine how distressing it is for you to be here and to see your child this way. We
will be here for you and give you support, and rest assured we will do all that we can to look
after Jessica the best way we can.
 
KEY ISSUES
 Recognition of hemolytic disease of the newborn and its immediate treatment
 Empathetic but realistic communication with the new parent
 Ability to relate to mother's disappointment with need for medical intervention
 
CRITICAL ERRORS
 Failure to recognize hemolytic disease of the newborn and failure to advise phototherapy
 
IMPORTANT POINTS FROM THE COMMENTARY
 Dominant cue in this case: neonatal jaundice in the FIRST DAY OF LIFE
 o Indicates a PATHOLOGICAL AND POTENTIALLY DANGEROUS rise in the bilirubin levels
 Hemolytic disease is the most common cause of potentially dangerous neonatal jaundice.
o Jaundice on the FIRST DAY OF LIFE is hemolytic UNLESS PROVEN OTHERWISE
o Readily treatable, complications avoidable
o Early diagnosis is MANDATORY
o Hyperbilirubinemia is likely to reach a maximum level around the third day of life
 Seek evidence confirming the existence of hemolysis and defining the degree of
hyperbilirubinemia
o Hepatosplenomegaly may or may not be present
 CRUCIAL lab tests: blood grouping of mother and the infant, and direct coombs test
o Positive direct coombs = CONFIRMS that the infant's red cells have been sensitised by
antibodies and establishes diagnosis due to an ABO incompatibility
 Deciding further management depends on estimation of SERUM BILIRUBIN LEVELS (direct and
indirect).
o BILIRUBIN - derived from the catabolism of heme proteins produced in the breakdown of
red blood cells
 Unconjugated (indirect) bilirubin - converted in the liver to the Conjugated (direct)
bilirubin, and is excreted into the bile.
 Conjugated is NOT reabsorbed once it enters the intestinal tract.
 Thus in THIS CASE SCENARIO, the level of bilirubin is INSUFFICIENT to warrant an
exchange transfusion, but the level of unconjugated hyperbilirubinemia
exceeding 240umol/L confirms the need for PHOTOTHERAPY
 DEGREE of hemolysis should be defined by measuring the INFANT'S HEMOGLOBIN
 
 
 
 
Condition 075 Immunization advice
 
Your next patient is baby Laura brought by her mother to a general practice at six weeks of age, as part
of routine postnatal follow-up. Laura is the couple's first child. The baby is breastfed and gaining weight
normally. Her mother wants to know what you would advise about immunisation because she and her
husband have recently heard conflicting views expressed in the media. General examination of the baby
reveals no abnormality. She was given her first hepatitis B vaccination soon after birth.
 
TASKS:
1. Outline the current immunisation protocol you would recommend and what diseases the
programme is protecting against.
2. Discuss any concerns the parents have about immunisation.
 
You will not be expected to take any additional history or ask for examination findings.
 
APPROACH
 I appreciate that you have come to discuss about it, what do you know about immunization?
 I will be explaining to you what immunization is. If you do not understand anything along the way,
please don't hesitate to stop me and ask.
 We have white blood cells in our body which fights against infections. Whenever there is an
infection by the bug, these cells release some chemicals called antibodies that will kill the bug.
However, this process takes a long time. By the time your body have produced these antibodies,
the bug has already caused substantial damage to the body. There are also special type of white
blood cells called memory cells, which are specially-trained white blood cells which can recognize
infection by the same bug when infected in the future. So, if the child gets infected by the same
bug in the future, the memory cells are already trained to attack them immediately. This is the
type of cell which we utilize when we do immunizations. What we is we introduce a weakened
bug or parts of the bug which are chemically treated, to the child at regular specific intervals, so
that the child's white blood cells will be trained to act against the bug if he encounters it in the
future. This is what we call as vaccines. Please do not be stressed, the vaccines are not harmful as
the bugs injected are chemically treated and only produce a mild response in the body, just
enough for the body to produce antibodies and not the full blown infection.
 Immunization is offered at certain times starting at birth and then at 2, 4, 6, 12 and 18 months.
Later doses are usually at preschool age. Usually, more than one dose is required for complete
protection. With the development of immunization program in majority of the countries of the
world, a number of serious and lethal disease have been eradicated. That is why, immunization is
recommended for all children all over Australia. Within the government’s program, the diseases
that are covered are chickenpox, rotavirus that produces diarrhea, Hib, polio, infections like
measles, mumps, and rubella, hepatitis B, pneumococcal vaccine that prevents respiratory and
brain infections, meninggococcus vaccine that prevents against brain infections and DPT vaccine
that prevents against whooping cough, tetanus, and diphtheria or grey membrane infection of the
throat.
o At birth: Hepatitis B (hep B)
o At 2 months and 4 months: Acellular diphtheria, tetanus, pertussis (DTPa); H.influenzae type
B (Hib); oral or inactivated polio vaccine (O/IPV); hepatitis B (hep B); 7-valent pneumococcal
conjugate vaccine (7VPCV)
 o At 6 months: Acellular diphtheria, tetanus, pertussis (DTPa); oral or inactivated polio vaccine
(O/IPV); (hepatitis B [hep B] in NSW, QLD, SA. NT); 7-valent pneumococcal conjugate vaccine
(7VPCV)
o At 12 months: Measles, mumps, rubella (MMR); H.influenzae type B (Hib); meningococcus
(MenC): (hepatitis B [hep B]) in VIC, WA, TAS)
o At 18 months: Varicella zoster virus (VZV); 23-valent pneumococcal polysaccharide vaccine
(23VPPV)
o At 4 years: Acellular diphtheria, tetanus, pertussis (DTPa); measles, mumps, rubella (MMR);
oral or inactivated polio vaccine (O/IPV)
 As you know, all medications have side effects. Majority of vaccines have a few insignificant side
effects like local skin reaction (pain, redness, and swelling of the skin), sometimes especially with
DTPa the child can develop high-grade fever, but we usually give antipyretics half an hour before
the vaccine to prevent that. This side effect is sometimes accompanied by excessive, inconsolable
high pitched crying (because of pertussis component). But do not be too stressed, the side effects
are rare and with the use of acellular pertussis vaccine, these side effects have been minimized.
 There are some contraindications for these vaccines. Absolute Contraindications include
encephalopathy or a neurological illness within seven days of a previous DTP-containing vaccine or
an immediate severe or anaphylactic reaction to vaccination with DTP. A simple febrile convulsion
or pre-existing neurologic disease are not contraindications to pertussis vaccine. Children with
minor illnesses, i.e. without systemic illness and providing the temperature is less than 38.5 "C,
may be vaccinated safely. With a major illness or a high fever, the vaccination should be
postponed until the child is well. Live vaccines (MMR, oral poliomyelitis, rubella, chicken pox)
should not be administered to immunocompromised patients like a child with HIV, on
chemotherapy, or on treatment with high-dose steroids (>2mg/kg) for more than 2 weeks. An
anaphylactic reaction to egg is not a contraindication to MMR vaccine, but many authorities
recommend that in such a case it should be administered in an area where resuscitative
equipment is available and the child be observed for 4 hours.
 
Patient questions:
 Is it true that MMR vaccine is related to Autism?
o There have been a report of association of measles vaccination with autism. However, no
association has been convincingly demonstrated and several studies show no link at all
between these.
 I have heard a lot about homeopathic vaccination.
o Up till now, there has been no evidence within the medical literature that supports efficacy
of homeopathic vaccination. However, the decision is still yours.
 What if I travel in between and my son misses a dose?
o There is a special catch-up schedule for children who have missed their doses or who come
to Australia from overseas.
 I am going to give you written material that will tell you exactly when to bring the child for each
vaccination. It is important to maintain a record for your child (blue/yellow book).
 
 
KEY ISSUES
 Knowledge of basic principles of current immunisation regimens.
 Explanation and accurate information regarding benefits of immunisation
 Exploration of parental concerns.
 
CRITICAL ERRORS
 Candidate provides wrong advice regarding contraindications to immunisation.
 Recommendation or acceptance of sublingual homoeopathic vaccines.

IMPORTANT POINTS FROM THE COMMENTARY

 This scenario is concerned with counselling a young mother on the advantages and disadvantages
of immunisation. This requires of candidates a sound knowledge of the topic and an ability to give
the information to the parent in a manner that gives a balanced overview, without domineering
with their own personal feelings.
This is a very common situation in general practice where patients will often attend to discuss with
the doctor, beliefs they have, or to seek further information on a topic. Doctors should not
hesitate to admit that they do not know a particular answer but should offer to seek the answer
and communicate it at a later date.
 Updated immunisation schedules such as the one illustrated are available from paediatric
hospitals.
 Candidates should be aware of the absolute contraindications to the standard vaccinations and
also the false contraindications which are so often quoted.
 
 
 
Condition 076 Dark urine, facial swelling, and irritability
 
A five year old boy is brought to the emergency department because of swelling around the eyes. He has
only been passing small amounts of urine, which is dark in color. In the past 12 hours, he has become
restless and irritable.

The child had school sores (impetigo) three weeks ago, treated successfully with a topical antibiotic
cream, but has had no other prior illnesses.
 
Both parents are well. The child is an only child and has always kept in good health.
 
TASKS
1. Ask the examiner for the relevant physical exam findings you wish to elicit
2. Discuss with the parent your provisional diagnosis
3. Advise details of any investigations that are required and advise the parent of the treatment that
will be needed.
 
You do not need to take any further history.
 
