Paediatrics

Dr Riley Harrison
Case List
Immunization Counselling
• Mother refuses for routine immunization*
• Influenza vaccine counselling***
• Developmental delays
• Global developmental delay*****
• Physiological delay*****
• CP*****
• Abnormal audiogram*
Rash
• Scarlet fever****
• Kawasakii’s disease*
• Measles**
• HSP***
• Allergy***
• Herpes***
• Spider bite*
• Infectious Mononucleosis****
Fits and headache
• Febrile Convulsion***
• Breath holding attack*
• Increased ICP**
• Tension headache*****
Weight problems
• Failure to thrive****
• Anaemia*****
• Fussy eater**
• Cystic fibrosis*
• Obesity with asthma*****
Newborns & Neonates
• Newborn with respiratory distress**
• Neonatal jaundice**
• Crying baby*****
• Undescended testes, umbilical hernia and inguinal hernia****
• SOB and increased right dome of diaphragm*
• Heart failure*
• Hereditory spherocytosis****
GI problems (vomiting)
• Oesophageal atresia*
• Duodenal atresia**
• Pyloric stenosis***
• GERD***
• DIOS*
• Intussusception*****
• Gastroenteritis*****
• Toddler’s diarrhoea*****
Neck swelling
• Thyroid*
• Lymphadenitis*
Respiratory System
• Infections (croup, pertussis, bronchiolitis, epiglotitis)*****
• Parapheumonic effusion*****
• Asthma**
• Recurrent respiratory infections**
• OSA explanation***
• OSA not interested to the surroundings****
• Tonsillitis**
• Malaysia covid negative case*****
Accidents, NAI and injuries
• Spiral fracture*
• Buckle fracture****
• Pulled elbow**
• Rash on cheek*****
• Bruise on cheek (main complaint as crying) ****
• FB ingestion (detergent, batteries)*
• Burns**
• Head injury****
Emergencies
• Irreducible hernia**
• Testicular torsion*****
• Sepsis in chemo***
• Sepsis in neonate**
• Meningococcaemia**
Behavioral problems and psychology
• ADHD****
• Enuresis***
• Encoporesis***
• Head collision*
• Psychogenic cough*****
• Psychogenic abdominal pain*****
Swelling around the eye
• Orbital cellulitis*
• Nephrotic syndrome*
Limping
• Septic arthritis ***
• SCFE**
• Perthes**
• Irritable hip**
Miscellaneous cases
• DKA****
• Bee sting**
• Breast feeding vs bottle feeding (kindly check the handbook)*
• Oral thrush*
• Body odour**
• Blunt abdominal trauma *
• Down Syndrome Baby****
• SIDS****
Immunization

Mother refuses immunization

You are a GP. A mother, Linda, brought daughter for GP due to mild viral infection. Nurse checked
immunization an is not up to date. Mother refused immunization. Her daughter’s name is Rhea.
Task:
• talk to mother to understand the reason and advice

• approach
• Greetings!
• What would you like to know?
• How much do you know about immunizations?
• What is immunization – Important part of preventive medicine, major advantage – protection
against most childhood infections – some of those infections are life-threatening
• Let me explain you what a vaccine is. Our immune system consists of special cells and chemicals
which fight against infections.
• In addition, we can become immune to diseases either naturally by catching and surviving when
contact with illness.
• Another mechanism to build up resistance to an illness is immunization where we give vaccines to
the patients.
• The vaccine composed of weakened dead microbes/organisms which stimulates an artificial type
of infection without getting sick from it, stimulating body to produce Ab.
• Some vaccines – deactivated toxins.
• The antibodies produced from body can effectively destroy a microbes which could be virus or
bugs or fungus. If they enter the body, because of being recognizing them as enemies, the
antibodies destroy them.
• Vaccines can provide livelong immunity or in some cases, a booster dose is needed.
• Most vaccines are given in injections except Rota V vaccine.
• Sometimes, numbers of vaccines are combined in one injection.
• Vaccines are given according to recommendation which you can find in blue book.
• (The common diseases that can be prevented by vaccines are HBV, DPT, Hib, Polio, Pneumococcal,
MMR, chickenpox.)
• At school going age, Gadarsil to prevent cervical Ca is recommended.
• AS you know, vaccines are medications and so they have side effects.
• The common reaction will be local pain, local tenderness, swelling and mild fever, but they will
resolve spontaneously
• You can give Panadol, Tepid sponging and give ample of fluid.
• Severe reactions are rare, if happens, there are also immediate measures to relieve it
• Absolute contraindications – baby with previous serious anaphylaxis for immunization, Acute
neurological illness(encephalopathy) within 7 days of prev vaccination.
• Vaccination is totally FOC too.

• Q – why can’t I rely on natural immunity developed?

• A – because some are serious and can lead to severe problems. Although they can provide
immunity, the advantage of immunization is definitely a much lower risk and the child produces
 antibodies to the disease just like natural immunity. But in both scenarios, the child may require a
booster dose because immunity can drop overtime.

• Will my child not have any infections after vaccinations?

• Unimmunized baby can become very sick from illness. An immunized baby are less likely to cause
severe infections even if they are infected.

• Concerns
• Child having flu now - only a fever of 38.5 and more is considered to delay vaccination
• She and her husband searched a lot and found that as it can cause brain damage and fits –this is
not true. This may happen with the previous batches which contained mercury but it doesn’t
happen anymore with the ones we are using now.
• MMR can cause autism - there is no link between autism and the MMR vaccine . Research also
indicates there is no difference in the rates of autism between vaccinated and unvaccinated
children. While autism may seem more common in recent years, this is due to increased diagnosis
stemming from greater awareness about the condition.
• His older 4yrs brother had local reaction and currently stopped vaccination – unless severe
anaphylactic reaction, vaccination shouldn’t be stopped
• In women's gathering most of them were talking about the harm of vaccines – benefits are so much
outweight then the drawbacks as per previous discussion
• Any questions?

Influenza vaccine counselling

Father, Robert, comes to you to talk about his daughter, a 5year old girl, who has asthma, Olive, to
discuss influenza vaccine.
Tasks:
• Take history
• explain about the vaccine.

• History –
• Details of asthma, attacks, control, medications, anyone smoke at home? Pets and carpets? Are
you aware of her allergens?
• General health, BINDS, who is looking after her? Going to primary school now? Any reaction with
the previous vaccines?
• How is her eating and sleeping habit?
• Any other allergy?
• how severe was egg allergy, other allergies, epipen?

• Influenza, commonly called the flu, is an infection caused by a strain (version) of the influenza virus.
It mainly affects the nose, throat and lungs, although it can involve other parts of the body. In
healthy children it is much like a bad cold; however, influenza can cause more serious illness,
especially in very young children and those with chronic medical conditions.
• The influenza vaccine is the most effective way to reduce the chance of your child becoming sick
with influenza. So yes, flu can still occur despite of vaccination but the severity is reduced.
• The vaccine can be given to any child over six months of age. It is voluntary, but encouraged for
everyone.
 • If your child has a chronic medical condition like asthma in this case, it is strongly
recommended that they have an annual influenza vaccination. All household members should also
be vaccinated to reduce the chances of your child being exposed to influenza.
• Because the influenza virus mutates (changes) slightly from year to year, your child will need a new
and updated influenza vaccine at the beginning of each influenza season. Two doses are often
required in the first year of vaccination for children aged under nine.
• Side effects of the vaccine include pain and redness at the site of injection. Less commonly, children
may develop a fever or aches and pains, which last one to two days. The vaccine cannot cause
influenza as it contains inactivated (killed) influenza virus.
• While the current influenza vaccines are made using small traces of egg proteins, extensive
research shows influenza vaccines are safe for children with egg allergy or egg anaphylaxis. All
children will be observed for 15 minutes following the vaccination. We also have measures to treat
immediately if any severe adverse reaction occurs.
• Vaccination is the best way to prevent influenza.
• Influenza is very infectious so good hygiene is also important.
• Influenza is caused by a virus so antibiotics cannot be used to treat it.

• Red flags - symptoms of influenza –

➢ Fever
➢ aches and pains
➢ headache
➢ cough or noisy breathing
➢ sore throat and runny nose
➢ low energy
➢ nausea, vomiting and/or diarrhoea.

Developmental Problems
GDD
Your next patient in GP is a 8 month old baby boy, Dennis, brought in by his mom, Ariel, because her
son cannot sit with support.
Your tasks:
• Take further history for 5 mins
• Physical examination card from the examiner
• Tell the Differential diagnoses to mom
PEFE Card
• General appearance – looks well, vitals – normal
• Head circumference –10th percentile, weight and height – 50th percentile
• Low set ears, upward slanting of eyes, single palmar crease – all nil
• No Jaundice, No tongue protrusion
• Nervous system and back –
- inspection –no deformity, meningocele – nil
• Truncal hypotonia positive

History
• Show sympathy
• Ask milestones backwards and stopped when achieved, ask when did he achieved?
• Gross motor – Can he roll over the bed?
- Can he maintain his head upright?
• Fine motor – Can he pass things from hand to hand?
▪ Can he hold objects with his hands?
• Language - Can he say bi Syllables? (MaMa, DaDa)
▪ Does he turn to voice?
• Personal, social – Does he try to reach toys out of reach?
- Is he friendly to all comers?
• Hearing and vision – Does he enjoy musical toys? Turns towards sound? Eye contact?
 • DDx – CP – spastic/stiff legs?
- Down – Any feeding difficulties? Swallowing?
- Hypothyroid – Heel-prick test? Floppy? High-pitch cry?
- Any head injury? Nausea and vomiting? (SOL)
• BINDS history
• Birth – any infections during pregnancy? Any medications? Check-ups? How was the delivery?
Assisted? Any complication? How long was the labour? Term/preterm? Cry immediately after
birth? Any resuscitation? Any infection?
• Immunization
• Nutrition in details – breastfed or bottle? Any regurgitation?
• Social – Who looks after? Financial problem? How are you coping? (abuse)

Explain
• From the history and examination, Ivan seems to take longer to reach certain developmental
milestones than other children of his age. We measure those aspects including learning to walk or
talk, movement skills, learning new things and interacting with others socially and emotionally.
When there is delay in two or more areas, we call it Global developmental delay.
• Causes for GDD- congenital hypothyroid in which the child has lower thyroid hormone levels since
birth, cerebral palsy which is a non-progressive brain damage, Downs syndrome which is an
abnormality in the child’s gene, epilepsy, Tumors in the brain, or trauma.
• At this stage I would like to refer him to a specialist pediatrician who will do a full developmental
assessment and diagnose the underlying condition.
• (some cases, it could be physiological delay, prematurity)

Global developmental delay

You are a GP. You have been visited by a mom of in 21 month old child, Ivan who is not able to walk
yet. The mom is Susan.
Tasks
• history
• PEFE
• DDs

History
• Show sympathy
• Ask milestones backwards and stopped when achieved, ask when did he achieved?
• Gross motor – He cannot walk I understand. So can he stand without support? With support? Sit
without support?
• Fine motor – Can he scribbles? Build a tower of two blocks? grasp a pellet? Hold things with both
hands?
• Language – Can he speak other words than MaMa DaDa? Can he speaks MaMa DaDa? Do you think
he knows the meaning?
• Social – can he feed himself? Drink from a cup? Indicate wants? Give up a toy? Afraid of strangers?
• BINDS Birth history really important in this case
• Antenatal screening? Heel-prick test, any resuscutation, yellow skin, hospital stay
• Any siblings? How about them? Who is looking after the baby?Any trauma?
• Any changes in poo and pee?
 • hoarse cry, dry skin
• CP - any fits, any scissoring, stiffness

Explain
• From the history and examination, Ivan seems to take longer to reach certain developmental
milestones than other children of his age. We measure those aspects including learning to walk or
talk, movement skills, learning new things and interacting with others socially and emotionally.
When there is delay in two or more areas, we call it Global developmental delay.
• Causes for GDD- downs syndrome which is an abnormality in the child’s gene, epilepsy, Tumors
in the brain, cerebral palsy which is a brain damage or congenital hypothyroid in which the child
has lower thyroid hormone levels since birth or trauma.
• At this stage I would like to refer him to a specialist pediatrician who will do a full developmental
assessment and diagnose the underlying condition.
• (some cases, it could be physiological delay, prematurity)

Note
• Microcephaly <3rd percentile
• Primitive reflexes should disappear by 6-8 months of age

CP
Your next patient in GP is a 8 month old baby boy, Dennis, brought in by his mom, Ariel, because her
son cannot sit with support. You saw the patient 6 months ago when he came for routine immunization.
Then he missed his 6 month immunizations because his grandma passed away and mom didn’t have
time to come to the GP. Today Mom presented that her son cannot sit with support.
Your tasks:
• Take further history
• Physical examination card from the examiner
• Explain the diagnosis to mom

Approach
• DDX - Global delay – Down
- CP
- Autism
- Hearing and vision problem
- Local – Meningomyelocele
- Trauma

• If cannot use one side of body, add – infection, SOL, spinal injury

History
• Show sympathy for the loss
• Before immunization, concern is – cannot sit with support
• Gross motor – Can he roll over the bed?
- Can he maintain his head upright?
• Fine motor – Can he pass things from hand to hand?
 ▪ Can he hold objects with his hands?
• Language - Can he say bi Syllables? (MaMa, DaDa)
▪ Does he turn to voice?
• Personal, social – Does he try to reach toys out of reach?
- Is he friendly to all comers?
• Hearing and vision – Does he enjoy musical toys? Turns towards sound? Eye contact?
• DDx – CP – spastic/stiff legs?
- Down – Any feeding difficulties? Swallowing?
- Hypothyroid – Heel-prick test? Floppy? High-pitch cry?
- Any head injury? Nausea and vomiting? (SOL)
• BINDS history
• Birth – any infections during pregnancy? Any medications? Check-ups? How was the delivery?
Assisted? Any complication? How long was the labour? Term/preterm? Cry immediately after
birth? Any resuscitation? Any infection?
• Immunization
• Nutrition in details – breastfed or bottle? Any regurgitation?
• Social – Who looks after? Financial problem? How are you coping? (abuse)

PEFE
• General appearance – looks well, vitals – normal
• Head circumference – smaller than normal, weight and height – 50th percentile
• Low set ears, upward slanting of eyes, single palmar crease – nil
• No Jaundice, No tongue protrusion
• Nervous system and back –
- inspection – deformity, meningocele – nil
• Left hand and legs not moving, No fasciculation and muscle wasting
- Tone – increased on left side, Both upper and lower limb, jerk is also exaggerated

• Diagnosis – many causes but most likely Cerebral palsy. It is a non-progressive brain disorder
associated with posture and movements. May also associated with vision, hearing, lungs, feeding,
speech problems but now I don’t find those defects in your history.
• There are many different type. This type is spastic diplegia which affect one side of the body.
• The causes of this condition are infections during pregnancy, prolonged labour and birth asphyxia
(suffocation during birth), prematurity
I understand that this is tough for you but we are going to take care of him with a group of
specialists And also support groups available.
• Many patients with CP can lead a normal life with the improvement of the quality of care these
days, we will work together for the best outcome

• Paediatrician , ENT specialist, nutritionist, speech pathologist, physiotherapist, ortho surgeon,

social worker, occupational therapist – mention in details when management is asked.
• Warning signs of developmental delay!
• Generally it is more than 3 months of delay
• Does not follow moving objects with eyes by 2-3 months
• Cannot support head by 3 months
• No interest in peek-a-poo at 10 months
• Cannot point with index finger by 1 year
 • Cannot walk at all at 18 months
• Dramatic loss of skills once he or she once had

Hearing loss with audiogram

You are a general practitioner. A 3 years old child, Kelly, was brought to you by parents complaining
about speech delay. And they had their Audiometry done and the result is shown. The mom, Winnie, is
here now.
Tasks:
• History
• PEFE
• Explain the result and give differentials to the mother

History
• open question
• Speech – Two words sentences? Can she speak? One words? Bi-syllables? Respond to
sound/name?
• Other parameters, Can she run? Jump? Build a tower of 4 blocks? Feed herself with spoon?
• Family history – anyone with hearing problem? (Otosclerosis)
• BINDS (especially infections during pregnancy, toxemia in pregnancy, use drugs esp thiazides,
Genta, heart problems), perinatal problems – term? MOD? Any problem? Resuscitation? Jaundice?
 • Generally healthy? Ear infection? Respiratory infection? When? How frequent? How was it
treated?

• PEFE – general, vitals, Growth chart

• ENT examination
• Otoscopy
• Systemic examination – respiratory, CVS, Abdominal, Motor

• Explain the audiogram - Explain the audiogram – This is the audiogram which we draw a graph
according to the frequency of the sound he could hear. The red circles are for right ear and blue
cross are for left. So as you can see here, the hearing level of the right is reduced, falling in between
20-40 dB which indicates the mild hearing loss.
• There are two types of hearing loss, conductive which happens because of the structural defect
and sensorineural which happens because of nerves.
• What we tested is for conductive loss now.
• conductive hearing loss – some structural defect in conducting sound, like obstruction. Repeated
ear infection – resolved by forming granulation tissues – obstruct – hearing loss
• Other possibilities – Global developmental delay, Injuries, fluids in the ear, infections, less likey to
be tumor

Rash (kindly check the powerpoint for summary of all kind of rashes in Paed)
Scarlet fever
A 6 year old girl, Kelly, has sore throat, fever with chills, Strawberry tongue, perioral pallor, rash
(sandpaper like feeling). You are now talking to her mom, Paula.
Tasks:
• -Explain dx/ddx to mother
• -Counsel the mother accordingly about your provisional diagnosis
• -Management to mother

• Most likely – scarlet fever. The other possibilities would be measles, chicken pox, Rubella, other
viral rash, HSP and allergy but unlikely.
• Scarlet fever is an illness that can happen in kids who also have strep throat or strep skin infections.
The strep bacteria make a toxin that causes a bright red, bumpy rash.
• The rash spreads over most of the body and is what gives scarlet fever its name. It often looks like
a bad sunburn with fine bumps that may feel rough like sandpaper, and it can itch. It usually starts
to go away after about 6 days, but might peel for several weeks as the skin heals.
• In most cases, antibiotics are not needed and will improve with supportive management

• The rash is the main sign of scarlet fever. It usually starts on the neck and face, often leaving a clear
area around the mouth. It spreads to the chest and back, then to the rest of the body. In body
creases, especially around the underarms, elbows, and groin, the rash forms red streaks.
• Other symptoms of scarlet fever include:
• a red, sore throat
• a fever above 101°F (38.3°C)
• swollen glands in the neck
 • Also, the tonsils and back of the throat might be covered with a whitish coating, or look red,
swollen, and dotted with whitish or yellowish specks of pus. Early in the infection, the tongue may
have a whitish or yellowish coating. A child with scarlet fever also may have chills, body aches,
nausea, vomiting, and loss of appetite.
• To confirm whether a child has scarlet fever, depending on the child’s history, I MAY need to order
a rapid strep test or throat culture (a painless swab of the throat) to check for the strep bacteria.
• Eating can be painful for kids with severe strep throat, so serving soft foods or a liquid diet may be
best. Include soothing teas and warm nutritious soups, or cool drinks, popsicles, or slushies. Make
sure that your child drinks plenty of fluids. You can give over-the-counter acetaminophen or
ibuprofen for fever or throat pain.
• If the rash itches, make sure that your child's fingernails are trimmed short so skin isn't damaged
through scratching. Try an over-the-counter anti-itch medicine to help relieve the itching.
• In a few cases, scarlet fever is treated with antibiotics. Antibiotics kill bacteria and help the body’s
immune system fight off the bacteria causing the infection. Make sure your child complete the
entire course of the prescribed medicationif antibiotics are given. This will help prevent the
infection from causing complications like the rheumatic heart disease or kidney disease (APSGN)
or continuing further. The child should stay at home while they are unwell or at least 24 hours after
starting antibiotics.
• Practicing good hygiene is the best way to prevent scarlet fever. Here are some prevention tips to
follow and to teach your children:
➢ Wash your hands before meals and after using the restroom.
➢ Wash your hands anytime you cough or sneeze.
➢ Cover your mouth and nose when sneezing or coughing.
➢ Don’t share utensils and drinking glasses with others, especially in group settings.

Kawasaki
You are a GP and a 3 year old boy was brought to you by mom because the child has fever and rash.
Tasks:
• History from mother
• Ask examination findings from the examiner
• Diagnosis and management

History
• which came first?
• Fever Questions)→ since when? Have checked the temperature? Did you give medication? Did it
work? Any chills and rigors
• Rash Questions
• Site
• Distribution
• Duration
• Color
• Radiation
• How does it look like?
• Associated Symptoms : vomiting, Urinary symptoms (waterworks→ number of wet nappy, is it
smelly, cries while pee), Joint pain, headache, bowel habit. If present ask in detail each.
 • Any previous similar problem? Changed any cream or medication? Changed any shampoo or
shower gel or nappy brand (imp in case of nappy rash )?
• Kawasaki features (fever for 5 days plus 4 of the 5 criteria)
1. Conjunctivitis - Any red eye?
2. Lip and oral mucosa - Mouth? Ulcer? Tongue changes?
3. Desquamation in extremities - Rash in palms and soles? Swellings? Pain?
4. Kawasakii rash
5. Lymphadenopathy - Any swelling in the body?
• CRASH – Conjunctival, Rash, Adenopathy, Strawberry tongue, Hand and feet
• BINDS :
• General Health: Baby: feeding and sleeping well?
▪ Child: Growth and development
• Social History
• Similar problem In childcare and family
• Any complaint/Notices from Childcare
• Allergy History: If present, then details.(any pets)

General Appearance: Alert or drowsy,

• Signs of dehydration – CRT, skin, turgor, sunken eyes, mucous membranes, Anterior frontanalle
• Rash- Site, Distribution, Characteristics, blanchable or not, scratch Marks, secretions etc
• Growth Chart
• Vitals- Pulse, RR, BP, Temp, Saturation
• Lymph Node enlargement
• Neck Stiffness
• Eye – conjunctivitis, mouth mucosa, dry cracked lips, strawberry tongue
• ENT examination
• Hands and feet (desquamation)
• Systemic Examination- Cardiovascular, Respiratory, Abdominal
• (Genital Examination with permission of parents)esp in nappy rash

Explanation
• Condition called Kawasaki Disease→ our immune system produces some chemical substances
called antibodies to fight against infection. But sometimes these start acting against our own body
tissues without known cause. Here, these are acting against your child blood vessels (tube like
structure which carry blood to all parts of body) systemic vasculitis (skin – rash, Heart –
aneurysm)
• Reassure mother it is manageable
• Need to admit call ambulance and transfer as child is severely ill and need to undergo some
blood test
• Seen by a paediatrician and start him on iv fluids
• Invx: FBE (platelet count- as thrombocytosis can occur), ESR/CRP, UEC, LFT, Blood Culture, serum
to store, urine RE (sterile pyuria), Echo
• Treatment is immunoglobulin(substance that act against his immune system) and aspirin (to
reduce risk of clogging of blood cells)
• One main complication is affecting blood vessels supplying the heart so he needs to undergo
Echocardiogram scanning of heart which is is a painless procedure and needs regular follow up
in this regard later in future (initially right now, and after 6 weeks)
Measles
You are an intern at ED. 9 months old baby, Ivan, brought to you by his mom, Katie, as he got fever and
rash. Now he has been given fluids at ED.
Tasks:
• Take history for 5 mins
• PEFE
• Advice about the further management

History
• which came first?
• Fever Questions)→ since when? Have checked the temperature? Did you give medication? Did it
work? Any chills and rigors
• Rash Questions
• Site
• Distribution
• Duration
• Color
• Radiation
• How does it look like?
• Associated Symptoms : Cough? Runny nose? vomiting, Urinary symptoms (waterworks→ number
of wet nappy, is it smelly, cries while pee), Joint pain, headache, bowel habit. If present ask in detail
each.
• Any previous similar problem? Changed any cream or medication? Changed any shampoo or
shower gel or nappy brand (imp in case of nappy rash )?
• BINDS :
• General Health: Baby: feeding and sleeping well?
▪ Child: Growth and development
• Social History
• Similar problem In childcare and family
• Any complaint/Notices from Childcare
• Allergy History: If present, then details.(any pets)
• General Appearance: Alert or drowsy,
• Signs of dehydration – CRT, skin, turgor, sunken eyes, mucous membranes, Anterior frontanalle
Rash- Site, Distribution, Characteristics, blanchable or not, scratch Marks, secretions etc
• Growth Chart
• Vitals- Pulse, RR, BP, Temp, Saturation
• Lymph Node enlargement
• Neck Stiffness
• Eye –
• Mouth – Koplick’s spots (spots like grains of white sand surrounded by red area)
• ENT examination
• Hands and
• Systemic Examination- Cardiovascular, Respiratory, Abdominal
• (Genital Examination with permission of parents)esp in nappy rash

Explanation and management

• Measles - Measles is a viral infection that causes a fever and a distinctive rash on the body. Measles
is highly contagious and is spread easily through droplets from coughing and sneezing. Other DDx
– chickenpox, Rubella, allergy, meningococcaemia and other viral rash but less likely
• Most children who have measles are sick for less than a week, and should start to feel better about
two days after the rash appears. The cough may persist for two weeks.
• Sometimes, measles can cause a secondary infection – children may get ear infections,
pneumonia or diarrhoea and vomiting when they have measles. A rare but serious complication
of measles is encephalitis (inflammation of the brain).
• Notified to DHS
• No antibiotics is needed. You can make your child more comfortable by:
• encouraging plenty of rest
• offering them plenty to drink to avoid dehydration
• I will give Panadol for his fever
• Red flags - getting worse, vomiting and unable to drink much
• Seems more sleepy than usual, fits and confusion
HSP
You are a HMO at ED, a 4 years old boy, George, brought by his father, William. His son complained of
severe abdominal pain and he also noticed limping gait on his son, There is also rash over his son’s leg.
Your tasks:
• Take history
• Ask physical examination card from the examiner
• Explain the diagnosis
• Management with father

Outline of approach
• Three problems – which came first?
• Abdominal pain –site? Any particular time he complained of pain? Where exactly is the pain? Did
George cry because of pain? Any swelling or redness over the tummy?
• Rash – when did you noticed? Where is the rash? Other areas? Color? Does he scratch a lot? Any
pain over the rash?
• Limping – when which leg? Any swelling? Redness?
• Family history of similar problem?
• DDx – Is he hot to touch? (septic arthritis)
• Was there any fever or illness a few days ago? Any changes in poo and pee? Any blood? (HSP)
• Any bleeding from gum and nose? (ITP)
• Any bleeding problems like haemophilia?
• Severity – Does he look as usual? Eat well? Sleep well?
• BINDS

PEFE – General condition - good, Vitals – Bp – 100/60mmHg, Pulse – 84/min

• Nature of rash – as photo not blanched on pressure
• Abdomen – normal except mild tenderness
• Joint- movement limited due to pain otherwise normal
• Urine dipstick – RBC
• Investigations – Full blood examination normal, abdominal ultrasound normal

• HSP – tummy pain, joint pain and rash

• May follow viral infection, body produces antibodies to virus – cross reaction of antibody against
blood vessels all round the body, causing inflammation – vasculitis
• Vessels in Kidney – blood in urine (nephritis)
• Vessels in Bowel – tummy pain
 • skin vessels – rash
• Common condition at school going age
• Risk – Obstruction of the bowel and inflammation of affected organs
• Admission, inform registrar.
• Urinalysis to make sure that there is no renal involvement
• He will be on painkillers to reduce his joint pain (Panadol or Ibuprofen, if very severe he’ll be on
steroids which will shorten the duration of joint and abdominal pain)
• 30 % recurrence in first 4 months, regular follow up to check for the possible renal complication
• (Weekly for the first month after disease onset,
• Fortnightly from weeks 5-12,
• Single reviews at 6 and 12 months)

Peanut allergy
A 18 month old baby brought by his father to the GP with a rash round his mouth
• Task – history
• PEFE
• Dx and DDx to father
• Management

• Rash – 1st time? Site? Itchy? Pain? How long? Any other site on the body? Any relieving or
aggravating factor?
• Causes – any touch to chemicals, plants or animals? Any new food that he never has eaten before?
Drugs? Recent flu-like illness? New creams? Insect bites? Any possibility of burn by hot food or
drinks?
• Does he have any history of allergy? Eczema?
• Severe symptoms – changes of voice, swelling of tongue or throat, turning blue, sweaty, trouble
breathing? Can he eat well? (painful?)
• Any family history of allergy, asthma, eczema?
• BINDS (elder sis present in the history)
• What about other members? What are they having during breakfast? Is there any possibility that
his elder sister gave peanut butter to him?

