Pediatrics

ARIMGSAS
Pediatrics:
Normal Developmental Delay .....................................................................................................1
ADHD ........................................................................................................................................4
Domestic Violence ......................................................................................................................6
Respiratory Distress Syndrome ...................................................................................................8
Sudden Infant Death Syndrome ................................................................................................. 11
Breastfeeding ............................................................................................................................ 14
Quinsy/Peritonsillar Abscess ..................................................................................................... 17
Acute Tonsillitis ........................................................................................................................ 20
Periorbital Cellulitis .................................................................................................................. 23
Recurrent Otitis Media .............................................................................................................. 26
Strabismus ................................................................................................................................ 30
Head Injury ............................................................................................................................... 32
Urinary tract infection ............................................................................................................... 40
Gastroesophageal Reflux ........................................................................................................... 47
Pyloric Stenosis......................................................................................................................... 50
Congenital Adrenal Hyperplasia ................................................................................................ 55
Duodenal Atresia ...................................................................................................................... 58
Testicular Torsion ..................................................................................................................... 62
Incarcerated Hernia ................................................................................................................... 66
Intussusception.......................................................................................................................... 69
Acute Otitis Media .................................................................................................................... 72
Perthes disease .......................................................................................................................... 83
Irritable hip/ Transient synovitis ................................................................................................ 86
Slipped Capital Femoral Epiphysis ............................................................................................ 88
Osgood Schlatter Disease /Chondromalacia patellae/ Patellar Tendinitis ................................... 90
Developmental Dysplasia of the Hip ......................................................................................... 92
Osteomyelitis ............................................................................................................................ 94
Henoch Schonlein Purpura ........................................................................................................ 96
Hereditary Spherocytosis .......................................................................................................... 98
Pancytopenia ........................................................................................................................... 101
Post Chemotherapy Fever........................................................................................................ 104
Cryptorchidism/Umbilical hernia/Inguinal hernia .................................................................... 107
Down Syndrome Counselling .................................................................................................. 110

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Immunization advice ............................................................................................................... 112
Post-splenectomy case............................................................................................................. 116
Constipation ............................................................................................................................ 121
Recurrent Abdominal Pain ...................................................................................................... 124
Encopresis............................................................................................................................... 128
Acute abdomen ....................................................................................................................... 131
Abdominal Pain - IBD vs Coeliac Disease............................................................................... 134
Varicella ................................................................................................................................. 151
Roseola ................................................................................................................................... 153
Erythema Infectiosum ............................................................................................................. 155
Scarlet fever ............................................................................................................................ 158
Kawasaki disease .................................................................................................................... 160
Herpes Stomatitis .................................................................................................................... 162
Septicaemia ............................................................................................................................. 165
Septic workup counselling ...................................................................................................... 170
Meningococcal septicaemia ..................................................................................................... 172
Erythema toxicum neonatorum (Normal baby rash)................................................................. 174
Nappy rash .............................................................................................................................. 176
Immune thrombocytopenia...................................................................................................... 178
Acute Heart Failure ................................................................................................................. 181
Cardiac Failure........................................................................................................................ 183
Functional murmur .................................................................................................................. 187
VSD ........................................................................................................................................ 190
Nephrotic syndrome ................................................................................................................ 193
Poststreptococcal Glomerulonephritis ..................................................................................... 197
Enuresis .................................................................................................................................. 199
Vulvovaginitis......................................................................................................................... 203
Migraine ................................................................................................................................. 209
Tension headache .................................................................................................................... 211
Viral URTI.............................................................................................................................. 213
Increased ICP .......................................................................................................................... 216
Increased ICP - Space-occupying lesion .................................................................................. 220
Bronchiolitis ........................................................................................................................... 225
Asthma ................................................................................................................................... 233

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Croup ...................................................................................................................................... 237
Epiglottitis .............................................................................................................................. 243
Laryngomalacia ...................................................................................................................... 246
Post-viral Cough ..................................................................................................................... 248
Pertussis .................................................................................................................................. 250
Simple URTI........................................................................................................................... 253
Infectious Mononucleosis ........................................................................................................ 255
Foreign Body .......................................................................................................................... 257
Conjugated hyperbilirubinemia ............................................................................................... 264
ABO Incompatibility............................................................................................................... 268
Hereditary Spherocytosis ........................................................................................................ 270
Galactosemia........................................................................................................................... 272
Breastmilk jaundice................................................................................................................. 273
Acute Gastroenteritis ............................................................................................................... 275
Toddler's Diarrhea................................................................................................................... 282
Salmonellosis .......................................................................................................................... 284
Haemolytic Uremic Syndrome ................................................................................................ 286
Pinworm ................................................................................................................................. 288
Autism Spectrum Disorder - Asperger's Syndrome .................................................................. 294
Absence seizures ..................................................................................................................... 296
Sexual Identity - Homosexuality ............................................................................................. 298
ADHD .................................................................................................................................... 300
Oppositional Defiant Disorder ................................................................................................. 301
Breath holding Attack ............................................................................................................. 303
Headbanging ........................................................................................................................... 305
Brief resolved unexplained event............................................................................................. 307
Head Injury ............................................................................................................................. 310
Celiac Disease ......................................................................................................................... 316
Oral Thrush ............................................................................................................................. 319
Asthma ................................................................................................................................... 322
Cystic Fibrosis ........................................................................................................................ 326
Short Stature ........................................................................................................................... 329
Cerebral Palsy ......................................................................................................................... 332
Allergic Rhinitis ...................................................................................................................... 335

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Eczema ................................................................................................................................... 337
Egg Allergy............................................................................................................................. 339
Breastfeeding/Bottle-feeding ................................................................................................... 342
Advice on Neonatal Circumcision ........................................................................................... 344
Hearing impairment ................................................................................................................ 346
Counselling a family after SIDS .............................................................................................. 348
DM Type 1.............................................................................................................................. 350
Jaundice in a breastfed infant .................................................................................................. 353
Convulsion .............................................................................................................................. 356
Loud and disruptive behavior of a 6-year old boy .................................................................... 358
Neonatal Jaundice in the first day of life.................................................................................. 363
Immunization advice ............................................................................................................... 365
Dark urine, facial swelling, and irritability .............................................................................. 368
Fever and sore throat ............................................................................................................... 370
Fecal soiling ............................................................................................................................ 372
Bedwetting .............................................................................................................................. 375
Dandruff or head lice .............................................................................................................. 378
Severely ill with fever ............................................................................................................. 380
A lethargic febrile ................................................................................................................... 382
Wheezing and breathing difficulty........................................................................................... 384
Several bone fractures ............................................................................................................. 387
Heart murmur.......................................................................................................................... 390
Vigorous vomiting by a 3-week-old ........................................................................................ 393
Fever, irritability, ear discharge ............................................................................................... 395
Spontaneous bruising and nosebleed ....................................................................................... 397

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Normal Developmental Delay

You are in GP, Jane bring 21-month-old baby boy to see you. She's
concerned because in her day group, David is the only one in his group
who is not walking.

TASKS
1. Further focused history
2. Physical examination findings from the examiner
3. Explain the condition
4. Outline the management

Differential Diagnosis
▪ Global developmental delay
▪ Specific delay in walking
▪ Cerebral palsy

Developmental milestones

Can say about 25 words

I understand that you are concerned because your child is not yet
walking, can I ask a few more questions? When did he lift his head (2-3
months)? When did he start sitting with support (6months)? Without
support (8 months)? Can he stand while holding on to things? Can he
hold things with his hand and pass it from one to the other? Pincer
grasp? When did he speak his first word? Does he turn around when
you call his name or too loud sounds? Does he play peek-a-boo? Does
he play with other children? Can he indicate what he wants (15
months)? Can he drink from a cup (17 months)? Has he been
developing normally; can I see his growth chart? Do you have other
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kids? How would you compare their development?

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Any problems during your pregnancy? Have you ever been sick while
pregnant? How was the delivery? Were there any complications? Did
they do the heel-prick test? Does he get sick often since birth? Is
immunization up-to-date? Is he eating well? Any problem with
urination or bowel? How are things at home?

Physical Examination
General appearance, is there any scissoring of legs?
Vital signs
Growth chart
Neurologic examination: IT PRC (inspection, tone, power, reflex,
coordination)
• Increased peripheral reflexes

Management:
Majority of kids who are walking with support or can stand on their
own, they are statistically delayed but not pathologically abnormal.
Children who are quite large will not be quick with walking. At 21
months, in the absence of PE findings, we cannot fully say that he is
delayed. A most useful thing that's going to happen next is to observe
his progress.
***If with positive PE findings, cerebral diplegia - motor deficits only,
other aspects of development are okay;
It doesn't appear that he has a major problem. It may be that he is just
a bit slow to walk. Let us observe for progress but I can refer him to a
physiotherapist to help with his walking delay and I will review child in a
few month’s time. If he doesn't get better in a few months after he's
been to the physiotherapist, we can refer him to a pediatric specialist
to get him checked out.
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if there are other areas of delay, it may be Global Developmental delay

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ADHD

Sally Brown comes to see you in your GP with her 3-year-old Ava. Sally
is concerned about the behaviour of Ava, as well as her child care
teacher. She's having periods of destructive behaviour, damages toys in
her surroundings, gets frustrated easily and she's been noted to be
running around actively. She has a 5-year-old sister, Joan who is quite
different.

TASKS
1. History from Sally
2. Explain Diagnosis and Management

HISTORY
▪ Birth history
o Antenatal history
o Delivery
o Neonatal

▪ Home situation and family history

▪ Vision and hearing testing is done before

What are you going to tell mom? What is management?

Ask to talk to or get information from childcare. Is it possible that the
child is being bullied? What is her behaviour in child care? Ask about
how they handle it at home. How are they dealing with it in child care?
With your permission, I would like to contact childcare. And then you
would say, Sally, I think that one of the possibilities she is going to
develop ADHD. Apart from getting more information from child care, I
would like to refer her to a paediatrician. The first point of referral is
paediatrician they handle 95% of psychological and learning difficulties
in children. That’s the usual first point of call. If they're at school, the
school psychologist or special services department will be the first point
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of call. If they haven't had hearing and vision tests done, that's the next

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referral. It’s a matter of behavioural management. What are the things
you suggest or key principles in behaviour management? Get an
overview, what are the top 3 problems that you would like to address?
Question from the mother: one is medication, second is diet.
Ritalin is effective but not for a 3-year-old.

I understand that you brought Ava in because she's being very active
and destructive in daycare. Is that correct?
Developmental history
Differentials:
Autism - is she friendly? Does she like being cuddled? Does she
have repetitive behaviour? A most common presentation is
language delay.
I don’t think that she's too bad, and I'm confident that we could deal
with this effectively.

Essentials for making a diagnosis of ADHD

See the pattern of behaviour in more than 1 setting
Often worse in crowds or noisy settings

Management: Do assessment scales, get paediatrician involved,

structure the environment, behavioural modification at home,
minimize distractions, develop set routines

About 2.5-5% have ADHD

Amphetamine and Ritalin prescribed for ADHD, it stimulates the brakes

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Domestic Violence

You are a GP and an 8-year-old boy was brought by mother because of

slow progress at school recently.

TASKS
1. Take a history from the mother
2. Manage then case

Differential Diagnoses:
▪ ADHD
▪ Autism
▪ Trauma
▪ Infection
▪ Social
▪ School
▪ Home

APPROACH
▪ History
▪ Management

Sally based on my history, I've noticed that there's a lot of stress at

home that might be affecting your child's performance in school. I
will deal with that and explain to you what we can do about your
child. But first, I would like to tell you that you are a strong woman,
and I'm glad that you came here for help. Nobody deserves to be
hit or abused. I can see that you are in a very difficult situation, but
we are here to help you.
First of all, if you think that you are in immediate danger, with your
consent, I can call the police for you.

No, I don’t want to call the police.

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 You know you have an option. With your consent, I can refer
you to a domestic violence service and they can offer you
temporary shelter and financial support. How would you feel
about that?

I don't want to leave home.

We can make a safety plan, but first I would like to tell you that
I will notify that child protection services for the well-being of
your child.
Talk to your neighbour and if they think something is going on,
they can call the police. There is also the Daisy app, and when
something is going on, you can dial it and it calls straight to the
police.
Put some money also in a safe place where you can access it in
times of trouble.

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Respiratory Distress Syndrome

You are an HMO of the paediatric department in a rural hospital.

Victoria gave birth at the age of 32 weeks of gestation. The baby with
birth weight 1.9 kg, now the baby developed respiratory distress and no
cyanosis. Now the baby is stabilized with hood oxygen of 40%.

TASKS
1. Explain the condition to mother
2. Further management

If comes with history taking:

▪ Pregnancy: how was the pregnancy? Why preterm? Any PROM?

Steroids given? Antibiotic prophylaxis given for PROM? TORCH

infection? Drugs? Alcohol and smoking? Is swab test done?
▪ Delivery questions: how long? What presentation? APGAR score?
▪ Postnatal: when was the child born?
▪ When did the tachypnoea start? What did the child pass

meconium?
▪ What is child feeding? Is the child breastfed/bottle-fed? Frequency,

amount?
▪ How many hours do they sleep (up to 21 hours)?

Physical Examination:
Vital Signs:
RR: 40-60
HR: 120-160
Temp: 36-37
Sats O2: 98-100
BP: low (cardiac output = total peripheral resistance x HR) in
babies HR high, so low total peripheral resistance
General appearance
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Pale: anemia, constitution

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 Cyanotic: decrease the partial pressure of oxygenation,
increase the partial pressure of CO2
Any respiratory distress
Chest
• Inspection: shape, deformities, movement, symmetrical
(asymmetrical - one-sided pneumothorax or
hemothorax); signs of distress: nasal flaring, intercostal
recession, subcostal recession, trachea tug
• Auscultation: breath sounds - vesicular (bronchial
breathing, crackles is snapping open and close of the
alveoli, wheezing - turbulent flow through a decreased
diameter of the small airways like bronchiole); heart
sounds - murmur (turbulent flow)

Explanation:
• I understand that you are so concerned about your child, but I
would like to assure you she is stable now since we have given her
oxygen by mask. Would you like some water and tissue?
• I will explain to you about her condition. Your child has some
problem with breathing. It can be due to many causes but one of
the main causes and most likely cause in your child's case is the
immaturity of the lungs leading to a problem with the expansion
of the lungs. Normally, babies delivered after 34 weeks of
gestation, their lungs are mature enough to take the burden of
the outside environment. But in your case, since you delivered
your baby at 32 weeks, the lungs of your baby are not yet well
developed and there is a problem with the expansion of the lungs.
• This condition we call respiratory distress syndrome or hyaline
membrane disease. But there can be other causes like infection,
the stress of the delivery, among others.
• But since we are in a rural hospital, we have done everything to
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stabilize your child with the facilities available here, but babies
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 with respiratory problems need to be transferred to a tertiary
hospital where there is an intensive care unit available and
specially trained nurses and doctors that could provide adequate
care for your baby.
• I will liaise with the tertiary care hospital and inform the specialist
about your child's condition so that everything can be made ready
once you are transferred there. For your transfer, we have the
PIPER team who is composed of specially trained nurses and
doctors who can take care of your child while in transit. In the
tertiary hospital, the baby might be given artificially a substance
called surfactant most probably through the nose to keep the lung
expanded, but it would be decided by the specialist. At this stage,
do not feed the child, we will maintain the nutrition through IV
fluids.
• We will also take blood for investigations such as FBE, UEC, LFT,
TFT, CRP, ABG and blood culture. We will also give the first dose
of an antibiotic after the discussion with the specialist in the
tertiary centre. We might also do an x-ray of the chest, to rule out
other causes and to confirm the diagnosis. Please do not stress
yourself, exposure to radiation is not very high and will be
appropriated with the child's weight. In the meantime, if you want
me to call someone, I am happy to call your partner. Do you have
enough support?
• Can I go with the child doctor? It depends on your condition and
the obstetrician advice. If the obstetrician is happy to let you go,
then we can make all the arrangements for you to go with the
child.
• I would like to reassure you that many premature babies are
doing good after treatment has been instituted. We will do our
very best to manage your child's condition.
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Sudden Infant Death Syndrome

You are a GP. A mother of 6 weeks old newborn here for consultation
with you. Her neighbour had lost their 4 months baby due to SIDS and
she was concerned about it.

TASKS
1. Take History for 4 minutes
2. Counsel about her counsel

Positive points in history:

She and husband both smokers. Usually smokes outside sometimes in
the hall. Baby sleeps in their room in a separate cot. Immunize happy
to do. And is breastfeeding

APPROACH
History
Sorry to hear about your neighbour’s baby.
I know you are concerned about it. But before explaining about it, will it
be alright if I ask you a few questions?
▪ Pregnancy questions
o How did the pregnancy go? Any complications?
o Did you have any DM, hypertension, infections during
pregnancy?
▪ Delivery questions
o How was the delivery? At what term? Mode of delivery? Did
the child cry after birth? Did the child had to prolong
hospitalization after birth? Jaundice? Prematurity?
▪ Immunisation: have you started the child immunization?
▪ Nutrition: Breastfeeding? Or bottle feeding? How is the feeding
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going on? Is the child feeding well? any issues with nappies?
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Bowels? Gaining weight?

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 ▪ General health: Any fever? Rash?
▪ Development and Social History
o How coping? Happy family?
o Smoking and alcohol history of her and partner?
o Sleeping position of a child? Sharing of the cot? Do you all
sleep together on the same bed?
o How does the baby sleep, over the back or over the tummy?
Do you have a separate bed for the child? In the baby’s bed
have you kept anything around like toys?
▪ SADMA
o Do you use alcohol, illicit drug? Smoking?
▪ How is your mood?
▪ Do you have enough support?

COUNSELLING
I will be explaining to you the condition, SIDS is also called cot death
and it is one the major cause of death of a child under the age of 1 yr.
most of the time, the cause of the condition is not known, but there are
some risk factors that can be modified to prevent the occurrence.

Please continue breastfeeding. It is good that you have an opinion

about immunization and help to prevent life-threatening infection

Smoking is one of the risk factors. passive smoking is one of the risk
factors
I will arrange another appointment to talk about quitting smoking.
Please think about it as it is for the betterment of your child.
There are a few things that you need to take care of when the child is
sleeping. Do not sleep together. Wrap the child properly but the head is
exposed. Ensure the baby not overly covered, since hyperthermia is a
risk factor. Place the baby in the supine position (on his back) with no
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pillows or toys around the cot. Place the child in a separate bed.
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Whenever the child is active, put the child in a prone position under
supervision. (tummy time)

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Breastfeeding

You are a GP in a small country town, and you are doing a house call at
a 24-year-old Mary Spock who delivered her first baby 12 hours ago
with the help of a midwife at home. Everything went well but she is
concerned about breastfeeding and seeks your advice on how to go
about because she is keen to breastfeed for as long as possible.

TASKS
1. History for not more than 2 minutes
2. Counsel her regarding breastfeeding
3. Answer her questions

▪ History
o Congratulate the mother on her delivery
o Pregnancy questions
o Delivery questions
o Breastfeeding questions

• Have you started breastfeeding? Do you have any

problems with it? During antenatal visits, were you

diagnosed with an inverted nipple? Was that addressed?
• Contraindications to breastfeeding: Were you diagnosed

with any HIV, chronic diseases?

o Ask about mood to rule out post-partum blues
o Do you have good support?

▪ Management
o I appreciate that you came here to take advice regarding

breastfeeding. I will explain to you everything. If you have

questions, just stop me anytime.
o I will tell you about the advantages and disadvantages of

breastfeeding.
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• Baby
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▪ Protects against bugs: rotavirus

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 ▪ Decrease the risk for celiac disease, IBD
▪ Babies who are breastfed, are protected from an

allergic reaction. Babies who are formula-fed can have

allergies from the contents of the formula
• Mother
▪ Increases bond between mother and baby
▪ The less economic burden to the family
▪ Available every time
▪ Also, help in your weight reduction to pre-pregnancy

state when baby starts suckling the breast, a hormone

gets released called oxytocin which helps in bringing
the uterus size back to pre-pregnancy size
▪ It also decreases the level of some hormones like

cortisol in blood thereby decreasing the incidence of

mood disturbance after delivery in mother.
▪ Acts as a protective factor for breast cancer
▪ Exclusive breastfeeding can also to some extent act as

a contraception
o The best feed for the baby is breast milk. The breast milk varies
in composition from morning to afternoon and from 1st
amount to the last amount.
o In the beginning, it contains water and the end more fat. In
morning waterier and lunchtime more, fat
o For cracked nipple: there are some special classes at the
hospital to prepare the nipple during the last 2 months of
pregnancy. (if a pregnant woman is in the stem
o If you are using as medication during breastfeeding you need
to contact your GP regarding it as the medication can go baby
through breast milk
o At the beginning you should breastfeed on demand and the
baby gest adjusted gradually for 48-72 hours, then it will be 2-5
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o Working: can continue breastfeeding: you can express and
keep the milk in the fridge for 1-2days. If breastfeeding is not
enough any time you can add or top up baby. You can keep
breast milk for 2 weeks in the freezer and 3 months in a deep
freezer.
o Important in preparation
• Washed clean with a bottlebrush
• Stored in solution (Milton)
• Use cooled boiled water
• Follow the instruction
• Made up at one time for the day's requirement
• Only one day's feed prepared in advance
o Sometimes you can use both as supplementary or combination
o You can give bottle feeding while you are working

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Quinsy/Peritonsillar Abscess

Your next patient in GP practice is a 14-year-old girl complaining of sore

throat.

TASKS
1. History
2. PE from examiner
3. Diagnosis and Management

Differential Diagnosis
▪ Tonsillitis
▪ Pharyngitis
▪ Viral URTI
▪ EBV
▪ laryngitis

Positive points in the history: not eating and drinking well since last
night, started 3 days ago and progressively worse, positive fever around
39C and chills, no runny nose, + dysphagia and odynophagia, +nausea,
no vomiting, menarche at 12 regulars, not sexually active, no
medications apart from vitamins, no allergies, +previous history of
tonsillitis
Positive points in the PE: BP: 70/50, deviation of the uvula to the right
side with swelling of the left side, mildly dehydrated, pale and flushed
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APPROACH
▪ History
o When did your symptoms start? Any pain in swallowing? Any

difficulty in swallowing?
• When is it more painful? Solids or liquids?
• Is the pain only present in the throat or is it going

anywhere else?
o Associated symptoms: Do you have a fever? Rash? Runny

nose? Ear pain? Vomiting? Diarrhea? Ear discharge?

o System review
o How is your feeding? Are you eating and drinking well?
o Any change in your voice? (laryngitis)
o Any difficulty in opening your mouth? (trismus)
o Any lumps and bumps anywhere in the body?
o How are your waterworks? (rule out dehydration)
o Did you already have your menarche? When was your LMP?

Are your cycles regular? What is the usual duration of your

cycles?
o Sexual history (if age appropriate) are you sexually active?

What are your sexual preferences?

o BINDSMA especially immunization
o Contact history

▪ Physical Exam
o General appearance: pallor, jaundice, signs of dehydration,

rash
o Vital signs and growth chart
o ENT examination, LN exam
o Signs of meningeal irritation
o Systemic examination
o Office test: UDT, BSL
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▪ Diagnosis and Management

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▪ From history and examination, you have a condition called
peritonsillar abscess/quinsy. The tonsil is a gland present in the
throat and fights against bugs and part of our immune or defence
system of the body.
▪ There is an infection behind this gland and there is a collection of
infectious fluid or pus behind the tonsil. I can tell it because, on
examination, one part of the gland is swollen and inflamed, and is
pushing other structures to the other side of the mouth. This is
the reason why he is having a sore throat and painful swallowing.
▪ You need to be admitted in the hospital and you need to get the
fluid removed or drained because if not, the infection can go to
the blood and spread the infection to the other parts of your
body. In the hospital, you will be seen by the ENT specialist who
will do the procedure after numbing the area and after making
you comfortable.
▪ Because you also appear to be dehydrated, I will start you with IV
fluids and start you on the 1st dose of antibiotics, and I will also
take blood for investigations such as FBE, UEC, ESR/CRP, blood
culture. (DO NOT take a swab because you may induce respiratory
distress in the child)
▪ I will arrange an ambulance for you, and I will liaise with the
paediatric registrar and ENT registrar to make them aware of your
condition. Do you want me to call someone to be with you?

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Acute Tonsillitis

A 4-year-old boy was brought by his mother to your GP clinic because

she noticed that his child is not well, less and has whitish material in his
throat.

TASKS
1. History
2. PE from examiner
3. Diagnosis and Management

Differential Diagnosis
▪ Tonsillitis
▪ Quinsy
▪ Scarlet fever
▪ EBV
▪ Meningitis

Positive points in history:

Positive points in the PE/Investigations:

APPROACH
▪ History
o What do you mean by not well? Any fever? If present, ask in

detail
o Rash? If present, ask in detail.
o Flu-like symptoms? Sore throat? Colds? Ear pain/ear discharge?

Difficulty in swallowing? Any problem with speaking?

Cough/difficulty to breathe? Vomiting/diarrhea?
o BINDS: immunization
o How is the waterworks system?
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o Is he feeding and eating well?

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o Contact history, child care

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▪ Physical Exam
o General appearance: pallor, jaundice, signs of dehydration,

rash
o Vital signs and growth chart
o ENT examination, LN exam
o Signs of meningeal irritation
o Systemic examination
o Office test: UDT, BSL

▪ Diagnosis and Management

According to your son’s history and physical examination, he has a
condition called tonsillitis. Have you ever heard about it? The
tonsils are two small buds of tissue located at the back of the
mouth. They are part of the immune system and are the first line of
defence against bacteria in food or air. Tonsillitis occurs when the
tonsils become infected and can be caused by either bacterium (20-
30%) or viruses.
In your son’s case, I suspect bacterial tonsillitis because he’s
markedly unwell, and has tender, enlarged tonsillar lymph glands.
That is why I took a throat swab for culture. The most common
bacteria causing tonsillitis is streptococcus (GABHS).
I will prescribe an antibiotic (phenoxymethylpenicillin) for 10 days
(or erythromycin if allergic). You can also give him paracetamol to
relieve pain and fever. Most children with tonsillitis don’t feel well
and it hurts them to swallow. Try cool drink, ice block, and ice
cream. Don’t worry if he stops eating for a day or two. He would
pick up quickly after infection.
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. You need to continue antibiotic for a
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total of 10 days to prevent possible complications: can spread to

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sinus, nose or ears, quinsy (peritonsillar abscess), PSGN and

© 2020 ARIMGSAS
rheumatic fever. If not improving after 2-3 days → consider FBE,
ESR/CRP, EBV serology.

***If a child has moderate signs of dehydration, send to the

hospital.

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Periorbital Cellulitis

You are working as a HMO in the emergency department. You next

patient is Nadia, 13-year-old who was brought to your hospital because
of swelling of the right eye.

TASKS
1. Focused history
2. PE from examiner
3. Diagnosis and Management

Differential Diagnoses:
▪ Unilateral
o Insect bites
o Conjunctivitis - irritation, corneal injuries, photophobia, pain on

movement of the eyes

o Allergy
o Trauma
o Periorbital cellulitis
o Orbital cellulitis

▪ Bilateral
o Allergy
o Bilateral conjunctivitis
o Nephrotic syndrome

APPROACH

History
Since when? Sudden or gradual? Any pain?
Discharge (type, colour, amount, foul-smelling, sticking of eyelids in the
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morning), redness, the problem with vision, excessive tears, abnormal

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sensation inside the eyes (dryness, itching, foreign body sensation, etc),
pain on movement of the eye
Any trauma, insect bite, fever rash, joint pain, sore throat, swelling
anywhere else in the body, previous URTI, headache, nausea and
vomiting
Ear pain or discharge, runny nose
Bowel and waterworks
BINDS - feeding history and immunization important

Physical Exam
General appearance: signs of dehydration, rash
Vital signs
ENT - LN exam, sinus tenderness
Signs of meningitis
Eye exam - signs of trauma, photophobia, visual acuity, light reflex,
pupils equally reactive to light, EOM, visual fields, fundoscopy

Explanation
Features Periorbital Orbital
Cause Purulent conjunctivitis Purulent
Trauma conjunctivitis
Insect bites Trauma
URTI Insect bites
URTI
Clinical Fever, tender, swollen soft Same + proptosis
features tissue, difficulty in eye-opening Ophthalmoplegia,
chemosis, decreased
VA
Diagnosis Clinic CT - r/o abscess,
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sinusitis, and
intracranial extension
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© 2020 ARIMGSAS
Management IV flucloxacillin/3rd generation IV flucloxacillin until
cephalosporins then oral symptoms resolve
Augmentin x 5-7 days if completely
symptoms controlled
If >5 years or if severe: treat as
orbital cellulitis

▪ Most likely, you have orbital cellulitis. Our eyes are present in a
closed, bony socket called the orbit. In your child's case, there is
an infection going around and behind the eyes. If left untreated,
the infection can spread to the brain, some air-filled cavities in the
bone called sinuses.
▪ This is an emergency condition.
▪ So to prevent all these, I will refer you to the paediatric registrar,
ENT specialist and Ophthalmologist, who will admit the child and
start the child on painkillers, IV antibiotics and they will also do
further investigations like FBE, UEC, ESR, blood culture, urine m/c,
CT scan of the head to find the extent of the infection because if
not treated, it can affect the vision and lead to blindness, or
nearby regions like the brain.
▪ How long stay in the hospital?
Depends on how the response to treatment is.

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Recurrent Otitis Media

A 5-year-old girl with recurrent otitis media was treated with

Amoxycillin by your colleague 3 times in 6 weeks.

TASKS
1. History
2. PE from examiner
3. Tell the mother further management

Risk factors:
▪ ENT problems
▪ Adenoid problems
▪ Smoking at home
▪ Pets
▪ Day-care or school
▪ Viral infections
▪ Immunodeficiency states

Positive findings in history: the child has to snore and mouth breathing
history. They come with another relapse. Child is febrile
Positive findings in the PE: tympanic membrane bulging, red,

APPROACH
▪ History
o How many episodes in the past 6 months? How long did the

episodes last? In the previous episodes, did the perforation

heal, did the discharge come down? Did you have a review with
your GP? Was antibiotic given?
o What are the symptoms is the child having? Is there ear pain?

Ear discharge? If with discharge (type, colour, amount, foul-

26

smelling, blood-tinged) sore throat? Fever? Runny nose?

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Headaches? Rash?

© 2020 ARIMGSAS
 o Any concerns about hearing? Any previous audiometry done?
Does the child watch TV with high volume? When you call the
child, does he respond?
o Any complaints of the child about child care?
o Any speech problem? Any learning difficulties? Any hearing
problems? Any behavioural problems? How is school
performance?
o Does he have frequent URTI? Any allergy? Any watering of
eyes? Coughing? Sneezing?
o Any sleep problem? Does he snore at night? Daytime
sleepiness?
o How are his eating and feeding? Is the child gaining weight or
not?
o Is there anybody smoking at home? Do you have pets at home?

▪ Physical exam
o General appearance and growth charts
o Vital signs
o Ear examination: tragal sign (if painful, otitis externa), any

crusting in the external auditory canal, how is the tympanic

membrane, where is the perforation, type of discharge,
mastoid, hearing tests
o Throat: tonsillar enlargement
o Nose: polyps
o Lymph node examination

▪ Management
▪ From history and examination, your child is again having otitis
media. Our ear has three parts, outer, middle and inner ear. The
infection is in the middle part as it contains pus. This is what we
call the eardrum and it is normally clear and flat.
27

▪ However, on examination, it was found to be reddish and bulging

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out indicating that there is an ongoing infection and it contains

© 2020 ARIMGSAS
 pus or infected fluid. Ear infections are very common in children,
and it is often preceded by a viral URTI as was seen in your child.
In your child it is happening frequently, so we all it as recurrent
otitis media.
▪ The child needs to take an antibiotic, but this time for a longer
duration, which is recommended at 4 months. But, as there are
frequent ear infections, to rule out the causes of the risk factors
of the frequent ear infections, I will be referring you to the ear
specialist and the paediatrician. They might decide on continuing
the antibiotics or not.
▪ In the meantime, do proper ear toilet, no swimming for 2 weeks,
and give Panadol for pain. Once the condition resolves, we can do
hearing tests to check his hearing. If there are speech problems,
we can refer to the speech pathologist.
▪ If passive smoking history positive, please consider quitting as it is
a risk factor for recurrent infections in the child, and it will be
beneficial for both you and the child.
▪ I will review you after 2 days, then after 2 weeks again.
▪ The causes of recurrent infections can be smoking or if the tonsils
which are the glands present at the back of the throat which is
part of our immune system are enlarged, so the surgeon might
consider removing it. Like tonsils, there is also one more gland
present behind the nose which also can get enlarged due to
repeated infections and cause symptoms.
▪ If that is the cause, it also needs to be removed. Sometimes, the
cause of the infection can be absent ventilation to the middle ear
part, so the specialist might decide to put a small tube in the
eardrum which can help in drainage of discharge and ventilation.
It is done between the outer ear and the middle ear.
▪ However, it will be the specialist who will decide on the
management of your child's condition. And also, if the child is
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having snoring, daytime sleepiness, then we will refer you to the

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sleep clinic.

© 2020 ARIMGSAS
 ▪ Avoid smoke exposure, give pneumococcus vaccination, avoid
group child care.

**Within 2 weeks of symptoms, not responding to an antibiotic, or

more than 6 months, it is chronic otitis media.
**More than 3 episodes in the past 6 months or more than 4 in 1 year,
it is recurrent otitis media

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Strabismus

Little Johnny is brought by her mother Suzy to your GP clinic. Johnny is

referred to by maternal and child health nurse with concerns about the
misalignment of his eyes. Johnny is aged 5 months and is the first child
to Suzy who is 35 years of age. Johnny was born at term by NSVD. Suzy
had mild bleeding in the first trimester but no further problems in the
pregnancy. Suzy and his husband Michael had no concerns about
Johnny eyes alignment or visual function. Johnny always responds to
his mom's presence and he seems to see well. There is no other
concern by Suzy.

TASK
1. Take a focused history
2. PE from examiner
3. Diagnosis and management

APPROACH
▪ History
o Maternal infections? Drugs? Diabetes? Any issues during the

pregnancy? Term or preterm? Any instrumental delivery?

o After delivery, who first noticed it? Do you think it is present all

the time or intermittently?

o What did the nurse say about the other eye examinations?
o Well baby questions
o Any concerns anywhere else?

▪ Physical Exam
o General appearance? Any signs of dysmorphic features?
o Vital signs?
o ENT examination
o Eye examination
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• Light reflex, Hirschberg test, red-orange reflex

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(retinoblastoma, cataract), cover uncover test

© 2020 ARIMGSAS
▪ Management: From history and examination, your child is having a
condition called strabismus/squint. Whenever we focus on an
object, the centre black part should be in the centre, but in your
child's case, the pupil in one of the eyes moves towards the nose
side. This is called as squint. Normally, the eyeball or the eyes is in
the central position or the movements of the eyes is controlled by 6
muscles. If there is any weakness or problem with the nerve supply
to these muscles, for example, there is any injury during the birth,
can lead to this condition.
▪ Most of the time, in infants, it is congenital or present since birth,
and the cause is unknown, or it runs in the family, or there is a
family history of use of glasses or refractive errors. It is good that
we have detected it early, because whenever the eye sees an
object, an image is formed at the back of the eyes, which is called
the retina, and this image is sensed by the brain. But due to
squint, the formation of this image of the object is disturbed and
the retina cannot sense it and if left untreated, it can lead to
permanent blindness called amblyopia. The age limit according to
studies, needs to be corrected by 7 years old.
▪ So, it is important to refer the child immediately to the
paediatrician and ophthalmologist for further review. There are
many types of squint, and depending on the type and degree, the
specialist will decide on the treatment option. There is something
we call as pseudo squint, there is increased skinfold around the
eyes, which gives an impression of a squint. But it is better to take
an opinion from the specialist.
▪ What are the treatment options?
▪ As I said, the treatment depends upon the type and severity, and
specialist opinion. The most common treatment options are
correcting glasses, eye exercises where they train the squint eye,
or injecting some gels into the muscles of the eye or covering the
31

affected eye so that it gets corrected, or a surgical option is also

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possible.

© 2020 ARIMGSAS
Head Injury

A 15 years old child was playing football and collided with his friend and
was brought by his mom to the ED.

TASKS
1. Further history
2. PE from examiner
3. Immediate management

Positive points in the history: head collision when playing football, no

injuries anywhere else, loss of consciousness for less than 10 minutes,
did not wet himself, he remembers afterwards but forgot some things,
Positive points in the PE/Investigations:

APPROACH
▪ History
o How did it happen? Did he fall down?
o Hemodynamic stability: primary survey
o Details about the trauma

• Before the trauma: since when? What happened? Injured

head? Fell down?

• During: LOC? If present since how long? Any bleeding from

nose or ear? Any shakiness of body/limbs? Wet

himself/passed poo?
• After: gaining consciousness: did he remember the event?

Any memory loss? Could he recognize you at all? Any

vomiting? Does he complain of headache? The blurring of
vision? The weakness of the body? Feels tired? Any chest
pain, shortness of breath? Any injury anywhere else?
o BINDS: general history: growth and development? Previous
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medical and surgical history? Support? Any allergy? Past history

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© 2020 ARIMGSAS
 of bleeding disorders? Family situation and how is he at
school? Any medications?
o What did the paramedic say? How was he brought to the
hospital?