APPROACH
 PHYSICAL EXAMINATION
o GA: pallor, jaundice, lymphadenopathy, edema (where exactly is the edema present?
Involving which parts of the body? Periorbital edema/pretibial-thyroid/bipedal), signs of
dehydration (CRT, moist lips and oral mucosa, skin turgor), rashes?
o GROWTH CHART
o VS: BLOOD PRESSURE with Postural Drop*, pulse, RR, O2 sat, temp
o ENT: fundoscopy (papilledema?), periorbital edema? Nasal/pharyngeal congestion?
Exudates on the posterior pharyngeal wall (r/o strep throat), palpable thyroid, tenderness?
Any carotid bruits or thyroid bruits?
o CVS: heart sounds distinct? murmurs?
o Respi: Breath sounds? Any crackles (pleural effusion)?
o Abdomen: any visible masses or striae? Ascites present?
 Masses, tenderness (liver edge palpable)?
 Kidney ballotable?
o Back: costovertebral angle tenderness?
o Genital exam, with consent: check for scrotal edema as well
 OFFICE TESTS: Urine dipstick (blood and protein), BSL, 12L ECG
 RELEVANT PHYSICAL FINDINGS TO BE GIVEN TO THE CANDIDATE ON REQUEST
o Resting blood pressure: 145/90 mmhg, no postural hypotension
o Temperature 36.5C
o Pulse: 90/min, regular
o Periorbital edema: no edema elsewhere, no ascites or pleural effusions
o Cardiovascular system: normal
o Liver edge: palpable just below the costal margin
o Optic fundi: normal
o ENT examination: normal
 o Urine dipstick: Strongly positive (++) for blood and protein
 EXPLAIN PROVISIONAL DIAGNOSIS and MANAGEMENT
o From history and examination, it seems that most likely your child has a condition called
Post-Streptococcal Glomerulonephritis. Sorry for using the medical terms, but I'll do my best
to explain these to you. Normally our kidney serves as the main filtering organ of our body,
which tends to help us remove wastes such as urine, and also helps maintain our water and
our salt balance. Sometimes, when the body is affected by any infection, like a skin infection
as in your child's case, the body tends to respond by creating factors in the blood that fight
off these infections (antibodies). However for some unknown reasons, these antibodies also
tend try to attack our own cells in the body. In your child's case, the antibodies that fought
off against the bug called streptococcus which caused the skin infection tend to have the
propensity to attack the kidneys. Because of this, we could see blood in his urine manifested
by his dark urine, and also a salt and water imbalance in his body causing decreased
urination, retention of his fluids manifested by swelling of his eyes and high blood pressure.
In medical terms, we call this condition as post-streptococcal glomerulonephritis.
o This is not usually uncommon. But generally this condition has a good long term prognosis,
and with the proper treatment that we'll give now he will be able to recover well.
o As of now he needs to be admitted in the hospital to where careful monitoring of his BP and
urine output and intake of fluids will be done until his fluid balance in the body will be
restored. He will be referred to a specialist who might do further investigations to confirm
the diagnosis which includes blood tests such as UEC, Inflammatory markers such as
C3,C4,ASOT, DNAse B, FBE, and urine samples fpr urine microscopy and culture.
o Aside from that, strict fluid balance will be observed by restricting his fluid intake, measuring
his daily weight, and having a low protein, low salt/high carbohydrate diet. He might also be
given antihypertensive medications which will depend on specialist advise.
o Once discharged, your GP would have to monitor your son's blood pressure, renal function
initially weekly, and then as needed as he recovers. Regular urinalysis will also be done to
monitor the blood present in the urine as sometimes it may persist for even up to 2 years.
o I can give you reading materials to give you more insight to his condition.
 
 
KEY ISSUES
 Diagnosis of acute PSGN
 Ability to specify appropriate plan of investigations
 Development of coherent treatment plan
 
CRITICAL ERRORS
 Failure to admit to hospital
 
IMPORTANT POINTS FROM THE COMMENTARY
 Scenario involves diagnosis, from clinical signs and appropriate investigations and an empathetic
explanation of the treatment.
 Candidate should be able to arrive at the correct diagnosis, investigate, and treat appropriately.
FAILING to do so puts the patient at risk!
 
 
 
 
Condition 077 Fever and sore throat
 
Peter, a five-year-old boy is brought to you in a general practice setting by his parent with a fever of 40
°C that developed overnight. He complains of an intensely sore throat and finds it sore when he
swallows food or fluid, although he is able to do so.

TASKS:
 Indicate to the examiner the clinical examination you would perform to diagnose the problem.
The examiner will give you the results of the physical examination.
 Discuss with the parent any investigations you feel are necessary.
 Explain your diagnosis and suggest management to the mother.
 
You do not need to take any further history

 
APPROACH
 Doctor, I would like to know the physical examination findings of the child.
 What is the general appearance of the child? Is there any pallor, lymphadenopathy, rash?
 What are the vital signs? Temperature, blood pressure, respiratory rate, pulse rate
 What is the appearance of the tonsils? Is it erythematous and inflamed? Does it have exudates?
 What is the appearance of the pharynx? Is it erythematous?
 What is the appearance of the tympanic membrance? Is it red and bulging?
 Is there neck stiffness?
 CVS/Respiratory/Abdomen
 From my examination, most likely your child is having a condition called acute tonsillitis, probably
due to a bug called streptococcus. But I still need to confirm this that is why I would like to arrange
for a throat swab before we start with antibiotic treatment. A swab will be taken from your child's
throat to detect what bacteria is present which is causing the infection.
 Your tonsils are the two small pads of glandular (lymphatic) tissue located each side of the back of
your throat. They are part of your immune system. They make antibodies and white blood cells
(lymphocytes) to attack germs inside your mouth. This makes the tonsils part of your first line of
defence against bacteria in food or air.
 Tonsillitis occurs when your tonsils become infected, and can be caused by either bacteria or
viruses. In your son’s case, I suspect bacterial tonsillitis because he’s markedly unwell, and has
tender, enlarged tonsillar lymph glands.
  The symptoms of tonsillitis include white or yellow spots of pus on the tonsils, sore throat –
although some children complain of pain in their tummy rather than a sore throat, swollen lymph
glands under each side of the jaw, pain when swallowing, and fever, as what is happening in your
child.
 Tonsillitis can lead to a number of complications, including:
 Chronic tonsillitis which is the infection of the tonsils which does not clear up. The person
may go on feeling unwell and tired
 Secondary infections because the infection can spread to the person’s nose, sinuses or ears
 Glue ear (otitis media) – the adenoids which are lymph nodes located in the throat behind
the noseare part of the same group of lymph nodes as tonsils. When the adenoids swell up
(usually when the tonsils are also large), they can block the Eustachian tube, which goes
from the back of the throat to the middle ear. This is the thin tube that you push air along
when you ‘pop’ your ear. If this tube stays blocked most of the time, sticky fluid forms in the
middle ear which interferes with hearing. This is called a glue ear.
 Quinsy – if the infection spreads into the tissue around the tonsils, an abscess can form in
the throat, also known as a peri-tonsillar abscess. This causes severe pain and can interfere
with swallowing and even breathing.
 However, with appropriate treatment, acute tonsillitis should resolve completely. If the child
doesn’t have any allergies to medications, I will prescribe an antibiotic (phenoxymethylpenicillin)
for 10 days (or erythromycin if allergic). You can also give him paracetamol to relieve pain and
fever. Please also give him plenty of fluids.
 Most children with tonsillitis do not feel well and it hurts them to swallow. Try cool drinks (cold
drinks can hurt), ice blocks and ice cream. Don’t worry if the child stops eating for a day or two.
Usually, they pick up quickly when the infection has gone.
 If he is more lethargic, can’t drink, doesn’t wee or starts vomiting, you need to go to the hospital.
Otherwise, I will see you in 2-3 days to check up on improvement. If there is no improvement, the
child needs to continue antibiotic for a total of 10 days to prevent possible complications, and we
will proceed with investigations such as FBE, ESR/CRP, EBV serology to find out other causes of the
child's condition.
 
KEY ISSUES
 Appropriate examination interpretation, with appropriate diagnosis.
 Adequate treatment plan.
 Appropriate explanation.
 
CRITICAL ERRORS
 Failure to consider streptococcal tonsillitis as the diagnosis.
 Failure to discuss followup and screening for other conditions if there is no initial improvement.
 
IMPORTANT POINTS FROM THE COMMENTARY
 This scenario assesses the ability of the candidate to come to a logical conclusion as to the most
likely diagnosis (acute bacterial tonsillitis) in this situation based on the information provided and
knowledge of the natural history of disease processes.
 The scenario tests diagnostic acumen by showing how several conditions can be safely excluded
because of the history and the time frame and gives scope to considering other diagnoses if the
provisional diagnosis is not confirmed.
  
Condition 091 Fecal soiling
 
Mark, a five-year-old boy, is brought to see you in general practice setting, because for the past six
weeks he has been soiling his pants, with increasing frequency, with foul smelling semifluid feces. It is
now happening almost every day and he is being teased at school.
 
His parent cannot tell you much about his bowel habits as he now attends to his own toilet needs when
he feels like it.
 