• PEFE – General appearance, vitals, growth chart

• Examination of rash
• Any other rash in the body
• Respiratory examination
 • CVS and abdomen
• UDT, Blood sugar

• Possible causes – peanut allergy

• it could be due to allergy to new creams, drugs, plants or animals, or sometimes contact with some
metals like Nickel, or insect bite or viral infection but less likely according to the history
• Management – Antihistamine will be given and observation. Refer to allergen specialist after a few
days. Please avoid peanut next time. Majority of food allergies are not dangerous.
• If notice – SOB, turning blue, cannot talk, LOC – go to emergency

Herpes stomatitis
You are a GP. A mother, Kendy, brings two year old son,Nick, who is refusing to eat ,crying a lot and
has become irritable.
Task :
• History
• Physical examination Findings From Examiner
• Diagnosis and Management

• Why do you think he is refusing? Ill? History: since when not eating? Has he been drinking Noticed
any ulcers/rash near mouth? Did you give any hot food or drinks? Is it the first episode? Any fever?
Check for any immuno-comprised state?(medical condition in mom, HIV)
• Fever Questions → since when? Have checked the temperature? Did you give medication? Did it
work? Any chills and rigors
• Rash Qs- when and where did rash start? Any where else in body present (palms, soles and hand)?
any aggravating (worse) or relieving factor (better)? Itchy? Can you describe it for me
• Associated Symptoms : vomiting, Urinary symptoms (waterworks→ number of wet nappy, is it
smelly, cries while pee), (Joint pain, headache), bowel habit extra. If present ask in detail each.
• Any previous similar problem? Changed any cream or medication?
• BINDS :
• General Health: Baby: feeding and sleeping well?
▪ Child: Growth and development
• Social History
• Mother Coping
• Similar problem In childcare and family
• Any complaint/Notices from Childcare
• Allergy History: If present, then details

Examination
• General Appearance: Alert or drowsy,
• Signs of dehydration – CRT, skin, turgor, sunken eyes, mucous membranes, Anterior frontanalle
• Rash- Site, Distribution, Characteristics, blanchable or not, scratch Marks, secretions etc
• Growth Chart
• Vitals- Pulse, RR, BP, Temp, Saturation
• Lymph Node enlargement
• Neck Stiffness
• ENT examination
 • Systemic Examination- Cardiovascular, Respiratory, Abdominal
• Genital Examination with permission of parents
• Herpes stomatitis
• +ve point : Fever, Refusing to eat and drink, Ulcers around mouth
• Examination: Signs of dehydration, Shallow Ulcer over angle of mouth, Mild cervical LN may be
present

Explanation:
• Condition is Herpes stomatitis→ viral infection caused by bug named Herpes virus.
• Common condition, Clinical diagnosis, self limiting
• Starts with fever and has ulcers around mouth.
• Not feeding as the ulcer is painful
• Treatment is symptomatic rest, adequate fluid, panadol (not aspirin) for fever ,Antibiotics are of
no use. No role of antivral
• Will give lignocaine gel apply it around the ulcer and try to feed him if works continue applying
it at home every 3 hour and give him ample fluid
• Also recommend liquid diet of cool to cold and no acidic drinks
• 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.
• Red flags: if not able to feed well, he is feeling lethargic bring back to me or take him to ED
• Review and reading materials
• (If child is severely dehydrated then send to hospital for admission and iv fluids)

Spider bite
You are a general practitioner. A father, John and his son, Denny came to see you. Denny is 4 years old.
He has been crying up since he woke up from a nap. John is willing to know what happened.
Your tasks:
• Take history
• Physical examination from examiner
• Diagnosis and differential diagnosis

Outline of approach
• How can I help you?
• What was he doing before the nap?
 • Do you know why was he crying?
• Notice any swelling? Redness in the limbs?
• Any changes? Can he walk? Where is the pain?
• Any fever? Vomiting? Rash? Injury?
• Severe symptoms – any breathing difficulty? Noisy breathing? Shortness of breath? Blue lips?
Collapse?
• BINDS

• PEFE – general, vital signs , rash picture, systemic – respiratory, CVS, lower limb examination

• Explain – some sort of insect bite, spider bite while playing in the backyard. Differentials – cellulitis,
injury, allergic reaction, septic arthritis
• Reassure – local reaction and swelling, no systemic symptoms such as shortness of breath
• Go to emergency if SOB, racing of the heart, noisy breathing, turns blue , other rashes, dizziness,
sweating
• Try ice-compression to reduce the swelling

Infectious Mononucleosis
A 10-year-old child presented to you with a fever for 3 days (102’F). You are a HMO at ED. She was
having a sorethroat and she wasn’t improved. Now the rash came out. The mother was very worried
and came to see you.
Your tasks:
• History for 5 mins
• Physical examination from the examiner
• Manage the patient

• PEFE –temperature – 39.5, heart rate - 92, respiratory rate - 14, oxygen saturation – 99%)
• No Wheezing, No dyspnea
• General condition –alert
• No neck stiffness
• Respiratory system examination - unremarkable
• Tonsil examination – enlarged tonsils on the right side, erythematous, swollen with white patches
• Lymph nodes examination – 2 enlarged cervical lymph nodes
• Abdominal examination – enlarged spleen
 Rash

• which came first?

• Fever Questions)→ since when? Have checked the temperature? Did you give medication? Did it
work? Any chills and rigors
• Rash Questions
• Site
• Distribution
• Duration
• Color
• Radiation
• How does it look like?
• Associated Symptoms : Neck rigidity, vomiting, Urinary symptoms (waterworks→, is it smelly, pain
while pee), Joint pain, headache, bowel habit. If present ask in detail each.
• Any previous similar problem? Changed any cream or medication? Changed any shampoo or
shower?
• BINDS :
• General Health: eating and sleeping well?
▪ Child: Growth and development
• Social History
• Similar problem In family
• Any complaint/notice from school
• Allergy History: If present, then details.(any pets)

Explanation in details
• from history and physical examination, your child most likely has a condition called glandular fever
or it might be a reaction to the antibiotic. It is caused by a virus called EBV, which is usually spread
by direct contact with saliva.
• -This viral infection most of the time can initially mimic tonsillitis caused by a bacteria bug that is
why the previous GP might have started him on antibiotic.
• -in this viral infection, 90% of cases develop rash after start of antibiotic, so we need to stop
antibiotic and the treatment is just supportive. We confirm by doing a serology and full blood
examination.
• So now management:
• This is self limiting condition. Will get better in some time.
• Only thing u need to do is
 • let him take a lot of rest. Give plenty of fluids.
• Paracetamol for fever.
• If fever gets worse or his condition is not improving, or when there is difficulty in swallowing or
tummy pain, just get back to me.
• contact sports and heavy lifting should be avoided for the first month after illness because of risk
of damage to the spleen, which is enlarged now.
• Most patients with glandular fever recover uneventfully.
• Reading material, review.

Fits and headache

Febrile convulsion
You work as GP in suburban Melbourne, you are going to see Matthew, who tells you that his 2 year
old son, Steve, just had a convulsion for about 3 minutes. He is most upset and wants to get your advice
what to do.
Your tasks:
• Take relevant history
• Explain the diagnosis
• Advice for management

Approach
• Check stability
• Who witnessed 1st time?
• Before – what was he doing? What happened exactly? Any excessive sweating? Blue lips? Fever ?
(if +, how long, how high?), if playing, head injury?
• During – any change in posture? Stiffness? How long did it last? Did he wet himself or loose poo?
Bite his tongue or lips?
• Recovery – how did he recovered? Pallor? Drowsy or weak after recovery?
• DDX – infection – any cough, runny nose, rash?
• Breath holding attack – is he a stubborn child?
• SOL – any head injury? Weakness in limbs? Abnormal movement?
• Hypo/hyperglycaemia- Any change in his poo and pee? Appetite? Sleep well?
• BINDS
• Family history of epilepsy, febrile convulsion
• Does he go to day care?

• Explain- most likely due to febrile convulsion. But I need to examine him and also run some blood
tests including blood sugar and chemicals in his blood, CXR and urine to confirm it, to know the
source of infection since he has fever and exclude other conditions.
• A febrile convulsion is a common condition where a child has a convulsion or fit that is brought on
by a high temperature (fever, >38°C.), in the absence of diseases in the brain.
• Most children with fever suffer only minor discomfort. However 1 in 25 children will have a febrile
convulsion at one time or another. This usually happens between the ages of 6 months and 4/6
years. It is because their brain is immature compared to adults to adapt the height of temperature.
• Febrile convulsions are not harmful to the child and do not cause brain damage.
 • Not related to epilepsy. In epilepsy – pathology is abnormal electrical impulses in the brain causing
abnormal movement and seizure.
• Long term – it’s recurrent before 4-5 years. So whenever he has fever- Give Panadol, Tepid
sponging, Seizure happens –lie on side or abdomen, remove tight clothings, do not restrain, do not
put anything into mouth, note the time, consult with the doctor next day
• Test for epilepsy (EEG) is not indicated unless patient has prolonged or recurrent fits
• Red flags : Prolonged fits more than 5 mins, focal neurological deficit after fits, drowsy after fits,
high fever, rash, neck stiffness
• Reassure – less likely to be epilepsy

Breath Holding Attack

Your next patient in GP is a 3 years old boy, Simon, brought by his father, Jim. The father was very
anxious because Simon had a brief episode of seizures a few minutes ago. So he is very concerned and
willing to consult you.
• Your tasks:
• Take history from dad
• Physical examination from the examiner
• Explain about the diagnosis

Outline of approach
• Vitals – stable
• Fits in details –
• before- what was he doing?
• during - 1st time? Witnessed? Loss of consciousness? How long did it last? Did he turn blue? Breath
holding attack) Posture? Flex? (tonic, clonic) Limbs stiffness? Did he wet himself? (epilepsy), Did
he loose poo? Did he bite tongue? How did he recovered?
• After recovery – did he look alert or drowsy? Any weakness?
• DDx – Is he a stubborn child? Is he easily upset when you say no? ( breath holding attack)
- Did he skip meals ( Hypoglycaemia)
- Any head injury ?
• Any history of heart disease?
• Any history of epilepsy?
• Any fever? Cough? (febrile convulsion), rashes (meningitis)
• BINDS history – S – social- Home situation?
• Family history of epilepsy?
• Note : (if not first time, how did you respond after each episode? Any reduction of displine?)

PEFE
• General appearance, vital signs, growth chart, head injury, limb weakness, murmurs, bedside test
– ECG
• Local examination (if there is injury) – bruising, bleeding, any possibility of a fracture.

Explanation –
• Well conscious and healthy
• BHA or spells most possible according to the history
• Common in this age (6months to 6years peak 1-2 years)
 • Reaction to frustrations, minor injuries, being upset or angry
• Response by crying briefly then involuntarily hold the breath- cyanosis or blue – results in low
oxygen supply to the brain – loss of consciousness (hypoxic spell), everything’s normal, no
pathology inside the brain.
• Epilepsy? Epilepsy is the pathology inside the brain, hence there will be evidence in imaging of
brain. Features associated with whole body seizure, limb stiffness, biting of tongue, wet himself.
More likely to be BHA.

• Not the task in this case (management)

• Check the injury if present, painkiller
• Advice – reassure, not harmful. Observe the child, avoid painful events. Displine should not be
changed because of BHA. When happens again,
- lie the child on left side
- avoid excessive attention
- no need to blow air or splash water
- after the event, treat the child like this wasn’t happened (no discussion, punishment)
• Review, recheck understanding

Migraine/tension headache
You are a GP. 6 yrs old girl, Clarie, with headache. Talk to father, Thomas.
• Task –
• hx, Pefe, Dx and ddx,

PEFE – GA – well alert, well conscious, vitals - normal

• No pallor,
• No lymph nodes enlargement
• growth chart – normal
• Eye –no eyeball tenderness
• Cranial nerves – 2nd, 3rd, 4th, 6th - normal
• Fundoscopy - normal
• ENT, Sinus palpation - unremarkable
• No - Neck stiffness and rashes
• Neurological examination of upper and lower limb, other cranial nerves examination - normal
• Systemic - Respiratory, CVS, abdomen - unremarkable
• UDT, blood sugar- normal

D.Dx
• Viral infection
• Migraine ( photophobia + )
• Tumor
• Tension HA
• Sinusitis ( OM / URTI )
• Meningitis ( photophobia + )
• Vision problems
• Psychological
• Headache Qs→

• In Aggravating Factors: Flashes of light, any movement of head, straining like coughing, hard to
stay in Bright light
• Associated Factors for DDx: Fever, n/v, cough, sore throat, runny nose, watering of eye, h/o injury,
lumps and bumps in head, ear pain/discharge, visual problem, LOC, weakness, gait problem, any
fits?
• BINDS→ is she eating well? Is there any concern about the development? Do you have any other
kids? Any major difference you find with development of both?
• Any medical illnesses? (hypercoagulable state, genetic disorder, cancer, rheumatological disorder,
immunosuppression, hypertension may lead to headache)
• Go detail into social Hx→
• Are you a happy family? Do you spend time with her? Do you have financial problems? Does she
go to school? Does she like her teachers? Has she ever complained about any bullying? How is her
school performance?
• Family Hx→ migraine, similar problem etc

• Explanation (please put migraine at the first place if anything positive for migraine!) – It could be
migraine which is the recurrent headaches caused by dilation of blood vessels and release of
chemicals. It can be triggered by stress so in her case, it might be triggered by the divorce. Another
possibility is the stress headache or tension headache. As we all know, our body and mind work
together hand in hand. If there is some stress in the mind, the body sometimes express it as bodily
symptoms like abdominal pain, cough, aches in limbs. For Laura, it’s expressing as headache. Other
conditions are recurrent viral infection, sinusitis (infection in the bony spaces of face), very less
likely inflammation of the brain coverings or tumor.
Increased ICP (history taking is the same)
• PEFE – GA – well alert, well conscious, vitals - normal
• No pallor,
• No lymph nodes enlargement
• growth chart – normal
• Eye –no eyeball tendernessCranial nerves – 2nd, 3rd, 4th, 6th - normal
• Fundoscopy pic attached

• ENT, Sinus palpation - unremarkable

• No - Neck stiffness and rashes
• Neurological examination of upper and lower limb, other cranial nerves examination - normal
• Systemic - Respiratory, CVS, abdomen - unremarkable
• UDT, blood sugar- normal

• I found some changes in the eyes which is showing that she has increase intracranial pressure, that
means she has increased pressure inside her head. There are a number of possibilities.
• Idiopathic intracranial hypertension (when there is no obvious cause)
• Hydrocephalus (imbalance between production and reabsorption of brain fluid results in increased
amount of fluid)
• Other intracranial malformations (enlarged vessels in the brain)
• Intracranial neoplasma inside her head. (nasty growth inside her head)
• Infections in the brain or brain coverings but unlikely since the headache is already months.
• We need to run a few investigations to know the underlying cause. She needs blood investigations
and imaging MRI. So she will be admitted.
• The treatment is depending on the underlying cause. We treated with drugs for idiopathic
intracranial hypertension to reduce the pressure inside the head, insertion of shunt or tube for
hydrocephalus, blocking (embolization) or some surgeries or with radiation for vessels
malformation and surgery to remove if it is a nasty growth.
Unprovoked seizure
You are a HMO at ED. Your patient is a 5 years old boy who got seizures or fits at home for 8 mins and
now he is brought to you by his dad. The only witness is his dad. His dad was telling him that it was
sudden onset happened during while he was playing which lasted for 8 minutes. There was upward
rolling of his eyes, stiffness, jerky movement in upper limbs and lower limbs. He is stable right now.
your tasks:
• Take relevant history
• Explain about the condition and findings to the dad
• Mention possible causes.
Differential diagnosis
• CNS - epilepsy, infection, febrile conversion, SOL
• Head injury
• hypo/hyperglycemia
• electrolytes imbalance
• Breath holding attack
• Arrhythmia

History
• Check stability
• Who witnessed 1st time?
• Before – what was he doing? What happened exactly? Any excessive sweating? Blue lips? Fever ?
(if +, how long, how high?), if playing, head injury?
• During – any change in posture? Stiffness? How long did it last? Did he wet himself or loose poo?
Bite his tongue or lips?
• Recovery – how did he recovered? Pallor? Drowsy or weak after recovery?
• DDX – infection – any cough, runny nose, rash?
• Breath holding attack – is he a stubborn child?
• SOL – any head injury? Weakness in limbs? Abnormal movement?
• Hypo/hyperglycaemia- Any change in his poo and pee? Appetite? Skipped his meal?
• BINDS
• Family history of epilepsy, febrile convulsion

• Hello Mr, I understand you are very much concerned about your son, now he is totally stable and
well conscious.
• Let me explain you about what exactly happened in him. According to history by you, he had
convulsion or seizure, which means sudden onset and he lost his conscious level for a few minutes.
During the attack from a stiffness of the whole body an upward rolling of the eyes were there, we
call it seizure. And since it is not preceded by any factors, we call it unprovoked seizure.
• There are many reasons for having seizures. Seizures or fits can be due to many causes. So let me
discuss with you a few things. But I am very much concerned for the continuous fit lasted for 8
mins. It is called status epilepticus. Most likely, it could be epilepsy which is abnormal electrical
discharge produced in the brain. The body parts which are controlled by affected area got seizure.
There is recurrent tendency to get seizure.
 • Another reason is that it could be due to high fever which we call febrile convulsion. Because in
febrile convulsion, immature brain in the children are unable to adjust the body temperature which
result in seizures. This is less likely because he doesn’t have any fever.
• Another possibility is it could be infections in the brain or it’s covering. But it is less likely according
to the history because he doesn’t have any rash or he is relatively well. It could be some sort of
head injury as one of the possibilities but it is less likely again because he didn’t have any history
of head injury. It could be space occupied lesion in the brain like brain tumors or Abscess inside
the Brain but since there is no weakness on his limbs and since there is no vomiting, nausea and
no weight loss, it is less likely as well. And the next thing we need to consider is the low or high
blood sugar levels. They can also cause fits. Another causes chemical levels in the blood which is
one of the possibilities.
Management
• So now we haven’t identified the causes so he needs to be admitted for further assessment.
Specialists will do the further assessment. So I will inform this to the paediatrician now.
• We will need investigations to rule out other possibilities and to identify the cause which will
include blood tests for the blood glucose and blood chemicals plus he will need imagine of the
brain. And the specialist will arrange investigations. He is safe and under close observation now.
We can identify the exact cause when the results came back if imaging and a blood test everything’s
normal most likely cause will be epilepsy.
• We don’t usually do imaging of brain waves (EEG) for epilepsy in the first attack but I’m a bit
concerned that his fit was taking more than 5 mins. So he might need this imaging but specialist
will decide.
• So as a management we, we are going to run a few investigations and look for the causes. He
currently doesn’t need to take any medications unless there is fever to suggest for any infections.
• After the first attack of seizure, only 1/3 of the children experience further episodes. So the
treatment will be decided by the specialist based on the findings of the results. We are going to
run for those tests for epilepsy if any next attempt occurs and lasts for more than five minutes. If
it is diagnosed as epilepsy, he will need to take regular medications to control seizures and. So
whenever he got the seizures next time, during the attack, keep the child on his head with his chin
up. Do not put anything inside the mouth,. Take off clothing do not restraint. When eating foods
or while eating sweets remove them to make sure airway is patent. If more than five minutes you
will need to give diazepam from the back passage which we are going to teach you how to do this.
If more than 10 minutes, it’s called status epilepticus, call emergency 000 and go to the hospital. If
you agree, we are going to make a family meeting which will include parents and teachers to teach
them about first aid measures of the fits.

Weight Problems
Failure to Thrive
You are a general practitioner. Your next patient is a 18-month-old baby, Julia, brought by her Mom,
Emma. She is taking her to you because the local nurse was worried about Julia’s weight. The weight
chart will be given in the next slide, length and head circumference is within normal.
Tasks :
• Take relevant history
• Explain the weight chart and condition to the mom
History
• Any concern?
• Diet - your child’s typical daily diet ? What type of milk does she take (breast milk, cow’s milk,
formula milk)? How much milk does she take? Have you introduced solids? Does she eat meat?
Does she eat with the family at the table?
• How is her appetite
• Symptoms - vomiting, diarrhea, constipation
• In bowels : ask about is it hard to flush/ stick to the pan, foul smelling, any blood/mucus in poo
• Any Abdominal pain/ distension/ flatulence
• Any recurrent chest infections? Heel prick test? (cystic fibrosis)
• Health in general?
• Nappy: how is it ? Any reduction in number?
• BINDS: Details about birth (newborn screening tests, preterm/term), delivery and development,
how is the weight gain since birth
• Immunization, Ask about social Hx for negligence (who is taking care, do you have enough
support, do you work, planned pregnancy or not etc.)
• Past medical h/o
• Family h/o of cystic fibrosis, heart d/s, kidney d/s anybody in family on special die

Examination:
• General appearance: pallor, jaundice, dysmorphic features, any signs malnutrition (Evidence of
loss of muscle bulk and subcutaneous fat stores; especially upper arm, buttocks and thighs.), Rash/
bruises
• Growth Chart (sometimes might be asked to plot)
 • Vitals, ENT, Lymph node
• Systemic Examination
• Office Test: Urine dipstick, BSL
Invx:
• FBE, ESR
• UEC, LFT
• Iron studies
• Calcium, phosphate
• Thyroid function
• Blood glucose
• Urine for microscopy and culture
• Coeliac screen if on solid feeds containing gluten
• Stool microscopy and culture
• Stool for fat globules and fatty acid crystals

Explanation:
• Julia has a condition called failure to thrive or poor growth because of malnutrition. That there is
no serious medical condition that can be diagnosed. The actual problem is the quantity and quality
of food that is provided to her.
• I know it is really hard to cope with the babies. We are here to help you. (show empathy, don’t
scold), give enough support
• Dietician referral: We need to improve her feeding habits. I will give you some written material
about proper dietary habits. It is important to give her a balanced diet containing fruits, vegetables,
meat and milk to prevent any nutritional deficiencies.
• Baseline Invx
• Financial and social support
• Single mother support groups, Review
• You are doing the best you can I believe. Don’t blame yourself. Don’t forget to stay positive.
• Any questions, you can count on me for any help you need.