▪ Physical Exam
o Primary survey: DRSABCD: GA vital signs
o Secondary survey: vital signs

• GCS
• Neck and cervical spine
▪ Deformity, tenderness, muscle spasm

• Head
▪ Scalp bruising, lacerations, swelling, tenderness,

raccoon eyes, bruising behind the ear (Battle sign)

• Eyes
▪ Pupil size, equality, reactivity, fundoscopy for retinal

haemorrhage (may indicate non-accidental injury)

• Ears
▪ Blood behind the eardrum, CSF leak

• Nose
▪ Deformity, swelling, bleeding, CSF leak

• Mouth
▪ Dental trauma
▪ Soft tissue injuries
• Face
▪ Focal tenderness
▪ Crepitus
• Motor function
▪ Reflexes present
▪ Lateralizing signs
▪ Investigations
33

o Neuroimaging (discuss with senior doctor or neurosurgeon)

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• Definite indications:

© 2020 ARIMGSAS
 ▪ Any sign of basal skull fracture on secondary survey
▪ Focal neurological deficit
▪ Suspicion of open or depressed skull fracture
▪ Unresponsive or only responding non-purposefully to

pain
▪ GCS persistently <8
▪ Respiratory irregularity/loss of protective laryngeal

reflexes
• Relative indications
▪ Loss of consciousness lasting more than 5 minutes

(witnessed)
▪ Amnesia (antegrade or retrograde) lasting more than 5

minutes
▪ Persistent vomiting
▪ Clinical suspicious or non-accidental injury
▪ Post-traumatic seizures (except a brief (<2mins)

convulsion occurring at the time of impact)

▪ GCS persistently less than 14 or for a baby under 1-

year GCS persistently less than 15, on assessment in

the emergency department
▪ If under 1 year, presence of bruise, swelling or

laceration of more than 5 cm on the head

▪ Dangerous mechanism of injury (high-speed road

traffic accident either as a pedestrian, cyclist, or

vehicle occupant, fall from a height)
▪ Known bleeding tendency

▪ Diagnosis and Management

How to assess the severity of head injury
Minor - jump • No loss of • The patient may be
to consciousness discharged from the
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management Emergency Department to

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© 2020 ARIMGSAS
 • Up to one episode of the care of their parents (see
vomiting Discharge Requirements).
• A stable, alert • If there is any doubt as to
conscious state whether there has been a loss
• May have scalp of consciousness or not,
bruising or laceration assume there has been and
• Normal examination treat as for moderate head
otherwise injury.
• Adequate analgesia
Moderate • Brief loss of • If, on the history from the
consciousness at the parents and ambulance, the
time of injury child is not neurologically
• Currently, alert or deteriorating they may be
responds to voice observed in the Emergency
• Maybe drowsy Department for a period of up
• Two or more to 4 hours after trauma with
episodes of vomiting 30 minutely neurological
• Persistent headache observations (conscious state,
• Up to one single brief PR, RR, BP, pupils and limb
(<2 min) convulsion power).
occurring • The child may be discharged
immediately after the home if there is an
impact improvement to a normal
• Normal examination conscious state, no further
otherwise vomiting and child able to
tolerate oral fluids.
• A persistent headache, large
haematoma or possible
penetrating wound may need
further investigation, discuss
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with a consultant.
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• Adequate analgesia

© 2020 ARIMGSAS
 • Consider anti-emetics but
consider a longer period of
observation if anti-emetics
are given.
Severe • Decreased conscious • The initial aim of
state - responsive to management of a child with a
pain only or serious head injury is the
unresponsive prevention of secondary brain
• Localizing damage. The key aims are to
neurological signs maintain oxygenation,
(unequal pupils, ventilation and circulation,
lateralizing motor and to avoid rises in
weakness) intracranial pressure (ICP).
• Uncal herniation: • Urgent CT of head and c-
ipsilateral dilated spine. Ensure early
non-reactive neurosurgical and ICU
pupil due to intervention.
compression of • Cervical spine immobilisation
the oculomotor should be maintained even if
nerve cervical spine imaging is
• Central normal.
herniation: • Intubation and ventilation:
brainstem • Child unresponsive or not

compression responding purposefully

causing to pain
bradycardia, • GCS persistently <8

hypertension, • Loss of protective

and widened laryngeal reflexes

pulse pressure • Respiratory irregularity

(Cushing's triad) • In consultation with the

36

neurosurgeon consider
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© 2020 ARIMGSAS
• Irregular measures to decrease
respirations intracranial pressure:
(Cheyne-Stokes) • Nurse 20-30 degrees head up
• Decorticate (after correction of shock)
posture and head in a midline position
• Decerebrate to help venous drainage.
posture • Ventilate to a pCO2 35mmHg
4-4.5 kPa (consider arterial
catheter).
• Ensure adequate blood
pressure with crystalloid
infusion or inotropes (e.g.
noradrenaline) if necessary.
• Consider mannitol (0.5-1 g/kg
over 20-30 min i.v.) or
hypertonic saline (NaCl 3% 3
ml/kg over 10-20 min i.v.).
• Consider phenytoin loading
dose (20 mg/kg over 20 min I
.v.).
• Control seizures: see Afebrile
seizures
• Correct hypoglycaemia
• Analgesia: sufficient analgesia
should be administered by
careful titration. Head injured
children are often more
sensitive to opioids.
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© 2020 ARIMGSAS
From the history and examination, your child is most likely having
moderate head injury because the child had a loss of consciousness for
more than 10 minutes and memory loss for a few minutes. These
indicate that it can be a moderate head injury. So, at this time, we need
to admit the child, for observation. I will give adequate painkillers for
his pain. I will consult with the ED consultant and the paediatric
neurosurgeon, about the need for a CT scan because most of the time,
in these kinds of cases, CT scan is advised. We will keep you informed
about it once I discuss with them, but the sooner we do the CT scan, it
is better. Along with that, if the child develops vomiting, any persistent
headache, he becomes drowsy, any weakness in his hands and limbs
during the time of monitoring, also indicates the need for CT scan, so it
will be advised by the specialist. In the meantime, please do not stress
yourself, he is fine now, we are just keeping him for observation,
because sometimes, whenever there is an injury, the impact of injury is
38

seen later.
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© 2020 ARIMGSAS
VOMITING CLUSTER

39
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© 2020 ARIMGSAS
Urinary tract infection

Mother came with a 9-month-old female baby with fever and vomiting
for the last 2 days. You are a GP.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and further management

Differential Diagnoses
▪ UTI
▪ Pneumonia
▪ Meningitis
▪ Otitis Media
▪ Acute gastroenteritis

If no fever can suspect: pyloric stenosis, GERD, intussusception,

intestinal obstruction, hernia (strangulated/incarcerated), testicular
torsion

History
Intestinal obstruction: distention, passed wind
UTI: waterworks, any change in a number of wet nappies, any foul smell
while changing nappies, child cries while he passes pee?
Fever: rash? Noticed any lumps and bumps especially in the groin area?
Lethargic? Pulling his ear? Ear discharge?
Feeding or sleeping well?
BINDS (if comes soon after delivery, family history of kidney/urinary
problems
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D: Hello I am Dr____, I will be your GP for today. How may I address
you and your baby?
M: My name's Margaret, my baby's Lara.
D: Alright, hi Margaret. I can see from your child's notes that she has
been suffering from fever and vomiting for the last 2 days. Could you
tell me more about it?
M: She's been having a fever for two days now. It was around 38 when I
checked it, so I gave her a Panadol. And she's been vomiting since
yesterday night, about 5 or 6 times already.
D: Could you describe to me how the vomiting is? Is it forceful, what's
its color, and when does it often occur? Was it related to feeding
(GERD) or were there any triggers?
M: No, it's not related to feeding, it was just spontaneous, it wasn't
forceful. It was just white like milk.
D: Any differences in appetite? If so, how does it compare with your
child's feeding? Or could you say that your child seems to cry in
between feeds or seems to be hungry after a feed? (pyloric stenosis) Do
you think she has lost weight?
M: Yeah, she hasn't been eating right lately.
D: Do you feel or observe any lumps or bumps in the tummy while your
child is feeding?
M: None.
D: Does she draw up her legs while crying? Does she turn pale while
crying? (intussusception)
M: No.
D: Any changes in bowel motion? Has she passed wind? (intestinal
obstruction)
M: None, yeah I think she does.
D: How about her water works, is there any change in the number of
her wet nappies? Is the urine foul-smelling and does she cry when she
pees?
41

M: Yes, she wets her nappies less now and her urine smells a bit off.
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D: How high was the fever? Did it come with any rash? Have you
noticed any lumps in the body, especially in the groin area?
M: Fever was 38, but no rash or lumps in the body.
D: How is the activity of your child? Could you say that she became
lethargic or still the same?
M: She's become irritable since the fever and vomiting.
D: Have you noticed any ear tugging?
M: No, no ear tugging.
D: Is she sleeping well?
M: She's been irritable lately, so I think her sleep's not good as well.
D: Is she your first child? How old were you when you were pregnant
with her? Any complications during the pregnancy? How about her
delivery? Any problems at birth?
M: Yeah she's my first child. No problems with pregnancy and delivery.
D: Is the immunizations up to date? Can I see your green book?
M: Yeah I think so. *hands over the green book
D: Any problems with growth and development?
M: None.
D: Do you have another child at home that may have been sick recently
or anyone at home sick recently?
M: None
D: Any previous illness for your child?
M: None
D: History of congenital diseases or inborn diseases? Kidney disease?
M: None
D: Thank you for that information, Mary, I'd just like to talk with my
examiner, I will get back to you shortly.
D (to examiner): Is the patient alert, drowsy, lethargic? Any pallor or
jaundice? Any dysmorphic features such as down slanting of the eyes,
upturned nose, or simian crease?
E: Patient is irritable, no dysmorphic features
42

D: What is the CRT, how is the skin turgor, is there sunken eyes, and is
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the anterior fontanelle bulging?

© 2020 ARIMGSAS
E: CRT is greater than 2 seconds
D: What is the weight for height?
E: 50th percentile
D: What is the temp, HR, RR, and O2 sat?
E: temp is 38, PR is 120 bpm, RR is 30, O2 sat is 98%
D: Is there any rash the body, or skin pigmentation?
D: Any neck stiffness?
E: None
D: Are there any LN enlargements?
E: None
D: Any tragal tenderness or ear discharge?
E: None
D: Any visible distention or peristalsis? Palpable masses? Tenderness?
E: None
D: I would like to check the hernial orifice, genital exam to check for
ambiguous genitalia, and per anal inspection with the parent's consent
E: No abnormal findings
D: I would like to proceed with a urine dipstick test
E: Urine dipstick is positive for nitrites and leukocyte esterase
D: Thank you for that information, I would like to go back to my patient.
D (to the patient: Hi Mary. Based on the history, examination, and
initial investigations of your child, it seems that most likely she's got a
urinary tract infection. Have you heard about it?
As you can see here, this is our urinary tract--or the passage of our
urine-- and it is immediately close to our back passage.
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The urinary tract infection is caused by a bug that came from the child's
back passage when the child defecates or from the skin. It tends to
cause inflammation there hence contributing to the symptoms of
irritable urination, decreased urination, and even smelly urine. The pain
causes the child to vomit and the infection causes fever.
As your child is still 9 months old and is considered to be part of the
vulnerable group of patients, it is highly advised that she becomes
admitted to the hospital. I will refer her to a pediatric registrar for
further evaluation. As the initial urine dipstick is just a screening test for
the infection, the pediatric registrar might do a suprapubic aspiration
(I'm sorry for the medical term but let me explain this to you) to get a
sterile sample of the urine to specifically identify the bug that is causing
the infection. This will not be painful for a child as a local anesthetic will
be given. A needle will be inserted just below her umbilicus and a
sample of urine will be aspirated from there. We cannot rely on the
wee bag alone as the sample might get contaminated that might
compromise our test results. Do you understand so far?
Your child will also be started with antibiotics and will be given Panadol
to address her fever.
And to further confirm her diagnosis and to have a full picture of her
condition, we also need to do further investigations to rule out other
causes of fever and vomiting such as FBE, CRP, ESR, UEC, blood cultures
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and urine MCS.

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© 2020 ARIMGSAS
An ultrasound of her water work system will also be done to find if
there are any structural abnormality that might contribute to her
disease.
Again, I will arrange an ambulance for your child now so that we can
facilitate your transfer. I will also inform the hospital ahead of time so
that they can be aware of your situation. Is there anyone that I can call
to be with you for now, like your partner? We can also arrange a social
worker to take care of your other child while we admit her. Do you
have any questions so far?
Thank you. Rest assured we will do our best to give the best care
possible for your child.

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Gastroesophageal Reflux

You are a GP and a mother brought his 4 weeks old baby girl Lara. She
says the child vomits after feeding. There are no other symptoms. Mom
thinks that bottle feeding will be better for him.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and management

Differential Diagnosis
▪ Pyloric stenosis: 1st born male babies, test feeding (lump); projectile
vomiting; baby hungry; irritable; crying; decreased BW; 4-6 weeks
(not immediate as muscles; take time to develop)
▪ UTI: (fever, <4 weeks, septic look, dipstick)
▪ Reflux: vomitus remains the same; happy, gain weight; milk only
without changes inconsistency)
▪ Overfeeding
▪ Duodenal atresia
▪ AGE
▪ CAH

D: Good morning, I am Dr_____, your GP today. How may I address

you and your baby?
M: My name's Margaret, my baby's Lara.
D: Okay hello Margaret. I read from the notes that Lara seems to be
vomiting after feeding. Can you tell me more about it? How frequent is
it? Does it happen after every feed? What is the color of the vomitus?
M: She's been vomiting every after I breastfeed her. It's milky in color.
D: Is the milk digested at all? Have you noticed that the vomiting is
47

forceful? Is he hungry after vomiting? Once you finish feeding, do you

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notice a lump in his tummy?

© 2020 ARIMGSAS
M: Sometimes it's forceful. No. here's no lump in his tummy
D: Is she still gaining weight despite the vomiting.
M: Yes, she is, haven't noticed a drop in her weight.
D: Does he have any associated fever, irritability, lethargy?
M: None
D: How are his wet nappies? Any changes in the number of wet
nappies?
M: It's just the same.
D: Is he passing stool normally?
M: Yes.
D: Do you think he is a happy child? Is he able to sleep well at night?
D: Any complication with your pregnancy/delivery? Do you think he is
growing well? Is this the 1st baby in the family?
D: Is there a history in your family of bowel-related problems?
D: Have you tried bottle feeding up to now?

Diagnosis:
▪ Your child most likely has Gastroesophageal Reflux GER.
▪ The lower part of the food pipe where it connects with the
stomach is poorly developed in neonates/babies. It is the reason
why the milk in the stomach flows back into his mouth when you
put him down. It is a very common condition where the baby
vomits after each feed but otherwise the baby thrives well. This
condition gradually improves with time especially after the
introduction of solids (4-6mos of age). Majority of cases clear up
by 1 year of age.
▪ At the moment, we will do an ultrasound of the tummy to rule out
any serious condition such as pyloric stenosis. Most likely the
ultrasound will be normal. I will recommend giving him
frequently, smaller feeds, decrease the duration of feeding along
with time in between (normal 20 mins on each breast). You can
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thicken the feed with thickeners called Gaviscon. The way to

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prepare it is to take 1-1/2 tsp of Gaviscon, add a little amount of

© 2020 ARIMGSAS
 boiled cold water and little of expressed breast milk (20ml). Mix
them in a cup and feed the child with a spoon immediately before
feeding time. This helps the breast milk stay in his stomach.
Please elevate the head of the cot by 10-20 degrees. After each
feed, don’t put the baby immediately to sleep. Carry him for a
while and put him in the cot with the head elevated.
▪ We highly recommend breastmilk because it is best for baby.
▪ Reassure.
▪ If persistent:
▪ Ranitidine (Zantac) 1ml/day or omeprazole (Losec): <10kg →
5mg/day)
▪ If not improving: consider GORD → refer to gastroenterologist →
do manometry (measure pH and peristaltic movement of the
esophagus)
▪ Signs of reflux: arching back + flattening of back + screaming +
irritable + drawing of legs
▪ Complications: aspiration, ulcers, inflammation, dehydration,
▪ Improve at 6-9 mos: maturation of LES, the introduction of solids,
change in position

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Pyloric Stenosis

You are a GP in metropolitan practice and a 3-week old baby boy, John
presents with vomiting since birth.

TASKS
1. History
2. Physical examination Findings from Examiner
3. Diagnosis and further management

Differential Diagnoses:
▪ Intestinal obstruction
▪ Pyloric stenosis
▪ GERD

D: Hello. I am Dr____, I will be your GP today. How can I address you?

D: I understand from your notes that your child has been vomiting since
birth. Can you tell me more about this?
D: Could you describe to me how the vomiting is? Is it forceful, what is
the color, and when does it often occur? What are its contents? Any
triggers?
D: Any differences in appetite? How does it compare with your child's
feeding? And could you say that your child seems to cry in between
feeds--hungry all the time? Do you think she has lost weight?
D: Do you feel or observe any lumps or bumps in the tummy while your
child is feeding?
D: Does she draw up her legs while crying?
D: Any changes in bowel motion? Is she passing gas?
D: Some questions regarding her waterworks, is there any change in the
number of her wet nappies? Is it foul-smelling and does she cry when
she pees?
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D: Did she have any fever and did it came with any rash? Noticed any
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lumps in the body, in the groin area?

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D: How is the activity of your child? Could you say that she became
lethargic or still the same? Noted any ear tugging?
D: Is she sleeping well?
D: Is she your first child? How old were you when you were pregnant
with her? Any complications during the pregnancy? How about her
delivery? Any problems at birth?
D: Is she currently up to date with her immunizations?
D: Do you have another child at home that may have been sick recently
or anyone at home sick recently?
D: Any previous illness for your child?
D: History of congenital diseases or inborn diseases?
D: Thank you for that information, Mary. I will just talk to my examiner
and I will get back to you shortly.

D: VITALS: TEMP, HR, RR, O2 SAT

[I’m shifting the child to the resuscitation room. I will insert an IV line
and take blood samples for investigations such as an FBE and UEC.]
D: What is the CRT, how is the skin turgor, is there sunken eyes, and is
the anterior fontanelle bulging?
D: What is the weight for height?
D: Is there any rash in the body, or skin pigmentation?
D: Any neck stiffness?
D: Are there any LN enlargements?
D: Any tragal tenderness or ear discharge?
D: Abdominal exam: visible distention or peristalsis? D: Palpable
masses? *OLIVE SHAPED MASS. Tenderness?
D: I would like to check the hernial orifice, genital exam to check for
ambiguous genitalia, and per anal inspection with the parent's consent
D (to examiner): Is the patient alert, drowsy, lethargic? Any pallor or
jaundice? Any dysmorphic features such as down slanting of the eyes,
upturned nose, or simian crease?
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Office tests: urine dipstick, bsl

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Investigations: FBE, UEC, arterial blood gas (HYPOCHLOREMIC,
HYPOKALEMIC METABOLIC ALKALOSIS), Ultrasound of the abdomen

• Based on the history, examination, and investigations, it seems

that most likely your child has what we call Pyloric Stenosis. 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 okay to continue?

• *Draw*
• 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
the pylorus. 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.
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 diagnosis because of the symptoms and signs that she
presented--projectile vomiting, hungry feed, not gaining weight,
and movement of the gut at the site of the obstruction

• At this stage, it's an emergency condition and is related to life-

threatening complications. I will call the ambulance, arrange for
the piper (pediatric emergency transfer system), PETS/NETS, and
arrange transfer of your child to the hospital so that she can be
seen by a specialist. In general, the treatment involves stabilizing
the current condition of the child first by correcting any
imbalances of his electrolytes--or the factors that maintain salt
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and water balance in the body, and then assessment and

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 management by a possible surgery by relieving the tightness of
the pylorus of the stomach. Do you understand so far?[ If she
cries, pause for some time]

• If we intervene early, further complications can be prevented.

• As you have seen earlier, we already started correcting all the
fluid losses of your child as I already placed two IV lines to your
child where we have already started giving fluids to correct her
dehydration. We also did further investigations earlier and found
that there is an imbalance in the electrolytes. Due to her repeated
vomiting, hyponatremic, hypokalemic alkalosis. We might also
need to do an ultrasound to confirm the diagnosis.

• For now, I need you to stop feeding her by mouth temporarily as

it may worsen her condition. I will pass a small tube through the
nose into the food pipe (sorry for using the medical term), it's
called nasogastric tube, to remove the excess milk in the stomach
and prevent further vomiting (to decompress the stomach). Then I
will call the pediatric surgical registrar in the hospital so that
everything for the surgery is arranged before the child is
transferred, or during the time of transferring. I will fax all the
blood test results. The child might need surgery, most of the time
it can be a keyhole or an oval surgery. Usually, the tightened part
of the pylorus will be opened up so that the tightness can be
relieved.

• 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?
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• When can I start breastfeeding? = it depends upon the specialist
advise. Most of the time, breastfeeding is started 24-48 hours
after the surgery. Again it depends on the progress of the child.

• I will arrange a lactational nurse to teach you how to express your

milk and how to store it for now.
• Though it can be a life-threatening disease, we will do our best to
manage your child the best way we can. Do you have any further
questions?

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Congenital Adrenal Hyperplasia

Nadia is 5 days old, she was brought by her Mom to the ED because she
started to vomit and she’s not drinking well.

TASKS
1. History
2. Physical Examination findings from the examiner
3. Investigations
4. Diagnosis and management

Hello. I am Dr_____, I will be your GP for today. How may I address

you?
I can see from your child's notes that she has been suffering from fever
and vomiting and is not drinking well. Could you tell me more about it?
Could you describe to me how the vomiting is? Is it forceful, what's its
color, and when does it often occur? Any triggers?
Does she have a good sucking motion, or is it weak? And could you say
that your child seems to cry in between feeds--hungry all the time? Do
you think she has lost weight or fail to gain weight?
Do you feel or observe any lumps or bumps in the tummy while your
child is feeding?
Does she draw up her legs while crying?
Any changes in bowel motion?
Some questions regarding her waterworks, is there any change in the
number of her wet nappies? Is it foul-smelling and does she cry when
she pees?
Do you think there's something odd with how her genitalia looks
like?**
Does she have any rash or any darkening of some areas of her body?
Noticed any lumps in the body, in the groin area?
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How is the activity of your child? Could you say that she became
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lethargic or still the same? Noted any ear tugging?

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Is she sleeping well?
Is she your first child? How old were you when you were pregnant with
her? Any complications during the pregnancy? How about her delivery?
Any problems at birth? Did she undergo newborn screening or heel
prick testing after birth?
Is she currently up to date with her immunizations? 5 days old
How does she compare with other kids? - developmental history
DO you have another child at home that may have been sick recently or
anyone at home sick recently?
Any previous illness for your child?
History of congenital diseases or inborn diseases? Genetic diseases

Physical Exam
Is the patient alert, drowsy, lethargic? Any pallor or jaundice? Any
dysmorphic features such as down slanting of the eyes, upturned nose,
or simian crease?
What is the CRT, how is the skin turgor, is there sunken eyes, and is the
anterior fontanelle bulging?
What is the weight for height?
VITALS: TEMP, HR, RR, O2 SAT
Is there any rash in the body, or skin pigmentation?
Any neck stiffness?
Are there any LN enlargements?
Any tragal tenderness or ear discharge?
Abdominal exam: visible distention or peristalsis? Palpable masses?
Tenderness?
I would like to check the hernial orifice, genital exam to check for
Ambiguous genitalia and per anal inspection with the parent's consent

Office tests: urine dipstick, BSL

Investigations: FBE, UEC, LFTS, URINE MCS, ARTERIAL BLOOD GAS
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(HYPERKALEMIC, HYPONATREMIC HYPOGLYCEMIA), cortisol

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From history and examination and findings, I think that it seems that
your child has congenital adrenal hyperplasia, sorry for using medical
terms but I will explain it to you.
We have 2 kidneys in our tummy, on top of each we have a gland called
the adrenal gland. This gland secretes hormones which are required for
normal body function, and also for salt and fluid balance in our body.
Due to some unknown reason, the production mechanism of these
hormones is defective in your child leading to vomiting, refusal to feed,
etc. It is not an uncommon condition. Do you want me to call someone
to be with you or shall I continue explaining the rest of the plan?

I need to refer you to the hospital and arrange an ambulance. I will call
the pediatric and endocrine registrar to give comprehensive
management in your baby. A multidisciplinary team will be there to
fully manage his case in the hospital. Until they come, I will put an IV
line to start giving her fluids since she already lost a lot due to her
vomiting, and take blood for investigations (FBC, UEC, Urine MCS, LFTs,
acid-base balance, cortisol levels, blood sugar)
The treatment is replacing the hormones once the child is stabilized
with IV fluids.
I will also call the surgical team for the correction of genitals.
She will definitely need lifelong steroids, but it also depends on
specialist advise. however, she may suffer from the effects of these
steroids in the long run. She may also have to be screened in the future
again if she plans to get pregnant because of the risk of developing CAH
again in her baby.
Though an emergency case, we will do our best to manage your child
the best way we can. Do you have any questions so far? Thank you.
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Duodenal Atresia

You are working in a small country hospital as HMO. You have been
called to talk to a 27 y/o mother, Janelle, who gave birth to a baby boy
24 hours ago. She started breastfeeding but he has vomited several
times some greenish fluid and he has not passed meconium yet. The
neonatal check-up did not reveal any pathological findings, especially
anus was present. An abdominal X-ray is provided

TASKS
1. Take a brief history
2. Explain the X-ray findings to the mother
3. Discuss the most likely diagnosis and management with the mother

If 24h from birth, focus on birth history.

Hello. I am Dr_____, I will be your GP for today. How may I address

you?
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I can see from your notes that you just gave birth to your baby
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yesterday, and he has been vomiting since then. Could you tell me
more about it?
Could you describe to me how the vomiting is? Is it forceful, what's its
color, and when does it often occur? Any triggers?
Any differences in appetite? How does it compare with your child's
feeding? And could you say that your child seems to cry in between
feeds--hungry all the time?
Do you feel or observe any lumps or bumps in the tummy while your
child is feeding?
Have you changed wet nappies more than the usual? How many
nappies have you changed so far? Is it soaked? Does it have a foul
odor?
Any fever noted?
How was your pregnancy with your baby, any complications or
infections you had during its course? How old are you now? Did you
have regular antenatal checks? Did you screen for downs syndrome?
Underwent the sweet drink test?
How about your delivery? Did the baby immediately cry after it?
Do you have support for this baby?
Down syndrome features as well!
Face flat and small, eyes slope upwards at the outer corners, ears are
small, the tongue is large, and tends to stick out. With intellectual
disability, smaller height than average, floppy muscle tone, a simian
crease (single crease in the palm) and various heart, kidney defects.

Any family history of congenital or inborn diseases?

Breaking the bad news:

• I’m afraid I have some bad news. Do you want me to continue
with the consult or do you want me to call someone first to be
with you?
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• Here is an x-ray of your baby's tummy, normal x-ray will show
white in color. These are the lung shadows, this it eh backbone,
and the ribs.
• As the lungs contain air, air in x-ray shows this in black.
• Normally the tummy is black in color because of the air it has.
• These blackish shadows are abnormal. We call it the double
bubble sign.
• The food we drink goes to the mouth, food pipe, stomach, and
small gut. In your child's case, a part of the small gut is probably
absent, narrow, or blocked. Due to that reason, the air that the
child breathes or the milk that the child drinks cannot pass down
and in the x-ray we see these blackish air sacs.

• This is an emergency condition, and I need to call the PIPER team

to arrange transfer to a tertiary hospital.
• I will put a small tube through the nose to decompress the gut.
• Please do not feed your child right now
• I will put an IV line to your child and take blood for investigation
• Reassurance. Support. Reassurance
• In the hospital, the child might undergo surgery, and might open
the tummy using a keyhole or open surgery after the child is
stabilized.
• The damaged parts will be removed, and the normal parts will be
attached together
• Please do not stress yourself. I know you are very worried about a
newborn undergoing surgery in the hospital. We have specially
trained pediatric surgeons who are experienced in doing such
surgeries. In the meantime, I will talk to the specialist to arrange
everything needed for the surgery. I can fax all the initial
investigations we did to your child
• Arrange social worker for siblings
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• Do you want some counsellor to talk to you?

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 • In the meantime, any financial help, we can arrange for that as
well

• If they start crying, pause for a moment and reassure. Give them
their time.

DUODENAL ATRESIA VS HIRSCHPRUNG

HIRSCHPRUNG AGE 6-7DAYS

The digestive juices present in the intestine for the digestion of milk is
not passing down because of this blockage. It is coming out and it is
green in color

Intestinal obstruction
Usually, it is white in color, however, we should not see air here,
because of obstruction to the intestine.
Problem with the movement of the gut = paralytic ileus

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Testicular Torsion

An 18-year-old boy complained of pain in the right groin and vomiting

for 3 hours after riding a bicycle.

TASKS
1. History
2. Physical Examination Findings from the examiner
3. Diagnosis and management

The pain started suddenly, no urinary symptoms, no sexual symptoms,

no swelling in the groin region
Right side testis is red, swollen and tender to touch

Differentials
▪ Infections
▪ Epididymoorchitis
▪ Testicular torsion
▪ Hernia
▪ UTI
▪ Renal stones
▪ Appendicitis
▪ Trauma
▪ Hip problems

APPROACH
▪ Relieve pain with painkillers. Ask about allergy to painkillers.
▪ Pain questions. SOCRATES1

Where is the pain? Can you point with one finger the exact location
of the pain? When did it start? How did it happen? What were you
doing when the pain started? What type of pain is it? Is the pain
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travelling to anywhere else? Any associated symptoms with the

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pain? Is it a continuous pain or it comes and goes? Anything that

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 makes the pain better or worse? How severe is the pain from 1 to
10, 10 being the worst pain? Is this the first episode of the pain?
▪ Well, paediatric questions. How is your appetite? Any change in
your diet? How is your urination? Any change in the frequency?
Any change in color or smell? How is your bowel movement?
▪ Sexual history questions.
Are you sexually active? Do you have a stable partner? Do you have
a history of sexually transmitted infections?
▪ Differential questions.
Any fever? Abdominal trauma? Lumps and bumps anywhere in the
body? Any swelling in the groin?
Intussusception questions: Draws up legs while crying, turns pale
while crying, any abdominal distension, passed wind (flatus)
Appetite, lost weight, any diarrhoea/bowel motion (If present go in
detail)
Intestinal obstruction questions: Distension, passed wind etc
UTI questions: waterworks, any change in number of wet nappies,
any foul smell while changing nappies, child cries while he passes
pee
Fever questions: Rash(meningitis), noticed any lump in the body
especially groin area (r/o hernia), lethargic, pulling his ear/ear
discharge
▪ Do you take any prescription or over the counter medications? Do
you have any allergies?
▪ Past history. Do you have any medical or surgical illness?
▪ Family history. Do you have any family history of groin problems?
▪ Physical examination questions
General appearance
Vitals
Prehn's: on the elevation of the testis, pain decreases in
epididymoorchitis, the pain stays the same in testicular torsion
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Red, swollen testis, might be horizontal, and tender to touch

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Inguinal lymph nodes

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Management
Most likely you have torsion of the testis. Do you have an idea what this
is? I will explain to you about your condition. Normally is testis is
suspended by a cord in the scrotum. This cord contains blood vessels
that supply blood to the testis. Due to some unknown reason, like in
your case, the cord twisted on itself. Because of twisting around, the
blood supply is cut off.

• From history, the pain started suddenly, and you have no urinary
symptoms or sexual symptoms and not have any swelling over
your groin region to rule out a hernia. From your exam I could find
that you have a red, swollen, horizontally superseded testis,
making testicular torsion the most likely diagnosis.
• At this point, this is an emergency condition, and I need to
arrange an ambulance to send you to the hospital. There is a loss
of blood supply to your testis, and if this gets more prolonged, the
testis may get damaged. Usually, the crucial period from the onset
of your symptoms and to the loss of function of the testis is 6
hours, what we call the 6 golden hours. So, you already passed 3
hours, and I will refer you immediately for correction. You need to
undergo a surgery, where the specialist will make a small incision
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over the scrotum and untwist your testis. But at the time or
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 surgery, if the surgeons find that the testis is fully damaged, they
will take your consent to remove it. But don't be stressed by
yourself, because as I said, 6 hours is the golden hours, and the
sooner we detect it, the sooner we correct it. Before your
transfer, I will liaise with the surgeon and inform him about your
condition. From now on, please do not eat or drink anything. The
chance of occurrence of torsion of the testis on the other side is
also increased, so the surgeon will fix that as well. No
investigations required as it will waste time.
• Will it affect my fertility? No, we are trying to save the testis, and
you still have your other testis that will provide for your
reproductive function if we are to remove the other testis.
• Can it cause cancer? No.

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Incarcerated Hernia

A 5-month-old baby came to your GP clinic with his father because of

sudden onset intermittent screaming with a few episodes of
vomiting. The older brother has got a recent onset of gastroenteritis.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and management

APPROACH
▪ When did the intermittent screaming start? How did it happen?
What was he doing when the screaming started? How many
episodes of screaming has happened? Is it related to the vomiting? Is
the vomiting projectile? What is the color of the vomitus?
▪ Well, baby questions: Has the baby been irritable or has he been
hard to wake up? Has he been eating and drinking fine? Has there
been a change in the number of wet nappies?
▪ Closure:
Birth
Antenatal: did you have any infections, took any drugs, had
any trauma?
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?
Postpartum: did he spend any time in a special nursery? Was
heel-prick test done?
Immunizations
Nutrition
Development: How do you think he is growing compared to kids
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of his age group? Are you concerned his development when you
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compare him with kids of his age group?

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 Social history
Medications
Allergies
Past history
Family history
▪ Differential questions
• Intussusception questions: Draws up legs while crying, turns
pale while crying, any abdominal distension, passed wind
(flatus)
Appetite, lost weight, any diarrhoea/bowel motion (If present
go in detail)
• Intestinal obstruction questions: Distension, passed wind
• UTI questions: waterworks, any change in the number of wet
nappies, any foul smell while changing nappies, child cries while
he passes pee
• Fever questions: Rash(meningitis), noticed any lump in the
body especially groin area (r/o hernia), lethargic, pulling his
ear/ear discharge
▪ Physical exam
General appearance
PICCLE
Growth charts (until 12 years old only)
Dehydration
Vitals signs
Systemic Exam
Musculoskeletal system
ENT
CVS
Respiratory
Abdomen: distention, guarding, bowel sounds
Genital: don't miss hernia orifices, per anal inspection
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Neuro
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Office tests

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▪ MANAGEMENT
▪ From history and examination, most likely he is having a
hernia. This is our tummy wall. If he has any weakness in the
tummy wall, the abdominal contents can protrude out of
that weakness. Most often, then tummy contents are the
gut. Most of the time, the swelling goes back by itself. But if
it doesn't go back, it can lead to obstruction of the gut,
leading to symptoms such as pain, swelling, vomiting, and
we call that incarcerated hernia.
▪ The blood supply to the gut can also be hampered and if
that happens, the gut becomes damaged. That’s the reason
why this is an emergency condition.
▪ If this is not removed, it might get infected and the infection
might spread to the rest of the body. To prevent all of these
complications, we need to refer you to the hospital
immediately where a specialist can see you.
▪ As of now, please don't feed him or let him drink water. I will
put an IV line and start him on IV fluids. The child requires
surgery to put the blocked gut back inside. I will also insert a
tube through the nose which will go to his gut so that we
can release the pressure building up inside.

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Intussusception

You are an HMO in the hospital and your next patient is a 5-month-old
boy presented with vomiting and poor feeding.

TASKS
1. History
2. PE findings from the examiner
3. Diagnosis and management

APPROACH
▪ Vomiting questions: Can you tell me more about it? When did it

start? How did it happen? What is the colour and amount of

vomitus? Was it forceful/not? Was it related to feeding/food? Is he
hungry after the feed?
▪ Well, baby questions:
o Do you notice that he's been irritable or has been hard to wake

up?
o How are his feeding and drinking? Has he lost weight?
o Have you noticed any change in the number of his wet

nappies? Any diarrhea or change in bowel motion?

▪ Birth:
o Any problems during pregnancy and delivery? Did you take any

medications during pregnancy?

o Was he a term baby? What is the mode of delivery? What is

the reason for that type of delivery? Did he cry immediately

after birth?
o Did he require any time in the special nursery after birth? Was

the heel-prick test done?

▪ Immunizations: Are his immunizations up to date?
▪ Development: Any problems with his growth and development?
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▪ Social history:
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o Do you have any other children, how many?

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 o Is this your only baby or do you have any other kids? Do they
have this same problem?
▪ Does he take any medications? Does he have any allergies?
▪ Differential questions:
o Intussusception questions: Draws up legs while crying, turns

pale while crying, any abdominal distension, passed wind

(flatus)
o Intestinal obstruction questions: Distension, passed wind
o UTI questions: waterworks, any change in the number of wet

nappies, any foul smell while changing nappies, child cries

while he passes pee
o Fever questions: Rash, neck stiffness? (meningitis), noticed any

lump in the body especially groin area (r/o hernia), lethargic,

pulling his ear/ear discharge
▪ Physical exam:
1. General appearance
a. PICCLE
b. Growth charts (until 12 years old only)
c. Dehydration
2. Vitals signs
3. Systemic Exam
a. Musculoskeletal system
b. ENT
c. CVS
d. Respiratory
e. Abdomen: any visible distention? Any visible wave of
peristalsis? Any palpable lumps?
f. Neuro
4. Office tests: UDT
▪ MANAGEMENT
Based on the history and examination, most likely your child has
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intussusception. It is the sliding of one part of the gut to the other.

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Because of sliding, the bowel becomes blocked or obstructed
leading to pain and vomiting.

▪ Sometimes the sliding relieves by itself and baby

becomes normal. But if occurring repeatedly, it can lead
to bowel obstruction. It is most common in children
between 3 months to 3 years. The cause is not known.
But sometimes it can occur after viral gastroenteritis.
▪ It is an emergency condition, please do not give any
food and drink to your child. I will put an IV line and
start him on IV fluids, and the child might need
admission.
▪ I will refer you to a specialist who will come and assist
your child and might order blood examinations, and
ultrasound of the abdomen and abdominal x-ray to rule
out obstruction.
▪ Once the diagnosis is confirmed, the treatment is given
by the specialist, a radiologist and pediatric surgeon
who will do an air enema, which is passing a small tube
at the back passage where the air is passed. Throughout
the procedure, the child is monitored by the specialist.
They will try this procedure twice, and if not effective,
they will do an operative reduction which can be done in
open surgery or laparoscopically. Antibiotics can also be
given if deemed appropriate by the specialist.
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Acute Otitis Media

Alexander is a 2-year-old boy who presents to GP office with acute

febrile illness. He has runny nose for a few days and has become
febrile and irritable over past 24 hours. He did not sleep well the
previous night and has vomited twice today.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and management

APPROACH
▪ Hemodynamic stability
▪ Fever questions: When did it start? How high was the fever? Is any
rash present? Is there any neck stiffness? Did you give any
medications?
▪ Runny nose questions: When did it start? Did he have a cough,
shortness of breath?
▪ Vomiting questions: Can you tell me more about it? When did it
start? How did it happen? What is the colour and amount of
vomitus? Was it forceful/not? Was it related to feeding/food? Is he
hungry after the feed?
▪ Well, baby questions:
o Do you notice that he's been irritable or has been hard to wake

up?
o How are his feeding and drinking? Has he lost weight?
o Have you noticed any change in the number of his wet nappies?

Any diarrhea or change in bowel motion?

▪ Birth:
o Any problems during pregnancy and delivery? Did you take any
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medications during pregnancy?

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 o Was he a term baby? What is the mode of delivery? What is the
reason for that type of delivery? Did he cry immediately after
birth?
o Did he require any time in the special nursery after birth? Was

the heel-prick test done?

▪ Immunizations: Are his immunizations up to date?
▪ Development: Any problems with his growth and development?
▪ Social history:
o Do you have any other children, how many?
o Is this your only baby or do you have any other kids? Do they

have this same problem?

▪ Does he take any medications? Does he have any allergies?
▪ Differential questions:
o Intussusception questions: Draws up legs while crying, turns

pale while crying, any abdominal distension, passed wind

(flatus)
o Intestinal obstruction questions: Distension, passed wind
o UTI questions: water works, any change in the number of wet

nappies, any foul smell while changing nappies, child cries while
he passes pee
o Fever questions: Rash, neck stiffness? (meningitis), noticed any

lump in the body especially groin area (r/o hernia), lethargic,

pulling his ear/ear discharge
▪ Physical exam:

1. General appearance
o PICCLE
o Growth charts (until 12 years old only)
o Dehydration

2. Vitals signs
3. Systemic Exam
o Musculoskeletal system
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o ENT
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o CVS

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 o Respiratory
o Abdomen
o Neuro

4. Office tests: UDT

▪ Management:

Note: A child with otitis media can also have a serious bacterial
infection such as septicemia or meningitis. If systemically unwell,
consider coexistent causes of sepsis - do not accept otitis media as
the sole diagnosis in a sick febrile young child without elimination
of a more serious cause

• Most likely your child is having acute otitis media. Our ear has
three parts, outer, middle and inner ear. The infection is in the
middle part as it contains pus. This is what we call the eardrum
and it is normally clear and flat.
• However, on examination, it was found to be reddish and bulging
out indicating that there is an ongoing infection and it contains
pus or infected fluid. Ear infections are very common in children,
and it is often preceded by a viral URTI as was seen in your child.
The eardrum has a small hole and the infected fluid has already
come out, which will help reduce pain.
• Don’t be stressed since these holes heal spontaneously without
much affectation in hearing. However, a hearing test can be done
later once his present condition resolves.
• We will give antibiotics for 5 days as there is the presence of
purulent pus, pain killer such as Panadol, and please give him
adequate fluid as well. I will see you in 2-3 days for review.
• If your child is not eating well, not feeding well, drowsy, then see
me immediately. You also can-do gentle ear toilet, which is with a
cotton bud, remove excess discharge from the right ear so that
the ear is kept dry.
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LIMPING CLUSTER

1. Hemodynamic stability
2. Open-ended questions: When did it start? How did it start? What
was he doing when it started? Is it getting worse? Has he ever had
this before in the past?
3. Well, Baby questions:
a. The mental state of the baby: has he been 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 a number of wet nappies?
4. Closure: BINDSMA (BIND - until 12 years old), Past history, Family
history
a. Birth (especially important if less than 1-year-old)
i. Antenatal: did you have any infections, took any drugs, 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 a special nursery? Was
the heel-prick test done?
b. Immunizations
c. Nutrition
d. Development: 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?
e. Social history
f. Medications
g. Allergies
h. Past history
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i. Family history
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5. Differential diagnoses

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Features Developmental Irritable Perthes Slipped Osgood Trauma
dysplasia of hip/Transient disease capital Schlatter Septic arthritis/
the hip synovitis femoral Disease Osteomyelitis/
epiphysis Jogger's knee/ Malignancy
Runner's knee/ Henoch
Chondromalacia Schonlein
patellae/ Purpura
Patellofemoral Juvenile
pain syndrome rheumatoid
Jumper's arthritis
knee/Patellar
tendonitis
Age 0 - 2 years 3 - 8 years 3 - 8 years 9 - 13 >14 years Any age group
years
Risk factors: Risk factors: Risk Osgood Septic Arthritis
• Has he • Has he factors: Schlatter Fever, swelling,
had any had any Occurs in Disease - pain pain, nausea and
recent recent chubby on the tibial vomiting,
viral viral boys tuberosity constitutional
illness/UR illness/UR who are symptoms
TI? TI? quite Chondromalacia (sweating, not

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athletic patellae eating and

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 • Passive • Passive • (+) drinking fine,
smoking smoking crepitations generalized
Has he been on passive fatigue)
complaining flexion and
of any other extension of Any secondary
joint pains? the knee infection
• Clark's test contributing to
positive septic arthritis?
• Any activity • Any

that projectile
involves vomiting?
bending will Any rash in
cause pain the body?
Any runny
Jumper's knee - nose? Any
patellar tilt test lethargy?
(+) (meningitis)
• Any

increased
work of
breathing?
(pneumonia)

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 • Any smelly
nappies? Any
staining of
the nappies?
(UTI)
• Any vomiting
and
diarrhea?
Any blood in
the stools?
(Gastroenteri
tis)

Osteomyelitis
More subacute
presentation
than septic
arthritis

Malignancy
Swelling might be
there for a while,

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triggered by an

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 injury or they
found it during
an injury

HSP
• Recent viral
URTI
• Skin
involvement:
petechial
rash, scrotal
skin
tenderness
• Arthralgias of
multiple
joints
• Renal
involvement
--any tummy
pain or any
blood in the
urine?