TASKS
1. Take a further focused history from the parent
2. Ask the examiner for the appropriate findings on examination of the child which would be
relevant to your diagnosis
3. Explain your diagnosis to the parent and advise on management
 
APPROACH
 [if parent is not calm] I know you have a tough time washing all of Mark's clothes, and I know you
are very concerned about him. But before we do anything to him, I need to ask you a few
questions first to assess him further, and then we can formulate a plan to help him. Will that be
alright with you?
 [if parent is just ok] I can see from Mark's notes that he's been soiling his pants recently. Can you
tell me more about it?
 HISTORY
o Fecal incontinence
 Since when is he soiling his underpants? How often? When did you first notice it?
 How frequently does he usually open his bowels?
 Can you describe to me how his poop is? Is it loose or hard stools? Is it associated with
any blood or mucus?
 Does he complain of any tummy pain or pain elsewhere (anal pain) while passing
stools recently?
 If yes, Pain questions
 Does he have any previous episodes of constipation/hard stools/difficulty passing
stools/pain during passing stools? Any previous history of diarrhea?
 Is he toilet trained / I know he is toilet trained but did he have any similar problems
before?
 Did you have any difficulties during his toilet training before?
o Associated features
 Any nausea or vomiting or fever noted?
 Problems with his water works? Is he dry at night?
 How is his appetite? Any weight loss/weight gain?
o BINDSMA
 Birth (relevant): was he able to pass meconium (first stool) right after birth? / do you
remember if he had delayed passage of his stools after he was born?
 Immunization - not that relevant in this case.
 Nutrition: What does his diet usually consist of? Does he take a lot of fiber,
vegetables, and fruits? Does he drink a lot of water or not?
  Development: any concerns about his growth and development?
 School/Social: I'm sorry to hear that he's been being teased in school because of this
condition. Could you tell me more about it?
 If not sharing, you can reassure by using a confidentiality statement
 How long has this been going on?
 What does he usually do to cope with this?
 How is he as a student? Does he get along with his peers? Does he enjoy school?
 How is your situation at home? Who else lives with Mark? How is his
relationship with him? Any concerns at home?
 Medications: does he take any medications or supplements?
 Allergies: does he have any allergies?
o PMH: Does he have any other medical or surgical illnesses?
o FHx: Any family history of bowel conditions?
 PHYSICAL EXAMINATION
o GA: PICCLED, does he look active/lethargic/withdrawn?
o Growth Chart**
o VS: temperature*, HR, RR, O2 sats
o FOCUSED ABDOMINAL PE: any distention or visible masses or peristalsis? Any palpable
masses or tenderness or rigidity? Any organomegalies?
o RECTAL EXAM with the parents' consent and with a chaperone?
 Inspection: any visible lacerations, fissures, bleeding, skin tags, discharge, fecal
staining?
 Per rectal exam: any palpable masses or tenderness? Is there blood on the examining
finger?
o OFFICE TEST: UDS, BSL
 PE FROM THE CASE
o A shy boy
o Normal height and weight on the 50th centile
o Abdomen is soft
o Fecal masses are felt in the lower quadrants
o No other abnormality
o Anus appears normal, with some fecal staining adjacent
o No anal fissure apparent
o On rectal examination, the rectum is packed with firm feces
 DIAGNOSIS AND MANAGEMENT
o From history and examination, it seems that most likely your child has a condition called
ENCOPRESIS, have you heard about it? it is a condition where there is an unknowing passage
of fecal material in the underpants.
o [ILLUSTRATE] The common cause is constipation or fear of pain during defecation. In your
child's case, a few months back he was constipated and had anal fissures which was causing
the pain on defecation. Even though the fissures were treated, David still fears that it's going
to be painful again if he goes to the toilet. So as he is refusing to go to the toilet, he is now
becoming constipated again. Do you understand so far?
o Because of this chronic collection of feces in the bowel, there is formation of liquid stools
and it tends to leak around the hard stools causing his soiling. However, the bulky hard
stools still remain inside, aggravating his constipation.
 o Don't be stressed, it is a manageable condition. At this time the treatment is to empty his
bowel now by giving an enema. Once he empties his bowel, we can start him on stool
softeners.
o I also encourage you to start toilet training him again, and encourage him to go to the toilet
right after meals for a set period of time. You may use an egg timer for this.
o I can only imagine how distressing it is to wash his clothes every day but please do not scold
him. This takes a long time to get better, and needs a lot of patience on your part. You can
start a star chart to motivate him to empty use the toilet when necessary.
o I would also like you to talk to his teacher about his condition, and to address about
bullying. Please give him extra clothes which he can wear whenever he has soiling episodes
in school.
o Please do not scold the child, and talk to the teacher about bullying. This takes a long time
to get better and needs patience on your part.
o I will arrange a regular review with him to ensure that his constipation is not recurring.
o However, If the he develops severe pain, nausea, vomiting, or different pain from what he
feels now, please come back immediately for a review. Here are some reading materials
which can give more insight about your child's problem. Do you have any questions?
 
KEY ISSUES
 Explanation of diagnosis
 Initial emptying of the rectum and colon
 Need for prolonged treatment and follow-up
 
CRITICAL ERRORS
 Suggesting that sigmoidoscopy or colonoscopy is required at this stage.
 
IMPORTANT POINTS FROM THE COMMENTARY
 Majority of constipation cases are non-organic, that is they are related to an episode, in many
cases associated with the passage of a hard tool which may make the child wary of passing a
bowel motion subsequently
 Can be associated with a mucosal tear or anal fissure which distresses the child, further
compounding the problem.
o Recognize the pattern early and treat it with fecal softeners allowing the fissure to heal
 If the child remains fearful of going to the toilet because of anticipation of pain, this compounds
the situation which may lead to chronic constipation, toilet refusal, and in many cases, overflow
encopresis.
 Young children may develop fear of the toilet during toilet training if they are required to perch on
a toilet seat without support and this also may lead to subsequent constipation
 Constipation can also be secondary to emotional upset or trauma.
 AIMS OF MANAGEMENT
o Exclude any possible organic pathology
o Explore any precipitating features
o Provide adequate explanation of the processes involved for both parent and child with a
plan of action to alleviate the problem
 History SHOULD INCLUDE
o Thorough enquiry into the child's environment
  Diet, general health, growth pattern, the family dynamics, progress at school,
relationship with peers, and the like.
o Hirschprung disease at this age has usually presented with a history of constipation from
birth, often with a delay in the passage of meconium.
 If there is suspicion, referral to pediatric surgery should be sought to include bowel
biopsy
 Treatment
o Careful reassurance, explanation of the nature of the condition
o Comprehensive explanation about how constipation has developed, preferably with
illustrative drawings
 
 
 
 
Condition 098 Bedwetting
 
Johnny, a five-year-old boy, is brought to see you in a general practice by his mother because of a bed-
wetting problem, which occurs nightly. He has been fully continent by day since he was three years old:
and has previously been treated unsuccessfully with nightly amitriptyline (Tryptanol®). The wetting
exasperated his parents initially, but they now accept that it is involuntary and both parents are keen to
help him in any way possible.
 
TASKS:
1. Ask the mother for any further relevant history.
2. Tell the examiner what relevant examination findings you would seek.
3. Advise Johnny's mother how you will further assess and manage his condition.
 
APPROACH
 History
o I understand that Johnny has again started to wet his bed nightly. I know that you have prior
experience about this and he has been treated, thought unsuccessfully, with a medication
before. I appreciate and applaud you that you understand that this is not Johnny's fault,
and are very keen to help Johnny. I appreciate that you have come to me so we can all work
together to help Johnny about this problem. I just have a few questions, is that okay?
o When did this start? How does he react to it? How is his general health?
o UTI questions: Any pain/burning, sensation while passing pee, any change in colour or
blood? Frequent small passage of urine?
o Any polydipsia or frequent thirsts? Any polyuria or frequent passing of urine?
o Bowel: any loose stools? constipation?
o Any problems with growth and development?
o How is his fluid intake?
o I would just like to ask some personal questions. But I would like to assure you that
whatever we talk about here will be private and confidential unless it poses a risk to you or
to others. Will that be okay?
o How is the family situation?
o Any stress in the family? How is your relationship with your husband? How is your
relationship with Johnny? How is his relationship with his siblings?
o How is he at school? Does he have a lot of friends? Does he experience bullying in school?
Any problems reported by his teachers?
o Any family history of a similar condition?
 Physical Examination
o General appearance
o Growth charts
o Vital signs: BP
o ENT and LN examination
o Systemic examination
o Genital examination
o Office test: UDT, BSL
 I would also like to send a urine sample for urine microscopy and culture.
 Explanation:
Most likely your child is having a condition called nocturnal enuresis or bedwetting. From my
history and physical examination, I have found no physical problem and emotional stressors in
your child. Bedwetting is common in young children and is part of their physical and emotional
development. Usually the cause is unknown, but some may be due to genetic tendency which
means that bedwetting does tend to run in families. If one or both parents wet the bed when they
were children, then it is quite likely to occur in their children. Also when we are in sleep and our
bladder fills, it sends signals to the brain commanding to say that we need to get up to pass urine.
But sometimes in children, the response does not occur as they are in deep sleep, and lead to
involuntary passage of urine in the child.
Bedwetting isn’t a disease, a psychological problem or a response to allergies. It isn’t caused by
laziness or naughtiness either, so punishing a bedwetting child doesn’t do any good at all. I
understand that it is distressing to be doing excessive washing of bedclothes and pyjamas, but I
am enthusiastic with your interest in trying to help Johnny. It is important to be patient and
sympathetic, since your child can suffer distress and embarrassment about bedwetting.
At this stage, we do not need to start him on medications.
One way to help your child become aware of urinating during sleep is to use a pad and bell. With
this simple system, a bell rings and wakes the child once the pad is wet. Over a period of a few
weeks, the child gains greater bladder control until they are consistently waking up to go to the
toilet. The bell or alarm can be obtained through hiring or buying from pharmacies or through
some Community Health Centres or Children's hospitals.
The bell consists of a rubber pad that is placed in the bed under where the child's bottom will be,
and it is connected by a wire to a box with a battery powered alarm bell. The system operates at
low voltage and there is no risk to your child. The pad should be placed on the bed on top of the
bottom sheet and should be covered with a piece of thin material, e.g. an old sheet that has been
cut up into strips just big enough to cover the pad and long enough to tuck in on either side of the
bed. The wires should be plugged into the box, which should then be placed as far away from the
bed as the wire will allow. When going to bed, your child should switch on the bell and get into
bed. It is best if he or she only wears a pyjama jacket and underpants rather than pyjama trousers
or a long nightdress.
When your child wets the bed, a loud bell will sound. He or she should get out of bed as quickly as
possible, turn off the bell and go to the toilet to finish emptying his or her bladder. Then your child
should dry the pad using the piece of material, put a new piece of material over the pad, turn the
bell back on and get back into bed. You may have to help your child with some of this, at least for
the first few nights and especially if he or she is a very deep sleeper. Within a week or two your
child should start to have some dry nights. This may happen because he or she wakes up and goes
to the toilet before wetting the bed, or because he or she learns to hold on all night. However,
even with the alarm it may be some weeks before success is achieved and the alarm should be
persisted with for up to three months.
Your child needs to be very involved in the treatment plan if it is to work. The success rate is very
high is the child is also motivated. And as is the case with Johnny, it is good that he is also
motivated to help himself. As the treatment progresses, your child will probably have some good
nights and some bad nights. Be very positive on the good nights, and try not to be negative on the
bad ones. It can be helpful to keep a record chart of wet and dry nights. Your child should make
the chart themselves and choose how to complete it. Some children like to put stars or stickers on
for dry nights or to colour it in or draw pictures. Choose something that fits in with your child's
interests. Most children don't need rewards to encourage them to take part in treatment - the
prospect of a regular dry bed is usually enough. Some small treats along the way may be a good
idea, but don't promise them in advance. Rather, give them as a little surprise if your child is
 making some progress. Certainly don't offer big rewards (e.g. a new bike) because this can add to
the stress associated with treatment, and can be very disappointing if your child doesn't become
dry.
It is important for your child to drink plenty of fluid spreads evenly throughout the day. Although
lifting and restriction of fluids have not been shown to be effective generally, if you are keen to
continue this, you may feel free to do so as it occasionally does help some children. However,
don't give drinks containing caffeine (e.g. coffee, tea, hot chocolate, caffeinated soft-drinks like
Coca-Cola etc.) late at night.
Remember, bedwetting is not a behavioural problem. Most children have no lasting problems
from bedwetting.  However, many will feel embarrassed or ashamed. Family members of children
who wet the bed need to be supportive and not critical.
 