Anaemia
An 18-month old boy came to your GP clinic with his mother after a holiday. The child has flu-like
symptoms and look very pale. Blood test showed hypochromic microcytic anaemia with low iron
levels.
Tasks:
• Relevant History
• Explain the results and Manage the case
• Other recall: can come with not gaining weight and plot the growth chart also

History:
• Please tell me more about your son’s condition? Has he recovered from the flu? Any fever, cough,
runny nose?
• I need to ask you a few more questions that are related to the blood tests that we did.
• Anemia Qs:
• Is the child active? Does the child get tired easily?
• Nausea, Vomiting, tummy pain, tummy distention (colieac disease)
 • Any history of recent major illness and bleeding?
• Any history of easy bruising?
• Any medications being taken?
• Bowel habits: Frequency, color amount and easy to flush? Blood in stool? Any Diarrhea? Foul
smelling?
• BINDS: Pregnancy- LBW or preterm? Delivery? Growth and development? Immunizations? Do
you have a family history of anyone on a special diet?
• Feeding Habits of the Child (cow milk, coeliac disease)–
• how long did he have breast feeding?
• At what age did you introduce solid food?
• If any changes happened when solid was introduced?
• How many cups of milk does he drink everyday?
• How is his daily diet? (vegetables, meat)

Examination:
• General examination: pallor, jaundice, signs of dehydration, rash
• Vital signs and Growth chart
• ENT and Lymph node examination
• Systemic Examination: Abdomen, Respiratory, cardiovascular

Explanation:
• Blood test shows one of cell in your child blood system which is RBC imp to carry oxygen to all
parts of body with of a pigment called Hb is low. The size of this RBC is also small indicating it is
anaemia. For formation of Hb iron is required and the blood tests show the iron level is also Low.
• The cause of low iron level can be decreased intake or no proper absorption of the iron in the
digestive system.
• It could be because of the diet or
• If diet normal, with symptoms of stool etc : then can be due to malabsorption so need to do coeliac
disease serology {Serology (transglutaminase, anti-gliadin)-Screening}
• It is a condition where there is poor absorption of certain food from the gut.
• Gluten Hypersensitivity: diet with gluten will lead to some reaction in the linnning of intestine.
Normal linning is wavy→ in this condition it becomes straight leading to problem with absorption
of the nutrients and leading to symptoms. As a result, the child develops diarrhea with or without
vomiting, tummy pain, distention, and sometimes loss of weight. The exact cause is not known,
but research shows that it has been linked with certain autoimmune conditions.
• Refer to specialist: The definitive diagnosis will be done by endoscopic biopsy wherein we take a
small piece of tissue from the lining of the small bowel and we will check it on the microscope.
Duodenal Bx – Definitive diagnosis, but do not start on gluten free diet until diagnosis is made.
• Once the diagnosis is confirmed, you will need to have regular follow-ups with the pediatric
gastroenterologist. The treatment requires avoidance of gluten-containing foods (BROW → barley,
rye, oats, wheat). There are special food aisles in the supermarkets with food labeled as gluten-
free for your child. Please check all food items before giving it to the child. You will need to inform
the childcare or his school.
• +ve Hx is Cow milk intake more:
• A child around this age should eat solid foods like vegetables, meat, chicken, cereals, and milk. I
am afraid that the quantity of milk that he is taking is more than it should. It causes microscopic
bleeding from the gut ( excessive cow’s milk) and also the child feels full…he would not eat other
food.
 • Cow’s milk should be reduced not more than 500ml/day
• Try to introduce semi solid and solid foods
• I can give you a pamphlet what food that a child can take.
• It is preferred that you feed your child when he is hungry.
• Try to give him finger foods
• Make food looks more attractive and colorful
• It is alright to offer the food and refuses.
• Don’t punish the child. Don’t bribe the child
• The child needs to take some iron supplement (Ferrous sulfate syrup or drops) This should be given
for some time until haemoglobin is normal and for 2 more months to replace the iron stores.
• Warn about side effects: can cause staining of the teeth, constipation and black colored stools
• I would like to review the child in 1 weeks time (the mood changes – the appetite improves)
• I know that it is hard to feed, you need to be patient.
• Try to make the meal time a relaxed one.

Fussy Eater
2 yr old child, not eating much, parent is concerned. You are going to see the mother, Emily. The child’s
name is Fred.
Your tasks:
• Take an appropriate history
• PEFE on card,
• counsel the mother

History
• How can I help you today?
• Not eating well - When did this start? Has he always been refusing food or just recent occurrence?
What new foods have been introduced into the diet? Are you aware of types of food is the child
willing and unwilling to eat? How is his daily diet now? Is he having a lot of milk or juice?
• What is the rest of the family’s eating routine? Is he having meal together with the family?
• Has the child been sick lately? Chest - Any runny nose? Fever? Cough? (if present, ask whether
recurrent for cystic fibrosis) ENT – sore throat? Any difficulty in swallowing? Pulling of ear? Any
sores in mouth and gums? UTI – changes in urine? Smelly? Color? Bowel –any diarrhoea?
Constipation? Changes in poo? (if diarrhoea, ask for characters of stool, blood and mucus and
smelly for infections and coeliac disease), complain of any pain in the tummy? Any vomiting?
• BINDS, Birth, immunization
• Development and behavior – Is he gaining weight and developing like any other kids? Is he a
stubborn child?
• social in details, home situation, how many siblings? How about the eating habit of the sibling?
Who is looking after? Financially stable? How did you respond to his eating habits? Any recent
changes or major events that have occurred?
• Family history – anyone on special diet?

• REASSURANCE – Although Fred is a fussy eater, he is growing well and reaching the expected
developmental milestones. When I examined him, I didn’t find any organic problem as well. So he
is totally healthy.
 • It’s very common for children to be growing well but to simply be fussy. It is just a normal stage of
their development. Let me reassure you that it seems that they eat little but those healthy children
will never starve themselves.
• Typically, children actually eat less in the second year of life despite being more active as they are
distracted by their new-found freedom and their environment.
• I know this is a very stressful time for parents. Let me give you some advice upon how to deal with
a fussy eater.
• Meal times: Turn off the TV and try to make the food interesting. Change the way the food is
presented, prepare finger foods. Make the food look colorful and attractive. Eat together with
family.
• Offering food : Introduce a food several times before deciding that the child does not like it. Give
plenty of praise when they try a new food like using a star chart. Offer a wide variety of foods, it’s
ok you offer and he refuses. Try giving the child smaller quantities of high quality food (smaller
quantities may be less overwhelming).
• Eating habits : Avoid making juice and milk the main source of nutrition. Do not always give the
child what he or she wishes. encourage the child to eat what the rest of the family eats. Expose the
child to role model eaters, such as older siblings or other family member. Do not use coercion,
punishment or rewards to change eating habits. Try to ignore fussy eating as much as you can.
• Support : Encourage self-feeding. Let them make some choices and let them get involved in the
food preparation. Kids love to cook so let them help.
• I will refer you to dietician if you want (may help to reassure parents as to adequate nutritional
intake for their child and also may help with high energy tips)
• Reassure again
• Review
• Reading materials

Cystic Fibrosis
You are a GP. Naomi, a 15 years old girl came to you with her Mom, Chloe. Chloe has some concerns
about Naomi since she got a call from her teacher telling that Naomi had decline in her school
performance. Upon history, Naomi was diagnosed with cystic fibrosis since she was 5. There is two
charts showing decline in growth since 13 and reduced FEV1 for her age.
Your tasks:
• Further history
• Explain the charts and about mom’s concerns
• Dx and DDx

History
• The first chart is the FEV1 check which we check her lungs function by checking the volume of air
she exhaled in 1 min. So now her value is lower than the normal value which means that the lungs
are not functioning well.
• The second chart is her growth chart which is showing that there is a decline in her growth since
she turned 13.
• History - ask about follow-ups, general health, any chest infections, hospitalizations, vaccinations,
any loose motions, medications – enzymes and vitamins supplements, who is taking care of her
medications, bronchodilators, prophylactic antibiotics?
• Is she taking them regularly according to the prescription?
 • Any changes in her life since she was 13?
• Daughter – How’s everything at home? At school? Any problem? Is she active at school and at
home? Does she look stressed? Is she going along with her friends?
• Weight loss - Is she eating well? What kinds of food does she prefer? Any recurrent diarrhoea?
Does she look pale?
• Mother – any financial problem? Any stress?
• Mostly likely non-compliance

• Most likely it’s because she may have been non-compliant with medications because she needs
regular chest physiotherapy and regular enzyme supplements to maintain her lungs function and
process of food digestion and absorption.
• Underlying depression because of the divorce
• Bowels malabsorption problems (weight loss)
• Reduced intake and malnutrition

Obesity with Asthma

A 12 year old asthmatic boy, Charlie, comes to your practice, He is well controlled on inhalers. He is now
coming with his father, Bruce, for assessment.
TASK –
• plot the growth charts (> 95 percentile)
• take brief relevant history
• explain to the parent the chart and outline a management plan as required

• History –
• Ask about his asthma. When diagnosed? The need of medication? How was it controlled.
• General health?
• DDX- DM - urinary frequency esp at night? Increased thirst? Hypothyroid - Weather preference?
Tiredness? Cushings - any discoloration in body? Stretch marks?
• BINDS (diet in details, exercises, social – sedentary?)
• General health

• Explain the growth chart – normal – 5-85th percentile, overweight – 85-95, Obese - >95%
• So his weight is on the higher side.
• In a long term – Complications – Fat – insulin resistance – diabetes, heart diseases, liver diseases,
breathing and joint problems. Reassure – we will run blood tests to make sure there is no serious
condition
• Psycho – low self-esteem, negative self image and social isolation
• Asthma – well controlled, Can do exercises and sports with preventer. So you don’t have to worry
too much about this. The preventer medication will be well effective
• Management – refer to weight management clinic
• Advice –
• Cut out sugary drinks (switch to water) and junk food (no health benefit)
• Regular meals
• Get organized for child’s meal, plan the meals a week ahead, healthy and well balanced (I will give
you reading materials)
 • Lunch box – fruits, vegetables, rice crackers, beans, boiled eggs
• Use small plates to make portion size looks bigger
• Increased physical activity (1-5 yrs – 3 hrs active play, > 5yrs – 1 hr)
• Reduce screen time (<2 – 0, 2-5 years- 1 hr, 5-12 yrs – 2 hrs)
• Reading material, review

• Note : Presenting with itch? I will add some notes!

Newborns and neonates

Newborn with RDS
You are a HMO at rural hospital. A 25 years old mom, Jenny has just delivered a baby at 32 weeks. The
baby is in distress now and given CPAP. You are going to talk to the mom.
• Explain the condition to mom
• Further management

• Sympathy
• Many reasons leading to distress such as heart conditions, lungs conditions and birth defects but
most likely this respiratory distress is due to prematurity
• Prem baby – air sacs not open well because there is not enough surfactant in the lungs (which coats
the air sacs to be opened)
• That substance start to be produced at 24-28 weeks and completed at 36 weeks
• Your baby – 32 weeks – not completed
• Reassure – even born at 28 weeks can be managed well
• your case – already 32 weeks – certain amount already produced – not that serious but need to be
transferred
• Baby will be under care of professionals who specialized in taking care of prem babies
• he already had assisted breathing
• At tertiary hospital – replacement of surfactant by injections via Endotracheal tube in 2-4 doses
• Breathing support continues
• Oxygen therapy
• Check for associated conditions (eg PDA – heart condition – circulation is impaired treated by
medicines or catheter procedures)
• Antibiotics to prevent infections
• Keep in incubator, warm
• Monitor vitals – BP, temperature, Oxygen, breathing and heart rate
• IV nutrients will be given , later – expressed or formula milk through tubes via mouth or nose
• For you – any medical conditions – DM, HT, incompetetnt cervix?
• Chorioamnionitis - ? Fever – u need treatment as well
• If well – you can go along when you are stable
• Experts will try their best for the minimization of complications to the baby
• You will be assessed later for causes of prem for next pregnancy
Obstructive Jaundice in Neonates
You are a HMO. You are going to see a 3 weeks old jaundice baby, regained birth weight, well, no
fever, conjugated bilirubin raised given. Talk to the mother.
• History
• Management

History:
• Jaundice Qs: When did you first notice it?
• Where did it start?
• Where has it progressed to?
• How’s the baby doing? Irritable, drowsy/active
• Feeding Hx: Breast/bottle
• Associated Qs
• Fever, diarrhoea, vomiting
• How many wet nappies? Color?
• stools → colour and smell?
• Pregnancy Qs: How was the pregnancy? Any medical issue like thyroid disease, DM?----No
• Full term or preterm baby (up to 36 weeks), how many weeks?---
• After how many hours was the delivery? Any Infections ? Blood GP and any Anti D test
• Any instrumental delivery? →Cephalo haematoma (vacuum extraction) can cause jaundice
• Any resuscitation, cry immediately after delivery?
• Do you know his APGAR?
• Did you have any fever just before, during and after the delivery?
• Do you know whether the neonatal screening test has been done?
• Is it first child?
• Any family history of bleeding disorders, liver disease, similar condition

• Examination:
• GA: jaundice (icteric distribution→ Level of jaundice → extensive, upper chest, upper abdomen),
active, drowsy, dysmorphic features (Down syndrome)
• Birth weight, Head circumference → cephal haematoma
• VS
• Any lymph node enlargement
• Rash
• ENT exam
• Systemic review : Respiratory, CVS, Abdomen

Investigation in Jaundice cases

• need to order some tests
• FBE, CRP
• Blood film → look for spherocytes, blood smear
• Blood group for the baby and mom if not known from the history
• Total bilirubin direct and indirect
• Coombs test direct and indirect
• Urine test for microscopy, culture, sensitivity and reducing sugar
 • The further investigations include LFTs, USD of the abdomen and further liver biopsy
can be done to confirm the diagnosis of biliary atresia
or choledochal cyst, urine for reducing substances,
UC&E, TFTs.

Management:
• Concerned about your son’s prolonged jaundice because the rise in conjugated bilirubin means
obstructive jaundice.
• Arrange his admission to the hospital ASAP where he
will be seen by a pediatrician. He needs further
investigations to rule out some serious conditions
most importantly, biliary atresia as a cause of
increased bilirubin level, or choledochal cyst other inborn error of metabolism like galactosemia
• Biliary atresia (draw diagram and explain)is the obliteration of the extrahepatic
biliary system resulting in obstruction to bile flow. It
cannot be transported into the intestines so it is
retained in the liver causing jaundice and further
damage.
• Current Rx – procedure to cut some part of intestine and replace in bile duct (Kasai procedure)
• The cause is unknown and definite treatment is
surgery – liver transplantation – within 70 days of age.
• If the result is choledochal cyst, the treatment is surgery as well to remove the cyst.
Irritable baby
Your next patient in GP is a 6 week old baby, Kelly, brought in by her mother Aster because she thinks
the baby is crying a lot and makes her concerned seriously. She visited another doctor 3 weeks ago but
she was consoled that the baby is normal.
Tasks:
• Take relevant history
• Ask PE from the examiner
• Explain the baby’s condition to mom

• Greetings
• I noticed that you visited the doctor 2 weeks ago. May I know what the doctor said? Was any blood
test or imaging done?
• Crying – does she cry as usual or is it getting worse? How long have you noticed that cries a lot?
Do you think it is excessive or unusual? Does she cry throughout the day or any particular time of
the day? (irritable baby & infantile colic– cries more in the evenings), how long does it last when
she cries? How frequent? (any relation with food?) Did you notice any drawing up of the
legs?(infantile colic – more than 3 hrs in one cry, >3 times a week, duration> 3 weeks)
• DDx –
• Is she breastfed or bottle fed? How frequent do you feed the baby? Any problem with suckling or
breastfeeding? Do you think she get enough breastfeeding?
• Do you think she is very sensitive to external stimuli? For example, noisy environments, room
temperature not well adjusted? (irritable baby)
• Any fever? Hot to touch? Noisy breathing, cough, runny nose? (infection)
• Any vomiting? Swelling in the tummy? Groin? Any changes in poo and pee? (GI symptoms)
• I can see that you are distressed by her cries. How do you respond to them? (shaken baby
syndrome)
• BINDS
• Social history – planned pregnancy? (abuse) home situation? With whom are you living? Partner
supportive? Financial burden? What do you do for a living? If job+, who will be looking after the
baby when you are at work?
• How’s your mood? Appetite? Do you feel tired all the times? (if +, ask the questions for depression
– DSM 5 questions)

PEFE
• -GA, vital signs (important for this case)
• -Growth chart, Cyanosis and jaundice
• ENT examination
• Dehydration (if vomiting present)
• CVS, Respiration
• Abdominal examination
• Groin with consent (hernia) Genitals esp male babies (orchitis, torsion)
• Head to toe for any abuse
• UDT (not reliable in the baby of this age)
 • I did thorough examination on her and I haven’t found any serious problems or cause to make her
painful. I am happy to say that she is growing well and gaining weight. I agree with the opinion of
the previous doctor that she is perfectly healthy.
• The baby can cry a lot especially in her age without any reason. We call it irritable baby or unsettled
baby or infant distress/infantile colic. In this condition, the baby seems to be irritable all the time
and usually cries in late afternoon or evenings. It is common that it happens in 1 in 5 babies.
• There may be some contributory factors that can make baby irritable like hunger, noisy
environment, or poorly adjusted room temperature.
• It will resolve spontaneously after 4 months of age.

• These cries are described as PURPLE cries and it stands for the common parts of non-stop crying in
babies:
• P – peak pattern (crying peaks around 2 months of age, then decreases)
• U – unpredictable (crying can come and go for no reason)
• R – resistant to soothing (baby may keep crying no matter what you do to try to soothe them)
• P – pain-like look on baby's face
• L – long bouts of crying (crying can go on for hours)
• E – evening crying (baby cries more in the afternoon and evening)
• Parents may feel guilty and angry if they can't soothe their baby. The period of PURPLE crying tells
us that if a baby is not ill and parents have tried to soothe baby, it is alright if they cannot stop baby
from crying. Some babies are going to cry no matter what. The good news is that the period of
PURPLE crying will end.
• There is no organic cause.
• I can see that you are very distressed and tired. I know how difficult it can be to cope with a new
born. Please also take good care of yourself and contact me if any help needed.

Management/advice from RCH

• Parental Education
• Engage in a partnership with the parent/s
• This includes acknowledging their concerns, taking time to observe the baby-parent interactions
and offering follow-up. Observing the baby feed is helpful for parents who are concerned about
their baby’s feeding
• Explain normal crying and sleep patterns
• Use the normal crying curve to explain the natural history of infant crying (taken from Purple
Crying)
• Use a sleep / cry diary to explain the infant's cry / sleep / feeding patterns
• Encourage parents to recognize signs of tiredness (frowning, clenched hands, jerking arms or
legs, crying, grizzling Assist parents to help their baby deal with discomfort and distress
• Assist parents to help their baby deal with discomfort and distress

• Establish pattern to feeding / settling / sleep

• Establish pattern to feeding / settling / sleep
• Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play,
move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while
still awake)
• Avoid excessive stimulation - noise, light, handling. Excessive quiet should also be avoided. Most
babies find a low level of background noise soothing.
 • Darken the bedroom for daytime sleeps
• Carry baby in a papoose in front of the chest
• Baby massage / rocking / patting
• Gentle music
• Respond before baby is too worked up
• Give the primary carer permission to rest once a day without the need to carry out household
chores. Have somebody else care for the baby for brief periods to give the parent/s a break
• Provide printed information as parents are unlikely to remember much given their state of mind
at the time

Umbilical Hernia, Undescended Testis and Inguinal Hernia

A 7-month old child, John and his Mom Susan coming to see you. You are a GP. The child has an umbilical
hernia (reducible), undescended right testes and a right inguinal hernia (reducible). You can palpate the
right testis in right inguinal ligament.
Your tasks:
• Explain the conditions to mother
• Management

• Draw a picture of inguinal canal, scrotum and testes.

• Explain the hernias
• Umbilical, common, 30% newborns, conservative till 3 years. Resolves itself unless complicated.
i.e, the protrusion is trapped in place and twisted. Seek medical help if lump not going back into
the tummy, redness, bluish discoloration or cries a lot.
• The relation between undescended testes and inguinal hernia, the process of testes descending,
after descending, inguinal ligament closed. In this case, testes not descended, ligament still open,
part of bowel came out from that.
• The undescended testes could be a retractile testis too, where it is going down and coming up. If
this is so, we just need to monitor and it usually descend permanently before or at puberty.
• If this is not retractile, we should do a repair surgery at 6-12 months of age. We can do a surgery
to repair it together with the hernia through incision in the groin. We bring the testis and put in in
the scrotum through the small incision as a pocket in the scrotum. We will remove the hernia sac
through the small incision then the parts of the bowels are placed back in the belly
• 6-8 months is good to perform surgery. Your child – appropriate for surgery.
• Complications without surgery if the undescended testes still at puberty- may lead to high risk of
cancer and infertility later, embarrassing among friends physically.
• Tell about complications of surgery – bleeding, injuries to the nearby structures, anaesthesia risk
and infections
• Reassure safe hands of surgery.
• Review and refer to Paediatrics surgeon

SOB and Increased right dome of the diaphragm

ED. 3 weeks old baby come with breathlessness. everything seems to be alright at birth weight 97th
centile and then reduce gradually , Now about 50th centile Tasks –
• History
• PEFE
• Explain X-Ray to examiner
• Dx and DDx to mum

History
• Greetings
• Open question
• Refuse breastfeeding? – when did you first notice? How did it happen?
• Breathlessness – any blue lips? Mouth breathing? Fast breathing? Chest indrawing?
• DDx- Heart failure – Do you notice any blue lips or sweating when she is breast fed? How long? Did
she stop suckling because of this?
• Viral infection – any fever, cough, any rash?
• UTI – poo and pee? Any changes?
• How is the baby? Alert? Interested to the surrounding?
• BINDS history
• Family history of congenital heart diseases
• Mom’s mood and family support

Physical examination
• General appearance – floppy, drowsy, lethargic, pallor, jaundice
• Vitals signs (important here)
• Dehydration status (depressed anterior fontellnalle, thirsty, sunken eye, skin turgor, delay return
of capillary refill, body weight, urine output)
• ENT exam. Any dysmorphic featues
• CVS and chest – inspection – cyanosis, nasal flaring, stridor, fast breathing, chest indrawing, apnoea
• Palpation – palpate for heart sound
• Auscultation – any murmur?
• Chest – breath sounds, pulmonary oedma ( creps),
 • Features of heart failure – oedema
• Abdomen – liver, spleen
• Neurological examination
• BST – blood sugar, ECG

• Explain – birth – injury to the nerve supplies the diaphragm ( a muscular structure here to separate
chest and tummy. It is moving along with breathe in and out. now, due to nerve palsy, one side is
not moving, so the lungs cant expand causing breathlessness.

Heart Failure
You are an HMO in ED in rural hospital. David, 7 weeks old brought by his Mom Sella because of
coughing, wheezy and distress.
Tasks
• Take History from Sella
• Examination findings from examiner
• Diagnosis and management
DD
• Bronchiolistis
• Penumonia
• Septicemia
• URTI
• Congenital Heart Diseases

History
• Hameodynamic stability
• I understand that David is not well, can you tell me more about it?
• Since when having symptoms?
• Cough Qs→ since when, cough cough ….vomit/whoop/turns blue, productive/nonproductive, barky
cough
• Cold/stuffy nose, turns pale/blue when cries,
• Fever Qs, Rash Qs, wheeze Qs, feeding problem, lumps and bumps
• Number of wet nappy?
• BINDS- Birth in detail, immunisation, nutrition (feeding), development/growth (gaining weight),
social (support to mother, anybody sick at home, family hx of asthma and heart condition)

Examination:
• General appearance: Pallor, jaundice, cyanosis, dysmorphic features, hydration status
• Growth Chart
• Vitals: Pulse (rate, rhythm, RR and RF delay), BP (in all four limbs), temp, RR, SO2
• Systemic Examination
• Cardiovascular: Inspection, Apex Beat, Any thrill,
• Auscultation (murmur- character, radiation, grade etc)
• Respiratory System
• Abdomen Examination
• With consent of parent, genital examn
 • History +ve point→
• cough and wheeze since few weeks, no other symptoms, have problem with feeding
• Examination→+ve point
• GA: alert, looks unwell, non-toxic, moderate respiratory distress (mild intercostal retraction), a little
bit irritable, anterior fontanelle flat, not dehydrated, mucus membrane moist
• Gowth chart: under 3rd percentile for his age
• VS: Temp 37.2, pulse 68/min (radial), femoral pulse is not palpable. RR 70/min, O2 sat 96%
• BP: On the left arm 126/86, right arm132/92, left leg 69/41, right leg 63/49
• Chest: diffuse wheezes & crepitation bilateral with intercostal retraction
• Abdomen: soft, non-tender, active bowel sound, liver 3 cm below the right costal margin

Explanation (draw diagram)

• Heart Failure→ heart pumps blood to all parts of body through a tube like structure called blood
vessels. The major blood vessel is called aorta and it also supplies blood to our legs and lower part
of body. A part of this tube is narrowed and so the blood supply to lower part is decreased and there
is difference in blood pressure of both hands and legs.
• This narrowing increases the workload on heart and lead to failure of heart. this condition is called
cortaction of aorta
• Its an emergency condition
• Need to be admitted in Paed ICU (shift to tertiary hospital after consulting with paed registrar)
• Need to be seen by cardiologist and paediatrician
• Arrange urgent inv- blood test, ECG, Chest Xray, ECHO
• Might start on iv diuretic
• Final Management most likely needs to undergo surgery

Hereditary Spherocytosis
2 years old girl, Nina, was brought to the emergency department because of lethargy. In addition to
lethargy, she is having jaundice off and on for past 6 months. On examination, there were jaundice,
pallor, splenomegaly. No hepatomegaly and no lymphadenopathy. Her blood test result are in the next
slide.
Your tasks:
• Short history for 2 mins
• Explain blood result to mom
• Diagnosis to mom
• Further investigations to confirm the diagnosis
• Management to mom
• Details of anaemia – How does the baby look like? Lethargic? SOB? Pale skin? Irritable? How long?
• Jaundice – When did you notice? Which areas involved? Any changes in stool color? Urine color?
Any fever? Any distension of tummy (spleen)?
• BINDS – Can baby suck well? Grow well? Development? Birth history in details? Anything significant
after birth? Immunization?
• Any blood disorders run in the families?
• Support?