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 • Associated
with
intussuscepti
on

JRA
• Iritis: any
swelling or
redness of
his eyes?
• Family
history
• Multiple
painful joints

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PHYSICAL EXAMINATION:
Systemic Exam
1. Musculoskeletal system
• One joint above, one joint below
• Look (2S,2R, B, M, D) - swelling, scar, redness, rash, bruising,

muscle atrophy, deformity

• Feel - temperature, point tenderness (only way you can

differentiate septic arthritis and osteomyelitis - septic is

generalized, osteo is point tenderness), capillary refill time,
pulses
• Move - any limitation in the range of motion?
• Measure
▪ True length - from ASIS to medial malleolus
▪ Apparent length - umbilicus to medial malleolus
▪ Usually AL > TL but if TL > AL it means the hip is tilted

because of a pathology

• Special tests
▪ Roll test - passive internal and external rotation --> if you

trigger a quadriceps spasm, it is roll test positive --> it

confirms a Perthes disease
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 ▪ Laxity of knee and hip

INVESTIGATIONS
Bloods: FBE, UEC, ESR, CRP, LFTs, if febrile: Blood culture
Urine: if UDT is positive, can send for urine microscopy and
culture
Imaging: X-ray, Ultrasound --arrange both hip and knees,
bilateral

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Perthes disease

You are a GP and a 6-year-old boy was brought in by his mom

because he has been limping for the last 2 days and he refused to
bear weight on his left leg since this morning.

TASKS
1. Further focused history
2. Physical examination findings from the examiner
3. Arrange investigations
4. Diagnosis and management

• Well, doctor for the last 2 days he's been limping, sort of
hopping on his left leg. He's complaining of pain on his left
knee, but he's refused to get out of his bed
• History of trauma? They just keep bumping into things, must
have had trauma but I really don't know, but you know how
kids are.
• Fever? No doctor
• Feeding, appetite? It's gone down a bit for the last 2 days, he's
a good eater otherwise
• Swelling in the leg? No swelling
• Pregnancy and delivery? No complications
• Immunizations? Up to date
• Developmental problem? No. he's a healthy kid otherwise
• Does he complain about anything in school? No doctor
• PE from examiner:
• General appearance: in pain, irritable
Vitals: afebrile, rest is normal
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Left leg in external rotation position, not able to bear weight, no
obvious swelling, limitation of abduction and internal rotation of the
left hip

X-ray:

MANAGEMENT
• Most likely your child has Perthes disease, also called as avascular
necrosis of the head of the femur. So, this is the thigh bone, at the
end is the head of the femur. Sometimes because of unknown
reasons, the blood supply to the head of the femur is restricted,
leading to fragmentation and collapse of the head of the thigh
bone called avascular necrosis of head of the femur.
• It is not very uncommon.
• It usually presents with knee pain and limping.
• Risk factors are passive smoking and viral upper respiratory tract
infection.
• I will give him pain relief and crutches then I will refer him
immediately to the orthopedic surgeon who might consider doing
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further investigations including MRI and a bone scan to find out

the complete extent of the damage.
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• Once the complete extent of the damage is known, he might put
him on a specialized orthopedic support (Thomas splint) which
will prevent him from bearing weight and will help the head of the
thigh bone to regenerate. Sometimes the treatment can be
extended for up to 2 years. We will also need constant input from
physiotherapist.

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Irritable hip/ Transient synovitis

Sam a 4-year-old boy brought in by his father Dan because he has

been limping for the last 2 days and today, he wasn’t able to get up
from his bed. His parents are concerned because Sam is usually quite
active.

TASKS
1. History
2. PE from examiner
3. Investigations
4. Diagnosis and Management

History points:
▪ Viral URTI
▪ Limping for 2 days
▪ Roll test negative
▪ No point tenderness
▪ No laxity of knee or ligament
▪ UTZ: effusion of the left hip
▪ X-ray is negative

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• Most likely he's got irritable hip or transient synovitis. Since he
had a viral infection 1 1/2 weeks ago, the lining of his hip joint
called synovium got inflamed in response to the viral infection
leading to a collection of fluid within the hip joint.
• It is not very uncommon. It presents with hip pain and limping.
(any joint that is inflamed, you rule out septic arthritis)
• I will refer you to the orthopaedic surgeon who might consider
aspiration of this fluid from the hip joint to rule out serious
infection of the hip joint (septic arthritis). Once that's ruled out,
management is conservative. Before referring, I will give him pain
relief and crutches. Conservative management is PRICE (pain relief
and physiotherapy, rest, ice, compression, elevation - put 2-3
pillows under the heel)
• We will repeat the x-ray after 4 - 6 weeks because it could lead to
Perthes disease. The prognosis is good is the treatment is started
early on, but again, the specialist will be able to help you more
with that.

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Slipped Capital Femoral Epiphysis

A 12-year-old boy is brought in by his father to your GP clinic

complaining of pain in his left knee and limping for the last one
week. He's a basketball player and the pain started one week ago
but since this morning he's unable to bear weight.

TASKS
1. Further focused history
2. PE from examiner
3. Explain your most likely diagnosis and management to the
patient

Leg in flexion and external rotation on left side

No obvious swelling of redness
Restriction of only the internal rotation
Afebrile
>97 percentile for his age

X-ray

Draw line at the upper border of the head of the femur, the line
should touch the lateral 1/3 of the head of the femur.
Here, it misses the head completely.

HISTORY: (refer to limping cluster)

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Ask SOCRATES pain questions.

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Ask SCFE ruling in questions: weight

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Rule out septic arthritis as differential diagnoses by asking infection
questions
Rule out malignancy
Rule out HSP
Rule out JRA
INDSMA questions

PE:
PICCLE
Growth charts
Musculoskeletal tests - especially ROM of hip
Check for laxity of ligaments

INVESTIGATIONS
Bloods: FBE, UEC, ESR, CRP, ANA, RF
Imaging: pelvic x-ray because you want to compare both sides

MANAGEMENT:
• You have a condition called slipped capital femoral epiphysis.
This is the thigh bone and the head of the thigh bone. Since in
your son's case, he is chubby and he is athletic, the growth
plates, they tend to be weak. Since he is using his leg too much
because he is athletic, the head of the thigh bone has slipped
from its place. If left untreated, it can restrict the blood supply
to the head of the thigh bone.
• That's why I need to refer him immediately to the surgeon.
Before referring I will give him pain relief and crutches. They
will try to fix the head by pinning the head to stabilize the
bone. They might consider putting a pin on the other side as a
preventive measure.
• The outcome is usually good with treatment. Once he is
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discharged from the hospital after surgery, he needs to

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consider weight loss.

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Osgood Schlatter Disease /Chondromalacia patellae/ Patellar Tendinitis

A 15-year-old female who is a hockey player comes to you with pain

in the left knee and has been limping for 6 weeks.

TASKS
1. Relevant concise history
2. PE from examiner
3. Provide differential diagnoses to examiner
4. Answer patient's questions

Differentials
Osgood Schlatter disease
Jogger's knee
Patellofemoral pain syndrome

Pain started 6 weeks ago while playing hockey

Going upstairs and playing hockey makes it really bad
Severity: 7/8
Tried putting Voltaren gel
BMI is 23
Clark's test positive

History and physical examination: refer to limping cluster (general

approach)

MANAGEMENT
Osgood Schlatter
• Most likely you have Osgood Schlatter disease. This is your leg
bone, knee cap. There is a small tendon that connects your knee
cap with your leg bone called the patellar tendon. Since you are in
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a growing phase, the bones are growing faster compared to

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 you are athletic. Because of that, the short tendon is pulling on
the bone causing swelling and inflammation of the bone called
tibial tubercle apophysitis. It usually takes 3-6 months to get
better.

• Chondromalacia Patellae
• Most likely you have chondromalacia patellae. This is your leg
bone, thigh bone and your knee cap. Normally your knee cap or
patellae glides smoothly between the femoral condyles. But
sometimes, because of some tight soft tissues around the knee
cap, it gets displaced thereby causing friction between the
undersurface of the kneecap and the femoral condyle. It takes 6 -
12 months to get better. The physiotherapist will likely do
quadriceps and hamstring exercises. Can refer to orthotics to look
for other issues going on because a lot of time this involves
posture or gait abnormalities.

• Patellar Tendonitis
• Most likely you have patellar tendonitis. There's a structure called
the patellar tendon which connects your knee cap with your tibia.
Because of repetitive use, there are small tears in this tendon,
causing the pain. It takes 6-12 months to get better. The
physiotherapist will likely to quadriceps and hamstring exercises.

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Developmental Dysplasia of the Hip

You are a GP, the mother brings her 8 week old baby girl referred to
you by a nurse who's found asymmetric hip creases.

TASKS
1. PE findings from the examiner
2. Talk to mother about condition and management

Positive findings: C-section d/t breech

Left hip appears to be higher than the right hip
Asymmetric gluteal creases
Apparent length is less than the true length on the left side
No clicking on abduction
Limitation of abduction alone

Physical Examination
Look - hip creases, knee height discrepancy, gluteal crease
Feel - tenderness of the greater trochanter, tenderness in adductor
muscles
Move - limitation in abduction alone
Measure - AL is less than TL on the left side
Special test
1st: Barlow's test - dislocation; flex the hip to 90 degrees, adduct the
hip then push it down
2nd: Ortolani - relocation; push the hip up with two fingers on the
greater trochanter, and palpate a clunk if there is DDH

Investigations
< 3 months, do an ultrasound because the femoral epiphysis is not
ossified
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>3months, do an x-ray
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Management
• Most likely she's got developmental dysplasia of the hip. It's a
condition in which the head of the thigh bone is not well-formed,
and it doesn’t stay within the joint. The usual cause is related to
the mother's hormones during delivery. During delivery, there is
the secretion of certain hormones (Relaxin) that relaxes the pelvic
ligaments of the mother to help with the delivery. These
hormones they can travel through the blood, reaching the baby
making the baby's pelvic ligaments loose and they do not support
the head of thigh bone. It is not very uncommon.
• Usually presents with asymmetric hip creases or difficulty
changing nappies, limited abduction. Risk factors are breech,
firstborn premature female child.
• I will refer you to a paediatric orthopaedic surgeon who will apply
a Pavlik harness which is a splint to keep the head in place. The
prognosis is good if the treatment is started early on. We will
frequently follow her up with serial ultrasound and x-rays and she
will be managed by the orthopaedic surgeon from now on.
• **If < 6 months, use a Pavlik harness, which is a splint to keep the
head in the joint
• If 6 - 18 months, pelvic hip Spica
• If >18 months - open reduction internal fixation

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Osteomyelitis

You are an HMO in the ED of a rural hospital and a 2-year-old girl was
brought in by her parents because the child refused to stand up since
yesterday and she cries when you try to make her stand with
support.

TASKS
1. Further focused history
2. PE from examiner
3. Most likely diagnosis and management

irritable, crying a lot, did not walk the whole day, doesn’t want to
touch the right leg especially the knee
Number of wet nappies has gone down
irritable, crying, lying on the bed with the right leg is flexed, 38.9, PR
high, a child not letting you touch the leg, painful with minimal
movement, tenderness over the knee at the tibial tubercle, point of
tenderness 10cm below the tibial tuberosity, swelling, redness, and
tender
History of fall while playing with the kids at child care

History and Physical Examination: Refer to limping cluster

Physical Examination
Is there any point tenderness? The only thing that will differentiate
osteomyelitis from septic arthritis

Management
• Most likely your child has osteomyelitis. It is an infection of the
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end of the long bones, likely the lower leg bone in your child's
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case. The most likely cause is the injury that she had while she

© 2020 ARIMGSAS
 was playing at child care. I still need to confirm my diagnosis that
is why I need to run some investigations such as FBE, UEC, ESR,
CRP, blood cultures, complete septic screen, an x-ray of the knees
to rule out a fracture.
• I will refer her to the orthopaedic surgeon who might consider
doing an aspiration of the knee to rule out concomitant septic
arthritis and a bone scan to confirm it. She will be admitted to the
hospital and will need IV antibiotics (insert a PICC line). Usually we
need to give them antibiotics for 3 weeks through the veins
followed by oral antibiotics for up to 1 - 2 weeks. X-rays might not
show osteomyelitis at an early stage.

• Most likely your child has septic arthritis. It is an infection of the

knee joint. I still need to confirm my diagnosis that is why I need
to run some investigations such as FBE, UEC, ESR, CRP, blood
cultures, complete septic screen, an x-ray of the knees to rule out
a fracture.

• I will refer her to the orthopaedic surgeon who might consider

doing an aspiration of the knee to confirm it and a bone scan to
rule out concomitant osteomyelitis. We need to do a knee lavage
which means we washout the joint and then will start IV
antibiotics for 1 to 2 weeks, followed by the oral tail for 1 to 2
weeks.

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Henoch Schonlein Purpura

A 5-year-old boy was brought to you by his parents complaining of

limping for the last 2 days.

TASKS
1. Further focused history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

History and Physical Examination: Refer to limping cluster

INVESTIGATIONS:
• Blood: FBE (do it to see platelet count to differentiate it from
ITP. In ITP, platelets are decreased because antibodies attack
it), UEC, ESR, CRP, ANA, RF
• Urine: 24-hour urinary proteins (if more than 3g/day, give
steroids to protect the kidney; before giving steroids, make
sure they don't have intussusception by doing a screening
ultrasound of the abdomen because steroids make it worse),
protein-creatinine ratio
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MANAGEMENT
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• Most likely he has Henoch Schonlein Purpura. It's an autoimmune
condition. Since she had a viral URTI, his body started producing
antibodies against it. And those antibodies started acting against
his own tissues including his blood vessels causing the rash, his
kidneys causing blood and proteins in his urine, his joints causing
swelling and limping.
• Usually, this condition resolves on its own, but we will monitor his
urine output and the amount of proteins in his urine. If the urine
output is decreased or the amount of proteins in his urine is
increased, we might consider giving him steroids.
• I will need to admit him and will refer him to the paediatric
registrar who will confirm the diagnosis.

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COUNSELLING

Hereditary Spherocytosis

A 2-year-old girl was brought to the ED due to lethargy. She has been
having lethargy, on & off yellow skin for the past 6 months. On
examination, there was jaundice, pallor, splenomegaly, no
hepatomegaly, no lymphadenopathy. Investigation show low
haemoglobin, high reticulocyte count, elevated bilirubin, presence of
spherocyte in blood film.

TASKS
1. Explain blood results to mother
2. Inform the diagnosis to mother
3. Inform the investigations to confirm the diagnosis
4. Inform the management

Management
• Blood has 3 types of cells, red blood cells which carry blood to all
parts of the body with the help of a pigment we call haemoglobin,
white cells which helps us fight against infections, and platelets
which help in blood clotting. In your child's case, the RBCs are
affected as shown here: he has decreased levels of RBCs and
haemoglobin. Collectively, the condition is called anemia.
• We examined the child's blood under the microscope, and it
showed abnormally-shaped red blood cells. The normal shape of
red blood cells is doughnut-shaped, but in your child's case, it is
sphere/globular/ball-shaped. This RBC passes through tube-like
structures called blood vessels and capillaries. For passing through
these structures, the RBCs need to be flexible. Because of the
abnormal shape of your child's RBCs, whenever it passes through
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these tube-like structures, they are destroyed or they breakdown.

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 When there is a breakdown of RBCs, the haemoglobin is also
broken down.
• Because there is an increased breakdown of RBCs and
haemoglobin, bilirubin, which is a product of this breakdown, is
increased. This bilirubin is responsible for the yellowing of the skin
of your child. This bilirubin is removed from the body by the liver.
These dead RBCs are cleared by an organ present on the left side
of our tummy called spleen. Because there is increased
breakdown of RBCs, there is also increased workload to this
organ, thereby increasing its size. This organ is very important in
fighting infections.
• Also, because there is an increased breakdown of RBCS, the body
responds by increasing production of these cells that is why there
is increased number of baby RBCs or immature RBCs called
reticulocytes.
• All these findings found in your child such as abnormally-shaped
RBCs, increased baby RBCs, increased size of spleen, lethargy,
yellowing of skin, is collectively called hereditary spherocytosis. It
is a condition which runs in the family, but sometimes new
mutations/changes can occur. [if no family history is present]
• What we can do is to confirm the diagnosis is to involve a
haematologist and a paediatrician and do eosin 5-M staining.
• If haemoglobin is very low, blood transfusion can be done. This is
not a curable condition, but it is a manageable one.

• Long term management:

• We need to start on folate supplementation and increase intake
of folate-rich foods.
• We will do a regular follow-up on blood tests and if fewer RBCs,
we will give a blood transfusion. As the bilirubin increases, it can
get deposited in one of the organs below the liver called gall
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 bladder, so they need to have a regular abdominal ultrasound to
rule out gallstones.
• Even after all of these and the condition is still not controlled,
then the team can decide on removing the spleen, the organ
responsible for the RBC destruction).
• One thing to keep in mind, before we remove the spleen, she
needs to be immunized against 3 bugs: pneumococcal,
meningococcal, and H. influenzae. And most of the times, the
spleen is not removed until the age of 6 years.

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Pancytopenia

You are a GP and a 3-year-old boy was brought by mom because of

fever (39) and tiredness. They saw a GP yesterday who ordered some
blood tests. They have returned today to discuss the results with you.
Hgb 8g (11-12g/dL)
WCC 2000 (4000-9000)
Platelet Ct 20,000 (150,000-400,000)

TASKS
1. History
2. Discuss results
3. Outline management

Differential Diagnoses
▪ Decreased production:
o Hereditary (Fanconi anemia)
o Post viral (Parvovirus B19, HIV, Hepatitis)
o Drugs (Chloramphenicol, sulphonamides, antimalarials,

immunosuppressants)
o Leukemia (bone marrow exhausted of nutrition) → ALL
o Aplastic anemia

▪ Increased destruction
o Hypersplenism
o Myelofibrosis
o Infections

▪ Megaloblastic anemia

APPROACH
▪ Fever questions
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▪ Tiredness questions: when does he feel tired? Rest and activity

▪ Infection questions:
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o History of repeated infections?

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 o Any cough, runny nose, ear discharge, ear pain, noisy
breathing?
▪ Malignancy questions
o Nausea and vomiting and tummy pain, loss of appetite, weight

loss, lumps and bumps, rash, bleeding from

mouth/nose/anywhere else?
▪ BINDSMA
▪ Past history
▪ Family history
▪ Physical examination
o GA: PICCLE
o Vital signs
o Growth charts
o Dehydration
o Skin: bruising
o ENT

▪ Management

▪ Blood has 3 types of cells, red blood cells which carry blood to all
parts of the body with the help of a pigment we call haemoglobin,
white cells which helps us fight against infections, and platelets
which help in blood clotting.
▪ In your child's case, all of these cells are decreased. Collectively
this is a condition called pancytopenia. There are many causes of
pancytopenia, it may be due to improper diet, medications,
recent viral infections. Bu at this stage, I am more worried about a
serious condition called blood cancer. Are you okay to continue
with the consultation or do you want me to call someone to be
with you?
▪ I need to tell you that this is not yet a final diagnosis, but this is
one of the conditions I am most worried about. It is good that we
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picked it up early so that we can intervene early.

▪ At this stage, I am going to send the child to the hospital, where
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he will be seen by a multidisciplinary team consisting of the

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 paediatrician and oncologist. They will arrange other
investigations: blood picture (peripheral blood smear), UMCs,
serum folate, B12, blood culture, CXR, UTZ of the abdomen. Later
on, the child may undergo a bone marrow aspiration to confirm
the diagnosis.
▪ The child is first made comfortable, then specially trained
specialists called paediatric pathologists will take a small part of
the bone from the hip or the thigh or chests, and they will
examine it under the microscope. Now once the diagnosis is
confirmed to be blood cancer, they have different types of blood
cancer and do further investigations to find out what is the type
of blood cancer, and treatment depends on that.
▪ Most commonly, the treatment is chemo (giving drugs to cancer
cells), radiation (exposing to radiation to kill the cancer cells) or
combination of both, or bone marrow transplant (a part of the
bond is transferred)
▪ As the diagnosis is being confirmed, the child will be started on
antibiotics (if we suspect infection) or blood transfusion (if there is
bleeding)

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Post Chemotherapy Fever

You are an intern in a rural hospital. 7 years old John was diagnosed
with lymphoblastic leukaemia. He was given chemotherapy for 6
months and finished it a week ago. Now he comes with complaints of
URTI and fever39. His father has accompanied him. Tertiary hospital is
70KM from your place.

TASKS
1. Ask examiner for examination findings (You will be given only what
u have asked for)
2. Talk to father about your concerns and initial management plan

Positive findings: 110/70, 39.0C, 25RR

Nothing positive except temperature.
Mild congestion of pharynx
REFER THIS CASE!

PE:
GA: alert? Drowsy, irritable, lethargic?
Rashes? LN?
VS:
HEAD TO TOE EXAM
ENT: otitis media features? - TM congested, bulge, discharge,
swelling of the external ear?
NOSE: bleeding, runny nose, nasal discharge?
THROAT: tonsils enlarged, pharynx congested, follicles
present?
LN EXAM: cervical, axillary, supraclavicular, epitrochlear,
inguinal
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SKIN INFECTIONS OR RASH? Furuncle, carbuncle, folliculitis

RESPIRATORY: air entry, breath sounds/
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CVS: Heart sounds distinct, murmurs?

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 ABDOMEN: mass tenderness?
JOINT EXAM: tenderness, limitation of movement
CNS: neck stiffness
ANAL AND GENITAL: discharge?

OFFICE TEST: UDS

Explanation:
▪ From the examination, your child is having fever which can be due
to a lot of causes but is most likely due to a viral URTI. Your child
was recently treated by chemotherapy drugs. These drugs not
only kill cancer cells but also affects normal blood cells in our
body.
▪ I am more worried about their effect on WBCs, which are
responsible for fighting against infections. If they are decreased in
number, then a simple viral infection can become life-threatening,
leading to spread of infection in the blood, which we medically
call as sepsis.
▪ It is good that you came early so that we can control it. But in
your child's case, we could not find any source of infection, other
than a little bit of congestion in the ear and throat. So we need to
do some investigations to find it out.
▪ I will call the pediatric registrar if available in the hospital.
▪ Blood tests: FBE, ESR, CRP, BLOOD CULTURE, LFTS, UEC. We will
do a chest x-ray to find infection in the lung. URINE MCS to check
for infections in the urine.
▪ We need to start the child on a broad-spectrum antibiotic, then I
will refer you to a tertiary hospital where a multidisciplinary team
(pedia, onco, infectious disease specialist) can manage your child.
They will take measures for infection controls to prevent its
spread.
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▪ I will be in contact with them before the child gets there. I will fax
them all the blood test reports once results are available. I know
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that this is very stressful for you, as you have recently just come

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 back from the tertiary hospital. Please do understand that it is
very necessary to refer the child now so that we can prevent
further complications. In the meantime, if you need any financial
help, we could arrange for that.

▪ I will be with you until the ambulance arrives. So feel free to ask
any questions that you may have.

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Cryptorchidism/Umbilical hernia/Inguinal hernia

A 7-month old baby was brought to your GP clinic by his mother

because she noticed a lump in his groin area and another at the belly
button. You diagnosed it as umbilical and inguinal hernia and you also
noticed that the left sided testicle is undescended.

TASKS
1. Discuss condition to mother
2. Advise further management
3. Answer questions

Do you have any particular concern before I explain anything about

your son’s condition? This happens when part of the gut goes out into
the umbilical or inguinal area.
May ask: reducible/painful/vomiting/fever?
Any thyroid disorders (hypothyroidism)?
Family history of hernia?
Severe cough or constipation? Abdominal operation?
Term/preterm?

Management:
I have examined your child. I will be explaining the conditions one by
one, if you don't understand, please let me know.

Umbilical Hernia:
▪ This is the tummy wall. If there is any weakness in the tummy
wall, the tummy contents can protrude out. In your child's case,
the weakness is there in the belly button. Usually, in cases of
umbilical hernia, it gets resolved by itself by 1year of age, and
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larger ones at 4 years of age. The only treatment is to wait and

watch. In the meantime, you need to watch out if it becomes red,
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it doesn’t go back by itself, severe pain, vomiting. This is an

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 emergency situation and you need to seek help immediately.
Don't put anything on it like a coin over that place because it can
increase the risk for strangulation. Strangulation is constriction of
blood vessels that can arrest the flow of blood to tissue. He will
have severe pain with the change of the skin to blue or blackish.
Refer to surgery asap.

Inguinal Hernia:
▪ It's the same as the umbilical hernia but in the groin area. But this
has a high chance of not going inside the tummy and usually, the
contents which are the gut can get blocked and lead to vomiting,
distension of tummy, etc. So, at this stage, we need to refer to the
specialist for surgery. Good that you have come early, and we can
intervene early.
▪ 6x2 rule: if hernia diagnosed at birth to 6 weeks operate within 2
days; if at 6 weeks to 6 months, within 2 weeks; if 6 months
onwards, within 2 months

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Undescended Testis:
▪ This condition usually is found with indirect inguinal hernia (90%).
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It is also common in the preterm patient. (20%). Normally in

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 males, testis develops in the baby's tummy while baby is still in
your womb and descends to the scrotum or the sac at the time of
birth.
▪ But if it is not found in the scrotum at the time of birth, we usually
observe and wait for 3 months. If after 3 months, it is still not
descended, then the child needs surgery since if the testis remains
in the tummy, then it will lose its function when the child reaches
puberty.
▪ But for your child, it is a good thing is you have come early, and
since he is already 7 months old, I will refer you to a specialist
now since the optimal time of surgery is 6 to 12 months (but can
operate until 2 years old so as not to affect sperm production)

Problem of non-descent
• Testicular dysplasia
• Trauma
• Risk of malignant change (5-10x)

▪ Optimal time of surgery is 6-12 months. There is a decreased risk

of affecting fertility if the testis is repaired by 2 years.

Advantages of early orchidopexy

• Provides optimal chance of fertility
• Corrects indirect inguinal hernias (coexists in 80%)
• Reduces risk of trauma
• Reduces risk of torsion
• Reduces psychological consequences
• Lessens Risk of malignancy
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Down Syndrome Counselling

You are an HMO. The pediatrician has just seen a newborn baby and he
noticed features of Down syndrome. He requested you to tell the
mother about this.

TASKS
1. Ask the examiner features of Down Syndrome in the body
2. Counsel the mother

A most common sign of down syndrome: Generalized hypotonia

Knowledge about the features of downs is needed for the first task.

COUNSELING
▪ From my examination, I have found some features that made me
think that your child may have down syndrome.
▪ When a mother stands up, you should also stand up. Offer water
and tissue. Give the mother time to relax.
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▪ I know that this is a very hard time for you. If you can discuss with
your husband and you can make a mutual decision. Meanwhile,
we can take care of Mark in the nursery.

▪ Reassure the mother.

▪ I can also tell you, nowadays, there are special schools that make
people with down syndrome work normally in societies.

▪ Doctor, can he still play football?

Mary, most likely he may play football, but we need to wait for him
to develop because, in some down syndrome babies, their neck
tend to be very weak.

▪ Was it my fault?
It is not your fault. Sometimes these happen for no reason at all.

▪ I did my screening test for Down syndrome. Why did this still
happen?
Unfortunately, no screening test is 100% accurate.

▪ At this moment, we will arrange further investigations to confirm

this condition and to also check his general health.

▪ How can you be sure of this doctor?

I am not sure about this, that is why we need to confirm it by doing
genetic analysis. However, I have a strong suspicion for this, as the
features that he has are only seen collectively in a condition called
down syndrome.
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Immunization advice

Mother doesn't want to do immunization for her 6-month daughter.

You are in a GP practice.

TASKS
1. Take history.
2. Counsel the patient.

APPROACH
▪ I appreciate that you have come to discuss 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 has
produced these antibodies, the bug has already caused substantial
damage to the body. There is also a 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 are 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
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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
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as the bugs injected are chemically treated and only produce a mild

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 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 the majority of
the countries of the world, a number of the 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, a pneumococcal
vaccine that prevents respiratory and brain infections,
meningococcus 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); [Link] 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); [Link]

type B (Hib); meningococcus (MenC): (hepatitis B [hep B]) in

VIC, WA, TAS)
o At 18 months: Varicella zoster virus (VZV); 23-valent
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pneumococcal polysaccharide vaccine (23VPPV)

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© 2020 ARIMGSAS
 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.
o 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.
o A simple febrile convulsion or pre-existing neurologic
disease are not contraindications to pertussis vaccine.
o Children with minor illnesses, i.e. without systemic
illness and providing the temperature is less than 38.5
"C, maybe vaccinated safely.
o With a major illness or a high fever, the vaccination
should be postponed until the child is well. Live
vaccines (MMR, oral poliomyelitis, rubella, chickenpox)
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.
o An anaphylactic reaction to egg is not a
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contraindication to MMR vaccine, but many authorities

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recommend that in such a case it should be

© 2020 ARIMGSAS
 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 has 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).

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Post-splenectomy case

A 10-year-old boy injured his spleen and removed in the hospital. His
father wants to discuss his son's condition. The child is in the post-
operative ward and stable.

TASKS
1. Counsel the father regarding the child's case
2. Tell immediate and long-term risks associated with the condition
3. Answer the father's question

COUNSELLING
▪ I know that you are concerned about your child, and I am sorry for

what has happened to your child. Do you understand why your

child had surgery? Your child had an injury to his tummy, and this
had caused injury to one of the organs inside.
▪ The spleen is an organ present on the left side of the abdomen

under the rib cage near the stomach. It is an important part of the
body’s defence or immune system and helps to fight infections. It
also acts as a blood filter to remove unneeded materials such as old
or damaged RBC and bugs. One of the functions of the spleen is to
produce red blood cells and certain type of antibodies if our bone
marrow is unable to.
▪ One of the most common causes of removal of spleen is after

abdominal injury when it is not possible to preserve it. The spleen is

an organ that bleeds a lot. The surgeon tries to preserve it but if it
is severely damaged, the last option would be to remove it.
▪ Your son can live an active life without the spleen, but there is an

increased chance to contract serious and life-threatening

infections. I will be talking about long-term and immediate
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complications and how to address them. If you have any questions

or concerns do not hesitate to stop me.
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© 2020 ARIMGSAS
o Immediate: John will stay in the hospital until his condition
improves. It takes less than a week and can take 4-6 weeks to
heal. He will be given IV fluids and pain medications to ease the
discomfort and his condition will be monitored on a regular
basis. The things that can happen include bleeding in the site of
infection or injury to nearby organs and lung collapse. Others
are blood clot in the portal vein or the tube that carries blood
to the liver and thrombocytosis which is increased platelets for
2-3 weeks with an increased risk of thromboembolism or
clotting. But we will monitor your child throughout until he
recovers.
o The long term is an overwhelming infection especially with a
bug called streptococcus in 50% of cases. Others include
meningococcemia and Haemophilus influenza. This is called the
overwhelming post-splenectomy infections which are common
in the first 2 years after splenectomy in young children. But do
not be too stressed, the incidence can be reduced by
preventive measures.
• The first is a long-term antibiotic (amoxicillin 250mg OD or

phenoxymethylpenicillin 250 mg BID or

roxithromycin/erythromycin if allergic). The duration is still
under debate and study. It can be lifelong or according to
the needs or wishes of the patient especially if incapable of
taking it. In this case, we give for at least 2 years and have
standby antibiotics if the patients with signs of infection
(Amoxicillin, co-amoxiclav). It is very important for you to
carry the emergency antibiotic kit wherever you go. In case
the child experiences unexplained fever, tiredness,
weakness, the patient should take an antibiotic and consult
with the GP as soon as possible.
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• Your child must also receive PCV 5-yearly,

meningococcemia 3-5-yearly, influenza yearly, Hib vaccine

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once, if not immunized before.

© 2020 ARIMGSAS
• Education about risks and early recognition of infection.
Ideally, the patient should carry a medical alert bracelet.
With your consent, your GP should be informed and given
detailed information.
• Travel advice:
▪ Whenever the child travels to countries where

mosquito-borne or insect-borne diseases are

prevalent, the child needs to take precautions with
regard to that. Active malaria prophylaxis, mosquito
repellents, use of barrier precautions and avoid
bushwalking are advised.
▪ If a patient is travelling to a region where he could get

an unusual infection from ticks that are called

Babesiosis which can be fatal because the spleen is an
important organ to remove it, warn him before travel.
For this reason, contact an infectious disease
consultant or expert travel advisor before travel.
▪ If there is a probability of travel to endemic areas

where there is a high chance of meningococcal

infection, the patient should receive vaccine regardless
of previous vaccination status.
• If the patient has animal bites, then he should have
antibiotic coverage like amoxicillin or Augmentin for at
least 5 days.

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ABDOMINAL PAIN CLUSTER

APPROACH
▪ Pain questions. SOCRATES1

Where is the pain? Can you point with one finger the exact location
of the pain? When did it start? How did it happen? What were you
doing when the pain started? What type of pain is it? Is the pain
travelling to anywhere else? Any associated symptoms like nausea,
vomiting, headache or fever? Is it a continuous pain or it comes and
goes? Is it related to feeds? Does the pain occur at a particular
time? Is it present every day or just on weekdays or weekends?
Anything that makes the pain better or worse? How severe is the
pain from 1 to 10, 10 being the worst pain? Is this the first episode
of the pain?
▪ Well, Paediatric questions. How is her appetite? Any change in her

diet? Does she sleep well?

▪ How is her urination? Any change in the frequency? Any change in

color or smell? How is your bowel movement? Is she passing hard

stools? Is it smell offensive? Is there blood in stool? Is there pain
while passing stools?
▪ BINDSMA
o Are the immunizations up to date?
o Does her diet contain a lot of fruits and vegetables? Does she

drink a lot of fluids?

o Any problems with her growth and development?
o Any problems with school? Any problems at home? Is there

any bullying?
o Does she take any prescription or over the counter

medications?
o Any allergies? Any recent travel?
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o Any past history of medical or surgical illness?

o Any family history of migraine, thyroid disorder?
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▪ Differential Diagnosis questions:

© 2020 ARIMGSAS
 o Constipation
o Childhood migraine equivalent (pain with extreme pallor)
o Lactose intolerance (symptoms related to milk ingestion)
o Intestinal parasites
o Subacute appendicitis
o Psychosocial causes
o UTIs

▪ Physical exam questions

o General appearance

i. PICCLE
ii. Growth charts (until 12 years old only)
iii. Dehydration
o Vitals signs
o Systemic Exam

i. Musculoskeletal system
ii. ENT
iii. CVS
iv. Respiratory
v. Abdomen: mass, distention, tenderness, organomegaly,
bowel sounds
vi. Neuro
▪ Office tests: UDT
▪ Investigations: FBE, ESR, Urine analysis, TFT, stool analysis (m/c and
reducing substances), abdominal Plain X-ray (if constipation is
suspected)
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Constipation

You are a GP and a 7-year-old girl was brought by her mom because of
tummy pain for 4 weeks.

TASKS
1. History
2. Examination Finding from the examiner
3. Diagnosis and Management

APPROACH
▪ Pain questions. SOCRATES1

Where is the pain? Can you point with one finger the exact location
of the pain? When did it start? How did it happen? What were you
doing when the pain started? What type of pain is it? Is the pain
travelling to anywhere else? Any associated symptoms like nausea,
vomiting, headache or fever? Is it a continuous pain or it comes and
goes? Is it related to feeds? Does the pain occur at a particular
time? Is it present every day or just on weekdays or weekends?
Anything that makes the pain better or worse? How severe is the
pain from 1 to 10, 10 being the worst pain? Is this the first episode
of the pain?
▪ Well Paediatric questions. How is her appetite? Any change in her

diet? Does she sleep well?

▪ How is her urination? Any change in the frequency? Any change in

color or smell? How is your bowel movement? Is she passing hard

stools? Is it smell offensive? Is there blood in stool? Is there pain
while passing stools?
▪ BINDSMA
o Are the immunizations up to date?
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o Does her diet contain a lot of fruits and vegetables? Does she

drink a lot of fluids?

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o Any problems with her growth and development?

© 2020 ARIMGSAS
 o Any problems with school? Any problems at home? Is there
any bullying?
o Does she take any prescription or over the counter

medications?
o Any allergies? Any recent travel?
o Any past history of medical or surgical illness?
o Any family history of migraine, thyroid disorder?

▪ Differential Diagnosis questions:

o Constipation
o Childhood migraine equivalent (pain with extreme pallor)
o Lactose intolerance (symptoms related to milk ingestion)
o Intestinal parasites
o Subacute appendicitis
o Psychosocial causes
o UTIs

▪ Physical exam questions

o General appearance

i. PICCLE
ii. Growth charts (until 12 years old only)
iii. Dehydration
o Vitals signs
o Systemic Exam

i. Musculoskeletal system
ii. ENT
iii. CVS
iv. Respiratory
v. Abdomen: mass, distention, tenderness, organomegaly,
bowel sounds
vi. Neuro
▪ Office tests: UDT
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▪ Investigations: FBE, ESR, Urine analysis, TFT, stool analysis (m/c and
reducing substances), abdominal Plain X-ray (if constipation is
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suspected)

© 2020 ARIMGSAS
▪ Management:
▪ Most likely your child is having constipation. It is the production of
hard, small stools, or infrequent bowel movements.
▪ It can be due to a lot of causes, such as improper dietary habits,
the problem around back passage, thyroid disease, medications
etc. But in your child's case, it is an improper diet and low water
intake.
▪ I will arrange for the basic blood tests such as a full blood exam,
urine analysis and stool analysis and abdominal x-ray (if the x-ray
is shown, it will show faecal loading or faecal mass in the gut).
▪ For now, I could give your child some laxatives like lactulose which
could help soften your child's stools. Continue it until your child
develops a regular bowel movement.
▪ In the meantime, we need to make some dietary changes like
increase water intake at least 2-2.5 litres/day and fibre intake, and
to increase her physical activity. I could also refer you to a
dietician to help with her diet.
▪ Once her pain is subsided, she needs to be toilet-trained again --
she needs to go to the bathroom after every meal, breakfast,
lunch and dinner. And please have patience, because these
measures take a long time to act on the child. If she develops
distension, nausea, vomiting, or any change in the character of
pain, please go back immediately.

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Recurrent Abdominal Pain

Ronnie aged 6 years is brought by her mother Julie to your GP clinic.

She tells you that Ronnie had abdominal pain for the last few months
and she is quite concerned as her usual GP think that it’s not serious
and seeks your opinion. On further questioning, Julie describes the pain
as intermittent and mainly around the umbilicus sometimes severe
enough that Ronnie had to miss school. Ronnie is otherwise well and
had no significant medical or surgical problems. Ronnie lives with his
parents at home and had started school this year.

TASKS
1. Relevant history
2. Examination findings from the examiner
3. Diagnosis and management

APPROACH
▪ Pain questions. SOCRATES1

Where is the pain? Can you point with one finger the exact location
of the pain? When did it start? How did it happen? What were you
doing when the pain started? What type of pain is it? Is the pain
travelling to anywhere else? Any associated symptoms like nausea,
vomiting, headache or fever? Is it a continuous pain or it comes and
goes? Is it related to feeds? Does the pain occur at a particular
time? Is it present every day or just on weekdays or weekends?
Anything that makes the pain better or worse? How severe is the
pain from 1 to 10, 10 being the worst pain? Is this the first episode
of the pain?
▪ Well Paediatric questions. How is her appetite? Any change in her

diet? Does she sleep well?

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▪ How is her urination? Any change in the frequency? Any change in

color or smell? Any burning or stinging on urination? How is your

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 bowel movement? Is she passing hard stools? Is it smell offensive?
Is there blood in stool? Is there pain while passing stools?
▪ BINDSMA
▪ Are the immunizations up to date?
▪ Does her diet contain a lot of fruits and vegetables? Does she

drink a lot of fluids?

▪ Any problems with her growth and development? Is he gaining

weight properly? Does it affect his sleep?