If asked:
o During school camps or sleepovers, he could use a medication in the form of a nasal spray
called arginine vasopressin when it is important to remain dry and to avoid any
embarrassment. It helps a child's body make less urine at night, therefore reducing the risk
of the child's bladder overfilling during sleep. It is safe provided you never exceed the
recommended dose and avoid excessive fluid intake in the evening after dinner.
o The success rate with amitriptyline (Tryptanol®) is low. It can be a dangerous drug in
overdose and is rarely used now.
 
KEY ISSUES
 Empathy, support, and encouragement to both child and parent.
 Enquiry about a family history of enuresis.
 Exclusion of emotional stress at home or school.
 Exclusion of organic pathology by the history and by arranging simple urine testing.
 Advice about plan of action should be logical and clear.
 
CRITICAL ERRORS
 Suggesting a probable organic cause for the wetting and the need for invasive investigations.
 
IMPORTANT POINTS FROM THE COMMENTARY
 This scenario describes a five-year-old boy with persistent primary bed-wetting from three years
of age. He is otherwise well, has no daytime wetting or any other symptoms to suggest a
pathological cause for his wetting. The candidate should appreciate that the boy himself is very
keen to be dry, and that his parents are willing to help him achieve this
 
 
Condition 107 Dandruff or head lice
 
You have just examined 6-year-old Jodie, who has been brought to general practice by her mother
because of an itchy scalp and what appears to be dandruff in her hair.

Her parent is concerned that she may have lice in her hair which have been reported among other
children at her school. Jodie has excellent health otherwise. She has a 4-year-old brother who
occasionally scratches his scalp. On inspection of her scalp you have found "white specks" which are
firmly stuck to the hairs as illustrated.
 
Eyelashes and eyebrows show no abnormality/ There are no scaly dermatitis, though some redness
consistent with scratching is evident
 

TASKS
1. Explain your diagnosis and management plan to the parent, who is concerned as to whether this is
lice or dandruff
 
APPROACH
 [ESTABLISH RAPPORT] I understand that you are very concerned about your child as she is having
this condition, and it is good that you came here to have her checked.
o Aside from her brother, is there anyone else at home having an itchy scalp? Or itchiness
from anywhere else?
 From the history and examination, it seems that most likely your child is having head lice.
Medically, it is called Pediculosis hominis. This is an insect that lives in the hairy areas of the body
such as the head, eyebrows, eyelashes, rarely, within the pubic area. Let me reassure you that this
condition is NOT related to hygiene or cleanliness. This is a common condition across all age
groups, but is mostly present among school aged children. Given that there are reported head lice
cases in school, it is most likely that your child got it from a classmate as it is spread by direct
transmission from head to head. This insect then irritates the head causing itching. It lays eggs
that are called “nits” that usually hatch within 7-12 days. The nits can be seen at the base of the
hairs where they are glued to the hair, as what we can observe in your child here. These are
commonly mistaken as dandruff, but actually these are the lice's eggs.
 You have to know that this can spread easily within the family, as I am also concerned about your
other child who currently has head itching as well. All of your family members then needs to be
checked, and if head lice is present among them as well, we can begin the treatment. We can
arrange an appointment for them to have the check-up.
  The treatment fortunately is simple, but it needs to be done regularly for complete eradication. I
will write a prescription for a pyrethrin-based scalp preparation that you can easily find in the local
chemist.
o You need to wet the hair, apply the solution to the base of the hair, and thoroughly cover it,
leave it on for 10 minutes, thoroughly rinse your hair with plain water, and you may apply
shampoo afterwards. This treatment is quite effective and kills both the insect and the eggs.
However, you need to remove the eggs with the help of a fine-toothed comb after the
treatment, and drying with a clean towel. After 7 days, you need to repeat the same
procedure one more time.
o Alternatively, you can also use the conditioner and comb every two days until no lice are
seen for 10 days.
 You also need to wash his beddings with hot water. Don’t allow anyone to share his towels and
combs. You need to soak the combs in hot water for 10 minutes after the treatment. You may also
find anti-lice kits that contain permethrin in the form of shampoo, a fine-toothed comb and a
conditioner in the local chemist.
 Her hair does not need to be shaved or cut short. And once you have given the treatment to her,
you can already send her back to school the next day, but you need to inform the school about her
condition, so that other kids get checked as well.
 I will regularly review her, and if the condition persists despite our treatment, we can try another
type of scalp preparation (malathion-based) next time.
 If she develops any scalp wounds, scabs, or any fever, please report back to me immediately so
that I can check her.
 Here are some reading materials that may give you more insight to her condition.
 
KEY ISSUES
 Ability to make the correct diagnosis
 Succinct, accurate, decisive information-giving
 Ability to describe the correct treatment as outlined above
 Ability to reduce parental concern
 
CRITICAL ERROR
 Failure to diagnose head lice
 
IMPORTANT POINTS FROM THE COMMENTARY
 DOMINANT CUE: presumptive end-diagnosis already provided by the parent, namely HEAD LICE
 Candidate is expected to recognize the pattern of small white spots, or "nits" which are the eggs of
an infesting lice
 Diagnosis made almost instantly, as there are no features of any associated dermatitis which could
be suggested as an alternative
 Candidates are expected to be able to EXPLAIN this common condition, PRESCRIBE an appropriate
regimen, and ACHIEVE RAPPORT in order to ensure compliance, REDUCE ANXIETY, and achieve a
satisfactory outcome
 
 
Condition 113 Severely ill with fever
 
You are a junior Hospital Medical Officer (HMO) working in the Emergency Department. A 4-
month-old female infant is brought in by her parent at 0300 hours.
The baby has been increasingly unwell for 24 hours with the following history:
 Poor feeds — only one breast feed in that time.
 Feverish.
 Decreased urine output.
 Excessive drowsiness and difficult to wake for feeds.
 There has been no vomiting or diarrhoea, and no cough or wheeze.
The baby is the first born infant of healthy parents who are both currently well. She was
delivered normally at term after an uneventful pregnancy. She has been thriving and
developing normally until now.
 
TASKS:
1. Ask the examiner for the clinical findings you would wish to elicit on examination.
2. Discuss the likely causes of the infant's illness with the very anxious parent.
3. Explain your plan of management to the parent.

No further history is required.

 
APPROACH
 Physical examination
o General appearance: what is the level of consciousness? Is he well-
nourished? Any pallor, icterus, cyanosis, signs of dehydration?
o Vital signs: temperature, pulse rate, respiratory rate
o Are the fontanelles soft or tensed?
o ENT: what are the ear findings? Is the TM injected? Does the ear contain
fluid or pus? What are the throat findings? Is it hyperemic, inflamed? Is
there any pus?
o Are there abnormal lung sounds, heart sounds?
o Is the abdomen soft and non-tender?
 
 Management
From history and examination, I suspect that your child has an ongoing
infection going in the body. However, it can be difficult to determine the
exact cause of the infant's illness without investigations as babies present in
a different manner from adults. I will call the pediatric registrar who will
admit your baby immediately for investigation and treatment. This set of
 investigations is what we call as septic workup or septic screen to find out
the cause of the infection.
It involves doing a blood test wherein we take a sample of the blood from
the child's veins for FBE, ESR/CRP, and blood culture, to look for infection in
the blood. It might cause a little bit of pain from the needle prick but we will
use a local anesthetic spray a few minutes before the procedure that will
numb the area.
To rule out infection in the lung, we will do x-ray of the chest. I understand
that you might be worried about possible risk of radiation but rest assured
that it will be tailored according to his age and weight to limit overexposure.
This test is very important to look for infections or pneumonias within the
lungs.
To rule out urine infection, in babies of this age group, we usually obtain a
sample or urine through aspiration from the tummy and submit it for urine
microscopy and culture to look for possible infections. Please don’t be
stressed it will be done by a trained specialist. The nurse will also give him
some painkillers before the procedure. A very small needle is passed through
the skin into the bladder and the sample is withdrawn. Please don’t be
alarmed if you see traces of blood in his urine after the procedure. It is totally
harmless and commonly seen after such procedure.
To find infection in the brain, the other important test that I want to talk
about is a lumbar puncture where some fluid will be taken by passing a small
needle through the space between the lower spine. We will send this fluid
for testing for infections. This procedure again is done by the specialist.
Sometimes, there is small amount of bleeding from the area, but this is
expected. The child may be irritable for some time but rest assured that it is
unlikely to damage the spinal cord as the level is much lower.
An intravenous line will be inserted as well and once the investigations and
specimens are taken, we will start him on broad spectrum antibiotics
(cefotaxime/gentamicin) until the results of the tests arrive for more specific
cover.
 