• Approach
• Explain the blood tests. Hb which is the red pigment that carries oxygen in the blood is reduced,
Haematocrit which is the volume of the red cells also reduced. Reticulocytes, the number of
immature RBC is increased to compensate the decreased RBC in the system and there are also
presence of some abnormally shaped RBC called spherocytes. Bilirubin, yellow pigment which is by
product of RBC break down is also increased , it is also a sign of increased RBC breakdown.
• All these along with the history and enlargement of spleen in examination pointing towards
heredictory spherocytosis
• Draw a picture of RBC
• Normal – biconcave, can easily pass through the small blood vessels
• But this case – spherocytes – rounded in shape, can’t easily pass through the small blood vessles
especially inside spleen – trapped and destroyed by spleen (filtering of abnormal RBC by spleen)
• This condition usually runs in the family

• To confirm – Blood test –

• E5M test – Eosin 5 Maleimide test – Draw blood and it’s a binding test of the stain to proteins in
RBC. There will be lesser stain RBCs in HS as there are lesser proteins to be bound.
 • osmotic fragility test – Draw blood from veins, added to a special solution – normally blood cells
are not easily swells or bursted because they are biconcave in shape. In HS, they are rounded –
more prone to burst. (test positive)
• Another – Hb electrophoresis – to detect the types of HB – an electric current is passed through
the blood samples – different types of haemoglobin – separate at different rates and form the
bands, study the bands for different types and quatities of haemoglobin – to exclude other causes
of RBC break down.

• Management – short term – admit – do the test, confirm the DX and monitor
• Treatment according to severity – may need blood transfusion
• Long term – regular follow-up with specialist, clinically and blood tests
• Folic acid supplements – protect –RBC damage and closely monitor outcomes of RBC break down
which are
• severely low Hb and heart failure
• increased bilirubin, collection of bilirubin and stone formation
• Enlarged spleen – over function – destroys many blood cells – bleeding may occur
• May need splenectomy after 6 years of age (whole or part of it) after immunization against some
serious organisms – culprit is removed, relieves anaemia
• If managed effectively and monitored throughout life – outcome is excellent and lead a normal life
• Review, reading materials

GI problems
Oesophageal Atresia
You are a HMO. A nurse, Lily, has come in after passing NG tube in a newborn who started vomiting on
day1 of life.
Tasks
• take history from the nurse
• PEFE
• explain the given xray to nurse
• give your diagnosis

Approach
 • Vomiting Hx→ tell more about it, when start, colour and amount, forceful/not, related to
feed/food
• DDx
• Obstruction - Associated with lump and bump(tummy)
• Infection rash , fever?
• TE fistula – cough? Turning blue while feeding? (aspiration)
• VACTERL-vertebral defects(defects in backbone?) , anal atresia (passed meconium?), cardiac
defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities (any limb anomalies?)
– VACTERL should be 3 of them positive
• Severity – general condition? Floppy? Appetite? Pee and poo?
• BINDS

• PEFE – general appearance, vitals, Dehydration?

• Dysmorpgic features
• Respiratory, CVS, Abdomen
• Anal patency
• Dx- This Xray is as you can see, the NG tube coiled back in the oesophagus so that means there is
no lumen to go down, So it can be diagnosed as oesophageal atresia, which is a congenital
condition. It occurred due to the fault in recanalization of oesophagus during fetal development.
It is highly associated with tracheo-oesphageal fistula. Draw a pic and explain types, with or without
TE fistula. In this case, fundal gas is seen so most likely it is type C which is commonest type.
• Mx – NPO, IV fluids and surgery

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:
• Take a brief history
• Explain the X-ray findings to the mother
• Discuss the most likely diagnosis and management with the mother

• Approach
• Vomiting Hx→ tell more about it, when start, colour and amount, forceful/not, related to
feed/food, hungry after the feed,
• DDx
• Obstruction - Associated with lump and bump(tummy)
• Infection rash , fever?
• Severity – general condition? Floppy? Appetite? Pee and poo?
• BINDS

• Explanation – Imaging of the baby’s tummy, anterior view, chest bones and back bones are normal,
what I am concerned is there is abnormal air collection in food bag and 1st part of small bowel
• Due to narrowing of the 1st part of the small bowel, greenish vomiting is bile, bile ducts are
connected to the first part of small bowel, since there is obstruction, bile cannot go down, so comes
up in vomitus
• It is a serious condition – severe vomiting - fluid loss may affect kidneys, chemical loss – affect
heart and muscles
• Appreciate mom for taking the baby
• Mechanical obstruction- the only treatment option is surgery.
• Now – rural hospital, we don’t have adequate facility
• Refer to tertiary hospital, before referral, we will make her nothing by mouth, give her fluid through
veins and decompress (empty her food bag through the tubes inserted from her nose)
• On the way, the baby will be looked after by the doctor and nurses and you can also accompany
him
• Surgery is to cut off the narrowing part and reconnection
• Risk of surgery – bleeding, injuries to the nearby structures, infection, risk of anaesthesia
• done by the experienced hands, lesser risk
 • After surgery, bowel rest for a few days. If you are breastfeeding, express milk and discard to
maintain lactation
• Come here alone? Any kids at home? Social worker to look after
• Reassure

GERD
You are a GP. Your next patient in GP is a 4-week-old baby boy, George, who is on breast feeding
brought in by mom, Jane, because the baby vomits after feeding.
Tasks :
• Take relevant history from mom
• Explain diagnosis and management to mom

Outline of approach
• Details of vomiting – when? 1st time? How frequent? Vomitus? Color? Blood ? (complication)
Content? Goes away? How soon after feeding? Any cough? (aspiration)
• Dehydration - is there any change in the number of her wet nappies? How is the activity of your
child? Has she became lethargic?
• Does he look hungry after vomiting? (refusal of food) loss of appetite present in reflux ( because
of acid into oesophagus), Hungry and appetite present in pyloric stenosis
• DDx – Tummy mass/swelling/distension during or after feeding? (Hypertrophic pyloric stenosis),
Foul smelling pee? (UTI), Diarrhoea ? (GE) fever? Rash?(meningitis)
• Generally well? (Congenital Adrenal Hyperplasia – salt loosing through urine – may drowsy)
• BINDS history - Is she your first child? Any complications during the pregnancy? How about her
delivery? Any problems at birth? Is she a term baby?
• Is she currently up to date with her immunizations?
• Is she gaining weight?

• Explain the condition, draw stomach and esophagus.

• Food in the stomach overflow back into the gullet, causing the baby to bring up or vomit
• No problem if not complicated, stricture or oesophagitis, reduced growth,aspiration
• Resolves spontaneously 10-12months of age
• Thriving well
Management
• Position – 30’ head-up
• Small frequent feeds
• Thickened feeds (can use thickeners or pre-thickened feeds)
• Drugs – Gaviscon infant,
• Gaviscon – half teaspoon + 120 ml formula milk or 20 ml of expressed breast milk JUST after
each feeding
• (Note: If formula feeding- Not relieved, cow’s milk protein exclusion for 2 weeks,) if severe
Omeprazole for 4 weeks
• Red flags – if the baby is not thriving well, lethargic, drowsy, blood in vomitus, please come back
Pyloric stenosis
You are a HMO and a 4 weeks old baby boy, John presents with vomiting.
Tasks:
• -History
• -Physical examination Findings from Examiner
• -Diagnosis and further management

Outline of approach
• Details of vomiting – when? 1st time? How frequent? Vomitus? Color? Blood ? (complication)
Content? Goes away? How soon after feeding? Any cough? (aspiration)
• Dehydration - is there any change in the number of her wet nappies? How is the activity of your
child? Has she became lethargic?
• Does he look hungry after vomiting? (refusal of food) loss of appetite present in reflux ( because
of acid into oesophagus), Hungry and appetite present in pyloric stenosis
• DDx – Tummy mass/swelling/distension during or after feeding? (Hypertrophic pyloric stenosis),
Foul smelling pee? (UTI), Diarrhoea ? (GE) fever? Rash?(meningitis)
• Generally well? (Congenital Adrenal Hyperplasia – salt loosing through urine – may drowsy)
• BINDS history - Is she your first child? Any complications during the pregnancy? How about her
delivery? Any problems at birth? Is she a term baby?
• Is she currently up to date with her immunizations?
• Is she gaining weight?

• PEFE – GA, vitals, dehydtarion status, dysmorphic features, Growth chart

• any rash?
• Any pallor or jaundice? , any lymph nodes
• -What is the weight for height?
• neck stiffness
• Abdominal examination
• -visible distention or peristalsis? Palpable masses? Tenderness?
• Feeding test
• Hernia orifice (with consemt)
• Blood sugar

• It’s the condition we call pyloric stenosis, that affects the food tract, (draw a pic)
• Food normally moves from the food bag to the bowels via an opening called pylorus. In your bay’s
case, the muscles around the pylorus are bigger and squeeze the opening leading to narrowing of
pylorus. Therefore, food can no longer empty out of the stomach. So when there is no room for it
to pass through, it is vomited out.
• When it becomes severe, it may lead the baby to have a more severe vomiting and severe
dehydration.
• Management – your baby will be admitted and given fluid through veins, chemicals in the blood
will be checked and urine will be checked for culture and sensitivity to exclude infections in the
urine (USG is done in cases that cannot be diagnosed clinically). She may also need a tiny plastic
tube to be inserted from nose to the stomach for removal of stomach content. Chemicals in the
blood will be corrected. You have to stop feeding her at the moment. After these, the definitive
management is surgery, we call pylorotomy where these muscles are splitted and widen the
opening.
 • It will be safe under experienced hands.
• You may start the feeding 6hours after the surgery but some babies may still vomiting for quite a
few days but will resolve spontaneously.

DIOS
9 months old baby boy brought in by mom with vomiting for last 1day. He is a Known cystic fibrosis case
since birth.
• Tasks- Hx, PEFE, Explain X-ray, Diagnosis and DDs.

Approach
• Vomiting Hx→ tell more about it, when start, colour and amount, forceful/not, related to
feed/food, hungry after the feed,
• DDx
• Obstruction - Associated with lump and bump(tummy)
• Infection rash , fever?
• Severity – general condition? Floppy? Appetite? Pee and poo? (smelly urine and numbers of
nappies, last time he pass stool?)
• Cystic fibrosis – how are you coping? Regular follow-up? Any supplements? (pancreatic enzymes)
Any recurrent infections in the breathing system?
• BINDS (delayed passage of meconium? Diet – any change in diet?)

PEFE
• General appearance, vitals, growth chart
• Signs of dehydration
• Respiratory, CVS
• Focused abdomen (mass in RIF, absent bowel sound)
• Private part

• DIOS – distal intestinal obstruction syndrome – obstruction in the distal part of the small intestine
• Here in the X ray, this is the tummy and this black area here is the air trapped in the small bowels.
In distal parts there are some grey shadows which is most likely the old food or faecal mass
impacted in distal part of small intestine. So we can conclude that there is obstruction in distal
small bowels.
 • It is a common manifestation of cystic fibrosis patient in which the the distal small bowel has been
obstructed with fecal matters.
• It happens when there is change in diet, poor compliance with pancreatic enzymes or dehydration.
It could be intussusception, UTI, Gastroenteritis or other infections but less likely.
• You are at the hospital and safe hands now. We will try our best to sort it out.

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:
• History
• Examination Finding from examiner
• Diagnosis and management

• Stability
• Vomiting Hx→ tell more about it, when start, colour and amount, forceful/not, related to
feed/food,
• Associated with lump and bump(tummy)
• Intussusception Qs 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)
• UTI Qs water works, any change in number of wet nappies, any foul smell while changing
nappies, child cries while he pass pee
• Any fever?, Rash(meningitis), noticed any lump in the body especially groin area (r/o hernia),
lethargic,
• Feeding and sleeping well
• BINDS→ support and how is she coping. Family Hx of urinary/kidney problem. N –any new food?
Recent Rota virus vaccine?

• Examination: General, vitals, pallor, signs of dehydration

• Abdominal examination
• Neck stiffness, rashes
• CVS, respiratory
• sausage shaped mass RUQ or crossing midline in epigastrium or behind umbilicus, emptiness in
RIF, alternating high pitched active bowel sounds with absent sounds
• Genital area (hernia)
• Back passage for red currant jelly stool
• Explanation:
• Sliding one part of bowel into next part leading to obstruction. Common in children btwn 3 months
to 3 years
• Emergency condition ,call paediatric/surgical registrar.
• Admit, NPO, iv fluids. If required antibiotic is started by specialist.
• Inv: Xray and USG (Target sign & Crescent sign, to r/o obstruction also)
• Treatment by specialist(radiologist and paediatric surgeon): Air enema(Diagnostic and
therapeutic)- general anesthesia→ through a small tube placed at back passage, air is passed
 • If it not relieved, surgery may be needed
• Complication are small chance of perforation and bacteraemia..You are in safe hands now. We will
do intervention ASAP/
• pale child + severe ‘colic’ + vomiting=acute intussusception

Gastroenteritis
You are a HMO at the hospital. You are going to see a patient, a 6-month-old baby boy with acute
diarrhoea and vomiting for 24 hours.
Your tasks:
• History for 5 mins from mom
• PEFE card
• Dx or DDx to the mother

Examination
• General Appearance: Alert, thirsty
• No pallor or jaundice
• Mild dehydration positive
• Growth Chart – normal, weight last week – 8.1kg, Now – 7.3kg
• Vitals- Pulse, BP, Temp, Saturation ,RR - normal
• No Rash and neck stiffness, ENT examination – normal
• Focus on abdominal Examination- unremarkable
• With Parents consent: Hernial orifices- intact, Perianal inspection - no excoriation. no
abscesses/skin tags

Outline of Approach
• Diarrhoea History: when did it start? How many episodes? Poo (watery or well formed)? Color
(pale)? Bulky or greasy? Does it contain food particles (giardiasis)? Blood or mucous? Foul smelling?
Stick to pan?
• Vomiting –contents? Color? Smell? Forceful or not?
• Associated Symptoms for ddx- infections, lactose intolerance, coeliac disease, cystic fibrosis, IBD
(leave IBD in infants as only less than 1%)
• Abdominal pain and distension/bloating, fever, n/v, passes wind weight and appetite loss,
recurrent chest infection, problem around back passage,
• Any recent travel?
• Child feeding well? General health? Any Medication? Any allergy?
• Waterworks(Nappy) Qs: frequency, Smell, color
• BINDS
• Does he go to child care?
• Family Hx Anybody on special diet?
• Diet Hx- Fruit juice, milk ingestion etc
• If bottle fed, are the apparatus properly cleaned?
• Anyone in the family with the similar episode?
 • Most likely he is having a viral gastroenteritis which is not a serious condition. It is caused by the
virus causing the inflammation of the lining bowel and spreads through contaminated food or
water or by contact with an infected individual. It is usually self-limiting.
• Others can be bacteria or parasite infection but these are unlikely as his symptoms are mild.
• Sometimes, it can be due to excessive intake of fruit juice or food allergy or milk intolerance but
you didn’t give him any.
• I’m a lil bit concerned about the weight loss here, it might be because of severe dehydration or
not eating enough or cystic fibrosis which is defect in some enzymes of the body (may need to
admit because of this)

If you are bottle feeding your baby, replace formula feeds with oral rehydration solution or water for the
first 12 hours, then give normal formula in small, but more frequent amounts

Toddler’s diarrhoea
You are a general practitioner. Your next patient is 2.5yr old boy with diarrhea since the past 3 weeks.
Talk to the father.
Tasks:
• Take a relevant history
• -PEFE on card
• -DDx

Outline of Approach
 • Diarrhoea History: when did it start? How many episodes? Poo (watery or well formed)? Color
(pale)? Bulky or greasy? Does it contain food particles (giardiasis and toddlers)? Blood or mucous?
Foul smelling? Stick to pan?
• Associated Symptoms for ddx- infections, lactose intolerance, coeliac disease, cystic fibrosis, IBD
• Abdominal pain and distension/bloating, fever, n/v, passes wind weight and appetite loss,
recurrent chest infection, joint pain, rash, ulcer around the mouth, problem around back passage,
• Child feeding well? General health? Any recent Medication? Any allergy?
• Waterworks(Nappy) Qs: frequency, Smell, color
• BINDS
• Family Hx – anyone has the same condition? Anybody on special diet, travel Hx?
• Who prepare food for him?
• Diet Hx- Fruit juice, milk ingestion etc

• PEFE – all normal on card

Explain
• From history and physical examination, your child has chronic diarrhea as it is more than 2 weeks
in duration.
• most likely he has a condition called toddler’s diarrhea, which is a common type of diarrhea in this
age group, not serious or infectious, it is also self-limiting.
• It usually presents with diarrhea, three or more times a day with pale and smelly stool which usually
contains undigested food particles.
• There are some other possibilities like it could be due to an infection we call giardiasis or food
allergy or sugar intolerance. Could also be a problem with the absorption of nutrients from the gut
we call celiac or even due to medications like antibiotics. However, these are unlikely as your he is
growing and thriving well, no weight loss, pallor, rash or fever. Also there is no blood or mucous in
the stools.

Neck swelling
Thyroid swelling
You are a GP. Your next patient is a 11 years old, Patrick brought to you by his father Dave. He noticed
the lump in Patrick’s neck for 2 weeks.
Your tasks:
• Take history
• PEFE
• Diagnosis to the patient

History
• Lump Qs:Where exactly is the lump? When did you notice it? Is it painful? Did he have a recent
URTI or other infection (ear)? Did you notice any change in size or shape of the lump? Change in
color of overlying skin? Is it hard or soft? Is it fixed or mobile? Any other lumps and bumps in the
body?
• Any previous history of fever, night sweats? Is he pale or lethargic? Any symptoms of tiredness,
recurrent infections, bleeding, bruising? Any change in his appetite? Did you notice any mass in his
tummy? Is there any itchiness?
 • Hypothyroid questions – dry skin? Swelling/distension in abdomen? Tired or lethargic? Does he
look sad? Is he gaining weight more than usual? Any constipation?
• Waterworks? Is he in childcare/schooling? Contact history? Anyone else at home having a similar
problem? Any recent travel history interstate or outside Australia?
• BINDS:

Examination:
• General appearance: pallor, jaundice, rash, growth chart,
• Vitals
• Lump - site, size, shape, consistency, mobility and fixity, skin above the swelling (other LN Axillary,
inguinal), Deglutition and protusion
• ENT
• Systemic Examination (respiratory, CVS, abdomen, thyroid exam –eye symptoms – swelling around
the eyes, loss of outer part of eyebrows, reflexes in limbs, myxoedema)

Explanation
• The swelling is most likely coming from thyroid gland, which produces thyroid hormone which is
important for our body metabolism.
• It could be MNG in which the size of the thyroid gland is increased. Sometimes it is caused by
Hashimoto’s thyroiditis which is autoimmune inflammation of thyroid gland. It could be lymph
nodes, branchial cyst (congenital disorder), thyroglossal cyst less likely. We will need a couple of
blood tests and imaging to confirm the diagnosis.

Lymphadenitis
A mother of 3 year old boy came to your GP clinic complaining of a lump in her son’s neck. She is
worried because her nephew was diagnosed with lymphoma recently.
Tasks:
• Take History
• Ask examination findings from Examiner
• Diagnosis and management

History
• Lump Qs:Where exactly is the lump? When did you notice it? Is it painful? Did you notice any
change in size or shape of the lump? Change in color of overlying skin? Is it hard or soft? Is it fixed
or mobile? Any other lumps and bumps in the body?
• DDx - Any previous history of fever, night sweats? Did he have a recent URTI or other infection?
Any pulling of ears? Is he pale or lethargic? Any symptoms of tiredness, recurrent infections,
bleeding, bruising? Any change in his appetite? Did you notice any mass in his tummy? Is there any
itchiness?
• Waterworks and bowel motions? Is he in childcare/schooling? Contact history? Anyone else at
home having a similar problem? Any recent travel history interstate or outside Australia?
• BINDS: General Health? Growth and development? Immunisation
• Examination:
• General appearance: pallor, jaundice, rash, growth chart, signs of dehydration
 • Vitals
• Lymph node: site, size, shape, consistency, mobility and fixity, skin above the swelling (other LN
Axillary, inguinal)
• ENT
• Systemic Examination

Explanation:
• I think your child is having postviral lymphedinitis: these are glands that are important part of
immune system that fight against bugs and infection. Its commonly enlarged after a viral infection
previously.
• At stage, no need to worry, just give him some panadol if he has pain but lets wait and watch. Self
limiting and no mediation required (no antibiotics)
• Review after 3-4 days. In meantime, if develop fever, redness around the swelling, etc come back
to me immediately. Will do basic blood test (FBE, ESR/CRP)
• If parents very concerned: It won’t be late if we can wait and see for 3 days. If it is not improved, I
will refer to specialist for 2 nd opinion and will do further testing if required like LN biopsy.

Notes:
• Lymph node +ve;
• Post viral lymphadenitis,(firm,mobile,usually not painful)
• Bacterial lymphadenitis(fever,irritable,painful,red swollen,firm ,mobile ,grouped togetter)→ if
bacterial then management is to give antibiotics.If child is severely ill admission and iv antibiotics
• Lymphoma(not mobile,rubbery,not painful)

Respiratory system
Croup
Your next patient in ED is 8 months old baby brought in by mom because of cough, SOB and noisy
breathing. Mom is Daisy and child is Ted.
Tasks:
• History
• PEFE
• Diagnosis
• Management to mom

DD:
• Viral URTI
• Bronchiolitis
• Pneumonia
• Croup
• Whooping Cough
• Foreign Body
• Cardiac Cause
• Epiglotitis

History
• Is it the first time?
• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• Cough- when? How frequently? Sudden or gradual? Dry/phlegm? Worsen at day or night?
• Can you describe it for me? Special pattern like cough-cough-vomit? Any sound like whoop? Does
he turn blue, barky cough (brassy cough) , any noise at end of cough, any runny nose, any noisy
sound? Any hoarseness of voice? (older child), anything makes it better or worse? Any drooling of
saliva?
• SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Any recession
between the ribs? Any position that reduces SOB?
• By any chance, did the child left unattended (foreign body)
• Diarrhoea/vomiting? Any changes in pee? Colour and smell?
• Is the child active? Feed well? Sleep well?
• BINDS – Contact history, similar case in childcare or family and history of anyone smoking in
history
• Health In general? Repeated respiratory infections? Family Hx of asthma?

• GA: alert? Rashes? Vitals – please remember respiratory rate (3 months – 25-60, 6 months – 20-
55, 1 year 20-45)
• Growth chart
• Signs of respiratory distress – nasal flaring, accessary muscles, subcostal or intercostal recessions
• Hydration status
• Sunken eyes
• Mucus membrane appearance
• Delayed skin turgor (normal <1 min)
• capillary refill time
• ENT: ear, nose d/c, LN
• Chest: Stridor? chest movements? any wheezes, widespread crackles, ronchi? Vocal resonance?
Breath sounds?
• Heart and abdomen
• ***avoid throat exam as minimum handling required***

• Draw a pic. Croup is a condition caused by a viral infection. The virus leads to swelling of the
voice box (larynx) and windpipe (trachea). This swelling makes the airway narrower, so it is
harder to breathe.
• So even though it is less likely to develop severe symptoms, we need to observe for a while until
he is free from noisy breathing
• Will be managed with oral steroids, we will consider adrenaline if persistent or worsening
symptoms
• Note : (Consider a longer period of observation than 4 hours for a child who:
• presents overnight
• lives far from medical care
• presents with stridor more than once during the same illness has risk factors for severe croup)

• If no stridor and doing good, you can go home and take care of him at home.
• Are you confident enough to take him home if we discharge?
 • Red flags - Please have someone stay all time with him and please take him back if you notice any
struggles to breathe, or if he is very sick and becomes pale and drowsy, lips turn blue, or he starts
to drool or can’t swallow.

Bronchiolitis
Your next patient in a general practice setting is a 8 months old boy, Robert, who was prematurely
born and who is brought in by his father, Mr. Jones, because of a history of 2 days increasing cough,
fever and runny nose.
Tasks:
• Take History
• Ask Examination findings from the examiner
• Tell your diagnosis and further management

DD:
• Viral URTI
• Bronchiolitis
• Pneumonia
• Croup
• Whooping Cough
• Foreign Body
• Cardiac Cause
• Epiglotitis

• Is it the first time?

• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• Cough- when? How frequently? Sudden or gradual? Dry/phlegm? Worsen at day or night?
• Can you describe it for me? Special pattern like cough-cough-vomit? Any sound like whoop? Does
he turn blue, barky cough (brassy cough) , any noise at end of cough, any runny nose, any noisy
sound? Any hoarseness of voice? (older child), anything makes it better or worse? Any drooling of
saliva?
• SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Any recession
between the ribs? Any position that reduces SOB?
• Diarrhoea/vomiting? Any changes in pee? Colour and smell?
• Is the child active? Feed well? Sleep well?
• BINDS – Contact history, similar case in childcare or family and history of anyone smoking in
history
• Health In general? Repeated respiratory infections ? Family Hx of asthma?

• GA: alert? rash

• Growth Parameters → height and weight in normal percentile
• Signs of respiratory distress
• Grunting
• Nasal flarings
• Tracheal tug
• Subcostal and intercostal recession
 • Hydration status
• Fontanelle (closure after 1-1.5 years) → depressed or not
• Sunken eyes
• Mucus membrane appearance
• Delayed skin turgor (normal <1 min)
• capillary refill time
• ENT: ear, nose d/c, LN
• Chest: wheezes, widespread crackles, ronchi, grunting
• Heart and abdomen

• Explain – Bronchiolitis, inflammation and obstruction of the small airways, reversible, due to a virus
called RSV. Self-limiting in nature and needs careful monitoring for respiratory difficulties.
• Moderate: Give oxygen (<92%), Arrange ambulance and send to hospital
• Mx is mainly supportive
• If child becomes deteriorate, some cases might also need intensive care, nasal cPAP and intubation
• Feeding - will be fed orally if not possible then only they will put a tube in the nose and feed the
child.
• Child will be monitored closely
• No need of antibiotics (or antiviral), steroids or humidifier (nebulized saline shows evidence but
not standard therapy)
• Xray not required: but if specialist suspect pneumonia or condition of child deteriorate then might
consider it and also might consider antibiotics
• Will be discharged once he can eat well and maintain good oxygenation.