▪ Any problems with school? Any problems at home?
▪ Does she take any prescription or over the counter

medications?
▪ Any allergies? Any recent travel?
▪ Any past history of medical or surgical illness?
▪ Any family history of thyroid
▪ Differential Diagnosis questions:
▪ Constipation
▪ Childhood migraine equivalent (pain with extreme pallor)
▪ Lactose intolerance (symptoms related to milk ingestion)
▪ Intestinal parasites
▪ Subacute appendicitis
▪ Psychosocial causes
▪ UTIs
▪ Physical exam questions
▪ General appearance

a. PICCLE
b. Growth charts (until 12 years old only)
c. Dehydration
▪ Vitals signs
▪ Systemic Exam

a. Musculoskeletal system
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b. ENT
c. CVS
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d. Respiratory

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 e. Abdomen: mass, distention, tenderness, organomegaly,
bowel sounds
f. Neuro
▪ Office tests: UDT
▪ Investigations: FBE, ESR, Urine analysis, TFT, stool analysis (m/c and

reducing substances)
Abdominal Plain X-ray (if constipation is suspected)
▪ Management:

▪ From history and examination, your child is most likely have a

condition, a non-organic/functional abdominal pain. I can tell this
because the child is gaining weight and there is no vomiting, no
problem with passing stools, and the child is not constipated.
▪ This is a condition wherein a child gets 3 distinct episodes of
abdominal pain over a course of 3 or more months.
▪ I would like to arrange a few basic blood tests such as FBE, UEC,
CRP, Urine analysis and stool analysis. I
▪ t is a very common problem in school-aged children. It doesn’t
have any ill effect on the child's health. So, what you should be
doing is, whenever the child gets pain, tell him to take a rest, give
Panadol and you can apply local warm packs on the painful area.
But the pain is real in the child.
▪ Please maintain a diary of whenever the child gets the pain and if
it is related to any particular food or diet. This will help her to feel
involved in the management of this disease. The diary should
reflect what time of the day the pain occurs, the severity, scoring
this from 1 being least severe to 10 being most severe, how long
the pain lasts, and what helps in relieving it. The numbers of days
in a week pain is experienced is recorded. While this may seem to
make the child dwell his or her attention on the pain pattern, it
also helps to at a stage desensitize him from the effect of pain. If
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you find any stressor in school, please let us know, so that we can
contact the teacher and find it out.
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▪ We can arrange a family meeting and involve the child during the
discussion. [If there are stressors in the family, do a psychologist
referral for insight therapy].
▪ If there is any change in nature of pain, pain persists for hours or
any new symptoms develop like nausea and vomiting, diarrhea,
pain wakes her up at night then see me immediately.
▪ I will review you in 3-4 days to see how the child is doing.

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Encopresis

The father, John, of a 6-year-old boy, Peter, comes to your GP surgery

seeking your help because Peter’s bowel habit has changed. He has
been soiling his pants for several months and his friends have been
teasing him for that. The parents did not realize the problem for quite a
while because the boy goes to the toilet by himself and did not really
need any help for a few years.

TASKS
1. Take a further history
2. Ask the examiner about physical findings
3. Explain to the father the boy’s condition and management

APPROACH
▪ Bowel habits questions:

When did the soiling of pants start? How often does he soil his
pants? Is there blood or mucus in the stool? Does he experience
tummy pain? Does he have pain while defecating? Is he toilet
trained? Is he experiencing constipation as well? How often does
he move his bowel? Is there any associated vomiting?
▪ Well baby questions:
o Is he particularly irritable or particularly hard to wake up or

lethargic?
o How is his appetite? How are his eating and drinking? Is he

gaining weight?
o Any change in his urination? Any increase in frequency, is it

smelly or is there a change in color? Any burning or stinging

during urination? Is he dry during night-time?
▪ BINDSMA
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o Is there any history of constipation from birth? Is there any

delay in the passage of meconium (r/o Hirschsprung disease)?

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 o Does her diet contain a lot of fruits and vegetables? Does she
drink a lot of fluids?
o Any problems with her growth and development?
o Any problems with school? Any problems at home?
o Does she take any prescription or over the counter

medications?
o Any allergies? Any recent travel?
o Any past history of medical or surgical illness?
o Any family history of migraine, thyroid disorder?

▪ Physical Examination
o General appearance

i. PICCLE
ii. Growth charts (until 12 years old only)
iii. Dehydration
o Vitals signs
o Systemic Exam

i. Musculoskeletal system
ii. ENT
iii. CVS
iv. Respiratory
v. Abdomen: mass, distention, tenderness, organomegaly,
bowel sounds
**don't do per rectal examination because of the
possibility of fissures
[positive findings: Abd Ex-Faecal mass in the lower
quadrant, per anal exam - anus normal with some faecal
staining, no fissure, rectum packed with firm faeces]
vi. Neuro
▪ Office tests: UDT
▪ Investigations: FBE, ESR, Urine analysis, TFT, stool analysis (m/c and
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reducing substances), abdominal Plain X-ray (if constipation is

suspected)
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▪ Management:

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▪ Your condition is called encopresis. It is a condition where there is
the involuntary passage of faecal material in the underpants.
▪ Causes include constipation, inadequate dietary intake, and fear
of pain during defecation. Even though it was treated, the child
fears that if he goes to move his bowels, he gets pain. As he is
withholding his stools, he gets constipated. Because of this
chronic faecal retention, there is the formation of liquid stools,
and this trickles down unknowingly. Don't be stressed, it is a
manageable condition and it is not his fault. At this time, the
treatment is to empty his bowel by giving enema. Once he
empties his bowel, we can start him on stool softeners.
▪ We also need to make some dietary changes like increase water
intake at least 2-2.5 litres/day and fibre intake, and to increase
her physical activity.
▪ I could also refer you to a dietician to help with her diet. He needs
to be toilet-trained again -- he needs to go to the bathroom after
every meal, breakfast, lunch and dinner. Please be patient as
these measures take a long time to take effect.
▪ We also need to talk to the teacher about the bullying. If there is
any change in nature of pain, pain persists for hours or any new
symptoms develop like nausea and vomiting, diarrhea, pain wakes
her up at night then see me immediately.
▪ I will review you in 3-4 days to see how the child is doing.

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Acute abdomen

10-year-old boy Mike coming with severe tummy pain with his father to
the emergency department. You are HMO in ED in a rural hospital.

TASKS
1. History
2. Examination findings from the examiner
3. Investigations with reasons
4. Tell your most likely diagnosis and management

APPROACH
▪ Start with hemodynamic stability: if unstable proceed by DR ABCDE

protocol, start IV line and fluids and get blood for investigations
▪ Pain questions:

Where is the pain? Can you point with one finger the exact location
of the pain? When did it start? How did it happen? What were you
doing when the pain started? What type of pain is it? Is the pain
travelling to anywhere else? Any associated symptoms like fever,
nausea, vomiting, diarrhea, passing of wind (flatus) or tummy
distention? (If there is vomiting, ask about color, amount) Is it a
continuous pain or it comes and goes? Is it related to feeds? Does
the pain occur at a particular time? Is it present every day or just on
weekdays or weekends? Anything that makes the pain better or
worse? How severe is the pain from 1 to 10, 10 being the worst
pain? Is this the first episode of the pain?
▪ Is there any history of injury? Did you do anything after that? Did

you injure your head?

▪ Well child questions:
o Is he particularly irritable or particularly hard to wake up or
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lethargic?
o How is his appetite? How are his eating and drinking? Is he
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 o Any change in his urination? Any increase in frequency, is it
smelly or is there a change in color? Any burning or stinging
during urination? How is your bowel movement? Is she passing
hard stools? Is it smell offensive? Is there blood in stool? Is
there pain while passing stools?
▪ BINDSMA
o Are the immunizations up to date?
o What is her usual diet?
o Any problems with her growth and development?
o Any problems with school? Any problems at home?
o Does she take any prescription or over the counter

medications?
o Any allergies? Any recent travel?
o Any past history of medical or surgical illness?
o Any family history of migraine, thyroid disorder?

▪ Physical Examination
o General appearance

i. PICCLE: look for signs of injury

ii. Growth charts (until 12 years old only)
iii. Dehydration
o Vitals signs
o Systemic Exam

i. Musculoskeletal system
ii. ENT
iii. CVS
iv. Respiratory
v. Abdomen: bike handle mark, distention, tenderness,
guarding/rigidity, bowel sounds
vi. Genital area: blood in meatus
vii. Neuro
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▪ Management
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▪ At this stage, due to fall from a bike, pain in tummy and episodes
of greenish vomiting, I suspect the child to have injuries to his
tummy organs.
▪ This condition we call as blunt injury of the abdomen. The injury
can be to the stomach, liver, spleen, pancreas or bowels. In your
son's case, as he had green vomiting, most likely I think the injury
is in the small bowel.
▪ At this stage, I need to insert an IV line, start on IV fluids and take
blood for investigations such as FBE, UEC, CRP, LFT, Blood group
and cross match, coagulation profile. Please do not give anything
to eat and drink.
▪ I will arrange for a transfer to the rural hospital and I will liaise
with the surgeon at that hospital. In the meantime, I will insert a
tube through the nose going to the stomach to relieve the
pressure and arrange for a CT scan.

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Abdominal Pain - IBD vs Coeliac Disease

16-year-old boy comes to your FP clinic with tummy pain for 3 months.

TASKS
1. History
2. Explain differential diagnosis and further investigations

Differential Diagnosis
▪ Psychogenic
▪ Sexually transmitted disease
▪ Travel disease
▪ Coeliac
▪ Food intolerance/Food allergies
▪ IBS
▪ IBD

HISTORY
PAIN Q
▪ Associated with n/c, diarrhea, fever, rash
▪ Related to diet, affects sleep, weekends, suffered viral infection
previously before pain, occur at a particular time
▪ Bowel motion: hard stools, h/o constipation, soiling of
underpants, pain while passing stools, blood in stools, toilet
trained, hard to flush, distension/flatulence, mass in the tummy,
offensive

Associated features (if positive, then ask in detail)

▪ Do you have any nausea, vomiting, diarrhea
How is your bowel habits?
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▪ Diarrhea: how many times a day, since when did this start? How
was it before? Any intake of new food that changed it? You said
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▪ Does it stick to the pan? Hard to flush? Greasy? (R/O COELIAC
AND LACTOSE INTOLERANCE)
▪ Is it foul-smelling? Associated with blood and mucous?
▪ Urine: any burning, frequency, or pain while passing urine? Any
discharge?
Confidentiality statement before sexual history
▪ Travel: Any recent travel?
▪ Any weight loss? Is this intentional or unintentional? How is your
appetite?
▪ Any lumps or bumps?
▪ Any fever and rash?
any tiredness?
IBS QUESTIONS:
▪ Do you think this diarrhea is particular any food?
▪ Do you think your loose stools are related to a particular food?
▪ Have you maintained your food diary?
▪ Do you have constipation episodes in between your diarrhea?
▪ Thyroid: Do you have any weather preferences?
▪ Family history: Any family history of bowel disorders?

POSITIVE FINDINGS IN THE CASE

History of abdominal pain for 3 months. Central, abdominal,
intermittent, relieved by Panadol.
Loose stools for 3 months, 3-4 a day, no blood or mucus. History of
lethargy, decreased appetite, mouth ulcers, and rash.
History of weight loss, clothes loosening noted.
No travel history
+ family history of bowel problems (unrecalled problem)
No problems at school
No problems at home
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Lives with sister and mum

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Diagnosis and Management:

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▪ I understand you have tummy pain. There are many causes.
▪ I have taken your history and I have not examined you. And so far,
these are
▪ From history there are many causes for your tummy pain, and it
can be due to some problem in your gut like a problem with
absorption of nutrients in your gut, medically we call that
condition as coeliac disease (changing in the inner lining of the gut
due to gluten allergies--BROW: BARLEY RICE OATS AND WHEATS),
or it can be due to redness or swelling of the inner lining of the
intestine which we call as inflammatory bowel disease, and the
cause is not known for this. It can be an infection, allergies to any
food.

▪ IBD is the most likely cause, from your history, because you have a
history of weight loss, diarrhea, rash, mouth ulcers, and family
history. Or coeliac disease can be a cause.

▪ I would like to arrange some investigations: FBE, ESR/CRP, UEC,

LFTs, Stool microscopy and culture, Urine MCS, coeliac disease
serology (anti-gliadin and transglutaminase), reducing sugars
(lactose intolerance), TFTs.

▪ Refer to a gastroenterologist, who might do a colonoscopy to

further investigate the cause of your abdominal pain and
diarrhea.
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FEVER AND RASH CLUSTER

Differential Diagnoses (*most commonly comes out in the exam)

▪ Viral infection
▪ *Measles
▪ Rubella
▪ *Scarlet fever
▪ Meningitis
▪ Drug reactions
▪ *EBV
▪ *Varicella
▪ *Kawasaki
▪ HFMD
▪ Slapped Cheek: Parvovirus

HISTORY
**If you ask for rash, ask for scratch marks
**If the patient comes with fever and rash, ask which came first
▪ Fever questions
o When did your fever start? Have you checked the

temperature? Did you give medication? Did it work? Any chills

or rigors? Any fever dance**(associated with roseola)
o If the child presents with only fever, then ask about the rash
o Ask about associated features

• Before the start of the fever, are there any prodromal

symptoms (malaise, flu-like symptoms like runny nose,

sore throat, cough)?
• Is there ear pain? Any lumps and bumps around the body
▪ Rash questions: SIQORAAA
o Site: where is the rash located? Where did the rash start? can
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you describe the spread from me? Is it localized or generalized?

Is it present anywhere else in the body?
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o Intensity: how severe is the rash?

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 o Quality: is it itchy, oozing, scale? Can you describe the nature
for me?
o Onset: When did it start? When did you first notice the rash?

Did you have any change in cream or medications?

o Duration: How long has the rash been there?
o Course: were there any changes in the rash? Did it get bigger or

develops discharge?
o Frequency: how often do you get this? Is this the first episode?
o Radiation: does your rash go anywhere else?
o Aggravating Factor: is there anything that makes it worse?
o Alleviating Factor: is there anything that makes it better?
o Associated symptoms: vomiting, waterworks, number of wet

nappy--is it smelly, cries while peeing, join

▪ Well baby questions:
o Mental state of the baby: has he been really irritable, or has

been hard to wake up?

o Eating/Drinking: has he been eating and drinking fine?
o Wet nappies: Has he not been producing wet nappies for the

last 8 hours? (very dehydrated), change in the number of wet

nappies?
▪ Differential questions
o Other fever causes like UTI, meningitis, pneumonia, AGE

• UTI: are there changes in the number of wet nappies? Is

there smelly urine or change in the color of the urine?

• Meningitis: is there neck stiffness, headache, projectile

vomiting, lethargy?
• Pneumonia: is there cough, colds, shortness of breath, pain

on breathing?
• AGE: how is the bowel movement? Are there loose stools?

Is there an offensive smell of the stools?

138

▪ Closure: BINDSMA (BIND - until 12 years old), Past history, Family

history
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o Birth

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 • 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? (these are important in heart diseases
in newborn, a baby with a vision problem, baby with a
hearing problem, the child is mentally retarded, a child
with developmental issues, a child with slow school
performance)
• Delivery: was he a term baby? What is the mode of

delivery? (any instrumentation/forceps? [trauma,

cephalohematoma leading to unconjugated jaundice or
prolonged physiological jaundice] What is the reason for
the mode of delivery? Did he require resuscitation, or did
he cry immediately after birth? (Any premature rupture of
membrane or artificial rupture of membrane? [neonatal
sepsis]
• Postpartum: did he spend any time in a special nursery?

Was the heel-prick test done?

o Immunizations: Is the immunizations up to date? (Ask it is

relevant in cases of fever, rash, AGE, etc)

o Nutrition: What is his typical diet? Any changes in appetite?

(important in cases of FTT, pancytopenia, developmental cases,

slow school performance, constipation)
• If infant: is he breastfed or bottle-fed? When did you start

weaning? Any concerns about it?

o Development: 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?
▪ Social history
139

o Soon after delivery (is the mother coping?)

o Any sick contact history at home/childcare/school?
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 o Any complaint or notices from the childcare or school (is
somebody else sick there?)
o Allergy history: if present, ask in details (is it present in the
family, etc.)

PHYSICAL EXAM
***If suspecting septicemia, ask for vital signs first before taking
history or PE!
▪ General appearance: alert, drowsy, lethargic, active
▪ Signs of dehydration: CRT, skin turgor, sunken eyes, mucous

membranes, anterior fontanelle (in babies <18 months)

▪ Rash: Site, Distribution, Characteristics, blanchable or not, scratch

marks, secretions or any discharge?

▪ Growth Chart
▪ Vitals - Pulse, RR, BP, Temp, Saturation
▪ Lymph Node enlargement: generalized lymphadenopathies?
▪ Neck Stiffness
▪ ENT Examination
▪ Systemic: CVS, Respiratory, abdomen (hepatosplenomegaly)
▪ Genital exam with the consent of the parents (if relevant, like in

case of nappy rash)

▪ If newborn, tell: I would like to do a complete newborn

examination
▪ Office tests

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Disease Positive points Examination Manageme Photo
in history findings nt and key
issues
Chickenpox/Varicella Low-grade fever Cropping Symptomati
Prodromal flu- lesions c treatment
like symptoms Centripetal Educate
before fever, rash that it is
then rash Vesicular rash contagious
appears Scratch marks Notify child
Itchy rash care
Contact history Exclusion
very important until last
lesion has
dried
Roseola High grade fever Red Symptomati
for first 3 days maculopapula c treatment
then rash r rash on the No child
appears when trunk, face care
fever subsides and limbs, exclusion
blanchable

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 mild cervical
lymphadenop
athy
Erythema infectiosum Mild grade fever Bright red Explore
and flu-like flushed about
symptoms then cheeks with babysitter
rash appears circumoral to rule out
over the face pallor child abuse
A Head to toe
maculopapula examinatio
r rash can be n to rule
present on out child
the limbs abuse
Symptomati
c treatment
No child
care
exclusion
once the
rash

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appears

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 Serology for
parents
who are
pregnant
Parents
reassurance
Scarlet fever Fever for first 2- Red punctate Symptomati
3 days, rash, c treatment
responding to blanchable Penicillin
Panadol [rough rash], for 10 days
History of runny more in the Can go to
nose/sore neck, cubital school 24
throat fossa, spares hours after
palms and the start of
soles antibiotics
Red pharynx
with white-
coated
tongue

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Kawasaki disease High-grade fever Mucosal dry FBE, ESR,
for 5-6 days, not lips CRP, UEC,
responding to Hand urinalysis,
Panadol desquamatio antistreptol
Severely ill child n ysin, anti-
Might have a Eyes DNAse,
runny nose and conjunctivitis ECG, echo
sore throat non-purulent Admit
Lymphadeno Low dose
pathy aspirin, IVIG
Polymorphic Follow up
rash echocardiog
Temperature ram
more than 5
days
Herpes Stomatitis Fever Focus on Symptomati
Refusing to eat signs of c treatment
and drink dehydration Topical
Ulcers in the Shallow analgesia
mouth ulcers over with

144
Do system the angle of lignocaine
review (think the mouth gel

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 about Mild cervical Important
immunocompro LAD can be to feed a
mised states) present child
Advice
about being
contagious
If not
feeding well
or
dehydrated,
need to
admit
Septicemia/Meningoc Fever, Non-specific IV fluids
occemia prodromal macular Take blood
symptoms petechial for culture
Sick child rashes, non- Give IV
Contact history blanchable cephalospor
is important Vitals can be ins
unstable, cold Shift to the
clammy tertiary

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extremities hospital

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 (features of Rule out
shock) other
The pharynx causes by
can be red lumbar
puncture,
urine
culture,
chest x-ray
Notify child
care and
DHS
Contact
prophylaxis
Erythema toxicum The rash Papulovesicul Reassure
neonatorum (normal appears a few ar rash all Red flags
baby rash) days after birth over the body Review in 3-
No fever, child Can have 5 days
doing well pustules in
Rule out the later
maternal fever, stages

146
infections, Erythematous
drugs, GBS

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 swab, explore Otherwise
mother's mood active and
Ask about playful
feeding, urine,
bowels
Nappy rash Rash in the Red, moist, Hygiene
genitalia and erythematous advises very
buttock region lesion with importantly
extending up to some lesions Change
the groin clustered nappy
No rash Take swab to frequently
anywhere else rule out Barrier
The previous fungal cream (zinc
history of infections oxide)
diarrhea is Hydrocortis
present one cream/
sometimes antifungal
Don’t forget to cream
ask about nappy
change, brand,

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use of any
shower gels,

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 soaps or
medicines
Scabies Itchy rash worst Pruritic Application
in the night lesions which of
after a hot are papule permethrin
shower and vesicles cream in
No fever most the entire
Contact history commonly in body below
the the jawline
interdigital Treat all
spaces contacts
Take even if
scrapings for asymptoma
microscopy tic
Good
hygiene
Wash all
clothes

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DISEASE History and Investigations Management and key Photos
examination issues
Immune URTI followed FBE shows Admit
thromboc by a non- isolated Wait and watch
ytopenia blanching thrombocytopenia If active bleeding, steroids
purpuric rash Coagulation If not responding to
profile is normal steroids, IVIG
No improvement for more
than 6 months, do a
splenectomy
Complications:
spontaneous bleeding
Educate about
spontaneous remission is
very high
Advice about no contact
sports, no IV line or
immunization, no IM
injections, no NSAIDs or

149
aspirin

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 Prognosis: 90% full
recovery, 70%
spontaneous remission,
10% chronic ITP
Henoch- URTI followed FBE and Admit
Schonlein by a non- coagulation Call the paediatric
purpura blanching profile are normal registrar
purpuric rash Do ultrasound to Urgent ultrasound
May present rule out FBE, CRP, UEC,
with joint pain intussusception coagulation profile, IV
or limping, Stool microscopy fluids, NPO until
abdominal pain and culture if you intussusception is ruled
and bloody find diarrhea to out if the patient comes
diarrhea rule out infections with abdominal pain.
(intussusception Urine microscopy Otherwise, treatment is
) and culture can symptomatic
show RBCs and Short term steroids after
casts ruling out intussusception
Follow-up with kidney
function and urine

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function

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Varicella

An 11 year old girl came to your GP clinic brought by mom complaining

of fever and skin rash.

TASKS
▪ History
▪ PE from examiner
▪ Diagnosis and management

Positive findings in history: low-grade fever, prodromal flu-like

symptoms, before fever then rash appeared, itchy rash, may have
contact history
Positive findings in the examination: centripetal rash distribution
involves oral mucosa, maculopapular vesicular rash, and scratch marks
present

History and Physical examination: refer to fever with rash cluster

(approach)

EXPLANATION
From history and examination, your child has a condition called
chickenpox. Have you heard about it?
▪ It is a viral infection caused by Varicella Zoster Virus, sorry for
using that medical term but let me explain it to you. It is a viral
infection, and most likely your child got it from his classmate (or
tell who the contact is in history)
▪ It is highly contagious and it spreads from close contact and it is
airborne.
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▪ The rash usually heals in 7-10 days, leaving normal skin unless it
becomes infected.
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 ▪ In the meantime, the treatment is only supportive and
symptomatic which includes adequate rest, increased fluid intake,
Panadol for fever, and can use calamine lotion for the itching.
▪ If the itching is very severe, then I can give you an antihistamine.
▪ The child should not go to school until the last blister has dried.
▪ Please notify the school to inform them in case another child
experiences fever and rash as well.

Hygiene advises
▪ Please avoid scratching, and keep your nails clean and short.
Please provide cotton mittens if necessary
▪ Daily showering is advised, with an addition of mild
antiseptic or sodium bicarbonate if still itchy (half cup to
bathwater)
▪ Please pat dry with a clean, soft towel, and do not rub
▪ Red flags:
▪ If the child is not feeding well, has vomiting, severe
headache, neck pain, abdominal pain, weakness… or if the
child develops secondary infections (pneumonia, otitis
media, meningoencephalitis, and secondary infection of the
rash, etc.), please come back to me immediately
▪ Antibiotics may be required if they develop a secondary infection.
▪ I will give you a reading material about this condition to give you
more insight into your problem.
▪ I will review you in 3-4 days.
▪ If have time: ask about contact with a pregnant lady (e.g. Mother
is currently pregnant)
▪ You might need some prophylaxis and please see your GP
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Roseola

Your next patient in a GP practice is an 18month old child brought in by

mother due to high fever for 3 days. He has been seen by 2 other
doctors about his persistent fever. He then developed a rash this
morning, hence he was brought for consultation.

TASKS
History
PE from examiner
Diagnosis and Management

HISTORY
Which started first? Fever or rash?
FEVER
Since when? Have you checked the temperature? Did you give
medication? Did it work? Any chills or rigors? Any fever
dance**(associated with roseola)
When did the rash start?
Ask about previous consultations and what happened there. Any
investigations done?
Associated symptoms
BINDSMA

EXAMINATION
GA
Signs of dehydration
VS
Rash questions
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Red maculopapular blanchable rash on the trunk, with sparing

with the limbs and face
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Mild cervical lymphadenopathy

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+ points: high-grade fever for a few days, the fever subsides, and then
rash appears
Examination: +points: red maculopapular rash on the trunk, spares face
and limb blanchable, mild cervical ln

EXPLANATION
▪ Your child has a condition called Roseola Infantum. Have you
heard about it?
▪ It is a viral infection caused by a bug called human herpesvirus 6.
▪ It is very common in children.
▪ It is contagious, as it can spread from one person to another. It is
spread through tiny drops of fluid that are expelled when an
infected person talks, laughs, coughs, or sneezes.
▪ Your child can go to school, as the infection is only spread BEFORE
they develop the symptoms of the illness.
▪ Treatment is symptomatic, and he needs rest, adequate fluid, and
Panadol
▪ Antibiotics are of no use
▪ There is no known way to prevent the spread of roseola, and
there is no vaccine.
▪ Good and regular hand washing and drying are best to reduce the
spread. Sharing of eating and drinking utensils should be avoided
▪ Red flags
▪ See your doctor if your child is lethargic, hard to wake, if he
doesn’t drink, not eating well if you cannot reduce your
child's temperature, and if he develops fits as febrile
convulsions can occur if the fever is too high.
▪ The rash can disappear within 5 days.
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Erythema Infectiosum

You are a GP and parents Jen and John came to you because they are
concerned that the babysitter is mishandling their 5-year-old son,
Matthew. They left the boy and went to a party and when they
returned the baby was asleep. The baby sitter said everything was fine.
In the morning, Matthew had marks on his cheeks, which looks like he
has been slapped by somebody. They immediately brought the baby to
you.

TASKS
History
PE from examiner
Diagnosis and Management

HISTORY
RULE OUT CHILD ABUSE!!!
I understand that you have come to see me because you're
concerned about your baby sitter slapping your son. How often
does she look after Matthew? Is this the first time you're
concerned about her behavior? How is her relationship with
Matthew? Has Matthew ever complained about her?
Apart from the marks on his face, have you noticed other
injuries like bruising, etc.? did you contact the baby sitter?
What did she say? Any change in the behavior of Matthew
towards her or refusing her to go?
RASH history (refer to fever with rash cluster approach)
Fever questions

PE
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Head to toe examination to rule out child abuse (any evidence of

non-accidental injuries)
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 Positive points from history: mild grade fever and flu-like
symptoms, then rash appeared
Examination history positive points: bright red flushed cheeks with
circumoral pallor. Maculopapular and can be present on limbs

EXPLANATION
▪ I understand that you are suspecting that your baby sitter is
abusing your child, but it is unlikely in this case. I can tell this
because (give positive points in history--the child does not
complain about the baby sitter, there is no changes in his
behavior, no other injuries, etc.) From history, I am suspecting
that your child has a condition called erythema infectiosum. Have
you heard about it?
▪ It is a viral infection caused by a bug called Parvovirus B19. it is a
common condition that children have, which usually starts with a
mild fever a few days before the rash appears. The first symptoms
are usually mild, and sometimes parents don’t even know about
it, and then the rash appears.
▪ In these cases, usually, the rash appears first time on the face,
especially on the cheeks, which looks like somebody has slapped
over the cheek and then it spreads. The spreading of this viral
infection is airborne---comes from droplets
▪ The rash usually disappears by itself after a few days.
▪ We usually treat it symptomatically, and your child needs
adequate rest and fluids.
▪ Once you see the rash on the face, children cannot spread the
infection to others, and they can keep going to school.
▪ I know that you are very concerned about your child, so for your
assurance, I can arrange a serologic test to confirm this.
▪ In the meantime, if your child is not feeling well, not feeding well,
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pain, and swelling of the joints, please come back to me so that I

can review him again.
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▪ I have information for you here to give you more insight about
your problem
▪ IF YOU have TIME: has he been in contact with any pregnant
women? (if mom is pregnant, avoid close contact)
▪ If positive, please go to your GP so that you will have to
undergo a blood test and be given prophylaxis and proper
management of your exposure.

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Scarlet fever

Your next patient in a GP practice is a 6-year-old girl brought by her

mother due to fever and rash on the upper trunk and perioral pallor.

You are a GP and a 5-year-old child was brought in by mother

because of fever (38C), sore throat and rash.

TASKS
1. History from mother
2. Ask examination findings from the examiner
3. Diagnosis and management

(Other similar case:

A mother brings her 6-year-old daughter in with fever, sore throat
and a rash all over her body. On examination (all the characteristic
signs of Scarlet fever and rash given on the stem)
TASKS
1. Explain your diagnosis to the mother
2. Management)

Positive findings: fever for the first 2 days, then rough rash appears.
History of runny nose and sore throat. Fever responding to
antipyretics. Red punctate rash, blanchable (rough rash/sandpaper
rash), more in the neck, cubital fossa, spares palms and soles, red
pharynx and white-coated tongue (typical strawberry tongue
sometimes given)

History and PE: refer to fever with the rash cluster approach
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Explanation:
▪ Most likely you have a condition called scarlet fever. It is a
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bacterial infection caused by a bug called Group A Streptococcus

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 pyogenes organism. This bug stays in the throat of our body and
produces (erythrogenic) toxin causing these symptoms.
▪ The initial symptoms are malaise, sore throat, fever (may be
rigors) and vomiting. Rash appears after fever.
▪ Treatment is antibiotics for 10 days (phenoxymethylpenicillin,
dose according to age) for 10 days with rapid resolution of
symptoms. A child can return to school 24 hours after taking
antibiotics and feeling well. As I said, this bug produces a toxin.
Sometimes this toxin can affect the kidneys. This happens very
rarely, and we call this condition as poststreptococcal
glomerulonephritis.
▪ So, you need to monitor the child's urine output, color and if the
child is developing swelling in the body, legs and face. The other
rarest complication of this condition can also affect the heart and
joints.
▪ Please do not stress yourself, I'll be reviewing your child
frequently for these complications. And even if kidney problem is
found, it usually resolves spontaneously. But at this stage, I'm
explaining all these, so that you are aware of the child's condition.
▪ Investigations are basic blood FBE, ESR, CRP, throat swab.

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Kawasaki disease

You are a GP and a 3-year-old boy was brought to you by his mother
because the child has fever and rash.

TASKS
1. History from the mother
2. Ask examination findings from the examiner
3. Diagnosis and management

*Scarlet fever has throat findings, fever for 2-3 days, responding to
Panadol VS. Kawasaki disease is not responding to Panadol and has a
fever for 5 days.

Positive findings: fever for 5 days, runny nose, fever not responding
to antipyretics, severely ill child

History and PE: refer to fever with the rash cluster approach

Explanation:
▪ From the history and examination, your child has a condition
called Kawasaki disease. Normally our immune system produces
chemicals substances called antibodies to fight against infections.
Sometimes, due to unknown cause, but can be triggered by
previous viral infection, they start acting on our body tissues. In
this condition, it acts mostly on blood vessels (a tube-like
structure which carries blood to all parts of the body).
▪ Do not stress yourself, it is a manageable condition, it's good we
have picked it up early.
▪ We need to admit the child, and I will arrange for an ambulance
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to transfer the child to the hospital.

▪ I will also liaise with the paediatrician in the hospital and explain
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the child's condition. The child needs to be started on IV fluids,

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 and bloods need to be taken for investigations such as FBE, LFT,
CRP, UEC, AntiDNA-ase, Antistreptolysin antibody test, and blood
culture.
▪ The treatment in the hospital is immunoglobulins which are
substances which act on the child's immune system and aspirin
because in this condition, most of the times, one of the blood cells
called platelets increases in number.
▪ Usually, platelets normally help in preventing bleeding or helps in
clotting. To prevent clogging of blood vessels, we give this
medication. But please do not stress yourself because it is given in
a very low dose, decided by the pediatrician. We need to take
care of one of the serious complications of this condition. As this
condition affects the blood vessels, it can also affect the blood
vessels of the heart.
▪ So, in the hospital, the child may undergo scanning of the heart
what we call echocardiogram. Once the child recovers, the
echocardiogram might need to be repeated depending on the
specialist's advice. This is a self-limiting condition.

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Herpes Stomatitis

You're in GP, the patient is a 3-year-old boy called James Brown,

brought in by his mother, Mary. The concern is not wanting to eat
lunch for the whole day, and last night. He is irritable, crying a lot,
saliva dripping from his mouth. Mother also noticed an ulcer in his
mouth.

TASKS
1. Relevant history
2. Physical examination findings from the examiner
3. Explain the condition
4. Outline the management

Differential Diagnosis:
HFMD (fever, throat, ulcers in the mouth, palm and soles of the foot
and nappy areas)
Herpes stomatitis: most common
Herpangina
Agranulocytosis
Traumatic ulceration
Drug-induced

APPROACH
History
I know your son is not feeling well. When did it start? When did you
notice the ulcers? Before you noticed them, did he have any hot
foods or drinks? Is it the first episode? Anyone else in the family
with the same condition?
Does he have a fever? Up and down or constant? Did you give him
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any medications? Did he complain of headache? Have you noticed

drooling? Has he vomited? Have you noticed rashes on his palms,
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fingers, sole?

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I know he refused his food, but has he been drinking?
How is peter’s waterworks? Has it reduced? How many nappies?
Are they heavy? Is peter still active or does he appear drowsy?

Is peter generally healthy? Is he on any medications? Allergies? Any

concerns about peter’s growth and development? Is vaccination up-
to-date?
Do you have other children? Is he attending childcare? Has anyone
been sick there?

Physical examination:
General appearance: active/lethargic, irritable, signs of dehydration
(CRT, skin, turgor, sunken eyes, mucous membranes)
Skin: check for rash while undressed
ENT: conjunctivitis; mouth and throat - are there ulcers in the
mouth? Ulcers in the throat? LAD; neck stiffness

Management:
Condition: Mary, from my history and physical examination findings,
your son most likely has a condition called herpes stomatitis. Have
you ever heard about it?
Cause: It’s a common condition caused by the Herpes Simplex Virus
or the same virus that cause cold sores in adults.
Commonality: 90% of the general population has been exposed to
this virus.
Clinical features: In childhood, the primary attack can present with
fever, mouth ulcers and enlarged lymph nodes.
Course of treatment: You don’t need to give him antibiotics because
it is a viral infection. Like majority of viral condition, it is self-limited,
and healing occurs in 2 weeks. The main thing we should watch out
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for is his fluid intake because during this time it may be difficult to
eat and drink. Make sure that he doesn't become dehydrated. I will
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try to apply lignocaine gel which is a topical anesthetic gel and see if

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he can drink. If it works, you will need to continue applying the gel
at home every 3 hours and make sure he drinks ample fluid. I would
also recommend a liquid diet of cool to cold and no acidic drinks.
To control fever and pain, you can also give him Panadol. If he can’t
drink, I will need to admit him to the hospital for IV rehydration.
When you go home, you need to keep an eye on symptoms. If peter
is less active, cannot drink, is vomiting, or stops urinating, you need
to go to the hospital. It is a contagious disease. He should be
isolated from other children (should not go to childcare until after
ulcers are healed). He should have his own utensils, glasses, plates
and toys. I will give you reading materials and will review him
tomorrow to see if there is an improvement.

***
Severe primary attack or immunocompromised ➔ acyclovir
Often a virus will become silent and can be reactivated later in his
life. Usually, it happens when the immune system is down due to
other illness or stress. The commonest presentation of recurrent
herpes simplex attack is cold sores on the lips, although it is rare.

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Septicaemia

You are an HMO in ED, the 4-month-old boy is brought to you by his
parents at 3 am. The baby has been unwell for the past 24 hours.

TASKS
1. Further history
2. PE finding
3. Discuss the causes and management diagnosis

APPROACH

1. Ask for hemodynamic stability

2. Open-ended questions: When did it start? How did it start?
What was he doing when it started? Is it getting worse? Has he
ever had this before in the past?
What happened in the past 24 hours?
3. Well Baby questions:
a. The mental state of the baby: has he been 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? Any smelly urine or change in the color of
the urine?
4. Differential questions
a. Rash questions
b. UTI
c. Otitis media - any ear pulling?
d. Meningitis
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e. AGE - change in bowel habits? The character of stool?

Abdominal pain?
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[Link] - fever, cough, colds, shortness of breath

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5. Closure: BINDSMA (BIND - until 12 years old), Past history,
Family history
a. Birth
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? (these are important
in heart diseases in newborn, the baby with vision
problem, baby with hearing problem, child is mentally
retarded, child with developmental issues, child with
slow school performance)
ii. Delivery: was he a term baby? What is the mode of
delivery? (any instrumentation/forceps? [trauma,
cephalohematoma leading to unconjugated jaundice
or prolonged physiological jaundice] What is the
reason for the mode of delivery? Did he require
resuscitation, or did he cry immediately after birth?
(Any premature rupture of membrane or artificial
rupture of membrane? [neonatal sepsis]
iii. Postpartum: did he spend any time in a special
nursery? Was the heel-prick test done?
b. Immunizations: Are the immunizations up to date? (Ask it
is relevant in cases of fever, rash, AGE, etc)
c. Nutrition: What is his typical diet? Any changes in
appetite? (important in cases of FTT, pancytopenia,
developmental cases, slow school performance,
constipation)
i. If infant: is he breastfed or bottle-fed? When did you
start weaning? Any concerns about it?
d. Development: How do you think he is growing compared
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to kids of his age group? Are you concerned about his

development when you compare him with kids of his age
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group?

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 e. Social history
i. Does the child have any siblings? Do they have the
same symptoms? (fever, rash, diarrhea, vomiting) Any
family member with the same problem?
ii. Does the child go to school or child care? Any problems
in school? How is his behaviour in school? Did the
teacher say anything?
iii. Does he have friends in school? Is there any bullying?
iv. How is the situation at home? Are you a happy family?
[Link]
g. Allergies
h. Past history
i. Family history

PHYSICAL EXAM
1. General appearance - alert/drowsy/irritable/lethargic
a. PICCLE
b. Growth charts (until 12 years old only)
c. Dehydration - CRT, skin turgor, sunken eyes, mucous
membranes, the anterior fontanel
2. Vitals signs
3. Systemic Exam
a. Musculoskeletal system
b. ENT
c. CVS
d. Respiratory
e. Abdomen
[Link]
4. Office tests
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Explanation:
▪ From history and examination, your child has an infection going
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 infection by symptoms and examination. So, I will call the
paediatric registrar and will admit the child and do investigations
to find out the cause of infection. These set of investigations we
call it as septic workup or septic screen.
▪ We usually do a blood test, we take a sample of the blood from
the child's veins for FBE, UEC, 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 anaesthetic spray a few minutes
before the procedure that will numb the area.
▪ To rule out infection in the lung, we will do an x-ray of the chest. I
understand that you might be worried about the possible risk of
radiation will be tailored according to his age and weight to limit
overexposure. This test is very important to look for infections or
pneumonia 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 to
look for possible infections. Please don’t be stressed it will be
done by a specialist. The nurse will 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 a
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 I did by the specialist. Sometimes, there is a small
amount of bleeding from the area. The child may be irritable for
some time, but rest assured that it is unlikely to damage the
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spinal cord as the level is much lower.

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▪ We will start him on broad-spectrum antibiotic once blood is
taken for investigation. The specialist will come and see. [If the in-
country hospital and no specialist, transfer to a tertiary hospital.]

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Septic workup counselling

You are an intern in HMO and a 2-month-old child has been brought in
because of fever, lethargy and irritability. The pediatric registrar has
decided to do a septic workup for the child.

TASKS
Explain the component of the septic workup to the mom and how you
do it.

Septic Workup
▪ Blood Culture
▪ FBE, ESR/CRP
▪ SPA or straight catheterization for CS
▪ CXR
▪ Lumbar puncture

▪ I understand from the notes that your child has a fever and
lethargy. At the moment, he is being seen by the specialist
pediatrician. Apparently, no focus of infection is visible on
examination.
▪ It is mandatory to perform a full septic workup on all kids who
present with fever without a focus. This includes taking blood
samples to rule out germs or bugs in the blood, CXR to rule out
pneumonia, urine samples to rule out UTIs, and a sample of fluid
circulating within the backbone to rule out possible meningitis or
“brain fever”.
▪ I would like to explain to you how we will take these samples and
how we will minimize any pain or discomfort to your baby.
Usually, we take a sample of the blood from the child’s veins to
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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
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few minutes before the procedure that will numb the area.

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▪ The next procedure will be an x-ray of the chest. I understand that
you might be worried about the possible risk of radiation for such
a small baby. Please understand that the dose of radiation will be
tailored according to his age and weight to limit overexposure.
This test is very important to look for infections or pneumonia
within the lungs.
▪ In babies of this age group, we usually obtain a sample of urine
through aspiration from the tummy to look for possible infections.
Please don’t worry it will be done by experienced hands. The
nurse will 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 a procedure.
▪ 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 is quite safe in
experienced hands. Sometimes, there is a small amount of
bleeding from the area. 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.
▪ STOP after every explanation! Do not use MEDICAL JARGON
▪ Options: sucrose dummies, breastfeeding, bottle feeding,
anesthetics
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Meningococcal septicaemia

A 2-year-old boy is brought by his upset parents to a GP clinic in a small

country town, 500 km from the city. The child has become lethargic and
febrile for the last 4 hours. He has had a mild URTI for the last 3 days.