KEY ISSUES
 Recognition of clinical findings indicative of acute life-threatening sepsis in infancy.
 Recognition of an extremely sick infant requiring immediate diagnostic workup.
 Recognition that investigation and treatment must proceed together.
 Recognition that parenteral (preferably intravenous) antibiotics (broad spectrum coverage
to cope with all possibilities) will be required.
CRITICAL ERRORS
 Failure to admit the infant to hospital.
 Failure to undertake urgent investigations.
 Failure to recommend immediate antibiotic treatment
 
IMPORTANT POINTS FROM THE COMMENTARY
 This scenario describes a 4-month-old baby girl who presents febrile and obviously very
unwell. The diagnosis is most likely to be severe bacterial sepsis with no signs suggesting
the causal origin of the infection.
 This infant requires urgent admission to hospital for investigation and treatment.
 In this situation a cause of overwhelming sepsis must be sought and this will involve a full
work up of investigations to determine the probable origin and spread of infection. This
will include full blood examination including blood culture and inflammatory markers,
chest X-ray and examination of urine, preferably by suprapubic aspiration, and
cerebrospinal fluid via lumbar puncture.
 Infants present in a very nonspecific manner when infected: physical signs that may be
present in older children, for example neck stiffness, are absent. The medical attendant
therefore must seek out multiple possible infection sources. Having obtained these
investigations rapidly, the safest and most appropriate action is then to treat the infant
with antibiotic therapy preferably intravenously, providing a broad cover for appropriate
organisms (e.g. cefotaxime and gentamicin). There is no place in this situation for
observation while awaiting results as the infant may deteriorate rapidly and irretrievably.
Under most circumstances one or other of the above investigations will reveal the source
of infection. Young infants become ill quickly with bacterial infection and will deteriorate
rapidly if not investigated and treated urgently. Appropriate treatment often gives rapid
improvement.
 
 
 
Condition 114 A lethargic febrile
 
A two year old boy is brought by his very upset parents to a general practice in a small county town,
50km from a regional city. The child has become lethargic and febrile in the last four hours. He has had a
mild upper respiratory tract infection for the last three days. Now he has a high fever, is uninterested in
food, irritable and has a very cold skin. He is an only child of healthy parents.
 
On examination, he looks unwell, and has a fine nonspecific macular petechial rash on the trunk and legs
as illustrated below. Elsewhere the skin is cold and pale, especially over the extremities.
 

 
Vitals
Temperature 40C (tympanic)
RR 48/min
Pulse 150/min
BP 90/60
Neck stiffness - none apparent
 
TASKS
1. Explain the diagnostic possibilities to the parent
2. Outline your management plan
 
APPROACH
 Good morning, Examiner. Before I proceed further, given that his vital signs are unstable, I would
like to start with my initial management plan before I go with my first task. Will that be alright?
o IF EXAMINER agrees: I would like to transfer the child to the treatment room. I will insert IV
lines on him and take blood for culture, FBE, ESR and CRP, UEC, BSL, CLOTTING PROFILE.
 Good morning. I can only imagine how distressing it is to see your child this way, but rest assured
we will do everything we can to give the best care for your child, and to give you whatever
support you may need.
 DIAGNOSTIC POSSIBILITIES
o From his history and examination findings, we could see a lot of possibilities that may be
causing him to present with fever, rash, irritability, and decreased appetite. Given his history
of a previous upper respiratory tract infection, we can consider that he is having a clotting
disorder triggered by this previous viral infection, or just another viral infection that he is
developing again. However, given the fast nature of the progression of his symptoms and
 the characteristic of the rash that accompany it, I am most concerned of the possibility of
him having sepsis. Sorry for the medical jargon, but it means having an overwhelming
infection in the blood. And from the appearance of the rash, this sepsis seems to be likely
caused by a bug called Meningococcus. It is a bacteria which spreads by droplet, or airborne,
from a person who is sick with this who probably coughed off the bacteria which
unfortunately infected your child. Sometimes it can also be caused by another bug called H.
influenzae. Unfortunately, you have to know that this can lead to severe life threatening
complications as these usually affects the brain and subsequently cause derangements in
the function of the body. But don't stress yourself too much about this, as it is good that we
caught it early to avoid those complications, and your child will be taken care of by
experienced hands.
 OUTLINE OF MANAGEMENT
o Because of this, I will call an ambulance to transfer your child to a tertiary care hospital
immediately so that he can be seen by the specialist who will manage him further until he
recovers. I will liaise with the specialist regarding his condition so that he can be aware of
your child's current status.
 [If not yet done initially] As we are waiting for the ambulance, I will insert IV lines on
him and take blood for investigations to confirm the diagnosis ( blood culture, FBE,
ESR and CRP, UEC, BSL, CLOTTING PROFILE).
 I will also start him on IV antibiotics now (IV or IM cephalosporin or benzylpenicillin if
cephalosporin is not available). The specialist may decide to change this antibiotics
later on once blood test results are available.
 Once in the hospital, they might do further investigations to rule out infections
anywhere else in the body, which includes urine tests (Urine MCS), chest xray, and
even a lumbar puncture to check if the infection affected the fluid in the brain or not.
 [ILLUSTRATE] Lumbar puncture is a procedure where we get a sample of the
fluid surrounding the brain called, the cerebrospinal fluid, to check for presence
of infection. This is usually done as a pain free procedure, where a needle is
inserted in the lower back of the child, and is done by the specialist.
o If the condition is confirmed to be meningococcus, then I am legally obliged to notify the
department of health services about your child's condition, as they will be able to facilitate
contact tracing and assist in the antibiotic prophylaxis of immediate contacts of the child to
avoid spread of the disease.
 Again I assure you, your child will be taken care of by experienced doctors. We will all do our best
to look after your child. For now, I can also arrange a social worker for you to provide you with any
support that you'll need as you will be looking after your child as well.
 
KEY ISSUES
 Recognition of a seriously ill child who requires urgent hospitalization
 Suspicion of meningococcemia
 Recognition of urgency of treating potential septicaemia
 Recognition of need for urgent immediate administration of antibiotics prior to transfer
 Empathetic explanation of a serious disease
 
CRITICAL ERRORS
 Not recognizing the possibility of meningococcal disease
  Failure to ensure immediate administration of cephalosporin or penicillin and failure to arrange
urgent hospitalization
 
IMPORTANT POINTS FROM THE COMMENTARY
 Dominant cue: RASH, PALLOR, FEVER, UNINTERESTED WHEN HANDLED = SEVERELY ILL CHILD
o Usual pattern of febrile illness is a FLUSHED child, who feels hot, and protests when handled
 Any child which may be in the early stage be very nondescript, should be regarded as having
septicaemia UNLESS PROVEN OTHERWISE
o Probably meningococcal, but can also be H. influenzae if immunization is not updated
 Pattern recognition = PROMPTS URGENT ACTION = IMMEDIATE INTRAVENOUS/INTRAMUSCULAR
ANTIBIOTICS
o NOT be withheld while the child is transferred as it could be FATAL! You must give it RIGHT
AWAY!
o PREFERRED: Third generation cephalosporins (to cover H. influenzae), but penicillin G would
also be acceptable as initial treatment
 Close contacts of this child will require antibiotic prophylaxis once his treatment has been
arranged. BUT if clinical suspicion is strong, this should be commenced AS SOON AS POSSIBLE
 The appearance of a rash in a sick febrile child should alert the clinician to this possibility no
matter how atypical the rash may appear.
 
 
 
 
Condition 115 Wheezing and breathing difficulty
 
A 5-year-old girl is brought to the Emergency Department in by her worried parent. She has been well
until yesterday when she developed a cold. Last night she was coughing and woke with wheeze and
breathing difficulty. She went back to sleep on and off through the night but on waking this morning still
has an obvious wheeze. Her general health has previously been good, apart from an episode of mild
wheezing associated with a respiratory infection when she was 3-years-old. She also has a past history
of mild flexural eczema but has no known allergies. Her father had several episodes of wheezing until
the age of eight but none since. He does, however, suffer from seasonal hay fever.

Examination findings
She appears to be in some respiratory distress and has an audible wheeze.
Temperature 37.5 °C

Pulse 110/min

Respiratory rate 25/min

No cyanosis  

Clear nasal discharge  

Throat slightly reddened

Chest no deformity, percussion resonant. Generalised marked

inspiratory and expiratory wheezes. No crackles.
No other abnormality
 
TASK:
 Explain the diagnosis and your plan for further management to the parent.
 
There is no need for you to take any additional history or perform any further examination.
 
APPROACH
I would like to know that saturations of my patient. Because my patient is in some respiratory distress, I
would like to shift my patient to the resuscitation room, hook to O2 facemask at 10-15 L per minute,
given 3 doses (6 puffs) of salbutamol puffs at 20 minute intervals for 1 hour, and 1 dose of oral
prednisolone 2mg/kg now then re-assessed again later.
 