Epiglottitis
You are a HMO. Your next patient is 18 months old baby with high fever and difficulty breathing and
look very sick.
Tasks
• -history
• -PEFE
• -DX, Ddx
• -Immediate management

• Stability
• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Any recession
between the ribs? Any position that reduces SOB?
• Any cough? Any noisy breathing? Does he cry a lot when he was fed? (pain on swallowing), any
mouth breathing? Drooling of saliva?
• Does he sit still?
• Severity - does he look drowsy ? any difficulty eating or sleeping? any reduced number of nappies?
• By any chance, did the child left unattended (foreign body)
• BINDS , contact history
GA:
alert? Rashes? Vitals – please remember respiratory rate (3 months – 25-60, 6 months – 20-55, 1
year 20-45)
• Growth chart
• Signs of respiratory distress – nasal flaring, accessary muscles, subcostal or intercostal recessions
• Drooling of saliva
• Tripod posture (head forwardly extended)
• Hydration status
• Sunken eyes
• Mucus membrane appearance
• Delayed skin turgor (normal <1 min)
capillary refill time
• ENT: ear, nose d/c, LN
• Chest: Stridor? chest movements? any wheezes, widespread crackles, ronchi? Vocal resonance?
Breath sounds?
• Heart and abdomen
• ***avoid throat exam***

Explanation
• from history and examination your child most likely have a condition called epiglottitis.
• epiglottis is a flap in the throat made up of cartilage mostly. It works as a valve to prevent food and
liquids from entering the windpipe when we eat or drink.
• in epiglottis, there is inflammation and swelling of epiglottis usually caused by a bug resulting
airway blockage and breathing difficulty.
• We need to treat it right now as it can block the airway completely.
• other possibilities are pneunomia which infection of lungs, foreign body, pus collection in tonsils,
but less likely
• Treatment
• You will need the child to settle quietly on your lap in the position the child feels most comfortable.
• We w ill observe closely with minimal interference.
• Treat specific cause – Give him antibiotics through his veins after securing the airway (otheriwse,
IV access is deferred because upsetting the child may increase the obstruction of the airway)
• We will call PICU if worsening or severe obstruction for proper airway management.
• Oxygen may be given while awaiting definitive treatment.

Pertussis
Your next patient in a general practice setting is a 2year old boy, Robert, who is brought in by his father,
Mr. Jones, because of a history of 5days of dry cough, which got worse last night with sort of spasms of
cough which kept the whole family awake. Physical Examination is normal.
Tasks:
• History
• PEFE card
• Diagnosis and Management
 • Temp – 38’C
• petechial haemorrhages on the upper body and subconjunctival haemorrhages.
• Chest auscultation is normal.

• Is it the first time?

• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• Cough- when? How frequently? Sudden or gradual? Dry/phlegm? Worsen at day or night?
• Can you describe it for me? Special pattern like cough-cough-vomit? Any sound like whoop? Does
he turn blue, barky cough (brassy cough) , any noise at end of cough, any runny nose, any noisy
sound? Any hoarseness of voice? (older child), anything makes it better or worse? Any drooling of
saliva?
SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Any recession
between the ribs? Any position that reduces SOB?
• Diarrhoea/vomiting? Any changes in pee? Colour and smell?
• Is the child active? Feed well? Sleep well?
• BINDS – Contact history, similar case in childcare or family and history of anyone smoking in
history. Any pregnant woman or babies <6 months at home?
Health In general? Repeated respiratory infections ? Family Hx of asthma?

Explanation
• This condition is most likely pertussis, also known as a 100 day cough.
• Caused by a bug which is a bacteria called B.pertusiss spreads by droplet infection.
• I know that your child has had a dose of vaccine against this bug, but despite vaccination, some
children can have the infection as the immunity of the child is still developing and some different
strain of bacteria may be responsible for the infection.
• But the good thing is that this is a less severe form of infection because of the vaccine.
• Needs a course of Antibiotic and I will do test to confirm diagnosis in hospital (A nasopharyngeal
aspirate/swab for PCR ). This course of antibiotics will reduce the severity and complications but
not for total cure. He will be coughing for a few more weeks since its name 100 day cough. But
since there is vaccination, serious complications are less likely to happen.
• Need to notify DHS (suspected or confirmed)
• Care at home : Give your child small, frequent meals and fluids often (such as sips of water or
smaller feeds, but more often). Taking care of a child with whooping cough can be stressful. Ask
 for help from family and friends so that you can catch up with sleep. Do not allow anyone to smoke
in the home or around your child.
• After confirmation, Contact Prophylaxis will be given to close Household contacts (antibiotics
Azithromycin) and vaccination to all close contacts (if not up to date)
• If pregnant mom (late pregnancy) or babies (<6months) at home, prophylaxis AB should be given
even with suspected case.
• School exclusion till 5 days of antibiotics
• Reg flags – episodes of cessation of breathing, high fever, not feeding well, shortness of breath,
turning blue – hospital admission

Another case (passed feedback)

• The mother of a 2 yr old child had come to see you, her GP, about a week ago because her child
was having a cough. At that time you diagnosed it as a simple viral cough and sent them home after
reassuring. Afterwards the child developed severe bouts of cough with post tussive vomiting.
Immunization was up to date as I remember.
• The concerned mother is now back in your GP clinic to find out what is wrong.
• Tasks-
• Explain the diagnosis to the mother
• Management
• Clinical implications of the diagnosis to the mother
• The lady inside was very angry that I did not diagnose her kid correctly the first time. So it was
difficult to complete the tasks while comforting and reassuring her. Diagnosis- pertussis. I
explained that it has a prolonged course and that the exact diagnosis could be missed as it is a mild
cough at the beginning. Asked about contact with babies under 6 months and pregnant women.
He had a 6 week old sibling. Child goes to child care.
• I talked about antibiotics, infectious period, prophylaxis for the baby at home. Isolation of the
patient’s toys and utensils. Keep him at home for atleast 5 days. Proper immunization etc.
• I apologised for failing to diagnose the problem earlier.
• Checked understanding. Asked if she had any questions.
• ( My study partner passed this one.. She said she tried to calm the angry mother first saying that it
was missed because the typical features take a while to develop.. had stated the stages of the
disease and explained..explained about the bacterial origin and mode of spread.. then RP had
settled a bit and then asked why her son got it cause he was immunised- explained that no vaccine
is 100% effective, but the disease is always less severe compared to non immunised kids, then gave
Mx plan with Antibiotic- Clarythromycin for patient and all house hold contacts including sibling,
isolation til 5 day antibiotic course( as he is infectious during that period) , no sharing utensils, any
pregnant contacts, inform child care, Reporting to health dept, reassured cough will continue for
a while (its also known as the 100 day cough) then explained about red flags and told to present
immediately if any of those red flags appear..)

Parapneumonic Effusion
4 yr child, Bonnie, was having cough for last 4 days with high grade fever brought in by father, David.
Tasks:
• history
• PEFE
• explain X ray
• Dx n DD

• Is it the first time?

• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• Cough- when? How frequently? Pattern of cough? Dry/phlegm? Worsen at day or night?
vomit/whoop/turns blue, barky cough, any noise at end of cough, any runny nose, any noisy
sound like stridor?
• SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Recent Travel?
• Cardiac Cause : turns blue ? SOB?
• Diarrhoea/vomiting? Any changes in pee? Color and smell?
• Is the child active? Feed well? Sleep well?
• BINDS – Contact history, similar case in pre-school or family and history of anyone smoking in
history
• Health In general? Repeated respiratory infections ? Family Hx of asthma?

• GA: alert? Rashes?

• Growth chart
• Signs of respiratory distress
• Hydration status
• Sunken eyes
• Mucus membrane appearance
• Delayed skin turgor (normal <1 min)
• capillary refill time
• ENT: ear, nose d/c, LN
• Chest: chest movements? any wheezes, widespread crackles, ronchi? Vocal resonance?
Percussion? Breath sounds?
• Heart and abdomen

• David, here is the X ray of Bonnie’s chest. These black shadows are the two lungs and the white
area in the middle is the heart. The grey shadows on the lungs are the ribs. What I am concerned
is this white area at the base of the right lung. Actually the right lung is suppose to be seen full like
in this shadow of the left. Now the white area is here most likely it is the collection of fluid between
the two coverings of the lungs. We call it pleural effusion.
 • According to the history and examination, this fluid collection is most likely because of the lungs
infection called pneumonia. This effusion occurring due to pneumonia is called parapneumonic
effusion.
• Pneumonia is an infection in the lungs by bacteria or virus or fungus that leads the air sacs in the
lungs to fill with fluid instead of air, making it difficult to breathe.
• Other possibilities are bronchitis which is the inflammation of the airways, asthma, pertussis, other
viral infections, heart failure, GORD or inhaling smokes but these are unlikely in this case.

Recurrent Respiratory Infection

A father, Tim, is concerned that his son who is 2.5 year old son, Ivan, had recurrent respiratory tract
infections this year. He has come to your GP clinic to discuss if child requires about stronger antibiotic.
Tasks:
• Take History from father
• Examination findings from Examiner
• Tell your diagnosis and management

History:
• What do you mean by recurrent chest infection? How often ? How long does it last? What
symptoms does he have (fever, runny nose, cough etc)? Any rash?
• Any cough? Any night time wheeze (whistling sounds popping out of chest))/cough? Any shortness
of breath/difficulty to breath at night time? Any time turned blue? Any eye symptoms? Any hearing
problem?
• Any recurrent diarrhoea? Stool foul smelling? Does it stick to the pan? Or Heel prick test? (cystic
fibrosis)
• BINDS: birth, growth and development, diet, social history (go to childcare, contact history). Any
other medical illness does the child have?
• Family history of hay fever, asthma, cardiac condition or any other condition, does any body
smoke at home? Any pets? Carpets at home?Any allergy child has?
• Examination
• General appearance: jaundice, pallor, Growth chart
• Vitals
• ENT examination, Lymph node examination,
• System Examination: Respiratory, cardiovascular, Abdomen examination

Explanation:
• Say that what the child has been having is nothing but simple viral infection of upper part of
respiratory tract as his fever is never very high, he's thriving well and there are no serious
symptoms and signs that could be found on hx or PE
• It is common viral infections
• Very common in children to have 6 to 12 infection in a year. Their immune/defence system is still
developing and not as strong as adult.
• One thing that predisposes to infection is passive smoking, so we can book another appointment
along with partner to discuss about talking about quitting smoking as it would be beneficial for
them and the child
• If goes to childcare, mention it can also cause infection
• No need of antibiotics as these are viral infection and antibiotics are given for bacterial infection
 • When fall ill: adequate rest, panadol for fever, adequate fluid, if any severe symptoms like sob,
rash, wheeze, severe cough etc…come back to me
• Also can give nutritious diet like rich in Vit C and proteins to boost his immune system
• Keep up to date with immunisation: flu vaccine every year in spring time before start of winter is
recommended to any child over 6 months (it is not 100 precent effective but can cover few strains
and be helpful )
• Maintain good hygiene
• Avoid exposure as far as possible to severely ill patients
• Also tell no need of any investigations at this stage.
• ((Try to convenience parents : they will be worried about immunodeficiency or want antibiotics))

Recurrent Runny Nose

You are a GP. There is a 4 years old boy brought by father due to constant nasal discharge.
• Tasks:
• H/o for 5 min
• PE given at 5 min
• Dx/ddx
• Implications of Dx

• Vitals: Bp 90/60, PR 90, RR 20, SP02 98 on air, Temp 37

• Mouth breathing +
• GC at 50
• Mildly congested nose with pale mucosa
• No tonsillar enlargement
• Resp and skin: normal

•Details of runny/blocked nose – How long? Is this the first time? Is it seasonal like happening this time
very year? Do you use any medications for it? How does the discharge look like? Clear or any color? Any
offensive smell? Is it affecting one or both nostrils?
•Previous episodes – similar in nature? Any fever? How were they treated?
•DDx – Any watery eyes? Any sneezing? (hay fever) Any cough? Any fever? Any SOB? Any joint pain or
muscle pain (URTI), any medication used for blocked nose (decongestant spray overuse), Any headache?
Bad breath? Mucus dripping down the throat? Pain on the face? (sinusitis), any ear pulling or hearing
problem? (Cx)
•Any allergy or asthma history before? What about family history?
•Is it triggered by any allergens?
•Do you have carpets or pets at home?
•Anyone in the family having the same condition?
•Past medical, past surgery
•BINDS history
•DDx –He is well and healthy except this runny nose. Most likely he is having the recurrent Infection in
the airways (URTI) which is very common in children as their immune system is still developing. It is usual
for the children to have around 10 times of infections in a year.
•Another possibility is allergic rhinitis or hay fever which is an allergic response to specific allergens. It
causes the inflammation of the inner lining of the nose causing sneezing and nasal discharge. Allergens
are usually pollen, mold, dust or animal dander. Most common allergen is pollen. It is common in hot, dry
season as there are more pollens in the air.
•Other possibilities include vasomotor rhinitis where there is dilatation of the vessels in the nose likely
due to irritants, sinusitis which is the infection in the linings of the small spaces inside the nose and head,
Asthma, or very less likely foreign body in the nose, or growths inside the nose.
•Implications – We might need some blood tests to exclude allergic rhinitis because if this is left untreated,
in a long term, it may result in inflammation in the ear, sinusitis and asthma and also snoring resulted in
sleep disturbances and poor school performance.
•If this is just recurrent URTI, it will resolve spontaneously and less frequent when he is older.
• Reassure.

Asthma
Your next patient in general practice is a 6 year old girl, Laura, who has been brought in by her mother,
Samantha. Laura recently had a cold and developed some breathing problems which made it necessary
to take her to the local hospital’s emergency department. She was diagnosed with asthma and they
prescribed salbutamol puffer to be given spacer and a course of prednisolone is given. Laura has no
signs of asthma today. She has previous history of eczema which has been well managed by a barrier
cream. She has no history of allergy. She is generally healthy and her immunisations are up to date.
There is also no family history of asthma or any allergy. Samantha has no idea of asthma and is
concerned about it.
• Your tasks:
• Explain the condition.
• Review the prescribed medication and demonstrate the administration technique
• Explain Asthma Action Plan

• Outline of approach
• Asthma(draw diagram): It is a condition that affects the small airway passages of the lungs. In this
codition, these airways got inflamed, spasm and narrowed making it harder for air to flow in and
out of the lungs. Also it produces extra mucus. All these result in symptoms like cough, shortness
of breath and chest tightness. It may associate with some allergens or trigger factors sometimes.
• This is a long term condition but reassure that the condition has good prognosis.
• Risk factors: Not to smoke inside the home. Remove soft toys from the child's room. Wash the bed
linens under high temperature. Try to vacuum the carpets everyday. Avoid any other allergens and
precipitating factors. Avoid pets inside the home
• Use Salbutamol puffer with spacer 2 puffs as per requirement
• Use of puffer (MDI) with spacer-
• Always check the expiry date of puffer before use.
• Put the spacer together following the instructions that came with it.
• Remove the protective cap from the puffer.
• Shake the puffer well and prime it by pressing down a few times until a mist comes out.
• Insert the puffer firmly into the end of the spacer.
 • Place the mask over your child's face, making sure that it covers the mouth and nose. Try to get a
good seal on the skin so that no air can get in. In older children you may wish to use the mouthpiece
on the spacer, rather than the mask.
• OR:
• If your child is able to use a spacer without a mask, they should place the mouthpiece of the spacer
in their mouth and put it between their teeth, then close their lips around the spacer mouthpiece.
Make sure their lips cover the entire mouthpiece so there are no gaps.
• Ask your child to sit upright and breathe out gently. Hold the spacer and puffer level so that they
do not tilt up or hang down.
• Press the puffer once to release a dose of the medicine into the spacer. Do not remove the puffer.
• Allow your child to breathe in and out four times. This usually means leaving the spacer in position
for about 15–20 seconds. Do not remove the mask in between each breath – there is a two-way
valve system that will prevent any of the medication from escaping from the chamber.
• If further puffs are needed, shake the puffer again and repeat. You can shake the puffer while it is
still attached to the spacer.
• Recommended to dip plastic spacers into ordinary household detergent and dry in sunlight (no
rinsing, no wiping) every 10 days or at least monthly.

• Asthma action Plan

• I am going to write a long term plan
• Explain the mother the action plan(when well, not well, severe case) and what to do each time
• When well Use Ventolin : 2 Puffs as per requirement (green zones, no signs, just for activities like
before exercise)
• When not Well: use Ventolin 2 Puffs even used frequently and prescribe prednisolone 1mg/kg as
in the plan and see your GP within 48Hour (yellow, signs and symptoms present, waking up at
night)
• Severe Case: 4x4x4 → take 1 puff 4 breath 1 puff 4 breath 1 puff 4 breath 1 puff 4 breath and wait
4 minutes→ if improved, see your GP on the same day (red zone, difficult to breathe, Blue, unable
to talk)
• If not improved call 000 and tell acute asthma attack and continue ventolin as per 4x4x4 until
ambulance arrive
• Tell to continue the prednisolone as it is prescribed in hospital
• Note the trigger in AAP. 6 monthly review. Make sure she takes it with her. Give copies to school.

OSA
An 18-month-old child brought by his father to the ED yesterday because of breathing difficulty. The
baby was admitted for URTI and pulse oximetry readings were taken over night.
Tasks
• History
• PEFE
• Explain the investigations to the father
• Dx and DDx
 • Fever – when did it start? Did you measure the temperature? How long? Persistent or off and on?
Any shakiness?
• SOB – How long? How severe? Can he sleep and eat well? Any chest indrawing? Persistent or off
and on? Is it the first time?
- OSA – day time sleepiness and lack of energy. Snoring, mouth breathing?
• Causes - recurrent upper respiratory infection, Tonsillitis (sorethroat), ear infection
• Infection – any cough? Sounds like croup or whoop or barking? Any SOB? Any blue discoloration?
Any episode that stop breathing? (apnoea) Noisy breathing? Drooling of saliva? Staying like
bending forward position? Fever? Runny nose?
• How is he now? Active or drowsy?
• BINDS
• Contact history

PEFE:
•General appearance, Vitals, growth chart
•Dehydration
•adenoid facies- open mouth, dry lips, projecting teeth (incisors), inactive ala nasi, short
upper lip, high arched palate
• I will do ENT exam very carefully because I suspect epiglottitis as well (dangerous in
epiglottitis)
• Neck stiffness
• CVS and chest
• Abdomen

• Explanation of investigations:
- X-ray: lateral view of head and neck. Black area is air, white areas are bones and grey
areas are tissues. The problem here is this black line is airway and the opening of the
airway has been narrowed and covered by small grey tissue.
• Sleep study: This is the graph monitoring the oxygen saturation in the blood while he is sleeping.
the horizontal axis is time and the vertical axis is oxygen saturation. There are multiple drops during
the night to around 60% which should always be more than 94%. This happens because of some
episodes where the breathing stops and because of airways obstruction as you see in the Xray.
• All these are pointing towards enlarged adenoids which located in the roof of the mouth and part
of our body defense system. They can be enlarged when there is infections in your son’s case,
 recurrent tonsillitis or URTI. When they’re enlarged, it blocks the airway too as you can see in the
Xray. So it’s leading to a condition we called obstructive sleep apnoea. (obstruction and stopped
breathing episodes while sleeping) This is the source of snoring as well.
• It could be because of tonsillitis as well but the tosils have been removed. It could be because of
some infections such as pneumonia which is infection in the lungs or epiglottitis which is the
infection in the epiglottis which is flap in upper airway, croup which is the infection in the upper
airway as well but less likely.

OSA (snoring)
You are a GP. You are going to a mother, Paula, of a 3 years old child, Will. She is concerned her child
snores at night. (another case, cannot concentrate)
Tasks:
• History
• PEFE
• Explain Dx and DDx to the mother.

• History
• Snores at night – first time? any difficulty breathing, any change in color, pause in breathing
• Other symptoms – noisy breathing in daytime? Fever ? Cough ? Runny nose? Sore throat?
• OSA – sleepiness in daytime? Inability to concentrate ? How is his school performance? If +, can he
finish a task? Does he talk excessively? Does he seem hyperactive? (ADHD)
• Causes of OSA – recurrent sneezing? (allergic rhinitis), Sore throat? Recurrent ear infections or ear
pulling? Any medical or genetic condition? (muscle weakness and Down syndrome,
achondroplasia), Any surgery? (surgery for cleft palate)
• If+, ask details
• Anyone smoking in the family
• BINDS esp weight!

• PEFE:
• General appearance, Vitals, growth chart - normal
• There is no dry lips, projecting teeth (incisors), inactive ala nasi, short upper lip,
• ENT – bulging tympanic membrane and reddened, Enlarged tonsils
• Abdomen - normal

• Explain – OSA – draw a picture. Obstructive sleep apnoea (OSA) is a condition that causes repetitive
episodes of upper airway obstruction during sleep, leading to reduced oxygen and/or sleep
disturbance. This partial obstruction leads to snoring in most of the child.
• Obstruction can be caused by enlarged tonsils or enlarged adenoids which located in the opening
of the airway and part of our body defense system. So any inflammation of infections in breathing
system and ear, nose or throat can lead to enlargement of these structures. In this case, repeated
respiratory/ear infections lead to enlarged tonsil and partial obstruction of the airway.
• DDx – Enlarged tonsil, enlarged adenoids, obesity, Pickwickian syndrome, thyroid enlargement
• Reassure mom, we can manage effectively depending on severity.
Tonsillitis
A 4-year-old boy, Robert, was brought by his mother, Pancy, to your GP clinic because she noticed
that his child is not well, less and has whitish material in his throat.
Tasks:
• History
• Physical examination findings from examiner
• Diagnosis and Management

History:
• What mean by not well? Fever? If present, ask in detail.
• Rash? If present, ask in detail?
• Flu like symptoms? Sore throat? Cold? Ear pain/ear discharge? Difficulty in swallowing? Any
problem with speaking? Cough/ difficulty to breath? Vomiting/diarrhea?
• BINDS: immunisation, feeding and eating, contact history, childcare
• Social – Racial origin, Family history of Rheumatic fever or Rheumatic heart disease (risk
assessment)

Examination
• General appearance: pallor, jaundice, rash, signs of dehydration
• Vitals and growth chart
• Signs of meningeal irritation (neck stiffness)
• ENT examination, Lymph node examination
• Systemic examination
• Office test: urine dipstick,
• Unwell. High risk (indigenous Australians and family history of Rheumatic fever), suppurrative –
throat swab

Explanation:
• Tonsillitis: it is infection of the gland which is present in the throat. They are part of the immune
system and are the first line of defense against bacteria in food or air. Tonsillitis occurs when the
tonsils become infected and can be caused by either bacteria (20-30%) or viruses.
 • In your sons case, I suspect it is caused by bacteria mostly because he’s markedly unwell, and has
tender, enlarged tonsillar lymph glands (glands in the neck.The most common bacteria causing
tonsillitis is streptococcus (GABHS).
• I will perform the swab and confirm it.
• Before the culture result, I will give him simple painkillers and make sure you give ample of fluids.
We can try steroids if his pain is not better with simple pain killers)
• Note: Swab only done in some cases you desire for antibiotics
• Refer to hospital, he will be admitted. (if moderate to severe dehydration or severe pain)
• Start on antibiotics if throat swab positive: prescribe antibiotic (phenoxymethylpenicillin or
Amoxillin) for 10 days (or Azithromycin if allergic). (NB antibiotics to be started straight away
before the culture result in high risk group)

Notes:
• high-risk groups:
• for Rheumatic fever
• Indigenous Australians
• Maori and Pacific Islander people
• personal history of rheumatic fever or rheumatic heart disease
• family history of rheumatic fever or rheumatic heart disease

• Notes : The most widespread clinical prediction tool for GAS pharyngitis in children is the McIsaac
score, which consists of the following five parameters:
• body temperature (BT) 8°C;
• lack of a cough;
• tonsillar swelling or exudate;
• tender cervical lymph nodes; and
• age between 3 and 14 years

Child with fever came back from Malaysia

GP setting, you are visited by a family just came back from Malaysia. It is an Australian family that was
living in Malaysia for 6 months, Covid test was done and shows negative. Now the child is presenting
to you with a fever of 38.7., given Panadol. He is 4 years old now,
Tasks:
History for 6 mins
Explain DDx

History
• Is it the first time?
• Fever- when? Temperature? Continuous or come and go? chills and rigor? Rash?
• Cough- when? How frequently? Sudden or gradual? Dry/phlegm? Worsen at day or night?
• Can you describe it for me? Special pattern like cough-cough-vomit? Any sound like whoop?
Does he turn blue, barky cough (brassy cough) , any noise at end of cough, any runny nose, any
noisy sound? Any hoarseness of voice? (older child), anything makes it better or worse? Any
drooling of saliva?
• SOB - Any rapid breathing? Stops breathing at any time for a while (apnoea)? Any recession
between the ribs? Any position that reduces SOB?
 • Any sore throat?
• Diarrhoea/vomiting? Any changes in pee? Colour and smell?
• Viral infection – any headache, muscle and join pain? Any rash in the body? Any red eye? Loss of
smell or taste? Runny nose?
• Dengue – any mosquito bite? Camping activities?
• Is the child active? Feed well? Sleep well?
• BINDS – Contact history, any COVID contact, similar case in childcare or family and history of
anyone smoking in history
• Health In general? Repeated respiratory infections ? Family Hx of asthma?