TASKS
1. Relevant history
2. Examination findings from the examiner
3. Diagnosis and further management

Positive findings: fever, prodromal flu-like symptoms, sick child; may

have contact history, severely ill, child
Examination: cold clammy extremities, non-specific macular petechial
rash, non-blanchable, unstable vitals

Explanation:
▪ From the history and examination, your child is having a condition
called sepsis, which is an infection in the blood. From the rash, it
looks like it is caused by a bug called meningococcus which is a
bacterium.
▪ It is spread through droplet infection and causes severe life-
threatening infection. He needs to be transferred to a tertiary
hospital immediately and seen by a specialist. But before the
transfer, I will take blood for investigations and start him on IV
fluids. After that, I will give him his first dose of antibiotics.
▪ I will arrange an ambulance for the transfer of the child and liaise
with the paediatric registrar in the hospital about your child's
case. They might do further investigations to rule out other causes
like FBE, ESR, CRP, UEC< LFT, culture, urine culture, chest x-ray,
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and lumbar puncture.

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 ▪ If it is confirmed to be meningococcus, then we need to notify
the DHS and contacts will need to be treated. Also, we need to
inform child care for contact tracing.
Note: If the same case if the rash is not there, then it becomes a case of
septicaemia - management is the same except no antibiotic until the
diagnosis is confirmed and all investigations are done.

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Erythema toxicum neonatorum (Normal baby rash)

David, 5 days old, presented to you as GP as mom noted that he has

skin rash all over his body.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and management

Differential diagnosis
▪ Neonatal sepsis
▪ Varicella
▪ Listeria
▪ Miliaria
▪ Herpes
▪ Meningococcemia
▪ Erythema toxicum neonatorum (normal baby rash)

Positive findings: rash appeared in a few days, no fever or other

symptoms, child doing well, explore mother's mood, age is important
Papulovesicular rash all over the body. The child is active and playful.

Differential Diagnosis
▪ Miliaria
▪ Erythema toxicum neonatorum
▪ Neonatal sepsis
▪ Impetigo
▪ Listeria
▪ Varicella
▪ Staphylococcal infe3ction
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Features
▪ Very common condition
▪ The underlying pathophysiology is unknown
▪ Benign, asymptomatic, Self-limiting condition with no
complication
▪ Common in term babies between day 3 to the 2nd weeks
▪ 90% of cases peak at 2-3 days of age
▪ Resolve by the first week of life → but occasionally runs a
fluctuating course over a few weeks
▪ Broad erythematous base up to 2-3cm diameter with a 1-2mm
papule or pustule
▪ Fluid examination: eosinophils and no organisms

APPROACH
History of rash
Since when? Where? Does it spread? What makes it increase or
decrease? Have you had any past treatment or history? contact with a
person with similar symptoms? Is it itchy?

Explanation:
From history and examination, your child has a normal baby rash or
erythema toxicum neonatorum. It's a common condition. I can tell that
this is the condition because your child is active, playful, and not
lethargic, so let me reassure you that this condition goes away by itself.
It has an excellent prognosis and self-limiting. It usually resolves within
2 weeks. It is a clinical diagnosis, it does not need any investigations or
treatment. However, if the child develops a fever, not feeding well,
lethargy and vomiting, please see me immediately.
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Nappy rash

Your next patient in a GP practice is a 5-month-old Sherly because of

rash in his buttocks. She is worried about her daughter because this
is the first time, she noticed the rash.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and management

Positive findings: rash in genitalia, buttock to the groin area. No rash

anywhere else. Might have the previous episode of diarrhea.
Examination: red, moist erythematous lesion, with some lesions are
collected.

History and PE: Refer to fever with rash cluster approach.

Explanation:
▪ From the history and examination, your child has a condition
called nappy rash.
▪ It is a common condition which is due to the wetness or moisture
in the nappies leading to irritation of the skin and rash. In your
child's case, it is probably due to previous loose stools or diarrhea.
The urine and the moisture are a good culture media for the
growth of bugs so I would like to take a swab or skin scrapings to
rule out fungal infections especially candidiasis.
▪ Do not stress yourself, it is a manageable condition, I will give you
hydrocortisone and antifungal cream, and apply it on the rash
areas two times a day until the rash disappears. It is very
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important that you keep the area dry as much as possible, do not
use any powder which can irritate the skin, change the nappies
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frequently, and whenever there is a dirty nappy, change it

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 promptly, avoid excessive bathing and soaping in that area, use
moisturizer or barrier cream to keep the skin lubricated then
apply the nappies.
▪ If you notice any discharge from the area, the rash becomes more
swollen, the child develops fever, lethargic, not feeding well, see
me again immediately. I will review you again after a few days.

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Immune thrombocytopenia

Lily, four years of age are brought to your GP clinic by her mom
Stephanie. She is worried about Lily as she had developed a rash all
over her body since last evening. Lily is well otherwise and is playing
around. Lily has started kinder this year and had a cold and cough a few
days ago like few other children in school, but now seems to be
recovering. Lily lives with her parents and is fully immunized. She had
no significant medical and surgical problems in the past.

TASKS
1. Focused history
2. Examination findings and investigations from the examiner
3. Explain the diagnosis and management

Full blood examination:

Hgb: 125 g/l (100 - 145 g/l) No abnormality of the series of the red cells
is seen
White cell count: total count 11.2 x 10/L (7-14), differential count
normal for age, no immature white cells seen, white cell morphology
normal
Platelets: 15 x 10/L (150-400)
History: will have URTI previously, the rash develops after than in most
of the cases.

History:
▪ Rash questions: SIQORAAA
o Site: where is the rash located? Where did the rash start? can

you describe the spread from me? Is it localized or generalized?

Is it present anywhere else in the body?
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o Intensity: how severe is the rash?

o Quality: is it itchy, oozing, scale? Can you describe the nature
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for me?

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 o Onset: When did it start? When did you first notice the rash?
Did you have any change in cream or medications?
o Duration: How long has the rash been there?
o Course: were there any changes in the rash? Did it get bigger or

develops discharge?
o Frequency: how often do you get this? Is this the first episode?
o Radiation: does your rash go anywhere else?
o Aggravating Factor: is there anything that makes it worse?
o Alleviating Factor: is there anything that makes it better?
o Associated symptoms: vomiting, waterworks, number of wet

nappy--is it smelly, cries while peeing, join

▪ Well baby questions:
o The mental state of the baby: has he been really irritable, or

has been hard to wake up?

o Eating/Drinking: has he been eating and drinking fine?
o Wet nappies: Has he not been producing wet nappies for the

last 8 hours? (very dehydrated), change in the number of wet

nappies?

Examination: non-blanching purpuric rash

▪ Explain acute thrombocytopenia: have blood test results
▪ From history and examination, your child has acute
thrombocytopenia. I will explain to you what it is.
▪ Our blood has three types of cells, RBCs carry oxygen, they are
normal in number, WBCs fight against infection, they are also
normal in number, but the platelets that help in clotting or
prevent bleeding are decreased, which is the reason why there
are bruises in the skin due to bleeding.
▪ Most probably it's a reaction of the body to the viral infection.
Normally during infection, our body produces chemical
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substances called antibodies which fight against the infection.

▪ But sometimes due to unknown reason, it acts on these platelets
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decreases its number and function in the body. But let me

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 reassure you that this is a self-limiting disease. At this stage, I will
arrange hospital admission for observation as there is a risk of
spontaneous bleeding during the early phase of the disease.
▪ Most of the time, it resolves by itself, but the child might need
steroids or immunoglobulins if he develops active bleeding. But
let me reassure you again that it has a good prognosis. Do not
play any contact sports, rest at home, no IV/IM injections
including immunizations.
▪ If chronic thrombocytopenia (goes beyond 6 months), consider
doing splenectomy.

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CARDIAC CLUSTER

Acute Heart Failure

You're an HMO at the ED, you're asked to see a 6-week-old boy named
David Jones, who was brought in because of deterioration feeding,
noisy breathing and coughing over the previous 2 weeks. Accompanied
by increasing lethargy and some general distress.

TASKS
1. Focused history
2. PE findings from the examiner
3. Explain findings to the mother
4. Outline possible future management

The patient is hemodynamically stable

Cough on occasions, seems to be short of breath, not turning blue
Gaining weight okay for the first few weeks, not much in the last couple
of weeks

Looks like a scrawny 6-week-old infant, looks unhappy

Temp is 37, RR is 34, O2 is 94%
Systolic murmur at the left sternal edge radiating to the apex
Crackles all throughout right lung field
Hepatomegaly
Bulging precordium

PE: unwell, no signs of dehydration, no skin rash.

T: 37, HR: 68, RR:70, BP:126/86 (request BP in all limbs if you suspect
that it is elevated); O2: 96%
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BP: LA 126/86, RA: 152/92, LL: 69/41, RL: 63/59

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Chest examination: diffuse bilateral wheezy chest and crackles with
intercostal retractions; difficult to auscultate the heart due to noisy
breathing,
Abdomen: hepatomegaly 4cm below the right costal margin
Palpate for femoral pulses! Part of baby check!!!!

Differential diagnosis:
▪ Bronchiolitis
▪ Pneumonia
▪ Congenital heart disease
▪ Septicemia

If you get a baby who has reached the age of 6 weeks then presents
with the deterioration of feeding with shortness of breath, the lethargy
that should suggest to you a presentation of heart failure. They usually
present with cyanotic heart disease or heart failure.
Most likely the child has VSD, but you are not sure yet (obscured 2nd
heart sound because the murmur is pan systolic)
David's got a heart failure which means his heart is not coping with
pumping blood around his body. Some of the blood that the heart is
pumping is going in the wrong direction. The heart is really 2 pumps
side by side. The abnormality in this situation is the communication
between these two pumps.

Outline of management:
▪ Admission to hospital for treatment of heart failure at PICU
▪ Request urgent blood test, ECG and CXR
▪ Arrange urgent pediatric cardiologist review and 2d-echo
▪ Start IV furosemide (Lasix)
▪ The plan is for long-term follow-up.
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Cardiac Failure

You are an HMO in ED in rural hospital David, 7 weeks old brought by

his mom Sella because of coughing and is in distress.

TASKS
1. Take history
2. Exam findings from the examiner
3. Diagnosis and Management

Differential Diagnoses:
• Pneumonia
• Bronchiolitis
• Croup
• Cystic fibrosis
• Septicemia
• Cardiac causes

APPROACH
• History
• Hemodynamic stability
• I understand that David is not well, can you tell me more about

it?
• Since when did the symptoms start?
• Cough history: since when? Vomit? Whoop? Turns blue?

Productive/nonproductive cough? Barky?

• Cold/stuffy nose? Turns pale/blue when cries
• Fever Qs, Rash Qs, abnormal breath sounds, feeding problems,

lumps and bumps

• A number of wet nappies?
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• Feeding questions: Feels tired while feeding? Does the baby

sweat while feeding, takes rest in bet feeding?

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 • BINDS- Birth in detail, immunization, nutrition (feeding),
development/growth (gaining weight), social (support to
mother, anybody sick at home, family history of asthma and
heart condition
• If suspecting cardiac, ask mother’s age, pregnancy complication,
any maternal illness during pregnancy

• Physical Examination
• Gen Appearance: Pallor, jaundice, cyanosis, dysmorphic
• Vitals: Pulse (rate, rhythm, RR and RF delay), BP, temp, RR, S02
o If suspecting cardiac cause, ask all the BP from both upper

and lower extremities, it might be coarctation of the aorta

• Systemic Exam
• Cardio: Inspection, apex beat, any thrill
• Auscultation (murmur- character, radiation, grade, etc.)
• Respiratory system
• Abdomen Exam
• With the consent of the parent, genital exam

• History: cough, feeding problem, tired and sweats during feeding,

cyanosis
• + findings in COA
• Higher BP in upper than lower extremities
• Radial-femoral delay
• Femoral pulse absent
• murmur

Examination
• GA: alert, looks unwell, non-toxic, mod respiratory distress (mild

intercostal retraction), a little bit irritable, flat ant. Fontanel, not

dehydrated, mucus
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• If the only finding is a murmur, diagnosis is Cardiac Failure

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Explanation:
• From the examination, your child has most probably heart problem.

Normally, the heart pumps blood to all parts of the body. In your
child’s case, the heart is failing to do that. There are many causes
for it, but the most likely cause is:
1. If due to cardiac defects
o VSD - the heart has 4 chambers, the right side of the heart

pumps blood to the lungs to get oxygen to the blood. the

left side of the heart receives oxygen and pumps blood to
all parts of the body. Normally, there is no connection bet
left and right side of the heart. If there is a connection bet
the two, there is the mixing of blood. As the water flows
from high pressure to the low-pressure area in the heart,
the blood flows from the right side to the left side leading
to increase blood to the lungs. Thereby, leading to
respiratory symptoms.

b. If not sure what kind of defect just say:

• The heart pumps blood to all parts of the body. if the heart

fails to pump blood then there is increase pressure over the

lungs leading to respiratory symptoms

c. Coarctation
In your child case, it is failing to do so. Normally, the left
side of the heart pumps blood to all parts of the body
through a tube-like structure called Aorta. Due to some
unknown reason, somewhere in the aorta there is
narrowing. That's why there are disparity bet upper and
lower limbs. And also, the heart is trying hard to pump
blood across this narrowing and failing to do so.
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Draw a heart with narrowing of the aorta.

Normally, when your baby is in your womb, the organs
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develop. Due to some risk factors, like

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 • Infections during pregnancy
• Drugs
• Diabetes, etc.
• Unknown reasons.

During the development of the heart, there might some

structural abnormalities, so after birth, the child can have
feeding difficulties, respiratory distress depending on the
severity of the condition.

Management:
• It is an emergency condition, I would like to transfer the child to a

tertiary hospital through the NETS/PETS/PIPER (special ambulance)

• I will arrange the ambulance and refer to the senior doctor about
your child condition and cardio specialist can be arranged to see the
child. They will do further investigations like basic blood, LFT, Urea,
electrolyte, creatinine, chest x-ray, scanning of the heart
(echocardiogram), ECG
• ask the examiner if the pediatric registrar is available in your

hospital, if available, then just refer first to the pediatric

registrar before transferring

• The specialist in the tertiary hospital will assess the child and might
start on diuretics/ water pills and also might undergo surgery
depending upon the findings of the investigation.

• Provide support and reassurance.

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Functional murmur

4 y/o John come to your GP clinic, he was seen before by another

doctor during a holiday. A soft, cardiac murmur was heard. His parents
were asked to see the family doctor to decide if any further
investigation needs to be done.

TASKS
1. Take a history from the mother
2. Ask exam findings from the examiner
3. Tell your diagnosis, management to mother

APPROACH
History:
• First, reassure the mother
• I know you are concerned about John’s condition, before

telling you anything I need to ask a few Qs from you, is it ok?

• If concern not given in stem, what made you come today?
• Did the child had any fever at that time?
• What was the reason to seek another GP?
• Did the child had any bluish discoloration of the skin at that

time?
• Any SOB? How is his exercise tolerance? Is he an active and

playful child? Any swelling of his limbs? Any repeated chest

infections?
• Any concern about his growth and development? Is he

thriving well?
• BINDS- start from birth- any concerns since then? Any

diabetes mellitus during pregnancy? Mother’s age? Infection

during pregnancy?
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• Does he go to child care?

• Family history of heart condition?
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EXAMINATION
• Gen app: pallor jaundice, cyanosis, dysmorphic features
• Growth chart
• Vital Signs: Pulse (rate, rhythm, RR and RF delay), BP in all four ext.
• SYSTEMIC Exam
• CVS: inspection, apex beat, any thrill, auscultation (murmur-

character, radiation, grade, etc..), position changes with respiration

and posture
• Respiratory, Abdomen
• (+) point: the child is doing well, good exercise tolerance, no

symptoms

Diastolic murmur- send home

innocent murmur organic murmur
Growth Well thriving Usually underweight
Exercise Good Not good
tolerance
Cyanosis No Yes
Recurrent chest Usual 6-12 infections Very frequent
infection per year
Murmur Soft and cyanotic no Loud and can have
character diastolic component diastolic component
Radiation No Yes
Thrill No Usually present
Changes with Yes No
respiration
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Changes with Yes No

posture
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 Explanation:
▪ From history and examination, most likely your child has
functional murmur of innocent murmur. Normal heart sound is
lub dub. Anything else abnormal from these is called a murmur.
I'm telling in your child case it is functional or innocent murmur
cause from history, your child is growing well, having good
exercise tolerance, not having any respiratory symptoms like
shortness of breath and on examination the heart murmur was
soft, and I cannot feel it when I put my palm over his chest (thrill).
From all these reasons, I can tell the murmur is innocent. Most of
the children, when we examine them, we can find this. It is very
common in children or at this age. Most of the time the cause is
unknown, or it might be due to hyperdynamic circulation.
▪ On this case, the only thing we need to be frequent follow up. No
need of any investigation and referral to the specialist is not
required.
• If the mother is still concerned, you can do chest x-ray and ECG

and may refer to cardio specialist.

• Most of the time, it will disappear as the child grows.
• Red flags: SOB, develop problem, bluish discoloration of lips, etc.

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VSD

A 3-month-old baby Suzie was diagnosed with VSD 2 weeks ago. Father
George come to your GP clinic to discuss it.

TASKS
1. Explain about the condition
2. Answer the patient's questions.

Explanation:
▪ I will be explaining to you the condition. If you have any doubts,

please tell me. How was the child diagnosed with this? Are there
any formal reports given?
▪ Our heart has 4 chambers, the upper part is called the receiving

chamber, and medically we call it an atrium, the lower part Is

called pumping chambers and we call it as ventricles. It is divided
into left and right side by a wall called Septa and the connection
bet upper and lower chamber is maintained by a muscular band
structure called Valves which allows the blood to flow from upper
to lower chamber.
▪ Normally, there is no communication between the right and left.

In your child's case, there is communication between the

ventricles in the septa. If there is a connection bet the two, there
is the mixing of blood. As the water flows from high pressure to
the low-pressure area in the heart, the blood flows from the right
side to left side leading to including blood to the lungs. Thereby,
leading to respiratory symptoms.
▪ Draw a heart
▪ The things we need to monitor in your child are child

development, exercise tolerance, feeding, growth, respiratory

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symptoms, etc.
▪ The onset of the symptoms depends upon the site, size, number
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of the openings. If it is a small size, it will close by itself. If it is a

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 large size, then you might need surgery. If it's multiple, it will also
close by itself.
▪ But let me reassure you, the opening most of the time close by
itself. And as a GP, I will monitor/review your child frequently.
▪ If in the exam, cardiologist referral is not done, then refer!

▪ If you are planning to have another baby in the future, there is an

increase chance that the next baby may suffer also the same heart
problem. We can arrange for your wife monitoring early on by
scanning and blood test. Immunization is very important, and I
recommend for your child to have it.

▪ Please inform your dentist or another GP about your child's

condition. Previously, any child with this condition needs to take
antibiotics before any dental procedures. Antibiotics are being
given to prevent possible infection in the heart.

▪ But the recent guideline is not recommended nowadays. So, the

antibiotics prophylaxis before the procedure also depends upon
specialist advice.

▪ Is asked what surgery is done then you can tell this way or else
can skip it.
▪ If the size is big- need surgery under anesthesia to close it done by
a cardio surgeon.

2 methods:
1. Close way- they will insert a closed umbrella through the hole and
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opens the umbrella and close the hole, but not all holes can be
treated by this.
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2. Open way- incision over the chest- simplest surgery, actually it is
the first cardiac surgery to be performed in the medical history,
less complication- they put a patch to close the defect

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RENAL CLUSTER
Nephrotic syndrome

Next patient in a GP practice, is 5 years old Betty brought by her father

because of puffy face for the last 3 days.

TASKS
1. History
2. Examination Findings from Examiner
3. Diagnosis and Management

Differential Diagnoses questions:

▪ Allergy - any allergies, watering of the eyes (hay fever), runny nose
▪ Cellulitis (orbital/periorbital) - history of insect bites, fever, rash,

redness around the eyes

▪ Kidney - urine output (increased/decreased)
▪ Heart - shortness of breath, turning pale or blue, any heart

conditions
▪ Liver - yellow discoloration, any liver conditions
▪ Malnutrition
▪ Hypothyroidism
▪ Child abuse
▪ Conjunctivitis
▪ Medications

APPROACH
HISTORY
▪ HOPC
o What do you mean by having a puffy face?
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 o Since when? Where is the swelling more (more when they get
up in the morning in kidney problems, more at evening for
heart and liver)?
o Swelling anywhere else in the body?
o Any redness? Any pain around the eye? Any eye discharge?
o Any recent viral infection?
o Any recent changes in weight (increased or decreased)?
o Any insect bites, allergies, any discharge from the eyes?
o ANY TRAUMA? Did he fall anywhere?
o Any fever, nausea, vomiting, or rashes?
o Any difficulty in breathing? Did he turn blue?
o Chest pain or racing of the heart?
o Any distention of his tummy?
o Any kidney, heart, or liver problems?
o Any jaundice/yellowish discoloration of the skin previously?
o How is his waterworks? Is the urine output increase /decrease?

what is the color of the urine?

o Any diabetes?
o Is he taking any medications?
o BINDSMA

• What is his usual diet

• Are you a happy family?
• How are his growth and development compared to other

kids
o Any conditions in the family--heart, kidney, liver?

Physical Exam
GA
VS
Systemic exam: ABDOMEN!!
Genital exam with consent
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Office test: UDS, BSL

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 +findings: BP NORMAL, PUFFY FACE, URINE DIPSTICK SHOWING
PROTEINURIA AND NO RBC

NEPHROTIC VS NEPHRITIC
NEPHROTIC NEPHRITIC
proteinuria Hematuria
edema Hypertension
Can have URTI history Can have URTI, sore throat,
skin infection
No hematuria/little hematuria
ASO TITER AND C3 C4 NORMAL, HIGH ASO TITER HIGH, C3 C4 LOW
CHOLESTEROL LEVEL

Explanation:
▪ From history and examination, your child is having nephrotic
syndrome. Do you have an idea about this? I will explain to you
what it is. It is a condition where the filtering mechanism of the
kidney is affected. Due to that, proteins from the body is lost in
the urine leading to swelling of the face. The cause is usually
unknown but sometimes the condition is preceded by a viral
upper respiratory cause.
▪ At this stage, do not stress yourself, it is a treatable condition.
▪ I will refer you to the specialist who will do an FBE, UEC, lipid
profile, ASO titres, ESR/CRP, urine microscopy and culture, LFT
(protein level), C3, C4, 24-hour urine collection.
▪ Treatment in the hospital includes constant weight and BP
monitoring and diet restrictions, urine output and input charts,
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and they might give antibiotics to prevent infections. They might

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also start her on steroids. Please do not be stressed, most of the

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time, the condition resolves with the course of steroids. Once the
condition is resolved, to prevent further attacks, we will teach you
how to use the urine dipstick daily at home and we'll regularly
monitor your child with a renal function test.

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Poststreptococcal Glomerulonephritis

A father brought his 7-year-old son because the son passed dark urine
for 2 days in a GP clinic.

TASKS
1. History
2. Physical examination findings from the examiner

APPROACH

History
▪ Urine questions:
o When did it start? Did this happen suddenly? Is it constantly

the same colour throughout the day? Has he passed water

more frequently or less frequently? Has he complained of pain
while passing urine?
▪ Any recent sore throat/ skin infection? If yes, when did he get it?

How was it treated?

▪ Any liver problem?
▪ Any abdominal pain skin colour changes, any joint pain, any rash,

any blood disorder/bleeding disorder?

▪ Any trauma in the loin area?
▪ Any change in diet like beetroot, blackberries?
▪ Any eye puffiness, facial puffiness, leg swelling?
▪ Any headache, shortness of breath, any fits? (high BP)
▪ Any concerns about weight and appetite?
▪ Any family kidney problem?
▪ Immunization? Growth and development?
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Physical Examination
▪ General appearance: pallor, jaundice, signs of dehydration, rash,
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oedema, growth chart

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 ▪ Vital signs
▪ ENT, LN examination
▪ Systemic examination: Cardio, R/S, abdomen
▪ Genital examination with the consent
▪ Office test: urine dipstick, BSL

Explanation:
▪ From history and examination, your child is most likely have a
condition called, post-streptococcal glomerulonephritis. It is a
condition where the filtering mechanism of the kidney is affected.
That is the reason why blood cells are lost or passed in the urine
leading to dark-coloured urine. It is most of the time, preceded by
a viral upper respiratory tract infection, or skin infection, caused
by bugs. Please do not be stressed it is a manageable condition.
▪ I would like to refer the child to the hospital for admission. I will
liaise with the paediatric registrar in the hospital and arrange for
an ambulance for immediate transfer. In the hospital, the child
will be managed by frequent weight and BP monitoring. As BP is
very high, the specialist may start him on BP lowering
medications.
▪ Some investigations may be done such as FBE, UEC, LFT, CRP, ESR,
C3, C4, urine analysis. Input and output chart is maintained.
Please let me reassure you in most of the case, the condition
resolves by supportive treatment.
▪ How long will my child stay in the hospital? It depends on the
progress of the child and how he responds to treatment.
▪ Once the condition is resolved, most of the time, most patients
will have their normal kidney function back. Once you are
discharged from the hospital, I will monitor your blood pressure
and renal function test regularly.
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Enuresis

A 6-year-old is bedwetting at night. He is dry during the day for 2 years

old. The urine microscopy and culture are negative.

TASKS
1. History
2. Examination findings from examiner
3. Diagnosis and management

Differential Diagnoses
▪ Primary enuresis:

Neurological causes
▪ Secondary enuresis: dry for some time, and then starts to wet the

bed again
UTI
Renal tract abnormality
Spinal abnormality (neurological)
Diabetes
Psychological

APPROACH
History
▪ I understand it is very distressing to you. Before I can manage the

condition, will it be alright if I ask a few questions?

▪ When did this start? Is there any time during the day that he is dry?

Is there any time during the night that he is dry? How does he react
to it? Any swelling in the body?
▪ UTI questions:
o Any pain/burning, sensation while passing pee, any change in
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colour or blood? A frequent small passage of urine? Can he

control it in the daytime?
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 ▪ Any polydipsia or frequent thirsts? Any polyuria or frequent passing
of urine?
▪ Bowel: loose stool? Constipation?
▪ BINDS
o Family situation?
o Any stress?
o Any family history of a similar condition?
o Growth and development?
o What about fluid intake?

Physical Examination
▪ General appearance: pallor, jaundice, any dysmorphic features,

edema, growth charts?

▪ Vital signs
▪ ENT and LN examination
▪ Systemic examination
▪ Genital examination
▪ Office test: UDT, BSL

Positive points in history: all normal

Explanation:
▪ Most likely your child is having a condition called nocturnal
enuresis or bedwetting. Usually, the cause is unknown. 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 the involuntary passage of urine in
the child. So please don’t blame him. I understand your concern
about cleaning and laundry, but usually, most children grow out
of it by the age of 5 or 6 years. But sometimes it can take a long
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time. But sometimes, it can run in families also.

▪ At this stage, we do not need to start him on medications.
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▪ We can use the bedwetting alarm to help him achieve dry nights.
The alarm consists of a rubber mat 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 mat 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 mat 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 alarm and get into bed. It is best if he or she
only wears pyjama jacket and underpants rather than pyjama
trousers or a long nightdress.
▪ When your child wets the bed, a loud alarm will sound. He or she
should get out of bed as quickly as possible, turn off the alarm and
go to the toilet to finish emptying his or her bladder. Then your
child should dry the mat using the piece of material, put a new
piece of material over the mat, turn the alarm 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.
▪ Your child needs to be very involved in the treatment plan if it is
to work. 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 is important for your child to drink plenty of fluid spread evenly
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throughout the day. Don't try to restrict the amount of fluid your
child drinks in the evening as this will not help and can even delay
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the process of being dry at night. However, don't give drinks

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 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 with bedwetting. However,
many will feel embarrassed or ashamed. Family members of
children who wet the bed need to be supportive and not critical.

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Vulvovaginitis

A 4-year-old girl, Sara came with her mother to your GP clinic and her
mother complained to her that Sara has yellowish vaginal discharge and
has been complaining of pain during passing urine.

TASKS
1. Take a history from mother
2. Examination findings from the examiner
3. Diagnosis and management

Differential Diagnosis
• Child abuse
• UTI
• Foreign body
• Vulvovaginitis
• Threadworms

APPROACH
HISTORY
▪ Discharge details: When did this start? What is colour? Any foul

smell? Is it blood-stained? Is it associated with itching? Any similar

episodes previously?
▪ UTI questions: is the child toilet-trained? Is there pain during

urination? Any burning sensation? Is its foul-smelling? What is the

color of the urine? Increased in the frequency of urination? Any
fever?
▪ Bowel habits: have you noticed any worms in passing in the back

passage? Does she scratch her bottom at night? Any time the child
has been gone unsupervised or inserted any foreign body? (Do you
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think she might have put something in her private area)?

▪ Any tummy pains? Any trauma? Polydipsia? Any abnormal
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behaviour?

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 ▪ BINDS questions
o Rule out child abuse.
o How is the home situation? Who I the primary carer?
o Does she go to childcare? Does she complain of anything?

▪ Any past history of allergy? Eczema?

▪ Risk factors for vulvovaginitis:
o What is she wearing? (tight clothes/jeans)
o Any use of soaps, bubble baths?
o Any change in cosmetics?
o Does she go for swimming?
o Is she toilet-trained?
o Is she obese?

PHYSICAL EXAMINATION
▪ General appearance
▪ Vitals and growth chart
▪ Systemic examination
▪ With consent of parents: pelvic and perianal area -->inspection

only: discharge, any inflammation, any scratch marks

▪ Office test: UDT, BSL

Positive points: no child abuse, only discharge, vulval area: only redness
can be seen

Explanation:
▪ From the history and examination, your child has a condition
called vulvovaginitis. Have you heard about it? Usually, in
children, female hormone levels are low, and because of that, the
skin over the vulval area is thin, which makes it prone to infection.
The bug can come from anywhere in the back passage causing
infection in the vulvar or vaginal area. Treatment is simple. Advise
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your child to avoid bubble baths, use cotton underwear and loose
clothing, general vulvar hygiene, wipe bottom from front to back
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to avoid infection, warm shallow bath with a cup of vinegar, use

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 of zinc cream or castor oil to relieve redness. No need for
antibiotics. If by any chance she develops a fever, is lethargic, has
a bloody or smelly discharge, you need to bring her to the
hospital. I will follow her up in a few days to see the progress.
▪ **Any time you suspect child abuse, or even if the mother is
concerned about child abuse, but in history, there are no positive
findings, then notify and involve child protection authority.

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HEADACHE CLUSTER
Headache cases: tension d/t home environment, tension d/t bullying,
cluster headache, posterior fossa tumor, migraine, URTI (sinusitis),
meningitis, SAH, TIA, stroke, temporal arteritis, malignancy/SOL

Differential Diagnosis (Pediatrics)

▪ Migraine
▪ Tension headache - always ask about home and school

environment for pediatric

▪ Cluster headache
▪ URTI/Sinusitis/Dental
▪ Refractory errors/Vision problem
▪ Meningitis/Meningoencephalitis
▪ SAH
▪ Trauma
▪ Tumor/Malignancy
▪ Psychogenic (stress, anxiety)

Adults:
▪ CVA/TIA/Stroke
▪ Temporal arteritis
▪ Cervical spondylosis
▪ Benign intracranial hypertension
▪ Decreased blood sugar level (hypoglycemia)

D: Good morning, I am Dr____, your GP today. How may I address you

and your daughter?
M: I'm Mrs Jones, my daughter Daniella.
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D: Alright, hello Mrs Jones and Daniella. I read from the notes that your
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daughter is having recurrent headaches. Can you tell me more about it?

© 2020 ARIMGSAS
M: It's been 2-3 months. I thought she was playing with me, but I think
now she's really in pain.
D: Where is the exact site of pain? When did it start? Is it sudden or
gradual? How long has she been having these headaches? What type
of pain is it, band-like, crushing, shooting? Does it go anywhere else? Is
it projectile? Does anything make it better or worse? When pain
starts, how long does it last? On a scale of 1 to 10, 10 being the highest,
how bad is the pain? Did you take anything for the pain? Any similar
experiences in the past?

DDx
D: Is it associated with nausea and vomiting? Any vision problems? Any
pins and needles? Any weakness anywhere in the body?
(migraine/complex migraine)
D: [Assure privacy and confidentiality] Who else is at home? Does she
have any siblings? Do they get along well? Are there any stresses in the
family? Are you a happy family?
Is she happy at school? Has she complained to you anytime about
school? Does she have a lot of friends at school? Does she get along
well with her peers? How about with the teachers? Has the teacher
spoken to you about anything? Has she complained to you about
bullying? Does the headache happen on all days or only on weekdays?
(tension headache)
D: Do you experience a runny nose or tearing from the eyes? [It is a
cluster in space and time - it usually happens at the same time every
day (alarm clock headache); a cluster of symptoms: lacrimation, runny
nose, periorbital pain]
D: Any fever, cough, colds, sore throat? Any secretions from the nose?
Any teeth problems? (URTI)
D: Do you wear glasses? When was the last time you saw an
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optometrist? (vision problems)

D: Any fever, nausea, vomiting, any pain in the neck or any neck
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stiffness? Any rash anywhere in the body?

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(meningitis/meningoencephalitis) [if meningoencephalitis, ask about
confusion, lethargy, very high fever]
D: Any nausea, vomiting, vision problems (diplopia, down and out eyes
--3rd nerve palsy) (SAH)
D: Any recent head injury? (trauma)
D: Is there any early morning vomiting? Is it projectile or forceful or
does it fall away from the body? Does the headache wake you up at
night? (if the pain wakes up the patient from sleep, it is an organic
cause), any lumps and bumps around the body? Any recent change in
weight or appetite? (Malignancy/Tumor/SOL)

BINDMA (ask BIND up to 10 - 12 years old)

D: Do you have any concerns with her growth and development?
(Development)
D: Any medical or surgical conditions in the past?

Physical Exam
D: What is the BP, temperature, PR, RR, sats
D: Is there any lymphadenopathy? Neck stiffness?
D: is there any sinus tenderness? Eye examination - visual acuity, visual
field, fundoscopy
CVS, R/S, Abdomen (Pelvic, Inguinoscrotal), CNS - I would like to do a
full neurological examination including cranial nerve

Office tests: UDT, BSL

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Migraine

A 10-year-old girl presents to your GP along with the mother. Mother is

concerned as her daughter is having headaches.

Tasks:
History
Physical examination
Management

History and PE: Refer to the headache cluster approach

Management:
▪ Condition: Based on the history and physical examination findings,
most likely you're having a condition called migraine. Do you
know what it is?
▪ Cause: There are certain blood vessels which constrict and there
are certain blood vessels which expand and because of this you're
having headaches.
▪ Commonality: It is not an uncommon condition.
▪ Complications: Mostly no complications for migraine.
▪ The course of the disease/treatment: Mrs. Jones at the very start
of the headache, give your child simple analgesics like Panadol
(paracetamol) [if it doesn't subside with that, go to neurofen, if it
doesn't work do paracetamol + neurofen combination, if still not
working, go to sumatriptan or ergotamine; in adults, if no
neurofen, go to Panadeine (paracetamol + codeine
8mg)/Panadeine extra (paracetamol + codeine 15mg)/Panadeine
forte (paracetamol + codeine 30mg)]
▪ At the start of the headache, make your child lie down in a quiet,
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darkroom. Avoid reading, avoid watching any television or any

screens. If your child is having more than 3 attacks in a month,
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then we can give certain special medications to prevent the

© 2020 ARIMGSAS
 frequency or severity of further attacks (prophylaxis) such as
propranolol, pizotifen/ketotifen
▪ Refer: Mrs. Jones, I have assessed your child in quite a detail, at
this stage I don't think your child has malignancy or your child
needs a CT scan. (If still insists, I would refer you to a specialist,
who would decide it for you if the specialist thinks you need it)
▪ (If you’re an HMO, I will call my registrar)
▪ Red flags: If she develops severe vomiting, or any new symptoms,
like weakness anywhere in the body, please come back
immediately.
▪ Review: I will review you on a regular basis. (if in the hospital:
once you are stable and discharged from the hospital, I will give a
letter to your GP who will follow you on a regular basis)
▪ Reading material: Here are some reading materials, for your
further insight.

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Tension headache

A 10-year-old girl presents to your GP along with the mother. Mother is

concerned as her daughter is having recurrent headaches.

TASK
1. Get relevant history
2. Physical examination findings from the examiner
3. Diagnosis
4. Management

Positive points in history: Child does not like going to school. Friends
are bullying him. Pain only on weekdays, no pain on holidays. No
nausea, no vomiting, no vision problems.
Positive points in the PE: all normal

History and PE: Refer to the headache cluster approach

Management:
▪ Based on the history and physical examination findings, most
likely your child is having a condition called a tension headache.
Mrs. Jones, because your child is having a tough time at school
and is being bullied, he's having this headache.
▪ This is the mind, and this is the body. (Draw the mind-body axis)

▪ When we have stress, our mind can usually cope up with it. But if
we have overwhelming stress, the mind cannot cope up with it
and it gets on to the body and comes out as bodily symptoms.
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▪ In your child's case, bullying is the stressor, and headache is the

symptom. Mrs Jones, I would like to arrange a family meeting and
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with the teacher, and explain the situation to the teacher, so that

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 no more bullying happens. I encourage that you speak to her
about the school environment at home. Do not scold or punish
her for being bullied.

*** Case where parents having issues with each other.

Mrs Jones, I understand you are going through some difficult times, and
not getting along with your partner. And because the child is a witness
to this, it's affecting her, that is why she's having the headaches and not
performing well at school. I would like to arrange a family meeting. I
would also like to arrange for a marriage counselor. If the symptoms
are severe and affecting her day to day life, I would also like to arrange
a pediatric counselor.
What will the pediatric counselor do? Behavioral therapy talk therapy
(Cognitive behavioral therapy) - identify the stressors, teach coping
strategies.

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Viral URTI

A mother of a 6-year-old child has come to your GP clinic with

complaints of the daughter having headache since morning.

TASKS
1. Take history
2. PE findings from the examiner
3. Diagnosis and management

Differential Diagnoses
• Migraine
• Tumor
• Meningitis
• Tension
• Vision problem
• Viral URTI
• Sinusitis
• Trauma
• Diabetes mellitus
• Ear infection

HISTORY
▪ Where is the exact site of pain? When did it start? Is it sudden or

gradual? How long has she been having these headaches? What
type of pain is it, band-like, crushing, shooting? Does it go
anywhere else? Is it projectile? Does anything make it better or
worse? When pain starts, how long does it last? On a scale of 1 to
10, 10 being the highest, how bad is the pain? Did you take
anything for the pain? Any similar experiences in the past?
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▪ Is it associated with nausea and vomiting? Any vision problems?

Any pins and needles? Any weakness anywhere in the body?

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(migraine/complex migraine)

© 2020 ARIMGSAS
▪ [Assure privacy and confidentiality] Who else is at home? Does she
have any siblings? Do they get along well? Are there any stresses in
the family? Are you a happy family?
Is she happy at school? Has she complained to you anytime about
school? Does she have a lot of friends at school? Does she get along
well with her peers? How about with the teachers? Has the
teacher spoken to you about anything? Has she complained to you
about bullying? Does the headache happen on all days or only on
weekdays? (tension headache)
▪ Do you experience a runny nose or tearing from the eyes? [It is a
cluster in space and time - it usually happens at the same time
every day (alarm clock headache); the cluster of symptoms:
lacrimation, runny nose, periorbital pain]
▪ Any fever, cough, colds, sore throat? Any secretions from the nose?
Any teeth problems? (URTI)
▪ Do you wear glasses? When was the last time you saw an
optometrist? (vision problems)
▪ Any fever, nausea, vomiting, any pain in the neck or any neck
stiffness? Any rash anywhere in the body?
(meningitis/meningoencephalitis) [if meningoencephalitis, ask
about confusion, lethargy, very high fever]
▪ Any nausea, vomiting, vision problems (diplopia, down and out
eyes --3rd nerve palsy) (SAH)
▪ Any recent head injury? (trauma)
▪ Is there any early morning vomiting? Is it projectile or forceful or
does it fall away from the body? Does the headache wake you up at
night? (if the pain wakes up the patient from sleep, it is an organic
cause), any lumps and bumps around the body? Any recent change
in weight or appetite? (Malignancy/Tumor/SOL)
▪ Do you have any concerns with her growth and development?
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(Development)
▪ Any medical or surgical conditions in the past?
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PHYSICAL EXAMINATION
What is the BP, temperature, PR, RR, saturation?
ASK FOR FUNDOSCOPY IF THERE IS INCREASED BP AND HEADACHE
Is there any lymphadenopathy? Neck stiffness?
is there any sinus tenderness? Eye examination - visual acuity, visual
field, fundoscopy
CVS, R/S, Abdomen (Pelvic, Inguinoscrotal),
CNS - I would like to do a full neurological examination including cranial
nerve
Office tests: UDT, BSL

Positive points: fever, runny nose, sore throat, myalgia for the last 2
days. Family history of migraine, no contact history
Exam: temp:38, no other positive points. ENT exam: mild congestion
on-ear and throat

EXPLANATION
▪ From history and examination, your child is having a headache
due to simple viral URTI.
▪ It is a self-limiting condition. You don’t have to stress yourself, the
condition goes away by itself.
▪ The treatment is simple analgesia with Panadol, adequate fluids,
and rest. However, if he presents with high fever, rash, headache
not responding to Panadol or simple analgesia, please come back
to me immediately.
▪ I will be reviewing your child in 3-4 days to see if she's improving.
▪ I will also give you a medical certificate for your child and for you
so that you can take care of your child.
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Increased ICP

A mother of a 10-year-old child came to the GP clinic with complaints

that her daughter has a headache. She is missing school due to
headache.