From the history and examination, most likely your child has an acute moderate attack of asthma.
Asthma is a common disease of the airways – the structures through which air passes when moving
from your mouth and nose down to your lungs. It causes the muscles in the airways to tighten, and the
lining of the airway to become swollen and inflamed, producing sticky mucous. These changes cause the
airways to become narrow, making it difficult to breathe. Typical asthma symptoms include: a tight
feeling in the chest, wheezing – whistling noise when breathing, shortness of breath, coughing, and
struggling to breathe. These symptoms are often worse at night, in the early morning or during exercise.
Children may also not eat or drink as much, cry, have a tummy ache and vomiting, become tired quickly,
get more puffed out than usual when running and playing.
Asthma can be triggered by numerous factors. These include exposure to cigarette smoke from parents,
airway infections especially during infancy, indoor and outdoor air pollution allergy triggers, such as dust
mites, animals, pollen or mould, weather conditions, such as cold air and exercise. Triggers for asthma
vary among children, and symptoms can be delayed after exposure to the trigger which makes the
diagnosis of asthma difficult.  
In your child's case, her risk factors for asthma is a past history of eczema, respiratory infection when
she was 3 years old, and a family history of atopy as well. Her acute attack of asthma now is most
probably due to the prior cold that she was having. I can say that this is a moderate severity of an attack
because she is having some trouble breathing, increased rate of the breaths and heartbeat, but with
normal mental status.
Do not be stressed, she is stable now. I have started oxygen via facemask on your child to help her with
her breathing, and also given her a short acting bronchodilator, which is the medication to help relax
and widen her airways to ease her breathing, and a steroid to decrease the inflammation. I will refer you
to the pediatric specialist for further assessment as well.
To manage further attacks, we would develop an asthma action plan for your child. This is a clear written
summary of your child's asthma management.
If your child develops symptoms of Asthma such as wheezing/chest-tightness/shortness of breath:
 For mild symptoms: take 2 puffs of Ventolin
 For more severe symptoms: take up to 6 puffs of Ventolin
 Use a spacer if she has one. Repeat doses as often as she needs to. Don't stop taking the
preventer.
 If she needs Ventolin more often than every 3 hours, see your doctor or go to hospital.
 If from previous experience you suspect this is a more severe attack, or if the symptoms are not
getting better in about 6 to 8 hours with regular use of Ventolin take Prednisolone 2mg/kg
immediately then once each morning for up to 3 days.
 Regarding sport or exercise, if this usually makes her wheezy, before starting, take 2 puffs of
Ventolin. She may need to repeat the dose if she also get symptoms during sport
 If she has a bad attack or are worried, if she needs Ventolin more than every 3 hours, If she gets
little or no relief from Ventolin, if wheezing lasts more than 24 hours and is not getting better or If
she has a very severe attack: call an ambulance and take up to 6 puffs of Ventolin every 15 to 30
minutes.

These may sound a lot and quite distressing, but do not be too stressed, if your child’s asthma is well
managed, she should be able to lead a healthy and active life.
 
KEY ISSUES
 Confident explanation of the diagnosis of asthma.
 Appropriate management of this attack of acute asthma.
 Candidate should outline an asthma treatment plan for the child for further attack as outlined in
the action plan table.
 Support and reassurance.
 
 
CRITICAL ERRORS
 Failure to diagnose asthma.
 
IMPORTANT POINTS FROM THE COMMENTARY
 In this scenario a 5-year-old child is presented by an exhausted parent who has been struggling
through the previous night with her child's acute breathing difficulty. A careful history determines
that the most likely diagnosis is asthma and examination reveals that the child still has significant
respiratory distress.
 Recognition of the anxiety created by this very worrying situation for the parent is important and
reassurance should be given throughout the consultation as to treatment and a subsequent plan
of action.
 There are several important issues that must be addressed in this scenario.
o Firstly, the child needs appropriate acute treatment to relieve her symptoms and this may
require hospitalisation in the first instance if she does not respond to initial treatment in the
practice.
o Secondly, the parent needs to be educated about asthma and the strong associated genetic
element, as well as what the common precipitating causes are in children, for example, viral
infections.
 o Thirdly, the parent needs to be counselled on factors that may aggravate the child's asthma,
for example, cigarette smoke, and an appropriate plan of action outlined for the parent in
the event of the child developing a further asthma attack.
 The clinician must ensure that the parent is confident in this management and has had
appropriate instruction in the use of bronchodilators and the equipment, for example, spacers,
associated with their use.
 A common omission in practice is adequate instruction for parents in methods of administering
medications and the care of equipment. Some practitioners are confident in instructing the
parents in their use, but if not, the help of an asthma educator should be sought, if available.
 It is important to emphasise that even though they have a plan to follow, they should immediately
seek help at any time irrespective of the plan if they are concerned about their child's condition.
 
 
Condition 121 Several bone fractures
 
You ae a hospital medical officer in a hospital emergency department. A 30-year old mother presents
her nine-week old baby boy Gregory. The mother says that the baby has a tender lump in his right thigh
and is not kicking his right leg. He cries when his nappy is changed. She recalls that he rolled off the
change table the previous day.
 
Your examination findings of Gregory are:
Normal percentiles
Afebrile
Anterior fontanelle pressure normal
Tender selling in the middle of the right thigh, most likely involving the femur
Some fingerprint bruising on the left upper limb
Old bruises on chest wall posteriorly
You arranged X-rays of his leg and chest. The X-rays show a fresh spiral fracture of the right femur
and three posterior rib fractures approximately three weeks old.
 

 
TASKS
1. Explain the X-ray results to the mother and take any further history you require from her
2. Explain the further management of this problem to her.
 
APPROACH
 Before we proceed further with the xray results, I would like to clarify some things about Gregory
so that I will be able to assess him further. Will that be alright with you?
 If mother is quiet or doesn't maintain eye contact with you, you can say:
o "You seem stressed. What happened? Is there anything bothering you? Would you like to
talk more about it?"
 o Confidentiality statement: You may share anything with me, as whatever we talk about here
will remain confidential, unless I see that it may pose harm to you or to others. Will that be
okay?
 RULE OUT ORGANIC CAUSES:
o From my examination, I have noticed some bruises on Gregory. Have you noticed these as
well?
 When did you first notice it? Is this the first time that this happened?
 Did he have any recent falls? How did it happen?
 Do you see bruises from anywhere else? Have you noticed any bleeding from his
gums, nose, or from anywhere else?
 Did he have any recent fevers? Is there anyone sick at home recently?
 Have you noticed any lumps or bumps or weight loss?
 Is he as active as he was before?
o Systemic review and well-baby questions: any cough, noisy breathing, vomiting, changes in
his bowel motion, concerns about his waterworks, appetite, gaining weight well?
 BINDSMA
o BIRTH: How was your pregnancy with him? Was it a planned pregnancy? Any complications?
Is he your first child?
o NUTRITION: Is he breastfed or bottle fed? Is he feeding well? Any concerns about
breastfeeding?
o DEVELOPMENT: Any concerns about his growth and development
o SOCIAL: are you enjoying motherhood so far? Who looks after him? Do you have any
support in taking care of him? How does your partner help you with this? Sorry to ask you
this, but is he the biological father of Gregory?
 Do you feel safe at home?
 You know sometimes when we are all under stress, other people may become
aggressive and violent and may lay a hand to others. Does this apply to you?
 Have you ever thought of harming yourself or others because of stress?
 Do you or your partner smoke, take alcohol, or any illicit drugs??
o Does he have any other medical or surgical illnesses?
o Do you have any family history of bleeding disorders, bone and joint conditions, or cancers?
 EXPLAIN X-RAY RESULTS
o I have the x-ray results back, and together with my examination findings from Gregory, it
seems that he has a broken bone on his thigh. For this reason at given that he is only 9
weeks old, and having all of these bruises, it is crucial that we have to admit him as we need
to address his broken bone, and he needs to be assessed further to figure out what may
have been causing these. It is possible that he may have developed blood or bone disorders
which we need to identify as soon as possible before any complication may happen. We will
do some blood investigations for this as well (FBE, ESR, CRP, COAGULATION PROFILE, UEC)
o I am just concerned that these injuries that Gregory has may also be some non-accidental
injuries, as these findings do not go well with how you described the manner of how he fell.
I am very sorry for saying this. I am not trying to blame you. I can imagine how it must be
very hard to raise a baby and that you are trying your best to be a good mom. Everything
will settle, and we are all here for you to give you any kind of support that you'll need in this
process. However, you must be informed that it is my legal responsibility to report this to
the child protection services, whenever there is suspicion of a non-accidental injury.
o Oh my god, they will take away the child from me
  It is not always the case Mary. They will talk to you separately and assess your
condition. And if they decide that the child is safe with you or not.
 As of now our utmost priority is the safety of your child, and I know that as a good mother, that
you also want him to receive the best treatment that he needs.
 We have a lot of support for you during these times, and let me assure you that we will look after
your child.
 
KEY ISSUES
 Empathetic attitude to a distressed mother who is asking for help
 Recognition that suspected child abuse (NAI) is required to be notified by law in most Australian
states or territories
 Arranging for the child to be in a place of safety (hospital) for treatment, and arranging help for
the mother
 
CRITICAL ERRORS
 Failure to diagnose non-accidental injury
 Failure to advise necessity of hospital admission
 
IMPORTANT POINTS FROM THE COMMENTARY
 Must be alert to the possibility of NAI in any presentation where explanation for the injury does
not tally with the injury sustained or where there are unexpected or unexplained minor injuries.
 Report the suspected abuse to the relevant government departments who will investigate the
situation and arrange appropriate follow-up.
 A specific child abuse team may be involved
 Child must be placed in safety
 In cases of infants with fractures, this usually means hospital admission, while help is being
arranged for the family
o Further examination required to determine extent of injuries: skeletal survey and blood
investigations
 Our role: continuing support for the family while in the process of investigation
 
 
Condition 126 Heart murmur
 
You have just seen a healthy 5-year-old girl in a general practice. Her family recently moved to your
area, and her previous doctor said that she had a heart murmur and should be reviewed from time to
time. She is an active child, who has had occasional sore throats (about once a year). She is having a
dental check in one week's time. Her parents and 3-year-old brother are in good health and there is no
family history of heart disease.
 
Examination findings:
Active, well-grown child. Vital signs normal, blood pressure 100/65 mmHg (upper and lower limbs).
Pulse normal volume and rate. Apex beat easily palpable in 5th left intercostal space (LICS) in
midclavicular line. Systolic thrill palpable at lower left sternal border. Heart sounds normal. Second
sound at pulmonary area normally split. Long, grade 4/6, harsh systolic murmur heard, maximal at lower
left sternal border, widely conducted over the whole precordium.
Examination otherwise normal.

TASK:
Explain the likely diagnosis and your management plan to the parent.
 