• Possible DDx – Atypical pneumonia, COVID pneumonia (need to check again), Strepcoccal
tonsillitis, Infectious mononucleosis, Dengue fever, Other bacterial infections or viral infections,
Malaria and TB very unlikely.
• Accidents, NAI and Injuries

CP child with Spiral Fracture

7yr old CP child (spastic quadriplegia) brought in by carer. He is screaming continuously for last 2 days.
He spent the weekend with parents who rarely visit him.
Task:
• HX
• PEFE
• Inv
• DX
• Your plan of management

• Authority
• Vitals
• What do you think what happened? How long is it? is it t the first time? Did it happen suddenly?
How frequent did he scream? Any other symptoms like fever, runny nose, cough, ear pain or
discharge? Any SOB or difficulty in breathing? How is his eating and drinking habits? Any vomiting
or diarrhoea? Any tummy pain you noticed or distension? How is his waterwork? Any changes in
color or smell? Did he cry when he pee? Any possibility of injuries or fall? Did you check with other
carer?
• How is his relationship with you? What about other carer? What about his parents? Do his parents
visit him regularly? Do you know anything about his parents?
• Past medical, surgical
• Immunization? Nutrition (who is taking care of his foods?) How is his development?

• PEFE – general appearance, vitals – temperature, pulse, oxygen and respiratory rate (can’t check
BP because the limbs are spastic)
• ENT
• Neck stiffness, rashes
• Respiratory, CVS, Abdomen
• Upper limb and lower limb examination (inspection, palpation only, movement must be stiff)
• The whole body for any bruising or swelling
• UDT, blood sugar level
 • Investigations
• FBC, ESR, CRP,LFT, RFT
• Xray of right leg (because of bruising in examination)
• (examiner will give you Xray and Dexa scan of the leg showing spiral fracture and osteopenia)

• During the examination, I could find some bruises on his right leg so I ordered imaging of that area
which showed there is a spiral fracture in his shin bone. (If X ray in your hand, show the fracture
line. If no Xray but just notes, draw a diagram of fibula, tibia and femur and fracture). There is a
break in his shin bone as you can see here . He must be crying and screaming because of the pain
from this fracture.
• What I am concerned is that it could be due to some accidents but it’s possible that it could be
non-accidental injuries as well. We will need to admit him to check for other injuries and to treat
the fracture too. To make sure he is safe, I need to involve the child protection authorities (CPA)
and make a meeting with his parents, you and the other carer.
• Another imaging is showing that his bone is thinner than normal. It can be because of many causes
like imbalance nutrition like reduced calcium intake or maybe because he is staying inside mostly,
so there is lesser sun exposure which results in low vit D levels. So I would like to check his daily
records of activities and diet as well.

Buckle Fracture
Your next patient in GP Practice is 10 year old Oliver, who has been brought by his mother, Tiffany,
Oliver is complaining of pain in the right wrist since yesterday and his mother is really concerned about
him. He looks a little anxious in the waiting area.
Tasks:
• Take History from mother
• X ray from examiner
• Discuss with mother what is the most likely cause of his condition and what is the further plan
of management.
Approach
• Details of pain – where? How long? Onset? Severity? Continuous or off and on? Relieving/
aggravating factors?
• DDx - Post Viral arthritis -any recent illness? With cough, runny nose?
• Septic arthritis – any fever? Redness? Swelling?
• Osteomyelitis
• Trauma – any injury? What was he doing before it?
• Complications – any change in color? Does he complain of numbness?
• Non accidental injuries – who is taking care of the baby? How are you coping?
• General health? Poo and pee? Appetite?
• BINDS

• A buckle injury of the wrist is a small area of compressed bone

• These types of fractures are more common in children, especially aged 5-10 years, due to the
elasticity of their bones
• The wrist may be tender, slightly swollen, and painful to move.
• This most commonly occurs at the distal radius or tibia following a fall on an outstretched arm
• There is no deformity.
• Pain is usually not severe and should be managed with a simple pain medication such as panadol.
• Since these injuries are stable and heal quickly without problems, x-ray or follow-up appointment
with the GP, fracture clinic or physiotherapy is usually not required.
• This injury is treated by wearing a removable back slab or ready-made splint which can be removed
for bathing or showering. An arm sling is optional for comfort.
• Remove your child’s back slab or splint three weeks from the injury. Wrist movement may be a
little stiff and sore at first. Rough and tumble play, and contact sports should be avoided for 6
weeks.
• Contact the doctor or the hospital your child attended if after three weeks from the injury:
• Your child’s wrist remains very painful or swollen
• Your child will not use their wrist, hand or fingers within 2–3 days of the back slab or splint being
removed.

Pulled Elbow
You are a GP. 18-month-old girl, Marinda, is brought to you by her mom, Hazel, because she noticed
that she didn’t move her right arm and hand suddenly a few minutes ago.
Your tasks :
• Take relevant history
• PEFE card from the examiner
• Explain the diagnosis to mom
• Management to mom

Approach
• DDx
• Injury
• Abuse
• Infection

History
• How did you notice it? 1 st time? Does she complained of pain? How did it happen? Suddenly?
• DDx - Can you recall any injury to her hand? Is there any chance that someone pull her hand? Did
she cry a lot after that? Do you notice any deformity, redness and swelling after that? Any history
of fall? Is she hot to touch these days?
• Complications – Do you notice any color changes in her fingers.
• BINDS Social history – support and background
• Mom’s attitude – how are you coping with the baby?, (abuse?)

PEFE
• General appearance – not distressed, well alert
• Vitals – normal
• Local examination – comparing with the left side, right hand is pronated, slightly fixed at the elbow
joint, right hand is held by left side.
• Motor – power is not tested
• Neurological -examination - normal
• No fractures in clavicle
• No shoulder joint tenderness
• Pain at the elbow present

• Hello Hazel, Marinda’s hand is not moving because of pain. It is because of a condition we call Pull
elbow. Draw a picture.
• Arm bone (humerus) and two forearm bones (radius and ulnar) are attached together at the elbow.
In this case that joint is dislocated (radius bone)
• Happens when the baby’s hand is pulled out by a force
• Sometimes it may happen after the fall (nursemaid elbow)
• It can happen accidentally. You are not the one to blame. The bones and tendons are still
developing at this age and easy to dislocate.
• Initial management
• reduction– a procedure to relocate the joint (just seconds of pain during relocation)
 • (face with the patient, press with right thumb at the head of radius, supination and flexion of elbow
done, successful if there is popping sound as the radial head relocates)
- (say we can prescribe her a good painkiller before the procedure if the mother is
concerned)
• She will be fine with no residual pain. She will be observed for a short while to check that she is
using her arm without any problems or pain. (Using the arm normally may be possible almost
immediately after the elbow is 'reduced', or it might take a bit longer. )
• reassure that she doesn’t have any fever and no vessels and nerves affected
• Further management
• Prevention – It is critical to prevent the further attack, avoid any condition that cause this problem
again. Avoid pulling the baby’s hand.
• Carry the child from armpit. Also let the family members know about the mechanism of injury and
beware of it.
• Review
• NB – X ray only when procedure not successful, Swelling, deformity
• Pronation/ flexion manoeuvre
• sit the child on the parent's lap
• grasping elbow closed
• Apply pressure over the radial head over pronation
• Fully pronate forearm and then flex the elbow

• Supination/flexion manoeuvre
• sit the child on the parent's lap
• apply pressure over the radial head
• supinate the forearm
• flex the elbow

Bruise on cheek
You are a GP. A mother comes with baby (3 months old boy)baby had been crying non-stop for 2 days.
Mother noticed bruise on right cheek. She and her partner are uni students
• Physical exam- all normal except for the bruise on cheek.
• Task- Hx, Dx and Mx.

• Details of the main complaint –

• Rash - when and where did rash start? Any where else in body present (palms, soles and hand)?
any aggravating (worse) or relieving factor (better)? Itchy? Can you describe it for me?
• Any previous similar problem? Changed any cream or medication? Changed any shampoo or
shower gel? Any trauma or injuries?
• Association – fever, cough, runny nose, any changes poo and pee? Did he cry alot? Is he eating well
and sleeping well? Is he active and playful?
• BINDS – Birth history, Was this a planned pregnancy? Any complications during pregnancy, birth
or after delivery? Is he gaining weight? Is he developing well like any other kids of his age?
• Social –any other children? Is this your first child? who look after, happy family, cope well? How is
his relationship with you and your partner? IS your partner biological father to the baby? Does you
 or your partner drink alcohol? By any chance, what about recreational drugs? What do you do for
a living? Financially stable?
• Show empathy
• Explain –According to the history, I am thinking that we need to admit him to know the cause of
the rash. I will also examine him and do the required investigations to rule out any infections or
bleeding disorder or other possible associated injuries. He will be seen by the specialist.
• Also I am suspecting some kind of non-accidental injury. Will get involve CPA. They will not take
the baby away. They will just interview you and partner to understand your difficulties and support
accordingly. They are just there to sort this problem out together with you and partner. Our aim is
to provide you with appropriate referrals and resources.
• Safe discharge plan for the child and their family (children and carers) has been approved by a
senior clinician. Children and their carers must have been linked with ongoing supports
• They may consider an intervention with parental agreement (IPA) which is a child protection care
agreement where you can keep the baby, look after the baby and they’ll arrange the supports
necessary.

Bruise on cheek
You are a GP. A mother comes with baby (3 months old boy)baby had been crying non-stop for 2 days.
She and her partner are uni students
Task- Hx, PEFE, Dx and Mx.

•Crying – does she cry as usual or is it getting worse? How long have you noticed that cries a lot? Do you
think it is excessive or unusual? Does she cry throughout the day or any particular time of the day?
(irritable baby & infantile colic– cries more in the evenings), how long does it last when she cries? How
frequent? (any relation with food?) Did you notice any drawing up of the legs?(infantile colic – more than
3 hrs in one cry, >3 times a week, duration> 3 weeks)
•DDx –
•Is she breastfed or bottle fed? How frequent do you feed the baby? Any problem with suckling or
breastfeeding? Do you think she get enough breastfeeding?
•Do you think she is very sensitive to external stimuli? For example, noisy environments, room tmperature
not well adjusted? (irritable baby)
•Any fever? Hot to touch? Noisy breathing, cough, runny nose? Rash? (infection)
•Any vomiting? Swelling in the tummy? Groin? Any changes in poo and pee? (GI symptoms)
•Any injury? (like while changing diaper or rolling)
•I can see that you are distressed by her cries. How do you respond to them? (shaken baby syndrome)
•BINDS – Birth history, Was this a planned pregnancy? Any complications during pregnancy, birth or after
delivery? Is he gaining weight? Is he developing well like any other kids of his age?
•Social –any other children? Is this your first child? who look after, happy family, cope well? How is his
relationship with you and your partner? IS your partner biological father to the baby? Does you or your
partner drink alcohol? By any chance, what about recreational drugs? What do you do for a living?
Financially stable?

•Explain –According to the history, I am thinking that we need to admit him to know the cause of the rash.
I will also examine him and do the required investigations to rule out any infections or bleeding disorder
or other possible associated injuries. He will be seen by the specialist.
•Also I am suspecting some kind of non-accidental injury. Will get involve CPA. They will not take the baby
away. They will just interview you and partner to understand your difficulties and support accordingly.
They are just there to sort this problem out together with you and partner. Our aim is to provide you with
appropriate referrals and resources
Safe discharge plan for the child and their family (children and carers) has been approved by a senior
clinician. Children and their carers must have been linked with ongoing supports
They may consider an intervention with parental agreement (IPA) which is a child protection care
agreement where you can keep the baby, look after the baby and they’ll arrange the supports necessary.

Detergent Ingestion
You are a HMO at ED. You are going to see a 15 month old baby, Roger, brought by his mom, Felicity.
He accidentally ingested some washing detergent a few hours ago.
Your tasks
• Take history
• Examination from examiner
• Management

• Stability
• Explore more – which one? Liquid or powder? Did you bring it? (concentration, pH), amount, time?
What did you do after you saw it? (any irrigation with water?), Did you give him anything like water
after that?
• Severity – breathlessness, noisy breathing, increased breathing rate, cough, blue lips., Blue skin,
cried a lot? (pain),nausea, vomiting, drowsiness? Drooling of saliva? Collapse?
• BINDS history
• Social history – who is taking care? Why was the baby unattended?

• PEFE – General appearance, vitals, Growth chart

• Oral cavity – any erosion, lesions, ulcers
• Drooling of saliva
• Signs of respiratory – nasal flaring, accessory muscle, chest indrawing
• Respiratory, CVS, Abdomen

• Invx – pH testing of product (>11.5 likely to cause ulcerations in GI),

• FBE, UEC, ABG ( for systemic toxicity), LFT, Urine RE, CXR
• Management – NEVER activated charcoal
• Asymptomatic – fluid dilution 10ml/kg of water (max 250 ml)
• If asymptomatic after 4 hours and can eat and drink – can be discharged
• If any symptoms – contact the senior and admit – OGD scopy
• Follow-up visit (stricture complication)

Foreign body in airway

You are a HMO in a hospital. Your next patient is a 3 years old boy, Dennis brought in by his dad, Ivan.
Dennis just got a continuous cough since a few minutes ago.
Tasks :
• Take history
• Order invx
 • Explain plan of management to the patient

Notes:
• DDx for sudden onset of cough in children
• Foreign body
• Infection – viral – croup, bacteria – epiglottitis, peritonsillar abscess, tracheitis
• Common cold
• Allergy

• Check stability
• Cough - When did it happen? was the cough continuous? How long? Is ot the first time? How did
it happen exactly? Any noisy breathing? Any SOB? Blue lips?
• FB – any possibility of him swallowing anything accidentally? Who is looking after him? By any
chance was he left unattended? What was he doing before? If eating – what was he eating? Any
possibility of choking? Do you notice any missing or broken parts of toy?
• Infection – fever, drooling of saliva? Secretion?
• Allergy – allergy history? Eczema? Hay fever?
• BINDS
• Social – are you coping well with the baby? Financially stable? (negligence)

PEFE
• General appearance, vitals
• ENT – any FB, any inflammation
• Signs of respiratory distress – RR, cyanosis, chest indrawing, stridor
• Respiratory examination – breath sound reduced on one side
• Abdominal examination
• Invx (only in symptomatic children)
• Neck Xray (to exclude epiglottitis if there is no reliable history for foreign body)
• Chest Xray (full expiration to exaggerate the differences between the lungs) and abdominal Xray
• Note : imaging is only done in suspected or known button battery, magnet, other radiopaque
object, unknown object or symptomatic child.

• I did thorough assessment on Dennis, what I suspect is most likely it is a foreign body in his airway.
Most likely ……….
• So I will inform the ENT specialist and anaesthetist after confirmation by investigation. (depend of
the result of Xray). The specialist will insert a small tube from his mouth and it will pass along the
airway and the foreign body will be removed. We call it bronchoscopy. This procedure will take
only a few mins and safe. The anaesthetist will make sure that he is painfree.

• Prevention (please talk about it in non-urgent cases)

• These kind of accidents can happen anytime, very common in his age. They don’t have abstract
thinking whether it’s good or bad.
• Prevention is critically important.
• Dennis needs to be looked after by one of the family members closely and full time unless he is
sleeping.
 • Any FB or anything that is harmful to a baby must be kept away (eg nuts, batteries, parts of toys,
medicines, detergents)
• This is serious when the ingested thing is large and obstruct the airway completely, life-
threatening. Sometimes, the type of the foreign body may also affect the severity. E.g, batteries
may contain dangerous substances that will destroy the lining of food passage leading to
perforation of food pipe.
• Red flags – if you notice sudden onset of cough, choking, blue lips, inability to swallow or talk –
please do emergency measures.
• Back slap and chest thrust (you can attend some first aid trainings for that or check the videos) and
call an ambulance and go to ED.
• But prevention is the most imporatant.

Burn
Mom with 2 ½ yrs old boy in ED due to burn. During having cup of tea, suddenly hot tea splitted over
her boy.
Task
History for 4 min
Ask Examination findings from the examiner
Tell immediate management and further management

Approach
• Haemodynamic stability (any respiratory difficulty) and hydration status, pain severity and give
pain killer,
• What type of burn, when, where, how, what area involve ? Any other area than the chest?
How did the baby react, any turning of blue, noisy breathing, loss of consciousness ?
Is it the first time, how is the family support, Sibling and a little bit of social history (to exclude
child abuse)
General Health, Immunization (tetanus status), Growth and Development
Time of Burn, time taken to travel here? Did you do any thing after the burn like washing in
running water etc?

Examination
 • General Appearance: restless/ respiratory distress, rash, burn description –Assess Type of burn ,
Extent of burn, Depth of burn, Exclude circumferential burn (if UL or LL)
• Any hoarseness of voice, stridor, black sputum (ET tube required)
• Growth chart
• Vitals signs
• Dehydration status
• Head to toe for any other injuries (abuse) , Genitals
• Systemic Examination : Respiratory
• TBSA < 10% - minor burn
• >10 % - major burn, all deep burn are major burn

Management
• Check tetanus status and document it
• First Aid - Cool Under Running Water for 20 mins (can do within 3 hours after burn when not done
yet)
• Admission, Analgesia, iv access, call burns unit team/paediatric regsistrar
• Fluid management there based on modified parkland formula
• Resuscitation fluids,((( ideally through 2 large bore IV/IO, through uninvolved skin at a volume/rate
estimated using Modified Parkland Formula (3ml x kg x %= total fluid for 24 hours)))
• Dressing - superficial - low adhesive dressing
• partial thickness - silver dressing
Face- usually vaseline,and expose ( treated by burn unit)
• Reassure. The burn seems just superficial/partial thickness. We admitted him just because the
area is larger than 10% of total body surface. So he will be monitored and given fluids. He will be
better after a few days.
• If in GP clinic presentation comes: first aid, cover with a plastic cling, analgesia, Tetanus status,
Refer to hospital immediately

Head injury
You are a HMO. 15 yr old boy was brought by worried father after a head collision injury during a game
on the field. Boy had lost consciousness for 4 minutes.
Tasks:
• -History for 5 mins
• -PE from examiner
• -Explain condition with reasons
• -Management

PEFE
• Physical examination from the examiner
• GCS - 12/15
• Vital signs - normal
• Head – There is a swelling in the forehead measuring 3x4cm in diameter along with a bruise
• Eyes and pupils - normal
• No discharge in ear and nose
• NAD in mouth and face
 • No neck tenderness
• Cranial nerves 2,3,4 normal
• Upper and lower limb neurological examination - normal

History
• Reassure
• Let me assure you that your boy has been looked after by experts, primary survey has been done
and he is stable at the moment. I just need to ask you a few questions…
• Details
• can you tell me more? before the event did he complain of any strange feeling like aura, strange
smell or tunneling of vision?
• when did he have his last meal? Has he lost his consciousness? And for how long? (Ask if not
mentioned in the stem) Has anybody witnessed the event and noticed any jerky movements of his
body or limbs or rolling of eyes? has he wet or soiled himself? does he have any injury to his head
or any other parts of his body? (Yes, swelling in head)
• how soon did he recover?
• Any memory loss? Is he able to recognise you?
• any headache, vomiting or blurring of vision? (vomited once so ask about amount, colour and
content)
• any residual weakness in his body? Any difficulty speaking?
• any chest pain or shortness or breath?
• any problems with his bowel motions or urine?
• Has this happened before?
• General questions
• PMH, PSH, history of bleeding disorder
• Family history
• school performance and stress at school
• home situation and stress at home

Explain
• from history and examination, your child most likely has a moderate head injury because the child
had a brief LOC and memory loss of only a few minutes and tell any other positive finding you will
have from the history.
• Let me assure you there is no neurological signs to worry about.
• At this time, we need to admit him for observation and monitoring.
• I will give him adequate painkillers for his pain
• I will consult with the ED consultant and paediatric neurosurgeon, to come and see him. He might
need CT but the specialist will decide this.
• if he does not take oral feed or vomit. Then He might need IV fluid.
• so in the meantime, try not to stress yourself he will be fine. We are just keeping him for
observation because sometimes whenever there is an injury the impact might be seen later.
• regarding the swelling in his head, it will usually resolve with time, there is no other problems apart
from this.

Emergencies
Testicular Torsion
You are HMO in ED. Father of a 12 year-old boy, complained of pain in the right groin and vomiting for
3 hours after playing basketball. The father is Freddy and the boy is Jaden.
Tasks:
• History
• Physical Examination Findings from examiner
• Diagnosis and management

approach
• History of pain in details – severity? Pain killers? Onset? Sudden or gradual? Off and on or
continuous? Moves to the groin? Aggravating factor/ relieving factor?
• Association –nausea and vomiting? Contents? How many times?
• Mumps complication - Fever or rash? now? Recent mumps?
• UTI – any pain on passing urine? Smelling urine?
• Abdominal causes - Any pain in tummy?
• Hernia - Any lumps in scrotum?
• Injury - Any injury?
• Torsion - Any redness in scrotum?
• BINDS (just ask about general health)
• Any possibility that he is sexually active?

PEFE –
• GA, vitals – vitals normal, he is in pain
• With consent of mom and roleplayer,
• Genital Examination: Inspection - horizontal testes, redness and swelling positive on right side
• cremasteric reflex - absent
• palpation - tenderness, Prehn’s signnot relieving pain
• UDT - normal

• Explanation- draw a picture

• Twisting of testis & it’s stalk including the vessels and sperm duct emergency condition.
• Need surgery and outcome is good if done within 6 hr.
• During Sx, if testis is dead then need to remove it and they will take consent . If viable, the surgeon
will fix the torsion and anchored it in position. He will also fix other testis to prevent recurrence.
No need of invx as it wastes time.
• Not affect fertility as other testis is functioning and it has no association with cancer

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. Older brother has got recent onset of gastroenteritis.
Tasks:
• History
• Physical Examination Findings from examiner
• Diagnosis and management
 • Stability
• Vomiting Hx→ tell more about it, when start, colour and amount, forceful/not, related to
feed/food,
• Associated with lump and bump(tummy)
• Intussusception Qs Draws up legs while crying, turns pale while crying, any abdominal
distension, passed wind (flatus)
• Appetite, lost weight, any diarrhoea/bowel motion (red stools)(If present go in detail)
• UTI Qs water works, any change in number of wet nappies, any foul smell while changing
nappies, child cries while he pass pee
• Any fever?, Rash(meningitis), noticed any lump in the body especially groin area (r/o hernia),
lethargic,
• Feeding and sleeping well
• Risks – flu-like symptoms? Any new food? Recent rota virus vaccine?
• BINDS→ support and how is she coping. Family Hx of urinary/kidney problem. N –any new food?

• Examination: General, vitals, pallor, signs of dehydration

• Abdominal examination
• Neck stiffness, rashes
• CVS, respiratory
• Genital area (hernia)
• Back passage for red currant jelly stool

• Hx: r/o intussusception, UTI, GE, meningitis, small bowel obstruction

• Exn: don’t miss hernia orifices, per rectal inspection
• Explanation
• Hernia is protusion of tummy contents like intestine through the weakness in tummy wall. If it can
not go back, we call incaercerated hernia.
• Emergency condition & referral to tertiary hospital .
• In Hospital- NPO, iv fluids and surgery to reduce the hernia is done.
• Incarcerated – Red in colour (irreducible)
• Strangulated- Bluish in colour (irreducible +twisting upon itself leading to loss of blood supply)

Post Chemo Fever

10 year old boy, Dennis, diagnosed case of leukemia, received his last dose of chemotherapy 2 weeks
ago, was stable until he developed fever of 38.5 degrees today. Brought in by father in ER of rural
hospital where you are working as an HMO.
Tasks: History
PEFE
Management plan

History
• Good to hear that he successfully finished his chemo.
• What happened? Any Fever?- if present go in detail?
• Any similar things happened before?
• Any rash? Lethargy? drowsy/sleepy always?
• System review: Headache?
 • eat well? Vomiting? Diarrhoea? Tummy pain?
• ear discharge? Any flu-like illness? Cough? Stuffy nose? Sore throat?
• Waterworks: does he complain Smelly urine? Any pain while pass urine?
• BINDS: birth history? Immunisation? Nutrition (feeding)? Development? Contact History?

Examination
• General Appearance: Alert or drowsy,
• Signs of dehydration
• Rash
• Growth Chart
• Vitals- Pulse, RR, BP, Temp, Saturation
• Lymph Node enlargement
• Neck Stiffness
• ENT examination
• Systemic Examination- Cardiovascular, Respiratory, Abdomen
• UDT, blood sugar

• Most likely it must be an infection because of the reduction in immunity by Chemotherapy. It

caused reduction in WBC which is part of immune system making the child prone to infections. So
to know the source of infection, we need to run investigations. It is important to know the source
of infection and treat it before it spreads to the whole body, we call it sepsis.
• The infection can be in the brain, in the breathing system, Urine tract, in the bowels or blood. We
need to baseline blood tests, inflammatory markers, and do full septic screening.
• I will give a dose of antibiotics and fluids through his veins after taking his blood for
investigations. Initial investigations will include his blood cell counts, his kidney and liver function,
his blood lactate, blood culture to know the organism and urine culture to check for possible urine
tract infection. He will be transferred to tertiary hospital by ambulance.
• During my examination, I found some inflammation changes in his throat so most likely it’s the
infection in the breathing system. So there they will take a swab from the nose and throat and send
for culture. A CXR will be needed as well.
• The other investigations will be depending on his further symptoms. These includes stool culture,
swabs from lesions if there is any evidence of ulcers or vesicles and lumbar puncture in which some
fluid will be taken from the space between the back bone and check for organism if they suspect
the infection in the brain.
• All tests will be performed by experienced staffs so he will be pain free.
• He will be on IV line for a while and the antibiotics will be changed according to culture results.
And it will be changed to oral medications.