TASKS
1. Take a history
2. PE findings from examiner
3. Discuss your diagnosis and management with the father

Positive points: 2 times/week headache x 3 months, vomiting, BP

140/90, fundoscopy findings: papilledema

HISTORY
▪ Where is the exact site of pain? When did it start? Is it sudden or

gradual? How long has she been having these headaches? What
type of pain is it, band-like, crushing, shooting? Does it go
anywhere else? Is it projectile? Does anything make it better or
worse? When pain starts, how long does it last? On a scale of 1 to
10, 10 being the highest, how bad is the pain? Did you take
anything for the pain? Any similar experiences in the past?
▪ Is it associated with nausea and vomiting? Any vision problems?
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Any pins and needles? Any weakness anywhere in the body?

(migraine/complex migraine)
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© 2020 ARIMGSAS
▪ [Assure privacy and confidentiality] Who else is at home? Does she
have any siblings? Do they get along well? Are there any stresses in
the family? Are you a happy family?
Is she happy at school? Has she complained to you anytime about
school? Does she have a lot of friends at school? Does she get along
well with her peers? How about with the teachers? Has the
teacher spoken to you about anything? Has she complained to you
about bullying? Does the headache happen on all days or only on
weekdays? (tension headache)
▪ Do you experience a runny nose or tearing from the eyes? [It is the
cluster in space and time - it usually happens at the same time
every day (alarm clock headache); the cluster of symptoms:
lacrimation, runny nose, periorbital pain]
▪ Any fever, cough, colds, sore throat? Any secretions from the nose?
Any teeth problems? (URTI)
▪ Do you wear glasses? When was the last time you saw an
optometrist? (vision problems)
▪ Any fever, nausea, vomiting, any pain in the neck or any neck
stiffness? Any rash anywhere in the body?
(meningitis/meningoencephalitis) [if meningoencephalitis, ask
about confusion, lethargy, very high fever]
▪ Any nausea, vomiting, vision problems (diplopia, down and out
eyes --3rd nerve palsy) (SAH)
▪ Any recent head injury? (trauma)
▪ Is there any early morning vomiting? Is it projectile or forceful or
does it fall away from the body? Does the headache wake you up at
night? (if the pain wakes up the patient from sleep, it is an organic
cause), any lumps and bumps around the body? Any recent change
in weight or appetite? (Malignancy/Tumor/SOL)
▪ Do you have any concerns with her growth and development?
217

(Development)
▪ Any medical or surgical conditions in the past?
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PHYSICAL EXAMINATION
What is BP, temperature, PR, RR, saturation?
ASK FOR FUNDOSCOPY IF THERE IS INCREASED BP AND HEADACHE
Is there any lymphadenopathy? Neck stiffness?
Is there any sinus tenderness? Eye examination - visual acuity, visual
field, fundoscopy
CVS, R/S, Abdomen (Pelvic, Inguinoscrotal), CNS - I would like to do a
full neurological examination including cranial nerve
UDT, BSL

Explanation:
▪ Normally, our brain is surrounded by a fluid we call CSF. This is
formed from the filtration of blood and absorbed back, and this is
done continuously.
▪ If there is an interruption in the absorption of this fluid, or
increase in the formation of the fluid, it can lead to increased
pressure around the brain. The brain is enclosed in the skull. The
increased pressure causes a headache, vomiting, increased blood
pressure, and this is called as increased intracranial pressure.
▪ I can say that this is my diagnosis because when I examined your
child's back of the eyes, the back is swollen.
▪ Most of the time, the cause for increased intracranial pressure is a
blockage to the flow of CSF, due to a mass, maybe a solid or
liquid, present in the brain, obstructing it.
▪ So, it is an emergency condition, the child needs an immediate
referral to a neurologist in the hospital. So, I will be referring you
to the hospital emergency department. I will inform the paediatric
registrar of the condition before the child is transferred. In the
hospital, the specialist will arrange for further imaging.
▪ Is it a brain tumour doctor? Sorry, I know you are going through a
218

hard situation, at this stage, I can't completely tell you, whether it

is a brain tumour or not. But the good thing is that we have picked
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it up early so that intervention can be done early. Please don’t be

© 2020 ARIMGSAS
stressed, if it turns out to be brain cancer or brain tumour, the
specialist will decide further management.

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Increased ICP - Space-occupying lesion

You are a GP and your next patient is a 10-year-old girl brought by her
mom due to headaches for the last 6 months.

TASKS
1. History
2. Physical examination from the examiner
3. Diagnosis and Management

Positive points in the history: gets headaches whenever she goes to

school (morning), but no bullying or problems in school, complains of
headache more in the morning, no vomiting but is nauseated,
sometimes gets better on its own or sometimes with Panadol, dull pain,
pain all over the head, sleep and studies are a fine, very happy family,
no previous trauma
Positive points in the PE: BP 140/70, low pulse (Cushing reflex)
FUNDOSCOPY FINDINGS: Papilledema

Differential Diagnosis
▪ Sinusitis (most common in GP)
▪ Migraine
▪ Toothache
▪ Trauma
▪ Analgesic-induced headache
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▪ Ear pain
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© 2020 ARIMGSAS
APPROACH
▪ History
o Mary, you look stressed, do not worry, we are all here to help

you. (if there are emotional cues, always deal with that)
o Pain questions
o Differential questions

▪ Physical exam
o General appearance
o Vital signs
o ENT exam
o Intraoral examination to look for any dental abscess
o Sinuses
o Neurological examination (MUST for any chronic headache

cases)
o Fundoscopy

▪ Diagnosis and Management

When I looked at the back of your child's eyes, I saw a swelling. And
this swelling is concerning me because it can be a sign of some
nasty growth in the brain. At this stage, I need to refer her
immediately for further assessment.

NORMAL FUNDOSCOPY
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COUGH CLUSTER

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© 2020 ARIMGSAS
Bronchiolitis

Jenny age 9 months is brought to your GP clinic by her mom Margaret.

She had colds for couple of days with fever and runny nose. Today she
is woken up with cough and rapid breathing. Yesterday she didn't eat
well as she does usually. She refused to eat breakfast this morning and
she only drank half a bottle of formula milk. Jenny's brother who is 3
years of age had cold for last one week and his asthma played up
needing Salbutamol regularly.

TASKS
1. Further focused history
2. Further examination and investigation findings from examiner
3. Probable diagnosis and treatment advise

Data from mother:

Weight: 7.5kg
Birthweight: 1.8kg
Cough is getting worse, breathing is getting faster, child is struggling to
breathe
Had difficulty of breathing during birth, kept in the hospital for a couple
of days
For the last 3 days, child is restless, has difficulty of breathing
PE:
Conscious, looking around, restless
No LN enlargements
Growth chart: 50th percentile in height, weight, head circumference
Mild dehydration: Eyes depressed but not sunken
HR: 120 bpm, temp: 37.8, sat: 92% room air
CVS: heart sounds audible and normal
225

R/S: air entry normal, wheezes in the chest

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Differential Diagnoses:

© 2020 ARIMGSAS
 ▪ Bronchiolitis
▪ Pneumonia/Sepsis
▪ Croup
▪ Asthma
▪ Foreign body
▪ Pertussis
▪ Viral URTI

Cough questions:
when did she start coughing?
Any timings of the cough? (daytime, nighttime, continuous)
How would you describe the cough? Looks like an asthma cough
Is it a barking cough? (croup)
Does she have a coughing fit, at the end does she vomit or makes a
noise afterwards, and her face becomes red afterwards? (pertussis)
Does he turn blue when he coughs (cyanosis)?
Have you noticed anything triggering the cough? Does anyone smoke at
home? Any pets at home? When was the last time you had steam
cleaning at home?
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Breathing questions:
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© 2020 ARIMGSAS
Do you notice if she uses her tummy while breathing? Or does her
tummy go in during breathing? Is she making any noise while
breathing? (croup)
Have you noticed rapid breathing? Have you noticed his breathing
stops at any time for a while (apnea)?
Are there any associated symptoms like a fever? Yes, there is a fever.
Have you measured his temp, how high was it? Continuous? Have you
tried any medication or anything for the temp? Skin rash?
Any abnormal movements (fits) – staring, smacking lips
Fluid intake? Feeding pattern? How much feeding has gone down? Is
he feeling well, how is his appetite?
Has he been vomiting? How many times a day? What time does he
vomit, any special time? (In bronchiolitis usually, vomiting occurs after
a cough)
Dehydration - Is he wetting nappies normally? Have you noticed
wetting nappies like before?
Have you noticed any change in his bowel movement, diarrhea? How
many times, what is the color, any blood or mucus

How is her activity? How is his mood: crying a lot, sleeping well, more
lethargic than before?

BIND
Do you have any other children, how many?
Is this your only baby or do you have any other kids?
Was the pregnancy normal, delivered/born full-term, normal or by SC
Any problems after delivery
Immunization up-to-date?
How is his growth/development (for older kids ask milestones: smiling,
sitting? crawling)
227

Does anything like this run in the family?

Have you had any medical condition like this in the family? Hay fever,
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allergy, asthma?

© 2020 ARIMGSAS
O/E:
GA: alert or not, rash
Growth Parameters: height and weight in normal percentile
Signs of respiratory distress
- Grunting
- Nasal flaring
- Tracheal tug

GA: pallor, jaundice? Growth charts?

Hydration status
- The fontanelle (closure after 1-1.5 years) depressed or not
- Sunken eyes
- Is mucous membrane appearance dry?
- Delayed skin turgor (pinch the skin in the abdomen and leave –
normal is less than 1 minute; if 1-2 minutes à mild, moderate, if >2min
à severe)
- Central & peripheral capillary refill time (central can be seen by
putting the hand in the chest)
VS
ENT: ear, nose d/c, LN
R/S: Subcostal and intercostal recession? Accessory muscle use?
wheezes, widespread crackles, rhonchi, nasal flaring, grunting?
Heart and abdomen
Urine dipstick at this age, urine bag is not reliable (suprapubic
aspiration not required)

Investigations:
At this time, I think we don't need to do any investigations. But if
required or anything changes, FBE and chest x-ray can be requested.
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After I’ve taken history and examination, it seemed that your child is
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most likely suffering from a condition called Acute Bronchiolitis.

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It is a chest infection in which there is inflammation of the bronchioles,
which are the smallest branches of the respiratory tree of the lungs.
This results in narrowing and blockage of the small air passages with
mucus, leading to a negative effect on the transfer of oxygen from the
lungs to the bloodstream.
It typically affects babies from 2 weeks to 12 months, especially under
10 months of age.
It is caused by one of the common respiratory viruses, especially
respiratory syncytial virus. The virus appears to have a particular
tendency to target the bronchioles in infants. It is a contagious
condition that is usually spread from droplets released into the air by
coughing. It can also be spread by hand contact with secretions from
the nose or lungs. Bronchiolitis usually occurs in the winter months.
At first, the infant usually develops symptoms of a mild common cold
with a runny nose, fever and cough for about 48 hours. As the infection
progresses over the next day or so, the following irritations develop an
irritating cough, wheezing, rapid breathing. These more severe
symptoms last about 3 to 5 days. In a very severe episode, there are
retractions of the chest and abdomen (‘see-saw’ movements), hypoxia
(lack of oxygen), possible cyanosis (blue lips or skin).
In a mild infection, the wheezing usually lasts for about 3 days only, and
as it settles the child gradually improves. Most babies can be treated at
home and are usually better in 7 to 10 days. The cough can last up to a
month or so. In some cases when the infection is moderate or severe,
the child becomes depleted in essential oxygen and fluids. Dehydration
is a problem because of drinking difficulty from constant coughing.
They require hospitalization as is the case with your child who has a
moderate type of acute bronchiolitis.
I need to refer you to the hospital, I will arrange for an ambulance. I will
give her oxygen here then we'll transfer you to the hospital where they
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would do continuous monitoring of the child. There is no particular

medicine, including antibiotics, that cures bronchiolitis because it is a
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viral infection. It gets better naturally but care is required. Usually,

© 2020 ARIMGSAS
children who get bronchiolitis and recurrent may get asthma or is more
likely to get asthma when they get older especially common in a family
with allergic history.

BRONCHIOLITIS
Feature MILD MODERATE SEVERE
Behavior/mental Alert, normal Irritable, Sleepy,
state restless lethargic,
drowsy
Work of breathing + ++ +++ --> ↓↓
(chest movements, (when child
accessory muscle gets
use, RR) exhausted)
Oxygen saturation >93% 90-93% <90%
Feeding/hydration normal May have Unable to
difficulty feed
feeding,
reduced
feeding
Apneic episodes (do None None or may Present,
you notice that she have brief prolonged
stops breathing episodes episodes
then picks up
again?)
Management Managed at Child needs Oxygen,
home oxygenation fluids,
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Encourage quiet We'll try to give monitoring,

resting. oral fluids then
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© 2020 ARIMGSAS
•Paracetamol is observe her non-invasive
recommended feeding. If she monitoring
for fever. doesn't drink
•The important well, we'll try
issue is to keep to insert a tube
up plenty of to the nose
fluids, especially going to the
in the very stomach.
young. Give 1 to Need
2 extra bottles a continuous
day or more monitoring
frequent No role of
breastfeeds. If antibiotics for
feeding is viral infection
difficult, give No role of
smaller steroids
quantities more No role of
often. steam
• Ensure the
home
environment is
smoke-free.

Seek help if any

of the following
occur:
•worsening
cough and
wheeze
•poor fluid
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intake—refusal
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to feed, fewer
wet nappies, less
than half normal
intake over 24
hours
•difficult, rapid
breathing
• difficulty with
sleeping
•blueness around
the lips
•child generally
flat and ill.

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Asthma

Elizabeth aged 3 years is brought by her mother Jenny to your surgery

with worsening of cough and breathing difficulty. She had a history of
URTI last week and had been unwell. Her runny nose and cold
symptoms have settled but cough had gone worse since last night. She
has diagnosed with asthma last year and currently is on Ventolin PRN.

TASKS
1. Further focused history
2. Examination findings from the examiner
3. Diagnosis and treatment advise

APPROACH
Is the Asthma stable, or is it an attack?
Stable
o Diagnose asthma
o Management plan (6-step)

Attack
▪ History
o What is the pattern of coughing? What does the cough

sound like?
o Breathing difficulty: rate of breathing, accessory muscle use,

what they have done?

o What are the triggers?

• Smoking, pets, carpets, dust mites, history of eczema,

hay fever, allergic rhinitis

o Who is giving her Ventolin? How often? What technique?
o Drug history, allergies, family history
o Feeding history
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▪ Physical exam
o Ask about the mental state
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o GA - PICCLE dehydration

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 o Growth charts
o Respiratory system

FEATURES MILD MODERATE SEVERE/LIFE-

THREATENING
Mental state/Behaviour Alert Alert/irritable Irritable/sleepy,
drowsy,
lethargic
Work of breathing (chest + ++ +++/↓↓
movements, accessory
muscles use, recessions,
nasal flaring, tracheal
tug, respiratory rate)
SaO2 >92% 90 - 92% >90%
Feeding/dehydration normal mild Moderate -
severe
Ability to speak Can Cannot Speaks in
complete complete a words/phrases
a sentence, or inability to
sentence interrupted speak

MANAGEMENT
▪ Mild asthma attack
o Ventolin

• If <6 years old: 6 puffs

• If >6 years old: 12 puffs
• Route: via a spacer
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• Frequency: every 20 minutes

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• Technique: 1 puff: 3-4 breaths

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 o Steroids - prednisolone ONLY IF:
• High-risk child: frequent exacerbations
• Prolonged symptoms (getting worse for 3-5 days)
• 2mg/kg body weight on day 1, 1mg/kg body weight on day

2 and 3 (maximum 50mg)

o Action plan
o Technique - show me how you use it
o Red flags
o Feeding and hydration
o Flu
o Triggers
▪ Moderate asthma attack
o Oxygen

• Facemask, 100%, 10-15L

o Ventolin

• If <6 years old: 6 puffs

• If >6 years old: 12 puffs
• Route: via a spacer
• Frequency: every 20 minutes
• Technique: 1 puff: 3-4 breaths
o Steroids - prednisolone

• 2mg/kg body weight

o Send to hospital

▪ Severe asthma attack

o Bring to the resuscitation room
o Call for help (book an ambulance)
o Oxygen

• Facemask, 100%, 10-15L

o Ventolin

• Continuous nebulized salbutamol (0.5%)

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• Children less than 25kg: 2.5mg

• Children more than 25kg or adults: 5mg
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o Atrovent (ipratropium)

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 • Children or less than 25kg: 250mcg
• Children more than 25kg or adults: 500mcg
• Give every 20 minutes
o Steroids (hydrocortisone, methylprednisolone)
• Preferably IV
• Hydrocortisone: 4-6mg/kg
• Methylprednisolone: 1mg/kg
o IV Aminophylline (make sure the child is not on theophyllines)
o Magnesium sulphate
o Non-invasive ventilation (CPAP)
o Invasive ventilation
• LMA (laryngeal mask airway)
• I-Gel (supraglottic airway mask)
• ETT (endotracheal tube)
o Adrenaline
• Only in pre-arrest situations

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Croup

Case: You are in a GP clinic and your next patient is 9-month-old John
who was brought by his father saying that he’s having noisy breathing.

Case: You are working as a Junior Doctor in a metropolitan hospital and

you are about to see Tom a 15 months boy brought to the Emergency
Department by his mother due to coughing and breathing difficulty for
one day.

TASKS
1. History
2. Physical Exam
3. Diagnosis and Management

Differential Diagnoses
▪ Viral URTI:
▪ Bronchiolitis
▪ Pneumonia
▪ Croup
▪ Laryngomalacia
▪ Whooping cough
▪ Foreign body: any choking episodes
▪ Cardiac cause
▪ Epiglottitis

Positive findings in the history: barking cough, fever can be present,

runny nose, symptoms are often worse at night.
Rao developed the flu-like illness two days ago with a runny nose,
cough and fever, last night he came down with a spasmodic, harsh
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brassy (barking) cough. He has been a previously well child. He is still

drinking fluids and has eaten alright yesterday
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Positive findings in the physical examination: Irritable behaviour,
stridor (high pitched stridor) tachypnoea, increased work of breathing,
lethargy, hypoxemia is a late sign.
Vital signs normal except for mild tachypnoea and a temp. of 38 degree
Celsius.
Mildly unwell looking boy with a loud audible inspiratory stridor,
followed by a harsh barky cough. Some retraction at rest. His larynx
looks quite red. Inspiratory stridor on auscultation with a mild
expiratory wheeze.
No other pathological findings.

APPROACH
History
▪ Is my patient hemodynamically stable?
▪ Fever questions:
o Any recent fever? have you checked it at home? Is it

continuous or intermittent? Have you given any medication?

Rash? Fit or seizure? Vomiting?
▪ Cough questions: Distinguish recurrent episodes from continuous

cough.
Ask about:
Onset (sudden onset of cough without a viral prodrome may
suggest foreign body inhalation).
Type of cough (paroxysmal cough may suggest pertussis,
chlamydia, or foreign body. Honking cough may suggest
psychogenic cough).
The pattern of cough (cough which is absent during sleep is
suggestive of habit cough).
Symptoms of sinusitis, chronic rhinitis, atopic conditions and
asthma.
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Exercise tolerance.
Any other medical concerns.
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Exposure to passive smoking.

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 o For how long is he having a cough? Sudden or gradual? What
time of the day? Does it wake him up from sleep? Anything
makes it better or worse?
Nature of the cough? Is the cough followed by vomiting?
Does he turn blue when he coughs?
Any drooling of saliva? Fast or noisy breathing? Does the
breathing stop for a while?
▪ General systemic questions:
o Activity? Sleepy or drowsy? Eating or drinking well? Any change

in the bowel motion or urine? A number of wet nappies?

▪ Others:
o any other kids at home? Sick contacts? Does anyone smoke at

home? Pets/carpets? Allergy, Birth history, immunization,

growth and development.
o Family history, past medical history

▪ Differential Diagnosis questions:

o URTI: is there runny nose, low-grade fever?
o Post viral cough: is there prolonged dry cough after URTI?
o Bronchiolitis: is there runny nose, wheeze, or fever? Is it

present at rest, or only during activities? Any time that the

child has stopped breathing (apnoea)?
o Croup: is it a barking cough with stridor?
o Pneumonia: any high fever, cough, crepitations?
o Asthma: any family history of atopy or allergy? How long has

the cough been there? (more than 1 year), any wheezing?

o Epiglottitis: Are there any particular posture that the child

prefers? (tripod position), stridor?

o Foreign body: any choking episodes? Any time that the child is

unsupervised?
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o Pertussis: is the cough followed by whoop or vomiting? Is it a

persistent cough? Any history of sick contacts?

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o GORD: does the cough come after feeding?

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 o Cystic fibrosis: is the child gaining weight? Any diarrhea? How is
his feeding? Was the heel-prick test done? Any family history of
cystic fibrosis?
o Tuberculosis: any recent travel?
o Cardiac disease: is he gaining weight? Failure to thrive?
Recurrent/repeated chest infections? Cyanotic spells?
o Psychogenic: how is your home situation? Who is the primary
carer? Any stress at school or at home?

Physical Exam
▪ General appearance: alert or not, rash?
o Growth parameters: height and weight in normal percentile?
o Signs of respiratory distress:

• Grunting, nasal flaring, tracheal tug, subcostal and

intercostal recession
o Hydration status:

• A fontanelle (closure after 1-1.5 years) - is it depressed or

not?
• Sunken eyes
• Dry mucous membrane?
• Delayed skin turgor? (pinch skin in the abdomen - normal is

less than 1 minute; if 1-2 minutes: mild to moderate; if >2

minutes: severe)
• Central and peripheral capillary refill time (central can be

seen by putting a hand in the chest)

▪ Vital signs: respiratory rate with saturation
▪ ENT: ear, nose discharge, lymph nodes
▪ Chest: wheezes, widespread crackles, rhonchi, nasal flaring,

grunting
▪ Heart and abdomen
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Management
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Children with croup should have a minimal examination. Do not
examine the throat. Do not upset the child further.

From history and examination, your child most likely has a condition
called Croup. It is a viral infection of the windpipe, and voice box.
Because the infection is over here, the child has noisy breathing, barky
cough, runny nose and fever which is often worse at night. It is a
common condition, and more common in children aged 6 months to 3
years. Treatment is supportive.

Features Mild Moderate Severe

Behaviour Normal Some/intermittent Increasing irritability
irritability and/or lethargy
Stridor Barking cough Some stridor at Stridor present at rest
Stridor only rest
when active or
upset
Respiratory Normal Increased Marked increase or
rate respiratory rate decrease
Tracheal tug Tracheal tug
Nasal flaring Nasal flaring
Accessory None or Moderate chest Marked chest wall
muscle use minimal wall retraction retraction
Oxygen No oxygen No oxygen Hypoxemia is a late sign
requirement requirement of significant upper
airway obstruction
Management Manage at ▪ Admit to ED ▪ Admit to ED
home ▪ Prednisolone Nebulised adrenaline
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symptomatically 1mg/kg AND (1 mL of 1% adrenaline

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prescribe a solution plus 3ml

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 Rest, second dose for Normal Saline, or 4ml
adequate the next of adrenaline 1:1000.)
fluid, evening. ▪ Give 0.6mg/kg (max
minimal OR 12mg) IM/IV
handling of a single dose of dexamethasone
the child, Oral • If good

Panadol for Dexamethasone improvement,

fever, 2 0.15mg/kg. observe for 4
doses of (Oral hours post
steroid (1 dexamethasone adrenaline.
given now, suspension ONLY Consider discharge
then one available in once stridor free
given at hospitals, NOT at rest.
home; available at • If there is

1mg/kg), commercial improvement then

small pharmacies) deterioration, give
frequent further doses of
feeding Observe for half adrenaline.
an hour post Consider
BUT if the steroid admission/transfer
mother is not administration. as appropriate.
capable of Discharge once • If there is no

taking care of stridor-free at improvement,

the child at rest reconsider the
home, ADMIT. diagnosis.
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Epiglottitis

Epiglottitis/Bacterial Abrupt onset Maintain a position of

Tracheitis Respiratory comfort with parents
(more likely if distress present
unimmunised Absent cough Defer invasive
against H. with low pitched examinations/
influenzae) stridor procedures (IV) or
imaging (lateral neck x-
Muffled/hoarse ray) in patients with
voice severe respiratory
Tripod/sniffing distress due to the risk
position of precipitating
Drooling respiratory arrest
Fever Early PICU/anaesthetic
review
Antibiotics: Ceftriaxone
50 mg/kg (max 2 g) IV
12 hourly

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Acute Epiglottitis
• acute inflammation causing swelling of supraglottic structures of the
larynx without involvement of vocal cords

Aetiology
• H. influenzas type b
• relatively uncommon condition due to Hib vaccine

Clinical Features
• any age, most commonly 1-4 yr.
• rapid onset
• toxic-looking, fever, anorexia, restlessness
• cyanotic/pale, inspiratory stridor, slow breathing, lungs clear with
decreased air entry
• prefers sitting up ("tripod" posture), open mouth, drooling, tongue
protruding, sore throat, dysphagia

Investigations and Management

• investigations and physical exam may lead to complete obstruction,
thus preparations for intubation or tracheotomy must be made before
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any manipulation
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• stat ENT/anesthesia consult(s)

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• WBC (elevated), blood and pharyngeal cultures after intubation
• lateral neck radiograph (only done if the patient stable)

Treatment
• secure airway
• IV access with hydration
• antibiotics: IV cefuroxime, cefotaxime, or ceftriaxone
• moist air
• extubate when leak around tube occurs and afebrile
• watch for meningitis
Acute epiglottitis is a medical emergency. When managing epiglottitis,
it is important not to agitate the child, as this may precipitate complete
obstruction
Thumb sign: cherry-shaped epiglottic swelling seen on lateral neck
radiograph

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Laryngomalacia

David, 3-month-old came with his Mom at your GP clinic as his

grandmother just arrived to visit him and was concerned about his
breathing.

TASKS
1. History from mother
2. Examination findings from the examiner
3. Diagnosis and differential diagnoses
4. Management plan

Positive points in the history: noisy breathing with a tracheal tug when
the baby cries, during bottle feeding, disappear when sleeping
Positive points in the PE: 120/min, RR 35/min, BP 60/50

History and PE: Refer to Croup

Management:
▪ From history and examination, your child has mild stridor (mild
noisy breathing) which is most likely due to a condition called
laryngomalacia. In this condition, the voice box is malformed and
floppy, causing it to fall over the airway opening and partially
block it producing the noisy breathing.
▪ The voice box is a tube-like structure, and weakness can occur due
to compression from the outside, some problem within the wall of
the tube, or something growing from the inside. In your child's
case, it is mostly due to the weakness of the wall of the voice box.
▪ I believe that your baby is having a mild form of it because he is
not displaying any symptoms of respiratory distress, he is feeding
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well and thriving well.

▪ However, I will refer you to the paediatrician for further
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assessment. He might do a nasopharyngolaryngoscopy (a tiny

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 camera that looks like a strand of spaghetti with a light on the end
is passed through your baby’s nostril and into the lower part of
the throat where the larynx is) to visualize the voice box. In 90
percent of cases, laryngomalacia resolves without treatment by
the time your child is 18 to 20 months old.
▪ If your child stops breathing for more than 10 seconds, turns blue
around the lips while breathing noisily or pulls in the neck or chest
without relief after being repositioned or awakened, please report
to the ED immediately.
▪ I will give you reading materials on laryngomalacia for further
insight and I will review you regularly.

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Post-viral Cough

Your next patient in general practice is Mr. John Holmes who brings his
2-year-old boy Joshua for a check-up because Joshua has had recurrent
episodes of cough since last 6 months and the parents are quite
concerned now.

TASKS
1. History
2. Physical examination
3. Diagnosis and Differential Diagnosis
4. Management

Positive points in the history: dry cough, following runny nose or

episode URTI, otherwise healthy. No positive family history. Father
smokes at home.
Physical examination: all normal.

Differential diagnosis:
▪ post-viral cough
▪ Allergic rhinitis
▪ Asthma
▪ TB (Travel history, night sweat, contact with TB patient)
▪ OSA

History and PE: Refer to Croup

Management:
▪ Since your child is well and there are no abnormal findings on
examination, most likely your child is having a condition called
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post-viral/recurrent cough. In this condition, children present

with cough for many weeks after a viral infection. In children, it is
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common to have 6-12 upper respiratory infections per year

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 because children's immunity is not yet very well developed. There
is no evidence that cough medicines, decongestants,
antihistamines and antibiotics have a role in treatment.
▪ What I would advise you to do is to refrain from smoking in the
presence of the child because passive smoking can increase the
chances of having URTI.
▪ There is no need for investigations at this stage. Give your child a
healthy, balanced diet and good fluid intake. If your child is not
feeding well, has difficulty in breathing, becomes irritable, please
report immediately.
▪ I will give you reading materials about post-viral cough for further
insight, and I will review you in 2 weeks.

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Pertussis

Your next patient in a general practice setting is a 2-year-old boy, Rao,

who is brought in by his father, Mr Jones, because of a history of 5 days
of runny nose and dry cough, which got worse last night with sort of
spasms of cough which kept the whole family awake.

TASKS
1. History
2. Physical examination findings from the examiner
3. Diagnosis and Management

Positive points in the history: about 5 days ago, Rao started to suffer
from a runny nose and sneezing, quickly followed by a hacking
nocturnal cough although he did not have a temperature and he
seemed to be generally not too bad. 2 days ago, he became a bit more
listless and lost his appetite. A younger brother (5 months) and his
mother also had the flu at that time. However, last night the cough got
worse. It seemed to come in spasms or bouts with a hacking cough
followed by a noisy inspiration and somewhat like a choking episode. It
kept everybody awake for most of the night. In the morning, Rao did
not want to eat his breakfast and became quite blue after another
episode.
PE findings: No abnormal findings.

History and PE: Refer to Croup

Management:
▪ From the history and physical examination, most likely your child
is having a condition called pertussis or whooping cough. It is the
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infection of the lungs which causes coughing followed by

whooping and vomiting. This infection is caused by a bug called
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Bordetella Pertussis and is extremely contagious.

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▪ It spreads by tiny droplets of fluid when coughing and sneezing. It
is more serious in babies less than 6 months of age and usually
required hospital admission for them.
▪ Many babies who get whooping cough catch it from older children
or adults who may not be aware of the infections. There is
immunisation for whooping cough. Children who have been
immunised can still get whooping cough, but it is usually not so
severe.
▪ The cough may persist as long as 10 weeks and they're usually
well between cough spells. It is basically diagnosed on the basis of
history and clinical examination but secretion from the nose
(nasopharyngeal swab) and blood test can be done to confirm if
cough is within the last 3 weeks.
▪ Treatment: Azithromycin 10mg/kg oral on day 1 then 5mg/kg
daily for 4 days. OR Clarithromycin 7.5mg/kg/dose oral BD for 7
days.
▪ If macrolides are contraindicated, treat with Trimethoprim-sulpha
methoxazole 0.5ml/kg BD for 7 days.

▪ Prophylaxis regimen is the same as the treatment regimen.

Prophylaxis should be given to family members living at the same
home, pregnant lady at last trimester, health care worker at
maternity or newborn ward, child care worker, children of less
than 6 months and who did not complete 3 doses of pertussis
vaccines.
▪ Prevention: the previous infection with whooping cough does not
provide lifelong immunity. Whooping cough vaccination is
recommended to all children at 2, 4, 6, 18 months and 4 years. An
adult pertussis booster dose is given at 12-13 years age. Close
contacts that are not up to date with their pertussis immunization
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should be given DTPa as soon as possible.

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▪ I will need to notify DHS. Also need to notify the childcare service
he attends. He needs to be excluded from crèche/school till 5
days after antibiotics.
▪ We will keep him in the hospital for a few hours only until he is
well rehydrated.

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Simple URTI

A father is concerned that his son who is 2.5 years old had recurrent
respiratory tract infections this year. He has come to your GP clinic to
discuss if a child requires a stronger antibiotic.

TASKS
1. Take a history from father
2. PE findings from the examiner
3. Tell your diagnosis and management

Positive points in history:

Positive points in the PE:

History and PE: Refer to Croup

Explanation:
What the child is having is nothing but a simple viral infection of the
upper part of the respiratory tract. I can say this because the child's
fever is never very high, he is thriving well and there are no red flags
that could be found on history and physical examination. It is common
in children to have viral infections, about 6-12 per year because their
immune system is not yet fully developed. However, exposure to
passive smoking increases their risk to get upper respiratory tract
infections, that is why it is important not to smoke in the presence of
the child. I can book another appointment along with your partner to
discuss quitting smoking as it would be beneficial to you and your child.
Antibiotics are not as effective as this is a viral infection. Whenever he
feels sick, give him adequate rest, Panadol for fever and adequate fluid
intake. Give him a healthy diet, and foods rich in vitamin C to boost his
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immune system. Keep his immunizations up to date, maintain good

hygiene, avoid sick exposure or contacts as well. If he develops a high
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fever, difficulty in breathing, become irritable, please report
immediately.

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Infectious Mononucleosis

You are in a GP practice. A child who had a sore throat 3 days ago and
was given amoxicillin by another doctor is brought now with worsening
symptoms and rash all over his body. His mother is here and concerned.

Another case: the 11-year girl was brought in due to inflamed tonsils.

TASK:
1. Take history
2. Ask examination from the examiner
3. Tell the most likely cause of the rash to mother

Positive points in history:

Positive points in the PE: tonsillitis, cervical lymphadenopathy,
splenomegaly
APPROACH
▪ Why did you see your GP? What happened? Is it the first time the

antibiotics was given? Did they take a throat swab before?

▪ Fever questions
▪ Rash questions
▪ Feeding habits: is the child eating and drinking well?
▪ Development
▪ Contact history
▪ System review: Cough, runny nose, vomiting, diarrhea, neck pain,

tummy pain?
▪ Any lumps and bumps?
▪ Any joint pains?
▪ BINDSMA: is the immunization up to date? Any sick contacts? How

long has he been not going to school? Any medication allergies? Is

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this the first time he's taken this antibiotic? If previously taken, did
he have any allergic reactions to the antibiotic? Did he travel
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anywhere recently?

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▪ Physical Examination
o General appearance: signs of dehydration, rash description
o Vital signs
o ENT examination: if follicle present, take the throat swab

• Lymph node examination

• Signs of meningitis
o Chest, Heart, Abdomen

▪ Management

▪ From history and examination, your child most probably has a

condition called Epstein Barr virus infection or Infectious
Mononucleosis, or it might be a reaction to the antibiotic. Is it
spread by direct contact? This viral infection, most of the time,
initially, can initially mimic tonsillitis, caused by a bacterial bug.
That's the reason why the previous GP might have started on an
antibiotic. [tonsils are the glands present in the back of the
throat]. In this viral infection, 90% of patients or cases, develop a
rash after the start of antibiotic. So, we need to stop the antibiotic
and the treatment is just supportive.
▪ Give adequate fluids, rest, Panadol for fever. I will give you a
school certificate and if you want a medical certificate for you as a
carer. To confirm our diagnosis, I will arrange a few basic
investigations such as FBE, ESR/CRP, UEC, throat swab, viral
serology, monospot test.
▪ This condition spreads through close contact, so please maintain
hygiene. It might take time to recover, approximately 6-8 weeks.
▪ In the meantime, if the child develops high fever not responding
to Panadol, severe vomiting, not able to tolerate oral feeds,
drowsy, lethargic, come back to me or go to the emergency
department.
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**No contact sports until full recovery

**If the child is less than 6 months old, admit the child immediately
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Foreign Body

A 2-year-old child brought to ED because the father is worried the child

has swallowed something. The child was playing & dad heard some
coughing & choking sounds.

TASKS
1. Take a focused history from the father
2. Ask for physical examination findings from the examiner
3. Arrange investigations
4. Explain the management

APPROACH
▪ History
o Can you tell me what happened? It's very good that you

brought the child here immediately. I know that you are

concerned with the child.
o Ask examiner: is the child hemodynamically stable?
o Can you tell more about it? What was he playing with? Was

it a battery or a magnet?
o When did it happen? How many hours back did it happen?
o Is it the first time? Following that, did he have any

symptoms like vomiting, SOB, DOB, choking, drooling? Any

gagging? Any tummy pains? Bleeding from nose and ears?
o How is his health in general? Any past medical history?

Medications? Allergies?
o Social History: Who is the primary carer?
▪ Physical exam
o Gen appearance: signs of respiratory distress
o V/S
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o ENT: clear? Any signs of FB? Injury?

o Chest: BS, equal on both sides?
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o Abdomen

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 ▪ Investigations
o Neck x-ray, Chest x-ray (AP & lateral), Abdominal x-ray

Scenario 1: Coin in the esophagus

This is the CXR of your child, normally x-ray contains 2 colors, black and
white. Most of the time black color is due to the air and gas. As you can
see the lungs contain air. And this is the lung.
White color is for solid structure like the bone. Point to the object.
White color indicates the object. It looks like from the x-ray; the object
is most probably in the food pipe. But it can also be in the windpipe.
We need to have another view to confirm it (lateral view).

From now on, please do not feed the child because the FB needs to be
removed. I will immediately liaise with the specialist about the child's
condition. Most prob. It will be an ENT specialist or pediatric surgeon
who will see the child. They will usually put the child to sleep or sedate
the child and put a tube-like structure which has a camera to be put
down the throat and try to remove. Please don't be stressed. The child
will be given IV to maintain nutrition. This will be given immediately
because our digestive system is tube-like structures.
• Draw esophagus and stomach

The lower end of the food pipe is narrow, and the lower end of the
stomach is also narrow. Most of the time the FB cannot pass through
them. That's the reason the specialist might advise further mgt.
**If in a rural hospital, refer the child to a tertiary hospital with an ENT
specialist.

SCENARIO 2: Coin in the stomach

Wait and watch. But liaise still with the specialist. Review after 2-3 days
in ED, not GP.
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Give red flags: abdominal pain, vomiting, fever, change in stool color
(dark stools), bleeding
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SCENARIO 3: Battery in esophagus
• NPO
• Specialist referral
• Immediate removal

SCENARIO 4: Battery in stomach

• NPO
• Wait and watch
• Specialist referral before sending the patient home

***If within 48hrs, if it didn't pass through pylorus, remove by the

endoscopic procedure.

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SCENARIO 5: You have a mother who brings the child 9-16 months with
few minutes of gagging episodes. Following that, she immediately
brought the child to your GP practice.
Normal physical exam
Investigations: 3 x-rays: neck, chest, abdomen x-ray
Refer

SCENARIO 6:
David, 2 years old, presented to you in your GP clinic with persistent dry
cough and low-grade fever over the last 8 weeks
TASKS:
1. Take a history from Mrs Smith,
2. PE findings from the examiner
3. Explain diagnosis, order investigations
4. Management plan

• Findings: unilateral wheeze, decreased air entry, crepitation

• Investigations: x-ray

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NEONATAL JAUNDICE CLUSTER
NEONATAL JAUNDICE
• Sepsis and thyroid disorders can give both unconjugated and

conjugated bilirubin
▪ Meningitis
▪ Pneumonia
▪ Gastroenteritis
▪ UTI

• Unconjugated hyperbilirubinemia: unconjugated bilirubin is more

than 85% of total bilirubin

▪ Haemolysis

• ABO incompatibility
• Rh incompatibility
• Birth trauma (cephalohematoma, caput succedaneum)
• Physiological jaundice - because of liver immaturity;
• Breastfeeding jaundice - some factors in the breastmilk

prevents bilirubin from being conjugated; if physiologic

jaundice does not resolve after 10 days or maximum of 2
weeks, it is most probably due to this
• Breastmilk jaundice - not feeding enough of breastmilk,

their body is being dehydrated, leading to haemolysis of

the RBCs
• RBC dyscrasias
▪ G6PD
▪ Pyruvate kinase deficiency
▪ Hereditary spherocytosis
• Conjugated hyperbilirubinemia (Direct bilirubin): conjugated

bilirubin is more than 15% of total bilirubin; anything that obstructs

the drainage of the bile
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▪ Biliary atresia
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▪ Neonatal hepatitis

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 ▪ Choledochal cyst
▪ Galactosemia

NEONATAL JAUNDICE
• Physiological
▪ Jaundice that appears after 48 hours and usually disappears

within 2 weeks if term infant, 3 weeks if the preterm infant

• Pathological:
▪ Any jaundice within the first 24 hours of birth
▪ Any conjugated hyperbilirubinemia
▪ Anything more than 15 mg/dL (255 mmol/L) total bilirubin
▪ Jaundice is increasing by more than 5mg/dL per day (85

mmol/L)
• Prolonged
▪ Any jaundice persisting more than 2 weeks in term infants, and

3 weeks in the preterm infant

▪ A most common cause is breastmilk jaundice, followed by the

thyroid, followed by conjugated hyperbilirubinemia

KRAMER SCALE
▪ Where have you noticed the yellowing?
▪ Zone I:
▪ Jaundice is just at the head and neck of the baby
▪ Bilirubin approximately 50 mmol
▪ Zone II:
▪ The lower part of the neck and upper part of the chest
▪ 100 mmol
▪ Zone III:
▪ Abdomen up to knees
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▪ 150 mmol
▪ Zone IV:
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▪ Arms and below knees excluding palms and soles

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 ▪ 200 mmol
▪ Zone V:
▪ Palms and soles
▪ More than 250 mmol

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Conjugated hyperbilirubinemia

You are an HMO in Paediatrics and David a 3-day old boy was brought
to you by his mom because of yellowish discoloration since this
morning.