APPROACH
Because the features of the murmur found in your child such as the presence of a thrill or a felt vibration
of the heart, and it is loud and harsh, it is most likely a murmur due to an organic or a defect in the
heart. Most likely your child has a condition called ventricular septal defect. I will be explaining to you
the condition and if you have any doubts along the way, please don't hesitate to stop me, and I will
explain it again to you.
The heart has four chambers: The two lower pumping chambers of the heart are called the ventricles,
and the two upper filling chambers are the atria. It is divided into left and right side by a wall called
septa and the connection between upper and lower chamber is maintained by a muscular band
structure called valves which allows the blood to flow from upper to lower chamber.
When blood circulates in the body, it enters the heart through the right atrium, passes through to the
right ventricle, and flows out through the pulmonary artery to the lungs, where it picks up oxygen and
gets rid of carbon dioxide.
From the lungs, blood returns to the left atrium and then enters the left ventricle, where it is
pumped to the body through the aorta, a large blood vessel that carries the blood to the smaller
blood vessels in the body.
 

When a person has a VSD, there's an opening in the septum between the right ventricle and the left
ventricle. This hole allows some of the blood in the left ventricle to go through the hole and back
into the right ventricle instead of out through the aorta. If the VSD is large, too much blood can
enter the lungs and may cause problems over time. The blood flowing through the hole creates an
extra noise, which is known as a heart murmur.
 
 
VSDs can be in different places on the ventricular septum, and they can be different sizes. Whether
a VSD causes any symptoms depends on the size of the hole and its location. Small VSDs usually
won't cause symptoms, and might close on their own, but this becomes less likely by the age of 5.
There's no concern that a VSD will get any bigger, though: VSDs may become smaller or close
completely without treatment, or they may not change. But they don't get any larger.
Older kids or teens who have small VSDs that don't close usually have no symptoms other than the
heart murmur. No restriction of activity is required and normal activities should be encouraged.
If there is a medium to large VSD, surgery may be necessary to close it. In most cases, this surgery
takes place in young children — usually in the first year of life.
But do not be stressed, because your child is growing well, is active, and is not experiencing
symptoms, these signs more likely suggest that it is a small defect and may not warrant an
operative closure.
 
However to confirm this, special investigations are required. I will refer you to a pediatric
cardiologist who might do a chest X-ray, which produces a picture of the heart and surrounding
organs, an electrocardiogram (EKG), which records the electrical activity of the heart, and an
echocardiogram (echo), which uses sound waves to produce a picture of the heart and to visualize
blood flow through the heart chambers. This is often the primary tool used to diagnose a VSD.
 
People with a VSD are at greater risk for developing endocarditis, an infection of the inner surface
of the heart caused by bacteria in the bloodstream. Bacteria are always in our mouths, and small
amounts get into the bloodstream when we chew and brush our teeth. The best way to protect the
heart from endocarditis is to reduce oral bacteria by brushing and flossing daily, and visiting the
dentist regularly. In general, it's not recommended that patients with simple VSDs take antibiotics
before dental visits, but this may be decided by the specialist.
 
KEY ISSUES
 Diagnosis of ventricular septal defect or diagnosis that this is an organic murmur probably a
congenital lesion.
 Referral to paediatrician or paediatric cardiologist.
 Explanation and reassurance.
 CRITICAL ERRORS
 Candidate regards this as an innocent functional murmur and does not recommend referral.
 
IMPORTANT POINTS FROM THE COMMENTARY
 This case features a healthy 5-year-old child who is being reviewed prior to dental check-up.
She has a known murmur considered innocent, but a careful cardiological examination points
to a pathological murmur due to a potentially serious heart condition, most likely ventricular
septal defect (VSD).
 Knowledge of the key clinical features of childhood cardiac murmurs is expected.
 Explanation of the indications for prophylactic antibiotic in the presence of a heart murmur is
also required.
 Heart murmurs are common in children and over 40% of healthy 4-year-olds may have a soft
innocent heart murmur if careful auscultation is carried out. The medical practitioner
therefore must recognise the features that distinguish innocent from significant murmurs.
 The presence of a loud pansystolic murmur with a thrill indicates an organic lesion and
warrants investigation. The echocardiogram, a non-invasive investigation, is usually able to
clearly define the lesion and no other investigations are necessary. However, most
cardiologists also perform an ECG and chest X-ray as part of the workup.
 A small VSD may be so small as to not warrant any surgical closure as it is not
hemodynamically significant and will cause no clinical problem to the patient. However, the
patient and family must be warned and constantly reminded of the need for appropriate
antibiotic prophylaxis for any operative or dental procedure.
 All doctors caring for children must be cognisant of the features of an innocent murmur and
the important differences between a functional and an organic murmur.
 
 
Condition 127 Vigorous vomiting by a 3-week-old
 
You have just seen a 3-week-old baby boy in a metropolitan general practice office consultation. He is
the firstborn son of healthy parents, and has been breastfeeding vigorously. Two days ago he vomited
for the first time and yesterday, his parent said, "the vomiting went everywhere… I've never seen a baby
vomit like that." The vomiting has continued so that he is now vomiting soon after every feed, yet he
seems hungry all the time
 
Examination findings you have elicited are
Well-nourished baby
Temperature: 37C
Pulse 140/min
Respiration 48/min
Upper abdomen distended during feeding
Gastric peristaltic waves are seen passing from left to right across the upper abdomen
No mass palpable
No signs of dehydration
No other abnormality
Large, forceful vomit of milk immediately after the feed
 
TASKS
1. Explain your suspected diagnosis and your management plan for the parent
 
APPROACH
 Based on the history, examination, and investigations, it seems that most likely your child has
what we call Pyloric Stenosis. Have you heard about this? Sorry for using a medical term but let
me explain this to you. But before I continue, do you want me to call someone to be with you as I
explain the diagnosis? Or is it ok to continue?
 [ILLUSTRATE] Normally, the milk goes to the mouth through a tube like structure called a food
pipe, to the stomach. The lower end of the stomach is called pylorus (sorry for using medical
terms). From this stomach, the milk then goes to the small gut. Sometimes, due to some unknown
reasons, in some infants, the lower end of the pylorus get narrowed. It might be due to thickening
or tightness of the muscle layer in that pylorus. That’s the reason why the milk or whatever the
child drinks, do not pass down to the small gut and the child vomits it out. And because the
stomach is not full after vomiting, the child feels hungry after every feed. I can tell that your child
is suffering from this because of the symptoms and signs that he presented--forceful vomiting, still
hungry after feeding, not gaining weight, and the feeling of having a lump in the tummy while
feeding. Unfortunately, the exact cause is unknown.
 At this stage, you have to be aware that this is an emergency condition and is related to life-
threatening complications. But don't stress yourself, as it is good that we caught it early.
 I will call the ambulance now and, arrange for the PIPER TEAM(pediatric emergency transfer
system) to oversee the transfer of your child to the hospital so that he can be seen by a specialist.
In general, the treatment involves first stabilizing the current condition of the child by correcting
any imbalances of his electrolytes--or the factors that maintain salt and water balance in the body
as he's been constantly vomiting, and then assessment and management by a possible surgery by
relieving the tightness of the pylorus of the stomach. As we are waiting for the ambulance, I will
 insert two IV lines on him and draw some blood to check for his electrolytes and blood gases, and
start him on IV fluids. For now I need you to stop feeding him by mouth temporarily as it may
worsen his condition. I will pass a small tube through the nose into the food pipe (sorry for using
medical term), it's called nasogastric tube, to remove the excess milk in the stomach and prevent
further vomiting (to decompress the stomach). Confirmation of this condition will also be done in
the hospital by doing test feeding, but may also require further investigation by ultrasound or a
barium meal (BARIUM MEAL HAS THE RISK OF VOMITING AND ASPIRATION).
 Pyloromyotomy is usually done to correct this condition after he is adequately rehydrated and
corrected of his electrolyte imbalances. Again, sorry for the medical terms but let me explain
these to you. [ILLUSTRATE] In this procedure, the thickened pylorus is split surgically down enough
to relieve the obstruction (split down to the mucosa but not through the mucosa). This treatment
resolves the problem very effectively. This will be done under anesthesia and is basically a pain
free procedure. This procedure will be done by an experienced surgeon, and the anesthesia done
by an anesthetist specially skilled to handle very young babies. Do you understand so far?
 After the surgery, your baby will be able to feed again within a few hours. He may have to have
the IV line for 24 hours to support his hydration. Generally, if everything goes well, he might be
discharged after 24 hours or based on specialist advise.
 In the meantime, if you have another child, I can arrange for a social worker to take care of her.
Do you need me to call anyone or your partner so that he can be with you right now?
 I will arrange a lactational nurse to teach you how to express your milk and how to store it for
now.
 [ If she cries, pause for some time, offer tissue, water] I understand that this can be very
distressing for you, but let me assure you that there is a lot of support for you and for your family
in this time of crisis.
 
When can I start breastfeeding? = it depends upon the specialist advise. In most of the time,
breastfeeding is started 24-48 hours after the surgery. And you may be able to go home 24hr after
the surgery. Again it depends on the progress of the child and specialist advise.
 
KEY ISSUES
 Diagnosis of pyloric stenosis
 Early referral to hospital/pediatric surgeon
 Explanation in clear terms of the condition
 
CRITICAL ERRORS
 Failure to diagnose pyloric stenosis
 Failure to refer to hospital or pediatric surgeon for assessment
 
IMPORTANT POINTS FROM THE COMMENTARY
 Pyloric stenosis: forceful/projectile vomiting + the baby appears hungry all the time + sudden
onset but severe
 Progression of disease: vomiting => progressive dehydration => electrolyte imbalance => lethargic
and disinterested in feeding
 Common DDx and how to rule them out
o Reflux = vomiting is NOT persistent
o UTI = associated with fever and an unwell infant
 Management
 o Clinical exam: test feed must be done--look for active peristaltic waves traveling from left to
right across the upper abdomen. The best time to feel the tumor is when the wave reaches
the right side of the abdomen, and is commonly felt after the baby has vomiting
o Investigations:
 NECESSARY: ELECTROLYTE AND ACID/BASE STATUS
 HYPOCHLOREMIC HYPOKALEMIC ALKALOSIS: corrected BEFORE surgery
 Other: ultrasound and barium swallow (though other hospitals are against this
because it can cause aspiration)
 See STRING SIGN of a narrowed pyloric canal
o Intervention
 Effective: Ramstedt Pyloromyotomy - thickened pylorus is split surgically down to the
mucosa but not through the mucosa.
o Advised that the baby is able to resume feeding soon after the surgery and can be
discharged within 24 hrs after the surgery.
 Often associated with a strong family history, which if present, should alert the clinician to the
possibility of this diagnosis
 
 
 
Condition 136 Fever, irritability, ear discharge
 
Alexander is a 2-year-old boy who presents to the general practice office with an acute febrile illness. He
has had a runny nose for a few days and has become febrile and irritable over the past 24 hours. He did
not sleep well the previous night and has vomited twice today. Shortly before presentation his mother
noticed a discharge from his right ear. There is no past history of significant illness.
 