Sepsis Work-up
You are a HMO in ED, 4 month old boy is brought to you by his parents at 3am. The baby has
been unwell for past 24 hours
• Task:
• Further history
• PE finding
• Discuss the causes and management

History
 • What happened? Any Fever?- if present go in detail
• Any rash? Lethargy? drowsy/sleepy always?
• System review: feeding? Vomiting? Diarrhoea?
• Ear pulling/ear discharge? Cough? Stuffy nose? Chest in drawing?
• Waterworks: number of wet nappies? Smelly nappies? Cry while pass urine?
• BINDS: birth history? Immunisation? Nutrition (feeding)? Development? Contact History?

Examination
• General Appearance: Alert or drowsy,
• Signs of dehydration – CRT, skin, turgor, sunken eyes, mucous membranes, Anterior frontanalle
• Rash- Site, Distribution, Characteristics, blanchable or not, scratch Marks, secretions etc
• Growth Chart
• Vitals- Pulse, RR, BP, Temp, Saturation
• Lymph Node enlargement
• Neck Stiffness
• ENT examination
• Systemic Examination- Cardiovascular, Respiratory, Abdomen
• UDT, blood sugar

Explanation
• From History and examination: your child has infection going on in body. But in infants we cannot
find out the cause of infection by symptoms and examination. So will call paediatric registrar
• Will admit and do investigation to find out the cause of infection.
• We call it as septic workup:
• Blood test: Usually, we take sample of the blood from the child’s veins to look for infection in the
blood. It might cause a little bit of pain from the needle prick but we will use a local anesthetic spray
a few minutes before the procedure that will numb the area
• Infection in lung: Xray of the chest. I understand that you might be worried about 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 pneumonias within the lungs.
• Urine Exmn: (infection in waterwork) 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 be stressed it
will be done by 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 procedure.
• Lumbar puncture: (infection in 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
specialist. Sometimes, there is 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
• Will start on broad spectrum antibiotic once blood is taken for investigation
• Specialist will come and see
• If in country hospital and no specialist: transfer to tertiary hospital
Meningococcaemia
A 2 year-old boy is brought by his very upset parents to a GP clinic in a small country town, 50 km
from the city. The child has become lethargic & febrile for the last 4 hours. He has had a mild URTI
for the last 3 days.
• Task:
• Relevant History
• Examination Findings From Examiner
• Diagnosis and further Management

• Meningococcemia/septicemia
• +ve point:Fever, Prodromal flu like Sympx,Sick child
• May have Contact Hx , Severely ill child
• Examination +ve point: Cold clamy extremities, nonspecific macular petechial rash , Non
blanchable, Unstable vitals
Explanation
• Infection in blood- Sepsis
• From the rash looks like caused by a bug called meningococcus which is a bacteria. It spread through
droplet infection and causes svere life threating infection.
• Need to transfer to teritary hospital and seen by specialist
• Take blood for inv and start iv fluid. After that will give a dose of antibiotic before transfer
• Need to do Investigation- to r/o other causes
• Blood investigations like FBE, ESR/CRP, UEC, LFT and Culture (to find the bug in blood), Urine
culture (to r/o urine infection) , Chest X-ray, sometimes specialist might do Lumbar puncture(after
ruling out the contraindications for it→take fluid that sourrounds the brain from the back bone to
find bug in it)
• If It is confirmed to be Meningococcus bug→ then need to notify the department of health and need
to treat contact
• Also need to Inform the child care
• Note : In same case if rash is not there, then it becomes a case of septicaemia- management is same
except no antibiotic until diagnosis is confirmed and all invx are done

Behavioral problems and psychology

ADHD

6 year old boy came with his mother who complains of receiving letter from school that he is not
doing well at school
Tasks:
• History
• Counsel her regarding the son’s condition

Diagnostic criteria for ADHD

• Onset before 12 years of age
• Symptoms – inattention 6/9
- hyperactive and impulsive 6/9
 • >= 6 months
• 2 situations at home and at school

Slow school progress Hx

• Causes→
• Bullying
• Child abuse
• ADHD
• Autism
• Oppositional Defines
• Chronic illness in child
• Absence seizures
• Hearing and vision problem
• Family stress
• Lead toxicity
• Head injury

History
• My understanding that he’s 6 years old and he has a performance or behavioural problem according
to the letter from the school.
• What did they told about him at school? Since when ?
• When did he start school? (r/o Separation anxiety at home)
• BINDS
• Birth Hx→
• How was the pregnancy? Any infection? IUGR?
• Full term or premature?
• Any problem during delivery? Any prolonged labour?
• Has she required resuscitation after born? New born screening test done (heel prick test, hearing
test)
• Any Hx of prolonged jaundice or meningitis?
• Immunization→ up to date
• Nutrition diet, lead exposure (very old house)
• Is he developing like any other kids of his age?
• Autism Qs→
• Does he maintain eye contact? Does he have lot of friends?
• Does he love to play any particular game? Any repetitive behaviour like head nodding? Does he
become upset if you change her routine?

• ADHD Qs
• Attention Qs (6 out of 9 criteria):
• Does he feel to give close attention to details or make careless mistakes in school-works or other
activities?
• Does he have difficulty sustaining attention in task or playing activities?
• Does he listen to you when you speak to him directly?
• Does he follow instructions and failed to finish school work?
• Does he have difficulty organizing tasks and activities?
• Does he avoid or dislike tasks that require sustained mental effort?
• Does he loose things necessary for task or activities? Eg. pencil
• Is he forgetful in daily activities?
• Is he easily distracted by external stimuli?

• Hyperactive Qs (6 out of 9 criteria)

• Does he often fidgets with hands or feet ?
• Has he teacher complained that he rarely sit still in the classroom?
• Does he run about or climb excessively during inappropriate situation?
• Does he have difficulty playing or engaging in leisure activities quietly?
• Does he often talk excessively as well?
• Does he blurt out the answer before the questions had completed?
• Have you ever witnessed that he has difficulty in awaiting turns?
• Has he ever interrupted or intruded on others? Eg. conversation or games?
• Do you think the comment from teachers are the same with what you notice?
• Social Hx→ Does he react with other family members, friends? Happy family? Any chance of
school bullying ? Have you heard anything from school? Stress at home? Any financial stress? Child
relationship with partner and siblings, friends?
• General health pervious head trauma, fits, epilepsy, c/o tiredness and lethargy, frequent
infections/falling ill, sleep problem
• Family Hx of similar condition, medication hx

• Management→
• Tell as behavioural disorder but most likely ADHD but can be other causes like autism, oppositional
defines, Asperger's syndrome etc so need to r/o the causes
• General in all cases tell this
• Any child with behavioural abnormalities or learning disability
• Give Questionnaire to parents and teachers
• Vision and hearing testing (if not done)
• Refer to specialist
• Needs neuro developmental assessment by experienced child psychologist
• Rule out for endocrine disorders(thyroid→ arrange if not done before)
• How are the parents coping? Do they need help?
• Depending on case further management you can tell further management
• General Advise:
• Do not punish the child
• Praise for good behaviour
• Spend some time with him
• Try to be close with him
• Insist on having his full attention
• Keep him away from dangerous environment
• Once diagnosis is confirmed start on treatment called Behavioural modification, Family
counselling, support groups, at last medication (tell all these if have time and management is your
task)
 • If advice in details needed
• Explanation- according to the history, he has problem with attention, very active behavior and
being very impulsive. All these features favored the condition we call attention deficit hyperactivity
disorder. It is one of the behaviour problems found at his age, but we cannot diagnose ADHD with
only one visit, to make sure about this, he needs frequent regular observations. He needs to be
assessed by experienced psychologists, paediatrician and child psychiatrist. Moreover information
from parents and teachers needs to be gathered regularly during observation. At the same time,
we need to rule out these cause including organic causes of such behaviour such as hearing deficit
or visual problem.
• Let me explain you about our plan of management. The first step is to refer to child specialist. Then
he will be managed by multidisciplinary team including child psychiatrist who assessed his
development and mood. Other specialists like eye specialist and ear specialist will also check to
make sure he has no such problems.
• Management
• The most important ineffective treatment for a patient is behaviour modification. Treatment will
be excellent if teachers and friends and parents will be involved. I’ll explain in short .
• He should have brief clear verbal instruction. Most important learning should be done when
concentration is best, usually in the morning.
• Use checklist.
• Let him sit at the front and centre in class, not near friends.
• Let him do homework in distraction-free environment.
• Regular schedule homework time. Regular rest break to reduce overactivity.
• Fixed routine
• Display schedule and rules at home in school in multiple places.
• To improve self esteem, set up for success.
• Use positive reinforcement. Reward should not be fruit or sweets. You can use colourful big boy or
good boy charts or you can also use stickers. Rewards should not be removed as punishment.
Remember reward and punishment should be separated.
• Ignore minor irritating behaviours.
• Social skills – Get him exposed to small groups rather than large.
• Reward for appropriate social behaviour like sharing.
• Teach problem solving skills one provoked.
• Encourage and supervised socialization for example playing sports.
• Regularly discussed consequences of his actions.
• Are you along with me so far? This behaviour modification is very effective. So second line is
medical treatment - There are some medicines used in treatment of ADHD which contains
amphetamine but it is rarely used because of less effectiveness and serious side effects.
• Remember you are not alone. We will work together as a multidisciplinary team for the best results
and I’m sure we are going to see the positive changes.

Autism
You are a GP. You are going to see a 4 years old boy, Shaun, brought in by his mother, Grace, because
he has some problems at home and school. School teachers commented that he is different from others.
• Your Tasks
• History
• Explain diagnosis
 • Outline the management

• Autism questions – Does he maintain eye contact? Does he have any repetitive behavior? Does he
look very irritable when you make changes to his routines? Does he stick to a particular game or
toys?does he have friends?
• Social Hx→ Does he react with other family members, friends? Happy family? Any chance of
school bullying ? Have you heard anything from school? Stress at home? Any financial stress? Child
relationship with partner and siblings, friends?
• General health pervious head trauma, fits, epilepsy, c/o tiredness and lethargy, frequent
infections/falling ill, sleep problem
• Family Hx of similar condition, medication hx

• Probably, he is having Autism, or autism spectrum disorder (ASD), refers to a broad range of
conditions characterized by challenges with social skills, repetitive behaviors, speech and
nonverbal communication.
• It is quite common and with the effective management, with the multidisplinary approach, he can
have a good quality of life.
• Specialist referral for further assessment
• → refer to paediatrician
• →Managed by MDT→ paediatrician, parent support group, behavioural thx
• →Regular assessment. Management is multidisciplinary
Enuresis
A 6-year-old boy is bedwetting at night. He is dry during the day since 2 years old. The urine
microscopy and culture is negative.
Tasks:
• History
• Examination findings from examiner
• Diagnosis and management

History:
• I understand it is very distressing to you. Can I ask Few Questions: Since when? Any time dry during
the day? Dry during night? How does he react to it? Any swelling in body?
• UTI Qs: any pain/burning sensation while passing pee, any change in colour or blood? Frequent
small passage of urine? Can he control it in day time(urgency)?
• Does he drink excessively?
• Bowel: loose stool? Constipation?
• BINDS: family situation? Any stress? Any family history of similar condition? Growth and
development? What about fluid intake?

Examination:
• General appearance: pallor, jaundice, any dysmorphic feature, oedema, growth chart
• Vital signs: pulse, BP, RR, Temp, Saturation
• ENT and LN Examination
• Systemic Examination: Abdomen, cardiovascular and Respiratory, Neurological
• Genital examination with consent
• Office Test: urine dipstick, BSL,
• +ve point: all normal
Explanation:
• Your child has a condition called noctural 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 in deep
sleep and leads to involuntarily (child does not know it) passage of urine in child. So please don’t
blame him. I understand your concern about cleaning and laundry but usually most children grow
out of it by age of 5 or 6 years. But sometimes it can take long time. But sometimes, it can run in
families also.
• At this stage, we can start no need of any medication.
• I can refer you to royal children hospital or can get in from pharmacy where he can get Alarm bed
etc.
• Explain how it works (see the next slides)
• Success to treatment is high if the child himself is motivated.(explain it is very important)
• Not need to restrict fluid intake at time it does not help.
• Advice parent: not scold, star chart, explain other siblings not to tease about it etc
• If go to school camp, then refer to paediatrician for desmopressin spray (tell it is a hormonal
medicine which restict the amount of urine formed in kidney)

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.
• Examination: +ve findings
• Abd Ex-Faecal mass in lower quadrant
• PR- anus normal with some faecal staining, no fissure,
• On rectal Examn- Rectum packed with firm faeces

• Your task is to:

• Take a further history
• Explain to the father the boy’s condition and management

• Encopresis (Cond 91)

• History-
• Since when, how often, blood/mucus, tummy pain, h/o pain while defecating and constipation,
toilet train, vomiting.
• R/o Hirschsprung disease(h/o constipation from birth and delay passage of meconium)
• Weight, appetite, dry at night time and any urine problem
• BINDS- Family and school/childcare Hx , thyroid disease, medication Hx, Diet Hx

• Explanation: Involuntary passage of faecal material in underpants.

• Cause: constipation, Inadequate dietary intake, fear of pain during defecation.
 • Chronic Faecal Retention→ enlargement of Large intestine and less to nervous stimulation(child
does not know when to go to toilet) Liquid stools from small intestine leak around faecal mass
leading to soiling of underwear
• Manageable and not his fault
• Treatment : empty by enema and laxative for long time
• Toilet training and Diet
• Do not scold the child, praise him, star chart. Talk to teacher.
• Red flags and review

Head Collision
You are a GP. Your next patient is 2 year old boy brought in by mom because the baby has been putting
his head against with the side of the cot. It makes the mum very concerned.
Your task are to:
• Take the history
• Ask physical examination from the examiner
• Explain about your management

Differential diagnoses
• behavioural problem
• attention seeker
• teething problem
• Epilepsy
• Head injury
• Conduct disorder

History
• Greetings
• How long have you noticed it? Is it the first time?
• Does he hit the cot all the time? Any particular time of the day that he bang his head?
• How frequent does he have this problem?
• How long does it last each time?
• Has he ever complained about pain on his head or do you notice any bruise?
• How did you respond to him when he bang his head?
• This behaviour gets better or more frequent?
• Did anything happen two months back?
• Is he only child? Any siblings? Is he getting along with mom? Any loss of consciousness? Is he
getting easily angry whenever you say no to him? Does he go to childcare? Any complaint from
childcare? Do you have any concern about his hearing and vision?
• BINDS - Is it the planned pregnancy? (negligence)
• Is his immunisation up to date? Do you satisfy with his weight and development?
• Any chronic medical problem? Or epilepsy?
• Social history - with whom does he live? How many people living at home? What do you do for
a living? Are you financially stable? Who look after him?
• How is your mood now? do you think your mood is low?
Physical examination
• Gender appearance
• Vital signs
• Growth chart
• Local examination - head - check for any proves any signs of injury, swelling? Throat- any tonsil
enlargement? Any active infection?
• To complete my examination, I want to do other systemic examinations.
• Based on the Story, what I have found is that he is growing well. The only problem is that he has
head banging.
• Head banging is a self limiting behavioural problem come on at his age. You can see most patients
has their own behaviour like thumb sucking or being very fond of blankets or toys. This behaviour
problem will go spontaneously with time. They usually settle over two years. Sometimes children
do this behaviour when they want to get attention especially from parents. You are the only parent
for him and he loves you so much and he wants to get your attention. That’s why he usually bang
his head especially when he gets along with you when you are at home to express his feelings.

• I already did the examination and I found no evidence of injury. So I want to reassure that you
don’t have to stop this behaviour and he won’t have any head injury.
• I do understand that his behaviour makes you stress a lot. I want to give some advice to know how
to deal with his behaviour who stop
• Avoid reinforcing behaviours like excessive attention or excessive punishment.
• Ignore the behaviour
• To make sure it is safe for him. You can place cushion or soft mattress .
• Monitor the condition of cot to ensure screws and hinges are not being loosened.
• Give him more attention whenever he is not banging his head. You can use positive reinforcement
such as telling a story at bedtime or rubbing his back to keep in touch physically with him or singing
a song at bedtime for him when he does not have such behaviour.
• I would also suggest you to get sound sleep and good rest as well because you look tired and
exhausted. I will arrange social support for you where social worker will come and visit you to look
after him and to do house chores. During this time, please take a good rest and have a sound sleep.
I will also contact Centrelink to support you financially. Are you happy with my plan?
• I will review him one week later.

Psychogenic Cough
You are a general practitioner. A 12-year-old child, Pandora, having a cough for 6 months intermittently.
She was investigated for asthma and everything was normal. Also was on asthma medications and it
wasn’t relieved. The mother, Molly, was so worried about her child and now come to see you.
Your tasks:
• Take appropriate history
• Tell the mother about the diagnosis/differential diagnoses
• Investigations

Proper approach
• Open question – how can I help you?
• How can I call your child?
• How is he?
 • Cough – Nature, dry or wet, phlegm, color, day or night, continuous or off and on? Special character
( barking, whooping)
• Association and differentials
• Were you aware of the correct technique for the use of inhalers for asthma?
• Allergy, eczema (asthma)
• Anyone smoke at home, near child?
• Sneezing, Runny nose, fever (URTI)
• Sorethroat, shortness of breath
• Social - Eating, sleeping, school performance, any recent family issues (psychiatry)
• Any special situation (when does he cough)
• Any LOW, LOA, travel history?
• Any pets or carpets at home?
• Anyone smoking in the family?
• Past medical and surgical
• Birth and developmental history (just a touch)

Explanation
• this is a psychogenic cough which happens without any underlying disease. It is common in this
age group and not serious.
• it is often related to stress or anxiety. Body and mind are connected together so whenever the
mind is stressful the body can express this by causing symptoms like cough in her case. Some
children presented with headache and some with tummy pain.
• let me assure you that this will go away by itself.
• Investigations (if asked) – FBE, ESR, CRP, CXR, PEFR (if still suspect asthma, Throat swab PCR if
suspected for pertussis

Psychogenic Abdominal Pain

Gp setting, 7 years old girl brought in by mom complaining of abdominal pain for 8 weeks.
Tasks
• -relevant focused history
• -PEFE
• -Dx and Ddx
• -Mx accordingly

Recurrent abdominal pain (3 distinct episodes of abdominal pain over 3 or more months)
Differentials
Organic
• Constipation
• Childhood migraine equivalent (pain with extreme pallor)
• Lactose intolerance
• Intestinal parasites
• Non-organic – psychogenic factors, anxious child, obscessive or perfectionist personality
Features of organic pain
• Periumbilical
• Radiates
 • Wakes the child from sleep
• Associated with nausea and vomiting
• Child is not completely well between attacks
• Weight loss
• Failure to thrive

Features of non-organic pain

• Acute and frequent coliky abdominal pain
• Localized or just above the umbilicus
• No radiation
• Lasts less than 60mins
• Nausea frequent and vomiting rare
• Diurnal (never wakes the child)
• Minimal umbilical tenderness

History
• Pain questions – where? How long? Continuous or off and on? How frequent? How severe? How
does it look like? How long does each episode last? Any radiation? Any relieving or precipitating
factor? (like passing motion relieves the pain?) Happen on weekends? Does it wake her up?
• Associated features – any nausea and vomiting? Diarrhoea? Any constipation? Changes in stool
like blood or mucus? Any changes in urine? Any pain while passing urine? Any fever? Any rash?
Turning pale? (abdominal migraine)
• BINDS
• Social - any recent changes or stress at home? (grandmother passed away with cancer)
• how is her relationship with her grandmother?
• who takes care of the child most of the time?
• How is her school performance?
• Is she generally an anxious child? Or a perfectionist? Family history of migraine?

• PEFE – GA, Vitals, growth chart

• Abdominal examination – Inspection, palpation, percussion, auscultation
• Hernia orifices and genital and anal area
• Other CVS and respiratory
• UDT

Explanation
• Most likely psychogenic abdominal pain. I haven’t found anything pathological according to the
history and examination. I would like to perform full blood exam, urine and stool test and USG to
make sure that she is ok but they are likely to be normal.
• Our mind and body are connected together so whenever the mind is getting stressed the body can
give such symptoms like tummy pain, headache or other symptoms.
• In her case, I found that she had a major change in life recently as beloved grandmother passed
away. Her sadness is affecting on the body as abdominal pain which is a bodily symptom. This is
very common situation.
• But the pain is real even though it is not serious
 • Management - These kind of pain usually transverses childhood without ill effects. You can try
simple measures like local warmth or rest for painful episodes. For life stresses like this, insight
therapy will be helpful. I would refer her to psychologist for full assessment and counselling too.
• Reassure !

Swelling around the eye

Orbital Cellulitis
You are working as HMO in the emergency department. Your next patient is Nadia, 13 year old who
was brought to your hospital by her mom Mrs. Smith as Nadia was complaining of swollen right eye.
Tasks:
• History from Mrs Smith
• Ask the examination findings from the examiner
• Diagnosis and management

• +ve points-It started 1 week ago,Had very bad cough with yellow phlegm 2 weeks ago, Saw a gp,
started on antibiotics: Amoxicillin, eye is hurting – big swollen RIGHT eye only,Day and night it is
the same,Very painful,No trauma. Vision: when look up and to the left – hurts, + double vision.
• Physical Examination: +ve points
• GA: alert but looks unwell not dehydrated no skin rash,T 38 HR 80 RR 30? 100/65 O2 sat 99
• Eye examination: Eye acuity Left 6/6, R 6/18 snellen chart
• Movement: R limitation of elevation, adduction and diplopia in all position
• + dilated conjunctival blood vessels
• Sluggish pupil reaction
• Dilated tortuous vein
• Left eye: unremarkable
• Right eye: chemosis, decreased visual acuity, proptosis
• Other systems: normal

Differential diagnosis
• Unilateral
• Insect bites
• Conjunctivitis
• Allergy
• Trauma
• Periorbital cellulitis
• Orbital cellulitis

• Bilateral puffy eyes

• Allergy
• Bilateral conjunctivitis
• Nephrotic syndrome

History
• Swelling Hx- since when? Sudden or gradual? Any pain?
• Discharge (type, colour, amount, foul smelling, sticking of eyelids early in morning), redness,
problem with vision, excessive tears, abnormal sensation in inside the eye (dryness, itching, foreign
body sensation etc), pain on movement of eye.
 • Any trauma, any insect bite, fever, rash, joint pain, sore throat, swelling anywhere else in body,
previous URTI, headache, n/v
• Ear pain or discharge, runny nose (sinusitis hx)
• Bowel and waterworks
• BINDS- feeding hx imp
• General health.

Examination
• General appearance and growth chart; rash
• Vital signs
• Lymph nodes and neck rigidity
• ENT examination- sinus tenderness
• Eye: proptosis, chemosis, signs of trauma such as bruising, insect bite, swelling involving what,
redness of conjunctiva, corneal problems, visual acuity, extraocular movement, temperature, visual
fields, fundoscopy
• Systemic examination

Explanation
• Most likely you have orbital cellulitis – infection around and behind the eye – It is not common.
• Spreading of infection from other sites mainly the ethmoid sinus (air filled cavity in skull bone – if
get infected then can spread to eye also)
• Emergency condition – we need to admit to the hospital, call the pediatric, ophthalmologist and ENT
specialist (if not available then need to shift to tertiary hospital)→ if not treated can lead to blindness
and spreading of infection to near by region like brain etc→ treated by giving antibiotics through
vein (iv) once recovers might shift to oral.
• Need to undergo inv- FBE, UEC, ESR, Blood culture, urine m/c, CT scan of head
• How long stay in hospital? depends on how is the response to treatment and her condition. It may
take 7 to 10 days if everything goes well.
• Even if it is periorbital cellulitis- John murtagh says- immediate referral in both cases

Nephrotic Syndrome
Your next patient in GP practice is a 5-year-old Betty brought by father because of puffy face for the
last 3 days.
Tasks:
• History
• Examination Findings from Examiner
• Diagnosis and Management

DD:
• Allergy
• Child abuse
• Kidney problem
• Heart problem
• Hypothyroidism
• Liver failure
• Malnutrition
• Cellulitis
History:
• Swelling Qs: since when? When more? Where is it? Any where else? Any redness present? Any
pain around eyes? Any insect bite? Any allergy? Eye discharge? Any trauma?
• Any fever, nausea, vomiting? Any rash?
• Any difficulty to breathe? Any time turned blue? Any chest pain? Any racing of heart? Any
cough? Any distension of tummy? Any cardiac problem? Any kidney problem? Any liver
problem (any jaundice previously)?
• Waterworks: how is it? Any increased or decreased? Any blood?
• Any time diagnosed with DM, taking NASIDS, repeated urinary tract infections?
• BINDS: immunisation, nutrition (diet to r/o malnutrition),
• Social Hx – happy family?: family hx of cardiac/liver/kidney problem?

Examination:
• General appearance: pallor, jaundice, signs of dehydration, rash, edema, growth cahrt
• Vitals sign: Pulse, BP, RR, Temp, Saturation
• ENT, LN examination
• Systemic Examination: Cardiovascular, Respiratory, Abdomen
• Genital examination with consent
• Office test: Urine dip stick, BSL
• +ve findings: BP normal, puffy face, urine dipstick showing proteinuria and no RBC.