TASKS
1. Focused history
2. PE from examiner
3. Arrange Investigations
4. Diagnosis and Differential Diagnosis to the mother

Positive points in the history: the color of the stools was a bit pale,
yellowing in palms and soles
Positive points in the PE/Investigations: total bilirubin was 250 mmol,
unconjugated bilirubin was 6 mmol, conjugated was 244 mmol
(predominantly conjugated hyperbilirubinemia), direct Coomb's test
negative

APPROACH
▪ History
o When did the jaundice start? What day is the baby on? Where

did it start first? Is it progressing?

o 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? Was
there any change in the frequency of feeding?
c. Wet nappies: Has he not been producing wet nappies for
the last 8 hours? (very dehydrated), change in the number
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of wet nappies?
o Rule out sepsis:
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• Have you noticed any fever?

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 • Meningitis: have you noticed any rash, vomiting?
• Pneumonia: have you noticed any increased work

breathing? Do you think he's breathing harder than usual?

• Gastroenteritis: have you noticed any vomiting, diarrhea or

blood in the stools?

• UTI: any pinkish discoloration or blood in the nappies? Any

overly smelly nappies?

o Clinically differentiate unconjugated and conjugated
hyperbilirubinemia
• What is the color of the stools? What is the color of the

urine?
• ABO and Rh incompatibility: What are the blood group of

the baby and the blood group of the mother? Did you have
a previously threatened miscarriage or a previous
pregnancy? (if the mother is Rh-negative, then the baby is
at risk if he is positive)
• Birth trauma: Delivery: was he a term baby? What is the

mode of delivery? (any instrumentation/forceps? What is

the reason for the mode of delivery? Did he require
resuscitation, or did he cry immediately after birth? Any
birth trauma or injuries to the baby?
• Breastfeeding jaundice: are you breastfeeding him? Have

you noticed any issues with sucking? Any issues with

attachment? Have you been counselled by lactation
nurses?
• RBC dyscrasias: Any family history of any blood disorders?
• Neonatal hepatitis: Has he been in contact with anyone

with hepatitis? Anyone sick at home?

• Galactosemia: Any family history of cataracts? What was

the result of the heel-prick test?

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o BINDSMA questions
a. Birth
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 1. 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? (these are important
in heart diseases in newborn, a baby with a vision
problem, baby with a hearing problem, the child is
mentally retarded, the child with developmental
issues, a child with slow school performance)
2. Postpartum: did he spend any time in a special
nursery? Was the heel-prick test done?
b. Immunizations: Are the immunizations up to date? (Ask it
is relevant in cases of fever, rash, AGE, etc)
c. Social history
1. Does the child have any siblings? Do they have the
same symptoms? (fever, rash, diarrhea, vomiting) Any
family member with the same problem?
2. Do you have good support? Is there any other in your
home that can look after your children? Do you have
any other things that you have to look after?
d. Medications
e. Allergies

▪ Physical Exam
o General appearance: PICCLED, dysmorphic features, growth

charts
o ENT: look for bilateral cataracts (galactosemia)
o Office tests: UDT - will tell if conjugated or unconjugated;

• if positive bilirubin, but negative urobilinogen =

CONJUGATED hyperbilirubinemia
• If negative bilirubin, but positive urobilinogen =
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UNCONJUGATED hyperbilirubinemia
▪ Investigation
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 o FBE, UEC, LFT, CRP/ESR, TFT, direct and indirect bilirubin, Direct
Coomb's test (measures the level of antibodies of the mother
present in the baby's blood), peripheral blood film, blood group
of mother and baby
• If you think it is unconjugated bilirubin, check for

haemolysis: reticulocytes, LDH, haptoglobin, unconjugated

bilirubin, peripheral blood film (spherocytes for HS)
o Urine: urine culture, urine for reducing substances
(galactosemia)
o Imaging: ultrasound of the abdomen

▪ Diagnosis and Management

Most likely your child has a condition called conjugated
hyperbilirubinemia, where a certain type of pigment has gone up in
the baby's blood. There are multiple causes of it. Let me draw a
diagram for you.
This is the liver, these are the ducts or tubes that drain bile from
the liver. Bile is the substance that is required to digest the fats.
There are a couple of possibilities in my mind, one is neonatal
hepatitis which is an infection of the liver, second is biliary atresia
where there is a malformation of the tubes carrying the bile from
the liver, three is a choledochal cyst, where there is an obstruction
of the biliary tubes thereby leading of retention of the bile, the last
is a genetic problem called galactosemia, where you have a
deposition of galactose in the liver. That is why I am going to admit
him and refer him to a paediatric registrar for further evaluation.
**phototherapy does not work for conjugated hyperbilirubinemia
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ABO Incompatibility

You are asked to see an infant Jessica who was born 24 hours ago with
jaundice. She is the first child of a mother whose pregnancy was
normal. Delivery was at term by midwife and was uneventful. Her
weight at birth was 3700 grams. Jaundice was noticed soon after birth.
She has been sucking well at the breast. On examination, she has
clinical jaundice, otherwise well and active. Mom wants to go home as
soon as possible because she's got a cat to look after.
TASKS
1. Advise the mother about the diagnosis
2. Explain further management to the mother

Positive points in the investigations: mother O+, baby A+, Coomb's test
strongly positive, unconjugated is 244 mmol/L, conjugated is 6 mmol/L

EXPLANATION

▪ Most likely Jessica has a condition called ABO incompatibility. The

red blood cells in our body, they've got a special protein on their
surface called antigens, and there are certain proteins in the
blood called antibodies which help fight against infections. Your
blood group is O positive.
▪ In people with O blood group, they have no antigens in the
surface of their RBCs, but they have anti-A and anti-B antibodies
which are the proteins that fight against infection or foreign red
blood cells. The baby has A positive blood. So, he has the A
antigen and anti-B antibodies. Sometimes during the 3rd stage of
labour, or during delivery, there is a silent exchange of blood
between the mother and the baby. Since you've got anti-A
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antibodies which reacted to the baby's A antigen, that lead to the

breakdown of the RBCs in the baby's blood, leading to the
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▪ It 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, or what we call kernicterus.
▪ That is why she needs to be admitted to the hospital. We will do a
treatment called phototherapy where she will be placed under a
special type of lights which will help in excreting this pigment
from the body through her urine and faeces. There are some side
effects of this treatment such as retinal and genital damage, that
is why we are going to cover the baby's eyes and the genitals. She
can also have dehydration, so we will make sure that she is only
under the lights when she is sleeping and not feeding. She can
also have green-coloured stools, however, this is expected,
because the excessive pigment will be excreted in the faeces. We
will continuously monitor her pigment levels or bilirubin levels.
▪ If the bilirubin level keeps going up despite the treatment, we will
consider another treatment modality called exchange transfusion,
where we will try to exchange the baby's blood with fresh blood.
▪ Address the mother's concern about the cat: do you have any
relatives or neighbours who can come and look after the cat? If
there's none, I can call the social worker to arrange a temporary
kennel service for the cat.

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Hereditary Spherocytosis

You are a GP and a father brings his 4-year-old boy to see you for the
blood test that you did yesterday because he was looking jaundiced,
after a viral URTI. The blood results show Hgb 160 g/L, increased
reticulocyte count, spherocytes on the PBS.

TASKS
1. Focused history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

OSMOTIC FRAGILITY TEST - the first line

FLOW CYTOMETRY - staining with 5-eosin Maleimide. Confirmatory
test.
Abdominal Ultrasound - check for gallstones - high risk to have
pigmented gallstones

For history and PE: Refer to Conjugated hyperbilirubinemia

EXPLANATION

▪ The surface protein called beta-ankyrin is absent which maintains

the normal biconcave or disc shape of RBCs. Since that skeletal
protein is absent because of a genetic condition, the RBCs become
spherical. The blood vessels in the spleen are very narrow.
Normally the biconcave shaped RBCs can easily pass through
these. However, the spherical RBCs cannot, and result to
haemolysis or breaking down.
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▪ I will refer you to a hematologist who will monitor his condition.

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He might start the child on FOLIC ACID 5mg once a day (The bone

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 marrow is under stressed to produce more RBCs (fear of
becoming pancytopenic). We will monitor his hemoglobin levels
regularly. He might be given a blood transfusion if his hemoglobin
levels fall below 70.

▪ After 6 years of age, the hematologist might suggest removal of

the spleen, but you have to be aware of the possible
complications of not having a spleen (post-splenectomy
overwhelming sepsis) that's why we are going to give him the
antibiotics he needs to take and the vaccinations needed to
protect him from these bugs. I can arrange another consultation
with you to discuss this further.

▪ Avoid contact sports as they are at high risk for splenic rupture.

▪ Review materials

***
Viral URTI makes the transition of biconcave to spherical faster.

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Galactosemia

A mother brings a 2 weeks old baby boy who is having jaundice since he
was 3 days old, to your GP clinic. His birth weight was 3.5kg, mother's
blood group and baby's blood group are both O+.

TASKS
1. Focused history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

Positive points in the PE/Investigations: cataracts, reducing substances

in UDT, Total 178 mmol, conjugated 110 mmol, unconjugated 68 mmol

For history and PE: Refer to Conjugated hyperbilirubinemia

EXPLANATION

Your milk has got a substance called lactose, which is broken down to
glucose and galactose by your baby's body. He has a condition called
galactosemia, in which the enzyme required to breakdown galactose is
absent, leading to deposition of galactose throughout the body,
including the brain, eyes causing cataract, liver causing jaundice,
pancreas causing diabetes, ovaries or testes causing gonadal failure.
That is why I am going to refer him to the paediatric registrar who will
manage him from now on. He will most likely need lactose-free formula
milk and he will be managed by a paediatric ophthalmologist for his
cataracts.
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Breastmilk jaundice

Baby Helen was brought to see you in your GP clinic because mom is
concerned about continuing jaundice. She is now 2 weeks old and was
born at term by normal vaginal delivery. Her birth weight was 3700
grams. She became jaundiced on day 3. she was treated with
phototherapy for 2 days. Since discharge from the hospital on day 8 of
age, jaundice has persisted. Baby is feeding well from the breast and is
active and clinically normal apart from jaundice. Her current weight is
3900 grams.

TASKS
1. Focused history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

Positive points in history:

Positive points in the PE/Investigations:

For history and PE: Refer to Conjugated hyperbilirubinemia

EXPLANATION

▪ Most likely your baby is having breastmilk jaundice. There are

some factors within the breastmilk that prevents conjugation of
the bilirubin.
▪ There is nothing wrong with your breastmilk, and it is a benign
condition and doesn't require treatment, and you can continue
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breastfeeding. Breastmilk jaundice can persist for as long as 3

months of age, but the baby will remain active and gain weight.
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▪ The diagnosis can be confirmed by suspending breastfeeding for
24 to 48 hours, which results in fall of bilirubin levels, after which
the breastfeeding can be continued. During the time of temporary
suspension, please express your breastmilk in order to maintain
lactation.
▪ If the feeding has gone down, or the baby is overly sleepy, not
gaining weight, jaundice becomes worse, wet nappies has gone
down, please report back immediately.

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DIARRHEA CLUSTER
Acute Gastroenteritis

A mother of 6-month-old baby came to your GP clinic complaining of

diarrhea for the past 12 hours.

TASKS:
1. Focused history
2. Examination finding from examiner
3. Diagnosis and Management

Acute Diarrhea Differential Diagnosis:

▪ AGE
▪ Otitis Media
▪ Pneumonia
▪ UTI
▪ Meningitis
▪ HUS, intussusception

Chronic Diarrhea Differential Diagnosis:

▪ Celiac disease
▪ Giardiasis
▪ Toddler's diarrhea (depending upon the age: 3 years old) (diagnosis

of exclusion)
▪ Lactose intolerance
▪ Cow milk protein allergy
▪ Any food allergy
▪ Travel
▪ Cystic fibrosis
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Positive points in history: since last night, increased number of dirty
nappies, no fever and vomiting
No birth problems, no immunization, breastfed
No other family member sick at home
Went to cousin's place 1 week back who had diarrhea
wetting nappies is okay

Positive points in the PE: alert, moderate signs of dehydration

APPROACH
▪ History
o Is the patient hemodynamically stable?
o IF ACUTE: Acute diarrhea questions

• How many episodes of diarrhea did the child have? Since

when is he having diarrhea? Is it a small amount or a large

amount? Is it watery or semi-solid or semi-liquid? Is it
associated with blood or mucus? Is its foul-smelling?
• System review/differential diagnoses questions:
▪ Any tummy pain, vomiting, fever, rash, runny nose,

cough, breathing difficulty, ear pain, ear discharge or

ear pulling?
• How is the child feeding? Is he taking oral fluids? Is the

child active or playful or has he become sleepy recently?

• How are his wet nappies, is there any decrease in the

number of wet nappies? Are they smelly?

• BINDS questions
▪ How was his birth? Any concerns after birth? Are his

immunizations up to date? (if they say no, tell him that

you will arrange another appointment for that)
▪ How are his growth and development?
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▪ Any contact with someone with similar symptoms?

▪ Any recent diet changes? Any food allergies in the
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 ▪ If he is breastfed, is the mom on any medications
especially antibiotics?
o IF CHRONIC: Chronic diarrhea questions
• How many times in a day? How many months has it been

going? Is its small amount of large amount? Is it watery or

semi-solid or semi-liquid? Is it associated with blood or
mucus? Is its foul-smelling?
• Does it contain undigested particles? Is it hard to flush? Is it

sticking to the pan? Is it greasy? (any case causing fat

malabsorption can have these features)
• Any pain in the abdomen? Any bloating sensation?

Excessive pass of the wind? Any fever, nausea and

vomiting? Appetite loss? Weight loss? Any rash? Joint
pain? Recurrent chest infections? Ulcers around the
mouth? The problem around the back passage? Itchy
bottom? Any passage of worms?
• BINDS questions
▪ Diet history: any recent introduction of new food?

Does he take a lot of juices and milk? Can you describe

his one-day diet to me? How is his health in general? Is
he feeding well?
• How about his waterworks?
• Social history
• Any recent sick contacts? Anybody in the family on a

special diet? Any family history of cystic fibrosis, celiac

disease, food allergies? Did you travel anywhere recently?

▪ Physical Exam
o General appearance: signs of dehydration, rash, lumps and

bumps
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o Vital signs
o ENT examination
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o Chest, heart, abdomen

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 o Anal inspection and hernial orifices (with the consent of the
parent)
▪ Diagnosis and Management
From history and examination, your child most likely has a
condition called acute gastroenteritis. The most common cause and
most probable cause in your child is a viral infection. I can tell this
because the diarrhea is watery, is not foul-smelling, not associated
with blood or mucus. These viral diarrheas are a self-limiting
infection or get resolved by itself. The only treatment that we have
to do is, give adequate fluids, every after diarrheal episode and
every half an hour/hour. The fluids can be Gastrolyte or ORS, but
please continue breastfeeding also. But if bottle feeding, stop it on
the first day and replace with gastrolyte or ORS, start it with half
dilution on the second or third day or when the number of
diarrheal episodes decreases, then resume with full strength when
diarrheal episodes cease.

FEATURES MILD MODERATE SEVERE

Body 4-5% 6-9% > 10
weight
loss
symptoms Thirsty, alert, Thirsty, restless, Infants:
restless lethargic, drowsy, limp,
irritable cold, sweaty,
comatose,
cyanotic limbs
Older:
apprehensive,
cold and
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sweaty,
cyanotic limbs
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Signs Normal Dry mucous Rapid feeble
membranes, pulse,
absent tears hypotensive,
sunken eyes
and
fontanelles,
very dry
mucous
membranes
Pinched Normal Retracts slowly Very slowly
skin test (1-2 seconds) (>2 seconds)
Urine Normal decreased Nil
output
Treatment If less than 6 Admit the child Admit the
months, admit the Oral rehydration child
child. Consider NGT Urgent IV
for steady fluid infusion:
If 6 months, if the infusion or IV isotonic fluid
mother is infusion if the
competent and the child develops
hospital is nearby, vomiting or the
then she can take child does not
the child home and tolerate the NGT
give small frequent
feeds oral
rehydration at
home and see GP
the next day or
after 24 hours.
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Give red flags:

drowsy, lethargic,
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not able to tolerate
feed, cold
peripheries, no wet
nappies, increase in
the number of
episodes of
diarrhea --> come
back to ED
immediately

If the mother is not

competent enough
and you feel that
the child will
deteriorate soon:
"Mother, now the
child may not be
having no or
minimal
dehydration, but in
infants, their
condition worsens
soon, so it is better
for you to take the
child to the hospital
for observation.
Even in the hospital,
the treatment is the
same.
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Oral rehydration:
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 • Small amounts
of fluids often
• Continue
breastfeeding
• Solids after 24
hours
• Provide
maintenance
fluids and loss

Hygiene advice:
Please wash your
hand after changing
the nappies,
dispose of the
nappies properly.
Wash your hands
before feeding the
child, because most
of the time, the
infection spreads
through
contaminated
hands.

Avoid:
antidiarrheal, anti-
emetics, antibiotics,
lemonade
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Toddler's Diarrhea

You are a general practitioner and your next patient is a 3-year-old

child, Tina, brought in by her father, James because she has had
diarrhea for 3 weeks.

TASKS:
1. Take a focused history
2. PE findings from the examiner
3. Discuss diagnosis and management with father

Positive points in history: diarrhea and vomiting, brought to GP,

stopped after 3-4 days, then diarrhea came back but different from the
last time
4/5 times stools in a day, normal color, no blood, with undigested food
particles, not smelly, not floating in the bowl, not hard to flush
Feeding is good, appetite is good
No tummy pain, no fever, gaining weight properly
Have not introduced a new food to her
Loves fruit juices
No travel
Does not go to child care, only at home

Positive points in PE:

The normal, very active child
No signs of dehydration
ENT exam normal, no lymph nodes
CVS/Respiratory/Abdomen all normal

Same history and PE for chronic diarrhea.

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Management
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From history and examination, your child has been having diarrhea for
more than 2 weeks, we call it as chronic diarrhea. There are many
causes for it: it can be an infection, food allergy, lactose intolerance,
problem with the absorption of nutrients in the digestive system,
among others. From history, your child most likely has a condition
called Toddler's diarrhea. Have you heard about it? It is a common
condition at this age, where children will have diarrhea, which is runny
or watery, with undigested food particles. Let me reassure you that it is
not risky and infectious. I can tell it is not caused by other conditions
because in those cases, the stools will be associated with blood or
mucus, it would be hard to flush, sticky stools, which is not present in
your child's case. On the other hand, your child is also, growing and
thriving well and there is no weight loss. One of the most common
associated factors for this kind of diarrhea is the excessive intake of
fruit juices and fibrous diet. But to rule out other causes, I'll be
arranging few investigations such as FBE, ESR/CRP, UEC, stool
microscopy and culture and for reducing sugar, and we will do celiac
disease serology if all the other investigations come out to be normal.
I will refer you to a dietician who will provide you with a diet plan, and
your child must avoid fruit juices and take a healthy balanced diet. I will
review you after 24 hours.

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Salmonellosis

• You are an HMO and a child diagnosed with salmonella is now ready
for discharge.
•
• TASKS:
1. Talk to mother before discharge
2. Answer the mother's questions
•
• Your son had a contagious bug called salmonella. Salmonella can
affect any age but mostly in childhood and young adults. The
severity depends on the age, general health of the person and on
the number of bacteria ingested. Most of the time the spread of this
infection is from people of have the bugs in them but do not have
symptoms and also from food like raw meat, eggs.

• Ask about the preparation of food, occupation, way of cooking food,

similar complaints in anybody else, pets.

• From where did he get the infection?

• How do you prepare food? we have a takeaway shop and have food
from there.
• He can catch an infection from people around him even if they don't
have symptoms. They are called carriers, but they still have some
bug in their tummies.
• We can say that if you go to the toilet and not wash your hands
properly you can transmit the infection through their contaminated
hands. Also, the knife, kitchen tools and towels used for raw food.
when you deal with raw food, use a separated knife. Dealing with
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raw eggs can also transmit infection.

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 I need to notify the department of health. The health authorities
might advise closing the business until the source of infection is
identified.
Notifiable disease: Salmonella is a reportable infection and I am
obliged to do it, but it does not mean that they will close your shop.
They will take samples from the food in your shop and they will do
stool culture for the family. They will take actions based on the
results.

▪ General hygiene, no antibiotics usually.

▪ Please do not stress, we will provide all kind of support if

required. We can refer you to the Centrelink.

▪ Child can go to school once diarrhea subsides.

▪ Child needs to have 3 consecutive negative stool samples.

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Haemolytic Uremic Syndrome

David is 4 years old, presented to you with a history of diarrhea,

vomiting, fever. You are an HMO in the ED.

TASKS
1. Further history from his mother.
2. Examination findings from the examiner.
3. Order appropriate investigations.
4. Diagnosis and Management.

Differential Diagnosis:
• Gastroenteritis
• HUS
• Intussusception
• Infection (Shigella, salmonella, campylobacter)
• Foreign body
• Septicaemia
• HSP

Positive points in history:

Positive points in the PE/Investigations: anemia, uraemia or renal
dysfunction, thrombocytopenia

APPROACH
▪ History
o Is my patient hemodynamically stable?
o Open-ended questions
o Well baby questions
o Fever questions
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o Vomiting questions
o Diarrhea questions
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o Differential questions

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 o BINDSMA
o Past med and Sx history
o FH
▪ Physical Exam
o General appearance: include a description of the rash if

present, signs of meningitis if present

o Vital signs
o Systemic exam
o Office tests: UDT can be positive for RBCs

▪ Diagnosis and Management

▪ From the history and examination, I have assessed that your child
is severely sick.
▪ There are many possible causes of your child's condition. It can be
an infection of the gut affecting the kidneys, which could be due
to two things, either haemolytic uremic syndrome, or Henoch-
Schonlein purpura, where our own antibodies start acting on our
blood vessels, leading to the symptoms in your child.
▪ At this stage, I will refer you to the paediatric registrar who will
further assess the child and possibly admit him.
▪ Meanwhile, I will start you on an IV line and take blood for
investigations such as FBE, UEC, CRP/ESR, LFT, blood culture.
▪ If HUS is confirmed, treatment is symptomatic which include renal
replacement therapies (dialysis). No antibiotic needed. I will also
refer you to the paediatric nephrologist.
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Pinworm

Your next patient in general practice is a 3-year-old girl, Mary, who has
been brought to you by his father, John. Mary has complained about an
itchy bottom for the last three days and since yesterday has had a few
bouts of diarrhea. He is supposed to go for a few days sleepover to this
grandmother, but his parents thought it might be worthwhile to
perhaps get some cream for his itchy bottom first.

TASKS
1. Focused history
2. Examine the patient
3. Explain your diagnosis and management to the father

Positive points in history:

Positive points in the PE/Investigations:

Differential Diagnosis
▪ Pinworm
▪ Vulvovaginitis
▪ Foreign body
▪ Eczema
▪ Child abuse

APPROACH
▪ History
o Open ended questions: When did the itchy bottom start?

When did the diarrhea start? Which came first? How did the
symptoms start? Is it getting worse? Is this the first episode?
o Well child questions
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• Mental state
• Eating/Drinking
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• Waterworks/Bowel

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 o Differential questions
• Pinworm: Any worms in the stools?
• Foreign body: do you think the child must have inserted

anything there? Is there any time that the child is

unsupervised?
• Child abuse: Have you noticed any unusual behaviours in

the child?
o BINDSMA
o PH and FH

▪ Physical Exam
o General appearance
o Vital signs
o Systemic exam

▪ Diagnosis and Management

▪ From history and examination, your child most likely has a worm
infestation. I can tell this because the itchy bottom comes at night
time which is also the time when the worms come out.
▪ The eggs enter the body through the contaminated food or
contaminated hands, then they hatch to adult worm in the gut. At
night time, the female worm lays eggs around the back passage
causing irritation and itching. If the child scratches his bottom, it
leads to the deposition of eggs under nails. Then when he touches
food with his contaminated hands, the cycle continues.
▪ The important point here is to focus on hygiene practices to
prevent transmission.
▪ We need to give medications to kill the worms. We also need to
treat the household members. We need to repeat the medication
in 2-3 weeks.
▪ To confirm the diagnosis, we need to do a scotch tape test. Please
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stick the tape on the back passage during the night time, and in
the morning, put the tape over the glass slide and bring it to the
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lab. You can also try to look at the back passage at the night time
to check and see the worms.

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SLOW SCHOOL PERFORMANCE CLUSTER
SLOW SCHOOL PERFORMANCE
▪ Behavioural disorders
o Autistic Spectrum disorder

• Can be diagnosed after 3 years old

• Autism
▪ Verbal and non-verbal will be gone

• Asperger's
▪ Verbal communication will be preserved, non-verbal

will be gone
▪ Sometimes have a special ability that other people do

not possess = “Savant syndrome"

Developmental Milestones
▪ Verbal communication
o 3 months - cooing
o 6 months - monosyllabic
o 9 months - bisyllabic
o 1-year-old - 1 word, 3-5 words
o 2 years old - 2 words, 30-word vocabulary
o 3 years old - 3-word phrase
o 4 years old - full sentence

▪ Non-verbal communication
o Eye contact
o Initiate playing with other kids
o Able to reciprocate emotions (if you hug her, does she

hug you back?)

▪ Repetitive behaviour
o Are there any words, or any phrase that she keeps

repeating?
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o Is there any toy that she likes, and when you take it
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away, she gets upset?

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 ▪ Rigid routine
o Does she have a rigid routine?

• When she gets home, does she always ask for a

sandwich? (specifically, that sandwich)

o Is there any particular part of the toy that they are

attached to, or just the whole toy?

o ADHD
• The symptoms are present in at least 2 places: at home AND at
school or with peers
• Can be diagnosed after 4 years old
▪ Deficits in attention
o If you give a toy/task to your child, how long is she able

to play with the toy/do the task?

o Does he pay attention to what goes around?
o Is she able to finish the task given to him?

▪ Hyperactivity
o Does she disrupt the class quite often?
o Does she talk rapidly without finishing sentences?
o Is she able to wait in line or wait in a queue, or does

she push people in line?

o How is her sleep? How long does she sleep usually?
o Do you think that she is aggressive towards other kids?
o Oppositional Defiance Disorder (childhood) --> Conduct
disorder (adolescence) --> Antisocial disorder (adulthood)
• can be diagnosed after 3 years old
▪ Disobedient
▪ Non-compliant
▪ Argumentative
▪ Stubborn
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▪ Pick-up fights
o Psychological stress: has he been under stress?
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• Bullying

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 • Domestic violence
• Change of school or home
• Marital stress
o Temper tantrums

• Does she accept "no" as an answer?

• Does she show any dramatic reactions such as kicking,

screaming, headbanging, breath-holding when his

demands are not met?
▪ Organic causes
o Hearing and vision
o Absence seizures

• Any episodes of staring blankly or daydreaming and they

become unresponsive? Is he conscious during that time?

• Is it associated with any automatism like lip-smacking,

chewing, grimacing?
• Any jerking of the upper and lower limbs? Any tongue

bites? Any loss of control of the bladder and bowels?

o Infections

• Meningitis (any patient who develops meningitis go

through follow-up audiometry because of the high risk of

hearing problems after infection)
• Any infections lately such as meningitis, lung infection,

diarrhea and vomiting, burning and stinging while

urinating?
o Anemia (A most common cause of slow school performance)

• Diet
• Diarrhea
• Bleeding
o Head trauma
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Autism Spectrum Disorder - Asperger's Syndrome

You are a GP and your next patient was a 4-year-old who was brought
in by his mother because he received a letter from his child care saying
that he is slow to learn and different from others. No significant past
history, no regular medications.

TASKS
1. Further history
2. Diagnosis and Management

Positive points in history: impaired non-verbal communication, has

repetitive behaviour, has a rigid routine

APPROACH
▪ History
o When did you notice it? How did it start? Are there any

behaviours at home that correlates with what the letter from

the childcare says?
o Differential questions

• Autism Spectrum Disorder

▪ Autism
▪ Asperger's syndrome

• ADHD
• ODD
• Psychological stress
• Temper tantrums
• Hearing and vision
• Absence seizures
• Infections
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• Anemia
• Head trauma
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o BINDSMA

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 o Past history and family history

▪ Diagnosis and Management

Most likely your child has a behavioural disorder. The most
common to present this way is autism spectrum disorder
characterized by impaired communication, repetitive behaviour
and rigid routine. It is important to confirm the diagnosis,
preferably by a specialist, that is why I am going to refer you to an
MDT which is composed of the paediatrician, child psychologist,
speech therapist. I will also refer you to the Autism Association of
Australia and Centrelink if needed. If the hearing and vision have
not been checked, the specialist might also consider a hearing and
vision check before diagnosis. It is a lifelong condition, but it can be
very well controlled with appropriate interventions. Further
management will be discussed by the team after confirmation of
the diagnosis.

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Absence seizures

9-year-old boy is brought in to your GP clinic by his stepmother because

of slow school performance for the last 3 months.

TASKS
1. Further focused history
2. PE from examiner
3. Discuss most likely diagnosis and management to the mother

Positive points in the history: he was daydreaming, unresponsive

during the daydreaming episodes, exhibiting lip smacking, chewing
Positive points in the PE/Investigations: seizures triggered by
hyperventilation

APPROACH
▪ History
o When did you notice it? How did it start? Are there any

behaviours at home that correlates with what the letter from

the childcare says?
o Differential questions

• Autism Spectrum Disorder

▪ Autism
▪ Asperger's syndrome
• ADHD
• ODD
• Psychological stress
• Temper tantrums
• Hearing and vision
• Absence seizures
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• Infections
• Anemia
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• Head trauma

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 o BINDSMA
o Past history and family history

▪ Physical Exam
o CNS exam very important but all are normal
o Ask the child to hyperventilate which triggers the daydreaming

episodes

▪ Diagnosis and Management

▪ Most likely your child has a condition called absence seizures. Our
brain has neurons or the nerve cells in the brain, and sometimes
there is abnormal electrical discharge from these neurons leading
them to have seizures or fits. I still need to confirm it that is why I
am going to refer him to a neurologist who will consider doing an
EEG, and an MRI if required.
▪ I will also do some basic bloods to rule out simple causes like
anemia. Once the diagnosis is confirmed, he will be started on
some medications, like ethosuximide or sodium valproate. The
specialist will try to tailor the dose of the medication to his weight
to minimize side effects such as anorexia, nausea, vomiting,
diarrhea and rash.
▪ Please avoid activities such as swimming unsupervised, mountain
biking, hiking, deep waters. If he develops a full-blown seizure, if
he is sitting, lie him in the left lateral position with chin down, and
call the ambulance.
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Sexual Identity - Homosexuality

You are a GP and a mother brings her 15-year-old son claiming that her
son's school performance has deteriorated from bad to worse for the
last 6 months.

TASKS
1. Further focused history from the mother/patient
2. Counsel the patient about the diagnosis and management

Positive points in history: likes another boy in class

APPROACH
▪ History
o Open-ended questions about school performance
o Differential Diagnosis of slow school performance (rule out

behavioural and organic causes)

o Would you want mom to be here, or do you want mom to wait

for you outside while we finish our chat?

o Is this a new thing or have you been liking boys ever since?
o Transsexualism: do you feel as if there is a girl trapped in a

boy's body?
o Transvestism: a paraphilia; do you dress up like girls and get

sexual pleasure out of it?

o Do you have any fetishes or sexual fantasies?
o Have you spoken to that guy?
o Do you just like him, or are you sexually attracted to him? (if

just like, it is okay; if sexually-attracted, it is homosexualism)

▪ Am I gay or not?
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▪ A lot of young people, they like people of the same sex. And
studies have shown that around 8-12% of the young people, face
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 people of the same sex, they are known in every culture and
society.
▪ At the moment, you are going through a phase, where you are
trying to work out your sexual identity. It doesn’t necessarily
mean that you are gay because people often experiment with
their sexuality.
▪ But remember, being gay is a normal sexual identity and there is
nothing wrong or abnormal about it. I know that you are worried
that your parents are not going to take it well, but your parents
are there to support you and help you get through it so
eventually, you should tell your parents so they can support you. I
am going to refer you to Family planning Victoria.
▪ They specialize in sexuality and reproductive health, and they can
give you information on safe sexual practices and help you with
psychological support through this hard phase of your life. And I
am always here to support you, anytime you have any concerns,
you can come back to me.

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ADHD

You are a GP and a 6-year-old boy was brought in by his mom because
of slow school performance. He is in grade 2 and she received a letter
from the school stating the deteriorating school performance for the
last 2 months.

TASKS
1. Further focused history
2. Diagnosis and Management

Positive points in the history: disturbing the class quite often, hard for
him to wait in line, hard to play with a toy for more than 5 minutes, not
able to finish the task given to him; noticed symptoms both at home
and at school

Management
Most likely your child has got a behavioural disorder. The one that
presents this way is ADHD. I still need to confirm it that is why I am
going to refer you to a specialist. They will consider checking his vision
and hearing if not yet done. They will do something called
psychosomatic testing, best done by a specialist (child psychologist). In
psychosomatic testing, they will send questionnaires to the family and
the school to prove that the symptoms are present in school and at
home. Once the diagnosis is confirmed, he will be started on
behavioural modification therapy. These are classroom strategies to
help in learning and concentration span. The specialist might also
consider starting him on some medications (Ritalin: methylphenidate)
to stimulate the area of the brain for impulse control and
concentration.
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Oppositional Defiant Disorder

A mother brought her 8-year-old son with problems of slow school

performance.

TASKS
1. Further focused history
2. Diagnosis and Management

Positive points in the history: argumentative, stubborn, refuses to

comply, picks up a fight, but is not cruel to animals or vandalize stuff

Management
Most likely your child has a behavioural disorder. The most common to
present this way is ODD. I still need to confirm it that is why I am going
to refer him to a specialist, a paediatrician and a child psychologist who
will confirm the diagnosis and rule out other behavioural disorders.
Management is behavioural modification therapy, best done by the
psychologist. It is not just behavioural modification of John, it is the
entire family dynamics that need to be changed. (ignore the non-
acceptable behaviour and reward the acceptable behaviour) You can
consider withdrawing some privileges like watching TV but do not do
physical punishments.

Temper tantrums management: Ignore what is ignorable. Avoid what is

avoidable. Distract what is distractible. 301
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Childhood Murmurs

SQIRT
▪ Site
▪ Quality (harsh or soft)
▪ Intensity/grading
▪ Radiation
▪ Thrill/Timing (diastolic or systolic)

• • Innocent murmur • Organic murmur

• Growth • Well thriving • Usually underweight
• Exercise • Good • Not good
tolerance
• Cyanosis • No • Yes
• Recurrent • Usual 6-12 infections • Very frequent
chest infection per year
• Murmur • Soft and cyanotic no • Loud and can have a
character diastolic component diastolic component
• Radiation • No • Yes
• Thrill • No • Usually present
Changes with • Yes • No
respiration
• Changes with • Yes • No
posture

Mitral stenosis: Mitral, harsh, grade 3, diastolic with opening snap

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Mitral regurgitation: radiates to axilla

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SEIZURE CLUSTER
Breath holding Attack

2-year-old boy, Sammy, brought to you by his father at your GP clinic.

His finger was jammed on the car door. He screamed, cried for a while,
held his breath for a few seconds and became blue. Now Sammy is
alright, but it is quite difficult to examine him.

TASKS
1. Take a history from the father
2. Tell probable diagnosis and management to the father

Differential Diagnosis:
▪ Breath-holding attack
▪ Epilepsy
▪ Infection
▪ Simple temper tantrum

APPROACH
▪ History
o Could you please tell me what exactly happened?
o I would like to offer him painkillers if he is not allergic to

anything.
o What happened, before, during, and after that event?
o Did this happen for the first time?
o How long did it last?
o Have you noticed any jerky movements? Any stiffness?

Uprolling of eyeballs? Did he lose consciousness? Was he

drowsy or difficult to arouse after that?
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o Any recent infection or head injury?

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 o Do you have any concerns regarding his growth and
development?
o Is he a stubborn of difficult child? Does he have any repeated
behaviour like headbanging? Any other behaviour issues?
o Any concerns regarding vision and hearing?
o BINDS
o Past history
o Family history

▪ Diagnosis and Management

▪ From the history, it seems like Sammy had a breath holding
attack. Have you ever heard about it? This is part of the tantrum.
▪ It is one type of behaviour disorder in children. It can happen as a
response to pain, frustration or stress. It may look scary but let
me reassure you that it is harmless. It is not associated with
epilepsy or any brain pathology.
▪ This condition is not going to cause any intellectual disability. Try
to avoid triggers, or situations that aggravate this problem.
▪ Stay calm and watch him until the full spell is over. Do not punish
him for this, appreciate for good behaviour.
▪ If you see that he develops seizure, and if the attacks last for a
longer time, call 000 and take him to the nearest ED.
▪ I will review the patient regularly, and give you reading materials
regarding breath-holding attack.

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Headbanging

Karen, the mother of a 3-year-old boy, complaining that the child is

banging his head several times a day.

TASKS
1. Focused history
2. Counsel the mother

Positive points in the history: a history of separation from the parents

Differential Diagnosis:
▪ Headbanging
▪ Temper tantrum
▪ Pain due to ENT infection or teething
▪ Vision and hearing problems
▪ Autism Spectrum disorder

APPROACH
▪ History
o When did this start? How often does this happen? For how

long does an episode last? Does it happen at any particular

time of the day?
o Have you noticed anything that makes it worse?
o Did he ever hurt himself while banging his head?
o Does he have any repetitive behaviour like thumb sucking?
o Does he go to childcare? Does he do the same thing at

childcare too?
o Does he play with other kids?
o Do you have any concerns regarding his hearing and vision? Is
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he able to talk?
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 o How is the home situation? Is there any recent change at
home? Who do you live with? How is his relationship with
other family members? Do you have enough support?
o I can see that you're quite stressed because of his
headbanging, how do you react when he does this? Do you
punish him?
o Well-child questions
o BINDSAR
o Past history
o Family history

▪ Diagnosis and Management

▪ Headbanging is a variation in the child's behaviour. It has a self-
calming effect. It is rarely self-injurious. He will grow out of it by 4
years usually.
▪ Try to ignore the situation but give positive attention when he is
normal. Restrict bedtime, try soothing behaviour like a warm
bath, place the bed or cot away from the wall. Do not punish or
lock the child.
▪ I will review you regularly and give you some reading materials
about headbanging. If the child becomes drowsy, irritable, has
jerking movements, please go to the ED immediately.

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Brief resolved unexplained event

Sara, a mother of a 10-week-old child, Tony, has come to ED as the

child looked pale, and became floppy. On arrival, the child is fine and
alert.

TASKS
1. Take a history from the mother
2. Tell the mother about the condition and management

Differential Diagnosis:
▪ Apparent life-threatening event
▪ Infections/Sepsis (pneumonia, meningitis, AGE, UTI)
▪ Airway obstruction (congenital abnormalities, infection, hypotonia)
▪ Abdominal (intussusception, hernia, testicular torsion)
▪ Metabolic (hypoglycaemia, hypocalcaemia, hypokalaemia)
▪ Heart causes (CHD, arrhythmia)
▪ Toxins/drugs
▪ Neurological (head injury, brain infection)
▪ Child abuse

At high risk:
▪ Neonates
▪ Recurrent episodes
▪ Has prior medical illness
▪ Premature

APPROACH
▪ History
o Ask the history from the person who witnessed the event.
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o Could you describe what exactly happened during the event?

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 o Was the child conscious or unconscious during the event?
What was the color of the body? Did he have jerky movement?
Did he have abnormal eye movement?
o What happened prior the event? Circumstances and
environment prior to the event?
o Did the episode have any relation to feeding? Any vomiting
after feeding?
o What is his usual sleeping position? What is the usual sleeping
arrangement?
o Any recent illness in the child or in the family?
o Did this happen for the first time?
o What have you done after the event? Any intervention done so
far?
o How is the home situation? Was this a planned pregnancy?
Who is taking care of the child? Are you the biological parents
of the child? Any stress at home? Any drug abuse by the
parents?
o BINDSAR
o Past history
o Family history

▪ Physical Exam
o General appearance: pallor, dehydration, rash, lethargy
o Vital signs
o Fontanelles
o Look for any signs of abuse
o Fundoscopy (check for any non-accidental injury case)
o CVS/Respiratory
o Abdomen: mass, distention, hernial orifices
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▪ Diagnosis and Management

Main management: Reassurance
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▪ You can keep the child in the hospital for observation. Call the
paediatric registrar.
▪ Can arrange for basic investigations: FBE, UEC, BSL, ECG. If the
child is febrile, do septic workup.
▪ If you find any signs of abuse, do a head to toe examination and
investigations.