Examination findings:
On examination he is febrile (temperature 38.8 °C) and flushed. There is clear rhinorrhoea.
The right ear canal is full of pus. The left eardrum is intensely red and bulging as illustrated. He has no
neck stiffness.
There are no other abnormal physical signs.
 
TASKS:
1. Explain the likely diagnosis to the parent.
2. Explain to the parent the management you would recommend.
 
You have obtained all the relevant findings on history and examination.
 
APPROACH
From the history and examination, most likely your child has a condition called acute otitis media. This is
a common childhood illness, and is often preceded by a viral upper respiratory tract infection.
I will explain to you the condition, and if you have any questions along the way, please don’t hesitate to
stop me and I will explain it to you again.
 
The ear is made up of three parts. The outer ear includes the part you can see and the canal that leads
to the eardrum. The middle ear is separated from the outer ear by the eardrum and contains tiny bones
that amplify sound. The inner ear is where sounds are translated to electrical impulses and sent to the
brain.
Any of these three parts can become infected by bacteria, fungi or viruses.
 
A middle ear infection usually happens because of swelling in one or both of the eustachian tubes, the
tubes which connect the middle ear to the back of the throat. The tubes let mucus drain from the
middle ear into the throat.
A cold, throat infection, acid reflux, or allergies can make the eustachian tubes swell. This blocks the
mucus from draining. Then, viruses or bacteria grow in the mucus and make pus, which builds up in the
middle ear.
 
Sometimes, if the pressure from the fluid build-up gets high enough, it can rupture the eardrum, with
fluid draining from the ear. This spontaneous drainage of the middle ear after perforation of the ear
drum/tympanic membrane leads to relief of pain and resolution of fever. Do not be stressed, the hole in
the tympanic membrane is usually small and heals spontaneously within a few weeks in the majority of
cases. Most children do not have significant, long-term deficits in hearing, but we could arrange for a
hearing test following healing of the drum to check this.
 
Ear pain is the main sign of a middle ear infection. Kids also might have a fever and trouble eating,
drinking, or sleeping because chewing, sucking, and lying down can cause painful pressure changes in
the middle ear. They are also often seen
tugging at the ear and are fussy and cry more than usual.
 
I will give your child Panadol for the relief of pain, and high dose oral antibiotics to clear out the
infection. Usually acute otitis media will resolve without antibiotics but the presence of a purulent
discharge from the right ear and a bulging left eardrum in your child necessitates its use in this case. We
could also get a sample of the discharge and send it for culture and sensitivity. You also can do gentle
ear toilet, which is with a cotton bud, remove excess discharge from right ear, so that the ear is kept dry.
I will give you reading materials for further insight, and I will arrange a review with you in one week for
further examination and inspection of the right eardrum. If the perforation does not heal spontaneously,
I will refer you to the ENT specialist. If your child is not eating well, not feeding well, drowsy, then see
me immediately. When the drum has healed, we could do a hearing check in 8 weeks time.
 
KEY ISSUES
 Management of acute otitis media in childhood.
 Ability to achieve rapport with anxious parent, who is blaming herself as she feels her inaction has
compromised her child's hearing permanently.
 
IMPORTANT POINTS FROM THE COMMENTARY
 While this scenario addresses otitis media, a common condition in young children, the important
issue to be addressed as well is the guilt the parent feels (inappropriately) that her inaction has
caused her child to be permanently deaf. This is not the case and spontaneous perforation is quite
common. Reassurance that this can occur in any case of otitis media, and often is beneficial in that
it relieves symptoms of pain and discomfort immediately should be emphasised. By the end of the
consultation, these fears of the parent should be allayed by appropriate reassurance.
 Perforation does not necessarily mean major damage to the tympanic membrane, which generally
heals completely without any hearing loss or damage to the middle ear. In this case, there is
evidence of significant infection in the other ear and antibiotics are considered appropriate in this
case. Gentle ear toilet with cotton buds to remove excess discharge is all that is necessary for the
right ear and antibiotic drops are not necessary. The parent should be cautioned about vigorous
cleansing of the external canal.
 Most cases of otitis media in young children have a viral aetiology and antibiotic therapy is usually
unnecessary. Otitis media is usually part of a generalised upper respiratory tract infection. While
the condition usually resolves completely without any sequelae, it is appropriate to review for any
complications and to arrange for a hearing test, especially if the parents feel that his hearing does
not seem normal following the illness. They should be counselled to present him again if this is the
case.
 If antibiotics are to be used, it is important to ensure that an appropriate drug is used in adequate
dosage.
 
 
Condition 143 Spontaneous bruising and nosebleed
 
You are working as an intern Hospital Medical Officer in a country base hospital. Robert, a 3 year old
boy, who had a cold two weeks ago, from which he has recovered, has come to see you for review. Over
the last few days his parents have noticed widespread unusual bruising of his skin. He had a small
nosebleed yesterday and he was brought to see you then.
 
Brief inspection showed an alert well developed 3-year-old. Numerous fresh bruises were noted on the
trunk and limbs and on his hand as illustrate below, and scattered petechiae were noted between the
bruises, maximal on the lower limbs. Vital signs were normal. You found no hepatomegaly or
splenomegaly and no lymphadenopathy. You arranged for an urgent full blood examination and he and
his mother have returned today to discuss the results, which are shown below.
 
Report: Full blood examination
Hemoglobin: 125g/L (100-145 g/L)
No abnormality of the red cell series is seen
White cell count
Total count 11.2 x 10^9/L (7-14)
Differential count normal for age
No immature white cells seen: white cell morphology normal
Platelets: 15 x 10^9/L (160-250 x10^9)
Comment: the platelet count is greatly reduced.
 

 
TASKS
1. Outline your provisional diagnosis and discuss your plan of management with the parent
 
APPROACH
 Good morning/Evening. I understand that you are to discuss Robert's blood test results. From the
history, physical examination, and investigation findings, it seems that your child has a condition
called Acute thrombocytopenia. I'm sorry for using a medical term, but let me explain this
condition to you.
  [ILLUSTRATE] Normally, we have three types of blood cells and each has its own respective
functions. We have red blood cells which carry oxygen in the body with the help of the pigment
called hemoglobin. We have white blood cells which fight against infections. And we have
platelets or thrombocytes that prevents bleeding. As shown here in your child's blood test results,
we could see that his RBCs and WBCs are normal in number, however, the platelet count is greatly
reduced. We call this sudden reduction of the platelets or the thrombocytes as, acute
thrombocytopenia. Do you understand so far?
 Because of this reduced number in platelets that prevents bleeding, our body then tends to bleed
easily especially in our smallest blood vessels which tend to be present near our skin. That is the
reason why there is collection in the blood in the skin called bruises, present in your child. This
reduction may have also triggered his nosebleed episode yesterday.
 This condition may have several causes, but in Robert's case, most probably this was triggered by
the previous viral infections that he had. In any viral infection, our body produces some chemical
substances called ANTIBODIES, which fight against the bugs. But in this condition, due to some
unknown reasons, these anti-bodies tend to act on the platelets, affecting their number and
function in the body. Overall we call this condition as Idiopathic Thrombocytopenic Purpura, sorry
again for using a medical term. But let me reassure you that it is a self-limiting condition which
means that this will resolve spontaneously.
 At this stage, I will arrange a hospital admission for observation as there is risk of spontaneous
bleeding anywhere in his body in the early phase of the disease. Most of the times it resolves by
itself but he might need steroids or immunoglobulins if he develops active bleeding while
admitted. But let me reassure you again, it has a good prognosis, with patients having 90%
resolution, and 75% achieving this over a 4 to 6 week period. In a further 10-15%, resolution
occurs in up to 6 months.
 For now, he needs to avoid playing contact sports or very vigorous physical injuries as a simple
injury may cause significant bleeding. I will also inform the hospital to avoid inserting IV or giving
him IM injections for now as these may also cause significant bleeding.
 In some cases that this condition goes on for more than 6 months, or if it recurs, I might need to
refer him to a specialist who can assess him further just to rule out other possible bleeding
disorders. In some cases where the condition seems to keep on recurring and is unresponsive to
medications, management may include a procedure called splenectomy or removal of the spleen
as this serves as the reservoir of blood cells in the body.
 I will give you reading materials to give you more insight about his condition. Rest assured we will
do what we can to provide the best care for your child.
 
KEY ISSUES
 Explanation of diagnosis of acute thrombocytopenia and its management
 
CRITICAL ERRORS
 Making a diagnosis of leukemiaon the basis of the blood test
 Indicating a poor prognosis for the condition
 
IMPORTANT POINTS FROM THE COMMENTARY
 Assesses the knowledge in relation to the condition of isoimmune thrombocytopenia of childhood
 Recognise that the only abnormality is the low platelet count hence making more sinister
pathology unlikely
 Adequate discussion of possible causes and the methods of treatment should follow
 Able to reassure the parent that there is a very unlikely possibility of any other pathology and
should also be able to indicate that the natural history of this condition is of spontaneous
remission and resolution in over 90% of cases.
 If this condition recurs, this should indicate a need for further investigation to exclude conditions
like lupus
 Hospital admission
o Platelet count very low
o Actively bleeding
o Parental concern about complications or alternative diagnosis is high, as in this case
 Candidate will be assessed on the manner of reassurance given to the parent of her worry that her
child has leukemia