Explanation:
• Your child has a condition called Nephrotic syndrome. The Filtering mechanism of kidney is not
functioning properly due to some unknown reason (may be due to previous viral infection – normally
our body produces chemical substances called antibodies which acts against bugs and forms
complexes but sometimes these get attached to the filtering part of kidney and affects the mechanism
) leading to loss of proteins from our body in urine. As a result, the water accumulates in body.
• So need to admit the child in the hospital and will laise with paediatric Registrar in hospital
• Treatment may includes: steroids, fluid restriction, diet modification (low salt), monitor BP and
weighed daily, antibiotics may be given (as prone for infections as lost proteins in urine),
Furosemide if oedema is severe.
• Invx: FBE, UEC, Lipid profile, ASO titres, ESR/CRP, Urine microscopy and culture, LFT (protein
level), C3, C4
• Don’t be stressed can be managed with medication
• After condition subsided will need frequent invx: Family will be taught how to do urine dipstick
daily at home and followed with renal function test.

Limping

Septic arthritis
• You are a GP, 1 year old brought by father because of fever for 2 days.
• History for 5 mins
• Tell examiner what PE you are going to focus on to and explain to examiner what are you
looking for
• Tell father the condition with reason

History
•Good to hear that he successfully finished his chemo.
•What happened? Any Fever?- if present go in detail?
•Any similar things happened before?
•Any rash? Lethargy? drowsy/sleepy always?
•System review: eat well? Vomiting? Diarrhoea? Tummy pain?
•ear discharge? Any flu-like illness? Cough? Stuffy nose? Waterworks: Smelly urine? Cry while pass urine?
•Any thing you find unusual in him? (limping +)

•-is he able to walk or bear weight?

-has this happened before?
•any rash? (HSP)
-any fever? (OM)
•-any joint pain or swelling? (Septic arthritis)
-any recent flu or viral infections? (Transient tenosynovitis)
-has he had any trauma?
•BINDS: birth history? Immunization? Nutrition (feeding)? Development? Contact History? Happy family?

•PEFE – General appearance, Vital signs especially temperature, Growth chart

•Knee examination- look – swelling, deformity, redness, feel – tenderness, check movement
•Examine on both sides and also hip and ankle
•Groin – lymph nodes Invx – USG for effusion

•Positive: redness and swelling on right knee, restrictions on movement because of pain. Hip joint and
ankle joint normal.

•DX – septic arthritis – Which is the infection in the joint and capsule. This infection likely to reach to the
joint through the blood stream from other parts of the body (source according to the history). Some times,
it could follow an injection, surgery or injury.
•We need immobilization and antibiotics (may be IV) after confirmation.

SCFE
Your next patient in general practice is a 12 year old girl, Samantha, who is brought in by her father,
John, because Samantha has complained about left hip pain over the last 3 months, although over the
last few days, the pain worsened and she walks with a marked limp and also complains about pains in
her left hip. She is a keen sports person, plays netball and cricket and is usually very active, although a
bit overweight. There is no history of trauma.
Your tasks:
• Take history
• X ray from examiner
• Explain diagnosis and management to the father

• how severe is her pain? Offer painkiller after allergy question

-when did it start? Sudden or gradual? Constant or come and go? Is it getting worse?
-where exactly the pain is? Any pain in the right hip or anywhere else? Does it go anywhere else?
-how does she describe the pain?
 -anything make it better or worse? Have you tried anything to relive it?
-is she able to walk or bear weight?
-has this happened before?
• DDx
• any tummy pain or rash? (HSP)
-any fever? (OM)
• -any joint pain or swelling? (Septic arthritis)
-any recent flu or viral infections? (Transient tenosynovitis)
-has he had any trauma?
-any loss of weight, appetite or lumps and bumps? (Malignancy)
• General health, joint and bone problems, medications?
• Family history of bone problems, Are you a happy family? (abuse)
• BINDS

• from history and examination, he most likely have a condition called SCFE have you heard about
it?
Draw a diagram just a ball and socket; this is the head of thighbone and this is the growth plate.
Any weakness of growth plate causes the head to slip out of its position. Leading to limping, pain
and restriction of movements.
-the cause is usually unknown but may be due to increase weight or hormones.
-it is important to treat to avoid complications like decrease in blood supply to the thighbone so
avoiding any bone damage or deformity.
• So let me tell you about the management, I will refer her to orthopaedic surgeon who will do a
surgical procedure for fixation and pin in site. Other side might be done as well. Treatment is urgent
and mandatory to prevent further slippage and complications.
• After Sx, weight reduction is critically important. Try to maintain the optimal weight because it is
one of the contributing factors.
• Also there may be involvement of physiotherapist to do the exercises.
• WE DO NOT OBSERVE! ANYTIME COMPROMISE!

Perthes disease
You are GP when a 6 year old child was brought in by mom because of limping on the left side.
Tasks
• -History.
• -PEFE
 • -Ix
• -Diagnosis and management

• how severe is her pain? Offer painkiller after allergy question

-when did it start? Sudden or gradual? Constant or come and go? Is it getting worse?
-where exactly the pain is? Any pain in the right hip or anywhere else? Does it go anywhere else?
-how does she describe the pain?
-anything make it better or worse? Have you tried anything to relive it?
-is she able to walk or bear weight?
-has this happened before?
• DDx
• any tummy pain or rash? (HSP)
-any fever? (OM)
• -any joint pain or swelling? (Septic arthritis)
-any recent flu or viral infections? (Transient tenosynovitis)
-has he had any trauma?
-any loss of weight, appetite or lumps and bumps? (Malignancy)
• General health, joint and bone problems, medications?
• Family history of bone problems, Are you a happy family? (abuse)
• BINDS

• PEFE – General appearance, Vital signs especially temperature, Growth chart

• Hip examination- look – swelling, deformity, redness, feel – tenderness, check movement
• Examine on both sides and alsoknee and ankle
• Groin – lymph nodes and testis (private area)
• Invx – USG for effusion

• from history and x-ray findings, your child most likely has a condition called Perthes diseas.
• It happens when the blood supply to the rounded head of the thigh bone is temporarily disrupted.
Without the adequate blood supply, the bone cells die, we call it avascular necrosis.
• Now we diagnosed it at early stage to we can stop the progress of the disease which may lead to
permanent damage or deformity.
Treatment
• Refer to specialist
 • Painkillers – which will reduce inflammation and pain
• Limiting activities – avoid high impact activities like jumping. Occasionally, cruches are
recommended to reduce weight on the joint.
• Regular observations with Xrays
• Physical therapy
• Casting and bracing
• it might take weeks, months or years to heal but mostly self-limiting.
• If fails or damage is more than 80% - surgical treatment

Irritable Hip
You are a general practitioner. Your next patient is a 4 years old boy, Liam, brought to you by his mom,
Eve, because she noticed he is limping.
Your tasks:
• Take relevant history
• Physical examination from the examiner
• Explain the provisional diagnosis
• Management

Approach
• Greetings. Limping – how long have you noticed it? Is it the first time? One leg or both? Does he
complain of any pain?
• Pain – when? Where is the pain exactly? Localized/travel to the other area? Aggravating/ relieving
factors?
• Severity – Does he cry a lot whenever he moves his leg or walks? Did you try something to relieve
pain? Was it effective?
• DDx – Injury – Does he have trauma to that area? Any redness/swelling? Deformity?
• Infection – Any fever?
• Transient tenosynovitis – what about fever a few days back? Flu-like illness? How recovered?
• Juvenile arthritis – any pain on other joints?
• Any loss of weight or loss of appetite?
• BINDS
• Family history – Blood diseases?

• PEFE – General appearance, Vital signs especially temperature, Growth chart

• Knee examination- look – swelling, deformity, redness, feel – tenderness, check movement
• Examine on both sides and also one joint above and below (hip and ankle)
• Hip joint – repeat look, feel, move
• +ve – all right hip movements are reduced because of pain

• Groin – lymph nodes and testis if male (private area)

• Invx – USG for effusion
 • Explanation – even though he is complaining of right knee pain, primary site is on right hip. When
I examined, his right hip joint is painful especially when moved. This condition is called transient
tenosynovitis or irritable hip.
• Draw a picture – the hip joint is covered by thin layer called synovium). It is now inflamed most
probably due to viral infection. 2 weeks ago, he had a viral infection and flu-like illness. This viral
infection causes inflammation of the joint lining. Both hip and knee joint are supplied by the same
nerve. So pathology in the hip joint may refer to knee joint ( we call it refer pain)
• It is common in his age and it is self-limiting. But to confirm the diagnosis and to exclude other
serious problems, we need to run blood tests (FBE, ESR, CRP), X-ray to exclude fractures and USG
to check for the fluid collection. (they are not usually required with the history less than 3 days
of the symptoms or if you know the specific condition by history and PE) and We will need
specialist opinion too.
• Reassure – not a serious condition, usually resolves with no sequel
• Aim – to rest the affected joint, the more he can rest, the quicker the recovery.
• Recommend – bed rest
• Rest is very important, moves early – may relapse
• He will temporarily need crutches whenever he walks to make sure his hips and legs are
immobilized.
• I’ll give him Panadol to relieve pain.
• Who will look after him at home? Are you confident enough to take him home?
• Follow-up – one week
• Follow up X ray after a few months for Perthes
• Red flags – If the pain get worse, fever very high or not alert – go to ED

Miscellaneous
Diabetes
You are a GP. You are going to Irene, a mother of 5 yr old child, Jeremy, comes here as she think that
her baby has been lethargic for a month. The baby is fully immunized and she satisfied with growth.
Tasks:
• History
• PEFE
• Ask inv
• Dx,giving your reasons to mother

• What do you mean by lethargic? Ill? Tired?

• Fever? Cough? Runny nose? Sore throat?
• Any pain in the ears?
• Poo and pee? Frequency? Smelly? Any pain during passing urine? If increased frequency –
excessive drinking of water? Any fruity smell breath? Weight loss? Excessive eating?
• Any pain in the tummy? Nausea and vomiting? (ketoacidosis)
• DM complications – urine changes (color), skin infections, visual problem, tingling and numbness
• Eat and sleep? School performance? Can he play well?
• BINDS + family history of diabetes

• PEFE – head to toe for infection and Blood glucose, UDT

• Investigations – blood glucose, HbA1C, urine C&S and baseline FBC, LFT, RFT
 • Diagnosis – Diabetes is a condition in which your child's body no longer produces an important
hormone (insulin). The symptoms are Increased thirst, Frequent urination, Extreme hunger,
Unintentional weight loss, Fatigue, Irritability or behavior changes and Fruity-smelling breath. Also
I found increased blood sugar and presence of sugar in the urine in my bedside tests. This usually
run s in the families. So the missing insulin needs to be replaced with injections or with an insulin
pump.

DKA
You are a GP in rural clinic with limited facility. Your next patient is a 17 years old farmer, Rhea, with
feeling unwell so that she cannot keep up with her work.
Tasks-
• History,
• PEFE,
• diagnosis with reasons.

• Tiredness – first time? Since when? Is it getting worse? Occur at rest or activities? How did it
relieved?
• Association – HEMIFAD – Any skin discoloration? Any chest pain? Racing of heart beat? SOB? Any
weight change? unusually thirsty? Increased frequency in passing urine? What about at night?
Weather preference? Any lumps and bumps? Weight loss + in history – no need snoring. Muscle
aches and pain? How is your mood? Any regular medication?
• Any burning sensation while passing urine? Smelly urine?
• Complication – any problem with vision? Tingling and numbness in limbs? Any weakness? Any
chest pain? Frothy urine? Skin infections?
• General health, Past medical, surgical
• Family history of diabetes and heart diseases, stroke
• SADMA

PEFE
• General appearance-
• Vital signs
• BMI-not available?
• Eye – fundoscopy , neck - thyroid
• CVS and respiratory
• Abdominal examination
• Neurology examination
• BSL, Urine dipstick, ECG

• Dx – diabetes ketoacidosis, in which case, the blood sugar level is so high leading to formation of
ketones in the body. It could be first manifestation of Type 1 diabetes mellitus in young patients.
 • It’s emergency but you are in the safe hands now. You will be treated with IV fluids to correct it.

DKA 2
You are a HMO in a rural hospital. Your next patient is a 4 years old
Vomiting twice and diarrhoea, nausea yesterday. He was diagnosed with DM 3 months ago. Now he is
stabilized.
Tasks-
• History 5 mins,
• PEFE,
• diagnosis with reasons.

History
• Details of vomiting and diarrhoea questions – duration, contents, color, amount, frequency
• Any street foods?
• Any tummy pain? Any excessive thirst? Is he drowsy and lethargic? Fast breathing? Fruity smell in
breath?
• Is his DM well controlled? Are you using insulin according to the prescription?
• Precipitants for DKA – Any skipped doses? Any cough? Fever? Runny nose? Rash? Urine changes?
Smelly urine?
• Complication of DM – any problem with vision? Tingling and numbness in limbs? Any weakness?
Any chest pain? Frothy urine? Skin infections?
• General health, Past medical, surgical
• BINDS

PEFE
• General appearance- ill
• Vital signs – stabilized
• Sunken eyes positive and skin turgor reduced
• BMI-not available
• Eye – fundoscopy - normal
• CVS and respiratory- unremarkable
• Abdominal examination - unremarkable
• Neurology examination – not done
• BSL – 25mmol/L
• Urine dipstick – glucose and ketones positive
• ECG - normal

Explanation
• Dx – diabetes ketoacidosis, in which case, the blood sugar level is so high leading to formation of
acidic substances ketones upto dangerous levels in the body. (explain the cause according to your
own history)It’s emergency but he is in the safe hands now. He will be treated with IV fluids to
correct it.

Bee Sting
You are a HMO. 3 years old Child stung by bees today, sting taken out, uncomfortable and crying kid,
had been bitten by bee before... At time.. Just local reactions... Pefe given in stem, vitals - normal, CVS
resp - normal -
Tasks
• -History
• -current and future mx

History
• Hemodynamic stability
• Details – how long ago? What was he doing? What happened after the sting? Any swelling? Rash?
Itchiness?
• Any rash in the body? Is it the first time?
• Systemic -SOB, noisy breathing
• -difficulty swallowing, hoarsness of voice
• -nausea, vomiting, tummy pain

• BINDS
• any problems during birth?
• immunization?
• is he thriving and growing normally?
• Does he take any medications?
• had he had any allergies
• family history of allergy, asthma,

Explain
• your child most likely has a local reaction to bee sting.
• usually presented with redness, local swelling at the site of the sting.
• let me assure you that it was not a severe one in your child’s case and was not life threatening.
• Current management
• I would like to keep him in ED for observation and to be seen by a specialist.
• We can give simple treatments such as
• Washing with soap and water
• applying cool and wet towels on the swelling and elevate the limb
• Moisturising creams (plain and unscented)
• Steroid creams applied early and regularly onto the sting or bite site can often give relief.
• oral antihistamine for 1-3 days to relieve itching.
• Long term management
• When happen again,
• Red flags : Hoarseness of voice, difficulty breathing, talking or swallowing problems, tummy pain,
vomiting.
• Some advice (RCH)
Outdoors
• Keep picnic food covered and wipe up spills immediately.
• Dress your child in long-sleeved shirts and pants that fit snugly around the wrists and ankles.
• Make sure rubbish bins are securely fastened so the contents don't attract insects.
• Stay away from pools of stagnant (still) water, which are breeding grounds for mosquitos.
 • Avoid perfumes and scented lotions, soaps and cosmetics.
• Cover infant strollers with netting.
• Insect repellents
• Follow the manufacturer’s instructions and only use insect repellents sparingly.
• In young children, insect repellents are safest if rubbed or sprayed on clothing rather than skin.
Don't spray them on the skin of children under the age of 12 months.
• The most effective repellents contain the chemicals DEET or picaridin. Choose sprays that contain
no more than 10 per cent DEET/picaridin – look for repellents especially formulated for children.
• Reapply insect repellent to your child after swimming or activities that make them sweat.
Indoors
• Don't turn the lights on in bedrooms until the windows are closed (or screened) and the curtains
are drawn.
• Fit insect screens to windows.
• Consider using an electric device that releases insect repellent into the room at night. These usually
plug into an electric outlet and the repellent (usually permethrin) is contained either in a bottle of
fluid or a small pad.
• When required, use insect sprays from the supermarket.

Oral thrush
6 months infant with History of oral thrush for 6 months and diarrhea.
Tasks:
History
PE from examiner
Dx and Management

Ddx
• Milk residue
• Oral thrush candida
• Lactose intolerance
• Celiac disease
• Immune suppressive condition
• S/E of antibiotics

History
• Details - Duration? Progressive? Constant or come and go? Anywhere else in the body? Have you
tried any medications?
• Severity – have you ever tried to wipe it out? Does he cry when he is fed? Does he look irritable?
• Other symptoms -Fever, rash? Any cough? Any diarrhoea? Vomiting? Change in the number of
wet nappies?
• BINDS
• Any antibiotics recently? Who prepare food for him? Does he use pacifier? Any changes in your
nipples? (breastfeeding mother)

PEFE
• G/A
• V/S
 • growth chart (declining)
• ENT especially oral cavity
• CVS and respiratory
• Genital areal (anal area)

• The white thrush in his mouth is most likely a fungal infection we called candidiasis.
• It is mostly happened when we got infected or when we have weaker immune system in our body
because of some conditions.
• In your baby’s case, it could be from an external source like something he put into the mouth or
weakened immune system or prolonged antibiotics.
• Could be due to immunosuppression state when there is antibody deficiencies or defects.
• -That’s why we need to do some blood test to know the exact cause
• Management
• -Investigation (FBE, ESR CRP, immunoglobulins IgA, IgG, IgM, swab of thrush MCS, stool MCS, celiac
screening)
• -Refer to pediatrician
• -Antifungal miconazole gel for 10 days and advice to wash nipples and sterilise objects in contact
with thrush.

Body odour
You are a general practitioner. 9 years old girl, Jenny, is brought to you by her mom, Vivian complaining
of a bad body odor.
Tasks:
• Take relevant history
• Physical examination from the examiner
• Explain the diagnosis to the mother

Differential diagnoses
• Puberty (increased activity of sweat glands)
• Poor hygiene
• Metabolic disorders (phenylketonuria, Trimethyaminura)
• Medical diseases (thyroid, liver, kidney leads to excessive sweating and diabetes – fruity smell)
• Certain foods – alcohol, curry, garlic, onion
• Drugs (nitrogen, Sulphur containing drugs)
• Foreign body in an orifice (especially young children)

• History – What do you mean by bad body odor? Where do you think it comes from? How long?
How does it smell like? (onions? Fishy?) Is the smell changing? Any particular time of the day?
• DDx – How is her daily personal hygiene practice? Any activities/sports she enjoys? Shower once a
day/ after activities? How was the heel-prick test, anything positive? Any problem with thyroid?
Any problem with liver and kidneys? How is her daily diet? Does she enjoys food such as curry,
garlic, onions??
• Puberty – Let me ask you some private questions about her progress into adolescent. Does she
ever tell you about her breast development? Pubic hair? Axillary hair? Has she started her
menstruation? Skin oily? Acne?
 • General health? Immunization? Social – does she have any problem at school? Home? (teasing,
poor hygiene due to depression), on any medication?
• Family history of metabolic disorders?

Physical examination
• General appearance, vital signs, BMI
• Smell in general, check skin especially intertriginous areas (skin folds)
• Breast development
• Acne, hirsutism
• Pubic hair
• Systemic examination – thyroid enlargement, respiratory, CVS, Abdominal

Explanation
• Dx - most likely due to early stage of puberty. In puberty, there are more active sweat glands than
childhood. When sweat becomes contact with bacteria from skin, the smell occurs. It is just the
usual progress of development. We can control it by using deodorants. (not antiperspirant as kids
need to be sweaty to be healthy)
• Other possibilities – poor hygiene, medical conditions (thyroid, liver, kidneys), Metabolic
conditions, certain foods and medications but less likely.

Blunt Abdominal Injury

10 year old boy Mike coming with severe tummy pain with his father to emergency department. You
are HMO in ED in rural hospital.
Tasks:
• History
• Examination findings from examiner
• Investigations with reasons
• Tell your most likely diagnosis and management

• +ve point acc to recall in hx: fall from bike, greenish vomitting (2 episodes)
• On examination +ve point: bruise above umbilicus and tenderness on epigastrium

History
• Start with haemodynamic stability: if unstable: DRABC, iv line and fluids, blood for invx
• Pain Qs: where, since when, severity (on scale of 0 to 10), travelling anywhere, any aggravating or
relieving factor, any trigger
• Associated symptoms: vomitting (if present in detail), any diarrhoea, passed wind, tummy
distension?
• Any fever, nausea? Any trauma? (if yes go in detail) Injury anywhere else? Did you anything after
that? Injured your head?
• Examination:
• General appearance: pallor, jaundice, head to toe examination looking for other signs of injury
• Vital signs
• Systemic Examination: Abdomen examination: bike handle mark, any distension, tenderness,
guarding/rigidity, bowel sounds
• Genital area: blood in meatus
Explanation:
• At this stage, due to fall from bike, pain in tummy and episodes of greenish vomitting→ I suspect
your child might have got injured his oragns inside tummy most likely suspect blunt injury
abdomen as he had green vomiting most likely think injury to the small intestine called duodenum
(draw diagram) can also have injury to liver, stomach, or pancreas
• Mx: nil by mouth, ng tube, iv fluid if in rural hospital then refer
• Need to find out the organ injured by invx: to r/o injury to pancreas, liver, intestine - CT scan
• Further Management depend on organ injury: theory from rch

Down Syndrome
You are an HMO and you are doing post-natal ward round. The nurse calls you and asks you to explain
to mother whose baby is suspicious of having Down's syndrome after examination by one of your
colleagues. Mother is very upset and she wants to talk to one of the doctor. The chromosomal test is
pending.
Task
• Counsel the mother

• Introduce yourself.
• I can understand you got the news that your child has been suspected to have Down syndrome. it
is understandable that you feel like this, it must be upsetting for you.
• Do you have any special concern at this moment? Do you know what Down syndrome is?
• I can understand your concerns. How do you cope with the baby?
• do you have enough support from your partner or family?
• I believe you need support at this stage. Let me first explain to you about down syndrome to give
you a better view about your baby’s condition and what management is available for him. If you
have, any questions please interrupt.
• Condition - Down syndrome is a genetic condition in which the person has an extra copy of
chromosome 21. Chromosome are the blueprint for body’s development. The usual number is 46
in each cells but in Down they have 47 in each cell instead of 46.
• Cause - having this extra chromosome happens by chance. It is nobody’s fault. It means nothing
that you did before or during pregnancy has resulted in this.
• Babies with Down could be born to parents of any age, race or social status.
• Clinical features
• babies with down clinically presented with upward slanting eyes, small fold of skin on the inside of
eyes, rounded face with flat profile, flat nose, low set ears, short neck, reduced muscle tone, are
usually smaller and weigh less at birth than others. They usually tend to grow slowly but eventually
meet many milestone.
• They can develop communication skills but might take a little longer.
 • Complications
• they are at higher risk of problems with vision, hearing, gut or heart defects, hypothyroidism, bones
problems and some degree of learning difficulties.
• We will get your child reviewed by the spec and they will rule out all of these conditions. Blood
tests (TFT), Echo, USD.

Management
• look you are not alone we are with you.
• let me tell you that medicine in Australia is very well developed. The number of health facilities
giving to down are expanding and promising.
• At this point, although it is a clinical Diagnosis we need to confirm it as well.
• let me assure you that your baby will be taken care of by MDT:
• we will regularly testing his vision and hearing. He may need speech and language therapist to
improve communication skills and use language effectively.
• physiotherapist may arrange exercises to improve muscle strength, posture and balance.
• emotional and behavioral therapist, psychologist all will help in addition to GP.
• there is also Down syndrome association of Australia. Social worker and financial support from
centerlink.
• -At the end, what you read on the Internet is not necessarily true. Down's patients can live up to
70 years or more. Down syndrome babies are socially happy and If they are provided with
appropriate stimulation and encouragement they can become productive members in our society.
• allow yourself sometimes to adjust, talk to your partner about how you feel.
• Reading material thanked her

SIDS
You have a 32-weeks pregnant lady at your GP clinic. She wants to know about SIDS because her
neighbor just lost the baby.
Tasks:
• Counsel your patient
• Greetings and ask her concern.

• Build rapport – How’s your pregnancy going so far? Do you have enough support? How old are
you?
• -Let me tell you about SIDS, risk factors, and preventive measures.
- SIDS also known as “cot death” is the major cause of death under the age of 1year.
• The causes are unknown but risk factors have been identified.
• Sleeping position: Sleeping position is important. Always place baby to sleep on its back with your
baby’s feet at the bottom of the cot.
• The cot environment. Infant’s dying from SIDS were found to be wrapped more warmly, wore hats,
used quilts or dooners, had cover over their heads, or were wrapped loosely. That is why always
use firm, well-fitting mattress. Don’t use cot bumpers. Keep soft toys out of the cot. Tuck in the
bed clothes securely and ensure the head is uncovered. Make sure your baby is not overheated.
Sweating around the head and neck indicates the baby is too hot. Avoid wearing hats at sleeptime.
• Smoking : Daily exposure of infant to smoke is highly significant and dose related. Make your house
a smoke-free environment at all times.
• Bed sharing: Bed sharing is a risk factor if parents have been smoking, using alcohol, or recreational
drugs. Baby should sleep in the cot. However, you might consider room sharing because there is
evidence which suggests sharing a room with the baby for the first 6 months may be beneficial.
• I will teach you how to recognize significant illness in your child. Spike a fever, not feeding well or
decreased nappies, etc..
• Statistics show that immunized children are at lower risk of SIDS than those who are immunized.
• Breastfeeding: Breastfeeding is a protective factor.
• There are some risk factors which we cannot influence such as prematurity, low birth weight, low
APGAR scores, Boys>girls.
- Investigation or blood tests? There is no investigation that can predict SIDS.
- I head about Home Apneic Monitoring (HAM), should I get one? HAM is not routinely
recommended as no study has demonstrated that this program reduces the incidence of
SIDS.
- Does previous SIDS increase risk of having another child with SIDS? Slightly. In this case,
home apnea monitoring can be considered mainly for parental support.