▪ Based on our conversation, most likely your child has experienced

an apparent life-threatening event which may look scary to the
observer but usually, no serious causes are found. This can
happen in children who are less than one year of age. (There is no
connection between this condition and SIDS) Sometimes it can
happen as a physiological response of airways or sometimes due
to gastroesophageal reflux.

▪ You have done the right thing to bring him here. I would like to
keep him in the hospital for observation, and I will call the
paediatric registrar to have a look and do a further assessment.

▪ Once he is discharged from the hospital, he will be reviewed by

the GP. If he develops any seizures, has the difficulty of breathing,
becomes lethargic, not eating, drinking, peeing well, please bring
him to ED immediately.

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Head Injury

A 6-year-old child was brought to your GP clinic by his parents as the

child hit his head while playing. On arrival, all physical examination is
normal.

TASKS
1. Focused history
2. Explain further management to the parent

Positive points in history:

APPROACH
▪ History
o Is the patient hemodynamically stable (if PE is not mentioned

to be normal)?
o Could you please tell me what happened?
o Has anyone witnessed it?
o Any loss of consciousness?
o Any episode of jerky movement, tongue bites? Did he soil

himself? Did he vomit after the injury? Did he becomes drowsy

after the head injury? Did he complain of any problem with his
vision?
o Have you noticed any discharge from his nose or ear (CSF)?
o Any weakness in any part of his body?
o Did he hurt himself anywhere else?
o Is it the first time?
▪ Have you offered him something to eat or drink after the

injury? Was he able to swallow?

o How is the home situation? Any problems at home? Who do
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you live with? Who is taking care of the child?

o How is his health otherwise?
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o Any past medical illness or bleeding disorder?

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 o How far do you live from the hospital?

▪ Physical Exam
o General appearance: AVPU
o Vital signs
o Cervical spine inspection - if you suspect any injury, put a collar
o Airway, breathing and circulation
o Secondary survey

▪ Diagnosis and Management

Your child's condition is stable now. He has vomited once after the
injury which can happen as a response to head injury. But if it is
recurrent, we need to admit him for further evaluation. For now, I
will give him Panadol. You can take him home but bring him back if
you notice that he is persistently drowsy, has recurrent vomiting, or
if he develops any fits.
Mild head injury:
o No loss of consciousness
o Up to 1 episode of vomiting
o The child is stable and alert
o May have scalp bruising
o Rest of the exam is normal

Treatment: may be discharged with analgesia

If there is doubt about the consciousness, treat as moderate head
injury

Moderate head injury:

o A brief episode of loss of consciousness
o Alert or responsive to voice
o 2 or more episodes of vomiting
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o 1 episode of convulsion which was less than 2 minutes in

duration
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o May be large scalp bruising

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 o Rest of exam in normal
Treatment: observe the patient for at least 4 hours with frequent
monitoring. Discharge the patient if stable. Give painkiller and
antiemetic.

Severe head injury:

o Decreased conscious state
o Any focal sign
o Signs and symptoms of increased ICP
o CSF leak (basal fracture)
o Injury in the cervical spine

Treatment: admit the patient. May require intubation if GCS is

below 8.

*Relative indication for neuroimaging: Loss of consciousness for

more than 5 minutes, amnesia for more than 5 minutes, the patient
has a history of bleeding disorder

HEAD INJURY GUIDELINES:

Minor • No loss of • The patient may be discharged
consciousness from the Emergency
• Up to one episode of Department to the care of their
vomiting parents (see Discharge
• The stable, alert Requirements).
conscious state • If there is any doubt as to
• May have scalp whether there has been the
bruising or laceration loss of consciousness or not,
• Normal examination assume there has been and
otherwise treat as for moderate head
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injury.
• Adequate analgesia
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Moderate • Brief loss of • If, on the history from the
consciousness at the parents and ambulance, the
time of injury child is not neurologically
• Currently, alert or deteriorating they may be
responds to voice observed in the Emergency
• Maybe drowsy Department for a period of up
• Two or more episodes to 4 hours after trauma with 30
of vomiting minutely neurological
• Persistent headache observations (conscious state,
• Up to one single brief PR, RR, BP, pupils and limb
(<2 min) convulsion power).
occurring immediately • The child may be discharged
after the impact home if there is an
• Normal examination improvement to a normal
otherwise conscious state, no further
vomiting and child able to
tolerate oral fluids.
• A persistent headache, large
haematoma or possible
penetrating wound may need
further investigation, discuss
with a consultant.
• Adequate analgesia
• Consider anti-emetics but
consider a longer period of
observation if anti-emetics are
given.
Severe • Decreased conscious • The initial aim of management
state - responsive to of a child with a serious head
pain only or injury is the prevention of
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unresponsive secondary brain damage. The

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• Localizing neurological oxygenation, ventilation and
signs (unequal pupils, circulation, and to avoid rises in
lateralizing motor intracranial pressure (ICP).
weakness) • Urgent CT of head and c-spine.
• Uncal herniation: Ensure early neurosurgical and
ipsilateral dilated ICU intervention.
non-reactive pupil • Cervical spine immobilisation
due to should be maintained even if
compression of cervical spine imaging is
the oculomotor normal.
nerve • Intubation and ventilation:
• Central • Child unresponsive or not

herniation: responding purposefully to

brainstem pain
compression • GCS persistently <8

causing • Loss of protective laryngeal

bradycardia, reflexes
hypertension, and • Respiratory irregularity

widened pulse • In consultation with the

pressure neurosurgeon consider

(Cushing's triad) measures to decrease
• Irregular intracranial pressure:
respirations • Nurse 20-30 degrees head up
(Cheyne-Stokes) (after correction of shock) and
• Decorticate head in a midline position to
posture help venous drainage.
• Decerebrate • Ventilate to a pCO2 35mmHg
posture 4-4.5 kPa (consider arterial
catheter).
• Ensure adequate blood
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pressure with crystalloid

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 infusion or inotropes (e.g.
noradrenaline) if necessary.
• Consider mannitol (0.5-1 g/kg
over 20-30 min i.v.) or
hypertonic saline (NaCl 3% 3
ml/kg over 10-20 min i.v.).
• Consider phenytoin loading
dose (20 mg/kg over 20 min I
.v.).
• Control seizures: see Afebrile
seizures
• Correct hypoglycaemia
• Analgesia: sufficient analgesia
should be administered by
careful titration. Head injured
children are often more
sensitive to opioids.

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Celiac Disease

The 9-month-old child has come to your clinic. Mother is concerned

because her daughter Christina is not gaining weight. 3 months ago, her
weight and height are at 50th percentile. Today, her weight is 6kg.

TASKS
1. Take a history from the mother
2. Ask PE from the examiner
3. Discuss your most likely diagnosis with mother

Differential Diagnosis:
▪ GIT causes
o Coeliac disease

• Introduction of solid foods

• Pale, greasy sticky stools
• Pallor (they usually have IDA)
• Weight loss
• Positive family history
o Cow's milk protein intolerance

• Present in 1st few months of life

• Diarrhea after being fed with formula milk for a few

months
o Lactose intolerance

• Flatulence, bloating, diarrhea

• Congenital or after gastroenteritis
• Symptoms appear few hours consuming lactose
o Pyloric stenosis

• Projectile, non-bilious vomiting

• 3-6 weeks of age
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o Gastroesophageal Reflux Disease

• Effortless vomiting
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 • A child can be irritable, cries, and have weight loss
o Cystic Fibrosis

• Frequent infections
• Sticky stools, diarrhea
▪ Non-GIT causes
o Inadequate intake
o Congenital heart disease
o Anatomical defect/deformity like cleft lip
o Child neglect
o Fuzzy eater (usually we don't do investigations, but if you see

at least 2 SD drop in weight, do investigations)

APPROACH
▪ History
o Detailed dietary history

• Amount and type of milk

• Introduction of solid foods
• Amount of juices and candies
• Is she a picky eater or does she eat whatever you offer

her?
o Does she have any vomiting?
o How are her bowel habits and water work?
o Does she have any fever, cough and difficulty in breathing?
o Does she have any frequent infection? (cystic fibrosis)
o Antenatal and birth history

• Was it a planned pregnancy?

• Was it a home or hospital delivery?
• Any illness or hospitalization after birth?
o Is the vaccination up to date?
o Apart from weight gain, any other concerns?
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o Social history

• How is the home situation? Who is the primary carer of the

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child?

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 • Does the child go to child care?
• Any financial problems?
• Any violence at home? Any alcohol or drug abuse in the

parents?
o Any family history of a similar problem?

▪ Physical Exam
o General appearance: pallor, dehydration, abnormal

pigmentation (malnutrition), bruises all over the body (non-

accidental injury)
o Vital signs
o Oral cavity: any thrush or ulceration
o ENT and lymph nodes
o CVS/Respiratory/Abdomen
o Muscle wasting and anal excoriation (lactose intolerance)

▪ Diagnosis and Management

▪ Most likely your child is having a condition called Celiac disease.
Have you ever heard about it? It is a condition caused by an
abnormal immune response to a dietary protein known as gluten.
Gluten is found in rye, barley, oat, or wheat. In people with Celiac
disease, sensitivity to gluten causes inflammation and damage to
small gut leading to malnutrition. I need to refer your child to the
specialist and arrange baseline investigations including iron
profile, full blood examination, celiac screening. I will refer you to
the specialist who will do a biopsy by putting a thin, flexible scope
in the tummy through the mouth and will take a small sample.
Once the diagnosis is confirmed, a gluten-free diet should be
taken. I will refer you to the dietician as well. This condition is not
curable, but we will work as a multidisciplinary team to control
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the symptoms. I will also refer you to Celiac Australia for further
support.
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Oral Thrush

6 months old child has come to your GP clinic with a complaint of oral
thrush and anal excoriation. Mother is also concerned about the child's
poor weight gain.

TASKS
1. Focused history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

Differential Diagnosis
▪ Oral thrush
▪ Lactose intolerance
▪ Celiac disease
▪ Immunosuppressive conditions
▪ A side effect of antibiotics

APPROACH
▪ History
o For how long is the child having this problem?
o Is child breastfeeding? (child is 6 months, and infection of the

nipple)
o For how long is the child breastfeeding or bottle feeding?
o Is the child irritable? Is he reluctant to eat and drink?
o Does he have fever, rash, cough, or recurrent infections?
o How is his waterworks? Did he have a change in the number of

wet nappies?
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o How are his bowel habits?

o Have you started to feed him solid foods?
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o Any family history of diarrheal disease?

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 o Has he been treated with antibiotics recently?
o Have you noticed anything that makes his symptoms better or
worse?
o Does he use a dummy or pacifier? How often do you clean it?
o How is your general health? Have you noticed any infection
and rash around your nipple?
o Are you taking a lot of cow's milk? (sometimes if the mother is
taking a lot, it can also cause reactions in the child)

▪ Physical Exam
o General appearance: pallor, dehydration, lethargy, growth

chart
o Vital signs
o ENT and lymph nodes
o Oral cavity
o CVS, Respiratory, Abdomen
o With the consent of the parent, examine the anal region for

any excoriations

▪ Diagnosis and Management

▪ Oral thrush is caused by the yeast, Candida albicans. We have all
got yeast in our bodies. But sometimes if the immunity becomes
low, or any imbalance occurs in the body, it can multiply and
produce infection. It can also happen as a result of taking
antibiotics, which destroys the normal bacteria in the gut.
▪ Your child might also develop oral thrush, if he sucks an object
which is already infected with thrush, like pacifiers. Usually, it is
not contagious, but it can be painful and can make the child
irritable.
▪ I will give your child a prescription for oral antifungal drugs for 10
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days which you will give to him after each feed. You can still
breastfeed your child, but if nipples are also infected, you should
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apply antifungal cream.

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▪ (Usually, we do not arrange for investigations if it is only candida.
But this patient is having weight loss, so do investigations.)
▪ We will do investigations such as FBE, ESR/CRP, and take a swab
of the thrush and send for microscopy, and stool microscopy.

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Asthma

Jenny 3 years old was brought to your surgery by her mom Michelle.
She had a cough and colds for a couple of days with fever and runny
nose. Her mom had tried OTC cough mixture but with no relief. She
seeks your advice as whenever Jenny gets colds it goes to her chest and
it takes ages to clear. She took her to another GP. Michelle is quite
concerned and seeks your help.

TASKS
1. Further history
2. PE from examiner
3. Investigations
4. Diagnosis and Management

Differential Diagnosis
▪ Cystic fibrosis
▪ Asthma
▪ URTI
▪ Bronchitis
▪ Bronchiolitis
▪ Pertussis
▪ Croup

APPROACH
▪ History

• Cough questions:
• May I know when did the cough start? Can you describe

the cough?
• Differential questions
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• Social history
• How is your home situation? Anybody smoking at
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home?

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 • Any pets, possible dust mites, carpets?
• Any family history of asthma?
▪ Physical Exam
• General appearance: pallor
• Vital signs
• Respiratory: air entry, abnormal breath sounds
• CVS/CNS/abdomen
• Office tests: UDT, BSL
▪ Diagnosis
Most likely your child is having a condition called Bronchial
Asthma. The diagnosis is made on a clinical basis (no diagnostic
exam).
*may do spirometry if the child is > 6 years old
▪ Management
• Assess Severity of asthma:
• Day and nighttime symptoms
• Frequency
• limitation of activities
• Classification of Asthma
• Intermittent
▪ Less than 2x/month
▪ Has nighttime symptoms
▪ Early morning cough

Treatment:
▪ Ventolin 2 puffs via spacer PRN
▪ Avoid asthma triggers
▪ Monitor basal lung function
▪ Develop an Asthma management plan
▪ Patient education and follow-up
▪ No need to refer to the specialist
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• Mild persistent
▪ Greater than 2x/month, symptoms with physical
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activity

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 • Moderate persistent
• Severe persistent
▪ More frequent daytime and nighttime symptoms

ACTION PLAN
• part of the management plan
• past treatment of asthma attack
• admitted at the hospital (HMO will do action plan)

• Personal details:
• Name
• Age and DOB
• Address
• Known allergy
• Name of GP
• Reliever meds:
• Ventolin 2 puffs whenever child required and keep a record
• Preventer meds:
• Continue every day irrespective if the child has surgery or not
• Inhaled corticosteroid (Flexotide) continue as you are advised, 2

puffs twice daily

• Prednisolone (50mg max dose): given today continue for 2 more
days to complete 3-5 days (moderate asthma)
• Day 1: 2mg/kg, day 2 onwards: 1mg/kg

I will teach you how to identify whether your child is well, unwell and
having an acute attack.
• Well:
• no night time and daytime symptoms,
• no limitation on activity
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• used <3x/week of Ventolin

• Unwell:
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• increase night and daytime symptoms,

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 • little limitation on activity,
• used Ventolin >3x/week
• Use Ventolin 2 puffs via spacer as much as you like
• Preventer: is on it already: continue the same dose
• Prednisolone 1mg/kg (kept at home)
• You need to see your GP within 48 hours
• High risk: prev. admitted to ICU, always getting severe attack,

frequent admission, on ventilator support

• Asthma attack:
• the child is short of breath, unable to talk, coughing
• Do first aid! 4x4x4
• 1st puff, 4 breaths- wait at least 30secs
• 2nd puff, 4 breaths
• 3rd puff, 4 breaths
• 4th puff, 4 breaths
• WAIT 4 MINS
• If not improving, repeat 3 cycles (12minutes) or call 000

depending on the severity and bring to the nearest hospital

• If improving: see GP today

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Cystic Fibrosis

15-year-old Cristina has come to you with mom Jennifer. Mom is

concerned about the poor school performance of Cristina. Cristina was
diagnosed with cystic fibrosis when she was 5 years of age, and she is
under treatment now.
You have 2 charts showing progressive decline in growth chart, as well
as her FEV1 as per her age.

TASKS
1. Take a history from the mother
2. Explain the results and address the mother's concern
3. Counsel the mother regarding her poor school performance and
further management

Positive points in the history: the history of separation between her

parents, she is spending around two hours for taking the medication,
but the mother is not aware if she is taking the medications (poor
compliance),

APPROACH
▪ History
o For how long have you noticed that she is having poor school

performance?
o Any recent change in the environment at home or school?
o Any recent change in her behaviour?
o How about her vision and hearing?
o Do you think that she is facing school bullying?
o Is she hyperactive or unable to finish the given task?
o Does she ever complain of any headache, vomiting?
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o Does she suffer from frequent infections?

o How is her health, otherwise?
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 o I understand that she was diagnosed with cystic fibrosis, when
was the last time that she visited the specialist?
o Is she taking the medications as it was prescribed?
o How is the home situation?
o Are you a happy family? How about her relationship with the
other family members and her friends?
o BINDSMAR: immunization, weight loss, growth

▪ Diagnosis and Management

▪ Most likely Cristina's poor school performance is due to the recent
stress in her life.
▪ I can arrange a referral to the psychologist for counselling, but I
am more concerned about her weight loss and abnormal lung
function.
▪ I have checked her growth chart which shows that she has poor
weight gain. Also, her lung function shows a progressive decline of
FEV1. FEV1 is the amount of air that can be exhaled forcefully in
the 1st 1 second. It is the predictor of lung function, and it also
dictates the progress and outcome and cystic fibrosis. It is
decreasing which may be due to poor compliance with the
treatment.
▪ I would like to arrange a referral to the respiratory physician for
complete assessment and further management. I will review her
regularly.

Another case:

Laura, a 10 weeks pregnant lady has come to know about cystic fibrosis
as her two-year-old child was diagnosed with cystic fibrosis. She wants
to know about the condition and the chances of having another baby
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with a similar condition.

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TASKS

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 1. Explain the condition to the mother
2. Discuss the management with the mother.

I am sorry to hear about your child who was diagnosed with cystic
fibrosis. How much do you know about this condition? Before I start, do
you have any particular concern that you want me to address first?
Cystic fibrosis is one kind of genetic condition, which is not uncommon.
It primarily affects the lung and the digestive system. When a person
has cystic fibrosis, their mucosal glands secrete very thick, sticky mucus,
and in the lung, this mucus clogs the tiny air passages and traps the
bacteria, and lead to frequent chest infection. The pancreas is also
affected. It is a leaf-shaped gland in our body, which release enzymes
and important hormones. Cystic fibrosis prevents the release of these
enzymes and causes impaired absorption of food, which leads to
frequent loose stools.
Unfortunately, there is no cure for cystic fibrosis, the purpose of the
treatment is only to slow down the progression of the disease.
I am going to refer him to the respiratory physician, and we are going to
work as MDT. He will be given antibiotics, chest physiotherapy will be
arranged, salt supplement and fat-soluble vitamins.
Genetic counselling will be arranged. CF is an autosomal recessive
disease, there is a 25% chance of having another baby with CF.
But we can check that during the pregnancy by doing an amniocentesis.
It is a procedure of taking a small amount of fluid from the bag
surrounding the child to analyze the genetics of the child.
He will be given flu shot yearly, and pneumococcal shot 5-yearly. I can
refer you to a support group and offer reading materials as well.
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Short Stature

8-year-old girl Simi was brought to your GP clinic because her mother is
concerned about Simi's height. Simi is the shortest among her
classmate.

TASKS
1. Take a history from the mother.
2. PE from examiner
3. List the differential diagnosis to the examiner

Differential Diagnosis:
▪ Familial short stature
▪ Constitutional delay
▪ Malabsorption problem
▪ Hypothyroidism
▪ A genetic or chromosomal problem like Turner's syndrome/Down’s

syndrome
▪ Iatrogenic: steroid-induced

APPROACH
▪ History
o When did you first notice this?
o Do you have any concerns regarding her growth and

development?
o How is her vision, hearing and speech?
o Birth history

• Was she born full-term or premature?

• Was it a home or hospital delivery?
• Was the heel-prick test done?
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• Any resuscitation required after birth?

• Any illness or hospitalization required after birth?
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o How is her general health otherwise?

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 o Does she suffer from frequent infections?
o Has she ever been diagnosed with asthma?
o Is she on any regular medications like steroids?
o Does she have any weather preferences?
o Could you please tell me about her daily diet?
o I understand that you are concerned about her height, how
about her weight?
o How about her school performance?
o Do you think that she is being criticized or bullied at school
because of her height?
o How is the home situation?
o Does she have any other sibling?
o Is there anyone else in the family with short stature?
• I would like to know the height of the parents
▪ Familial short stature: mother <152cm; father <162cm

▪ Physical Exam
o General appearance: dysmorphic features (Turner's syndrome:

short webbed neck, shield chest, widely spaced nipples, high-

arched palate)
o Is growth velocity available? (record the average weight and

height of the child within a period of 6 months)

• If the growth velocity is below 25th percentile, arrange all

investigations including karyotype

o Upper segment: lower segment ratio - normally 1 at the age of

7-10 years old

▪ Investigations
o X-ray of the left wrist (non-dominant hand) - compare the bone

age and the chronological age

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• I would like to arrange an x-ray of the left wrist and know

whether it is equal to the chronological age of the child

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• If bone age = chronological age: familiar short stature

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 • If bone age < chronological age: constitutional delay
o FBE, ESR/CRP, urine analysis, LFT, RFT, TFT, celiac screening,
growth hormone studies, karyotyping

▪ Diagnosis and Management

Familial:
▪ Only reassurance, no investigations required other than an x-ray
of the left wrist.

Constitutional:
▪ Most likely, your daughter is having a constitutional delay which is
a normal variation of growth, rather than a disorder.
▪ The exact cause is unknown but thought to be from multiple
genes from both parents.
▪ Let me reassure you that, there is nothing to worry about this and
the child will catch-up with growth and will attain a normal height
in the future.
▪ If you are concerned, I can refer you to a pediatrician to confirm
the diagnosis and we can arrange some blood tests to rule out
other possibilities.

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Cerebral Palsy

12 months old child, Johnny was brought to your GP clinic by his mom,
Stella. Stella is concerned because Johnny does not use his left arm and
leg.

TASKS
1. Take a history from the mother
2. PE from examiner
3. Explain your diagnosis and further management plan to Stella

Differential Diagnosis
▪ Cerebral palsy
▪ Brain tumour
▪ Child abuse
▪ Head trauma or any injury on the affected side
▪ Infections

Positive points in the PE: Hypertonia and hyperreflexia

APPROACH
▪ History
o What are your concerns?
o For how long have you noticed that he is having this problem?
o Developmental:

• Gross motor:
▪ Is he able to walk?
▪ Is he able to stand by himself?

• Fine motor:
▪ Does he reach and grasp things with his left hand?
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(usually happens at 5 months)

▪ Can he use his three fingers to grab things? (pincer
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grasp) (usually happens at 9 months)

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 • Social:
▪ Does he maintain eye contact?

• Language:
▪ Does he say at least one meaningful word? (usually at

age of 1)
• If he is not able to, go backwards. Is he able to

speak baba/dada (babbling)?

o Delivery
• How was your pregnancy with him?
• Did you have any infection during the pregnancy?
• How was the delivery? Was it a normal vaginal or a

caesarean section? What was the indication for it?

• Did he cry after birth? Did he require any resuscitation?
• How is his health otherwise?
• Is he able to eat or drink well?
• Did he have any history of trauma or injury?
• Did he have any severe infection?
• Did he have any formal hearing assessment after birth?
o How is your home situation?
o Do you have any family history of a similar problem or any
other illness?

▪ Physical Exam
o General appearance: pallor, dehydration, dysmorphic features
o Growth charts
o Vital signs
o ENT examination
o Neck examination: thyroid
o CNS examination: tone, power, reflex, sensory
o Musculoskeletal system: any deformity
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▪ Diagnosis and Management

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▪ Most likely your child is having developmental delay as he has
delayed development in major milestones. It can happen due to
different reasons, but in his case, it is most probably due to
cerebral palsy. Have you ever heard about it?
▪ It is a group of conditions that causes problems with movements,
vision, hearing, speech, and learning abilities. It can occur as a
result of damage to the brain during pregnancy, birth, or early few
years of life.
▪ Let me reassure you that it is a non-progressive condition.
▪ I would like to refer him to the pediatric neurologist to confirm
the diagnosis. Once it is confirmed, we will work as MDT
composed of a physiotherapist, occupational therapist, and
speech therapist.
▪ I can refer you to a support group and arrange a social worker for
you as well.
▪ If the child develops seizures, and unable to eat or drink, please
come back immediately.
▪ I will give you reading materials for further insight and review you
regularly.

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Allergic Rhinitis

A 3-year-old child has come to your GP clinic with the complaint of

continuous nasal discharge for the last 12 months. The child is
otherwise very well. No other abnormal physical finding.

TASKS
1. Take the history from the parent
2. PE from examiner
3. Explain most likely Diagnosis and Management to the parent

Differential Diagnosis:
▪ Allergic rhinitis
▪ Rhinosinusitis
▪ Foreign body
▪ Nasal polyp
▪ Cystic fibrosis
▪ Enlarged adenoid

Positive points in the PE: pale, swollen, boggy nasal mucosa with
hypertrophic turbinates

APPROACH
▪ History
o For how long has he been experiencing this problem?
o Could you please tell me the color of the discharge? Is its foul-

smelling? Have you noticed any blood in it?

o Did he have any other features like watery eye and sneezing

and fever?
o How often does he have this episode?
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o Anything that makes it better or worse?

o Have you noticed any noisy breathing?
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o Does it wake him up from sleep?

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 o Have you tried any medication? Did it help?
o Does anyone smoke at home? Is there any pets or carpet at
home?
o Is there any family history of allergy?
o How is it affecting his life?
o BINDSMAR

▪ Physical Exam
o General appearance: pallor, dehydration, adenoid face (open

mouth, crowded maxilla, short upper lip, nasal crease), polyps,

mass
o Throat: tonsils, adenoids
o Neck: lymph node enlargement
o Skin: eczema
o Chest: wheeze

▪ Diagnosis and Management

▪ Most likely your child is suffering from a condition called allergic
rhinitis.
▪ The inner lining of our nose is very sensitive. In response to an
allergen like dust or pollen, it becomes swollen and leads to
obstruction.
▪ You can try giving normal saline drops, and if it is affecting his
sleep, you can give antihistamine.
▪ I will refer the patient to an allergy specialist for special tests.
Avoid smoking at home, avoid close contact with pets.
▪ If the symptoms are not improving, then steroids can be
prescribed for a short duration.
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Eczema

The 11-month-old girl was brought to your GP clinic by her mom, with a
complaint of a rash over her cubital fossa. She keeps scratching over
the last 2 nights.

TASKS
1. Take a relevant history from the mother
2. Explain the most likely diagnosis
3. Manage the case

Differential Diagnosis:
• Atopic dermatitis
• Contact dermatitis
• Impetigo
• Urticarial rash
• Scabies
• Seborrheic dermatitis

Positive findings in the PE: scaly papules with excoriations at the

flexural surface

APPROACH
▪ History
o Rash questions:

• Could you please tell me where is the rash?

• Is it itchy?
• Anything that makes it better or worse?
• Any relation to food?
• Did you change the shower gel or body lotion recently?
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• Anyone else at home having a similar rash?

• Is this the first time this occurred?
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• Are there any pets or carpets at home?

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 • Does anyone smoke at home?
• Does she have a known allergy to anything?
• How is her health otherwise?
• Is she able to sleep properly at night?
• Any concerns regarding growth and development?
• Any family history of allergy or eczema?

▪ Diagnosis and Management

▪ Most likely your daughter is having a condition called eczema. It is
a common condition, but the exact cause is not known. It can run
in families.
▪ Let me reassure you that it is not contagious. It usually improves
by the age of two. Though it is not a dangerous condition, the
infection may occur from scratching.
▪ Keep the skin moist and apply moisturizer three to four times a
day especially after a shower. If not responsive, the steroid has to
be given.
General measures:
o Avoid close contacts with pets
o Clean carpets regularly
o Avoid smoking at home
o Avoid soap and perfume products
o Avoid dusty and dirty conditions
o I will arrange a referral to the specialist for the skin prick test so

that we can identify the other possible things that your child is
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Egg Allergy

The 9-month-old child has come to ED with his mom, with a complaint
of swelling in his lips after eating breakfast. On arrival, the child is
stable with normal vital signs, but mild swelling is present around the
lips.

TASKS
1. Focused history from the mom
2. Counsel the mom and discuss the management plan

APPROACH
▪ History
o What did the child have for breakfast?
o Was that food given to him for the first time?
o How long after breakfast did the symptoms appear?
o Apart from lip swelling, have you noticed any rash, breathing

difficulty, tongue swelling, vomiting, or loss of consciousness?

o How is his health otherwise?
o Any problems with his growth and development?
o Allergy questions
o How far do you live from the hospital?

▪ Diagnosis and Management

▪ Most likely, the child is having an allergic reaction to the food that
was given to him. It is a very common condition, and usually mild
symptoms occur. But there is a possibility of recurrence of the
symptoms and severe reaction can occur, which we call
anaphylaxis.
▪ I will give him antihistamine and will observe him in the ED for a
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while. If he remains stable, he will be discharged with an allergic

reaction action plan (NOT ANAPHYLAXIS action plan--this is only
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given if the patient has anaphylaxis).

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 ▪ He will then be reviewed regularly by your GP.
▪ I will refer him to the specialist and further tests will be conducted
to find out the potential cause of his allergy now and to find out
other substances that he is allergic to.
General measures:
o Try to avoid these types of food that cause an allergic reaction
o Check labels before buying food
o Maintain a food diary
o Refer to a dietician

If he experiences the difficulty of breathing or any other symptoms

of anaphylaxis, bring him back to ED immediately. I will give you
reading materials.

To diagnose anaphylaxis:
▪ One respiratory or cardiovascular symptoms PLUS
▪ One GIT or skin symptom

Management
▪ Remove the allergen first
▪ Lie the patient flat
▪ Adrenaline 1:1000
o Age is more than 12 years: 0.5mL
o 6 - 12 years: 0.3mL

▪ Fluid resuscitation 20mL/kg normal saline

▪ Call for help
▪ If the child is wheezing, give oxygen. If not working, can give

nebulized Salbutamol
▪ 2nd generation antihistamine may be given for the itching
▪ Inform the mother that the child is stable and under close

observation
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Counselling
▪ Most likely he had an anaphylactic reaction due to bee sting. It is a
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more severe form of an allergic reaction due to the bite or sting. It

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 can be life-threatening if not treated immediately. Now his
condition is stabilized but we have to keep him in the hospital
because there is a chance for recurrence.
▪ He will be discharged with an anaphylaxis action plan. It is an
action plan which helps you identify mild or serious allergic
reaction and its management. You will be given an anaphylactic
kit, which consists of an EpiPen and other medications. If you
suspect a severe allergic reaction, you should give an EpiPen as
instructed and call 000. An educator will teach you how to use the
kit.
▪ A referral to an allergy specialist will be arranged.

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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 your
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 of 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 a less economic burden to the family
▪ it is available every time and you can 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 the 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
the 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
▪ In the beginning, you should breastfeed 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 breastfeeding 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
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the milk in the fridge for 1-2days, 2 weeks in the 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,
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including:

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 • 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
with 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 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 view which she feels is accurate.
▪ A satisfactory explanation of the advantages and disadvantages of the different methods of
feeding.
▪ Candidates should know how formula feeds are prepared.
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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 with 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 circumcision is
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 a
pain-free procedure.
▪ Explain the 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 thus 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.
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• Minimizes the risk of subsequent development of penile cancer. However, infection by

a sexually transmitted infection, the HPV virus, is the major contributor to the
development of the disease. Cancer is still rarely seen in men who can retract and
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clean their foreskin regularly

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 • There's divided opinion regarding its advantage in reducing the incidence of sexually
transmitted infections. But there is some evidence that suggests that the risk of HIV is
lessened by this procedure.
▪ Explain the 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 septicaemia, 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 a bleeding disorder, or known recognized 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 into 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 345
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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 the 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 a fever? Is she irritable? Pulls on the 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 preschoolers, and most cases are mild and transient and are
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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
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outer ear can get blocked with things such as wax and foreign objects put in there by the child.

© 2020 ARIMGSAS
 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, chickenpox, 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 an appropriate level of support and reassurance.

CRITICAL ERROR
▪ Failure to refer for specialist assessment (audiogram) for definitive diagnosis.

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Counselling a family after SIDS
You work in general practice. You are counselling 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 immunizations. 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 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 about 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 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
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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
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work in a manner that will provide comfort to the family.

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 ▪ 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 pathologist 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 in 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 the need for coronial notification and autopsy
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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 about 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
consist of a combination of short-acting insulin and 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 an adjustment in the insulin dosage is required depending on the trend
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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
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glucose for energy, and the insulin might need adjustment. [In normal states these ketones

© 2020 ARIMGSAS
 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 before allowing Roger to attend
the school camp. If it would be possible for you, you and your husband or anyone 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
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▪ Ability to answer the specific questions of the parent accurately and sensibly
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CRITICAL ERROR

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▪ Failure to discuss symptoms and treatment of insulin-induced hypoglycaemia

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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 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 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?
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• After every feed, did he produce a wet nappy? How many wet nappies have you
changed so far? Any changes? Is it foul-smelling?
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o Rule out sepsis and conjugated hyperbilirubinemia symptoms

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 • 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
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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 into your child's
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condition and about breastfeeding. Do you have any questions?

© 2020 ARIMGSAS
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 haemolytic disease
▪ Insisting that the breastmilk is unsatisfactory for the baby and recommending permanent
cessation of breastfeeding

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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 signs 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 from 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. The 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 a special nursery? Was the 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
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group?
c. Family history
i. Do you have a family history of epilepsy? How about a family history of febrile
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 ▪ Closure
a. Immunizations: Are 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.
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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 probable 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 have 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 the 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?
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• 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
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 • Any episodes of staring blankly or daydreaming?
• 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 counsellor/Centrelink/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.
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o Do you have any questions?

KEY ISSUES
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 ▪ 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

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Heart murmur
You are working in 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 a 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 have episodes where his skin turned blue?
▪ Was he ever diagnosed with 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 heartbeat.
▪ 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
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easily detected, during an illness 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
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the murmur is louder.

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 ▪ 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
echocardiography.

KEY ISSUES
▪ Ability to assess confidently the features of an innocent heart murmur.
▪ Avoidance of unnecessary extensive investigation.

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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 An Rh positive

Direct Coombs test Strongly positive

Infant's Hb 170g/L

Blood film/Peripheral blood smear Micro spherocytes

Bilirubin (Total) 250 umol/L

Bilirubin (Conjugated) 6 umol/L at 24 hours

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o Feedback from biochemist: this is abnormal, but below the range at which exchange
transfusion is indicated
▪ ADVISE ON DIAGNOSIS AND MANAGEMENT
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 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 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 delivery,
there is a 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 orders 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-coloured 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 level
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 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 haemolytic disease of the newborn and its immediate treatment
▪ Empathetic but realistic communication with the new parent
▪ Ability to relate to a mother's disappointment with the need for medical intervention

CRITICAL ERRORS
▪ Failure to recognize the haemolytic disease of the newborn and failure to advise phototherapy
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Immunization advice
Your next patient is baby Laura brought by her mother to general practice at six weeks of age, as part of
the 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 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 has produced these antibodies,
the bug has already caused substantial damage to the body. There is also a 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 are 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, meningococcus 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)
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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
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pneumococcal conjugate vaccine (7VPCV)

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 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 the 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,
maybe 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, chickenpox) should not be
administered to immunocompromised patients like a child with HIV, on chemotherapy, or
treatment with high-dose steroids (>2mg/kg) for more than 2 weeks. An anaphylactic reaction to
the 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 the MMR vaccine is related to Autism?
o There has been a report of the 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 the
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).
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KEY ISSUES
▪ Knowledge of basic principles of current immunisation regimens.
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▪ Explanation and accurate information regarding benefits of immunisation

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 ▪ Exploration of parental concerns.

CRITICAL ERRORS
▪ The candidate provides wrong advice regarding contraindications to immunisation.
▪ Recommendation or acceptance of sublingual homoeopathic vaccines.

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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 colour. 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 Respiratory: 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
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o Liver edge: palpable just below the costal margin

o Optic fundi: normal
o ENT examination: normal
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o Urine dipstick: Strongly positive (++) for blood and protein

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 ▪ 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 to 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 to 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 for 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 into his condition.

KEY ISSUES
▪ Diagnosis of acute PSGN
▪ Ability to specify the appropriate plan of investigations
▪ Development of a coherent treatment plan

CRITICAL ERRORS
▪ Failure to admit to hospital 369
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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 the 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 membrane? 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
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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 –
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although some children complain of pain in their tummy rather than a sore throat, swollen lymph

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 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 nose are 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 an 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.
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Fecal soiling
Mark, a five-year-old boy, is brought to see you in the 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 a 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 a 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 waterworks? 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?
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• Immunization - not that relevant in this case.

• Nutrition: What does his diet usually consist of? Does he take a lot of fibre,
vegetables, and fruits? Does he drink a lot of water or not?
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• Development: any concerns about his growth and development?

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 • 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 organomegaly?
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 were
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 the formation of liquid
stools and it tends to leak around the hard stools causing his soiling. However, the bulky
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hard stools 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
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softeners.

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 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 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 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 into 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.

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Bedwetting
Johnny, a five-year-old boy, is brought to see you in 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, though unsuccessfully, with 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 with 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? A 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
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
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o Office test: UDT, BSL

▪ I would also like to send a urine sample for urine microscopy and culture.
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▪ Explanation:

© 2020 ARIMGSAS
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 the
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 Centers 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 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
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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
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idea, but don't promise them in advance. Rather, give them as a little surprise if your child is

© 2020 ARIMGSAS
 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 are not 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 with
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 history and by arranging simple urine testing.
▪ Advice about the plan of action should be logical and clear.

CRITICAL ERRORS
▪ Suggesting a probable organic cause for the wetting and the need for invasive investigations.

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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 hominins. 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.
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▪ 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 need to be
checked, and if head lice are present among them as well, we can begin the treatment. We can
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arrange an appointment for them to have a check-up.

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 ▪ The treatment, fortunately, is simple, but it needs to be done regularly for complete eradication. I
will prescribe 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 into 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

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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 feed — only one breastfeed 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 a 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 hyperaemic, 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 anaesthetic spray a few minutes before the
procedure that will numb the area.
To rule out infection in the lung, we will do an x-ray of the chest. I understand that you might be
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worried about the 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
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pneumonia within the lungs.

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 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 a
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 a 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 a 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 the hospital.
▪ Failure to undertake urgent investigations.
▪ Failure to recommend immediate antibiotic treatment

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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
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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
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the characteristic of the rash that accompanies it, I am most concerned about the possibility

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 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 antibiotic
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 x-ray, and
even a lumbar puncture to check if the infection affected the fluid in the brain or not.
▪ Lumbar puncture is a procedure where we get a sample of the fluid surrounding
the brain called, the cerebrospinal fluid, to check for the 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 the 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 the need for urgent immediate administration of antibiotics prior to transfer
▪ Empathetic explanation of a serious disease

CRITICAL ERRORS
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▪ Not recognizing the possibility of meningococcal disease

▪ Failure to ensure immediate administration of cephalosporin or penicillin and failure to arrange
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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
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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
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struggling to breathe. These symptoms are often worse at night, in the early morning or during exercise.

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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 the 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 gets symptoms during sport
▪ If she has a bad attack or is 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 the further attack as outlined
in the action plan table.
▪ Support and reassurance.
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CRITICAL ERRORS
▪ Failure to diagnose asthma.

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Several bone fractures
You are 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
changing 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 x-ray 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 the 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
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talk more about it?"

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 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 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 A systemic review and well-baby questions: any cough, noisy breathing, vomiting, changes in
his bowel movements, 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
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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
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 • 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 the non-accidental injury
▪ Failure to advise the necessity of hospital admission

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Heart murmur
You have just seen a healthy 5-year-old girl in 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 the
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 is otherwise normal.

TASK:
Explain the likely diagnosis and your management plan to the parent.

APPROACH
Because the features of the murmur found in your children 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 a 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.

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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
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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
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heart murmur. No restriction of activity is required and normal activities should be encouraged.

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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.

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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?
▪ 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
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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
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insert two IV lines on him and draw some blood to check for his electrolytes and blood gases, and

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 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. 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 especially 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 a 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 advice.

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 the hospital or pediatric surgeon for assessment

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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 the 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
eardrum/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
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arrange for a hearing test following healing of the drum to check this.
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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 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 the 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 for 8 week’s time.

KEY ISSUES
▪ Management of acute otitis media in childhood.
▪ Ability to achieve rapport with an anxious parent, who is blaming herself as she feels her inaction
has compromised her child's hearing permanently.

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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.

A 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 illustrated 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 are 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
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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.
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 ▪ 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 hospital admission for observation as there is a 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 into 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 leukemia based on the blood test
▪ Indicating a poor prognosis for the condition
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