SAMSON’S PLAB 2

Dr. Saptarshi Maitra’s Class Notes

PAADIATRIC COUNSELLING
FOR INTERNAL REFERENCE AND CIRCULATION ONLY
 TABLE OF CONTENTS
ASK THESE QUESTIONS IN EVERY PAEDIATRIC CONDITION? .................................................................................2
PAMGUD – TO BE RULED OUT ..........................................................................................................................2
PAEDIATRIC HISTORY...........................................................................................................................................2
CONSTIPATION IN A CHILD (254) ..........................................................................................................................3
NIGHTMARE IN A CHILD (243) ..............................................................................................................................5
Difference between Nightmare and Night Terrors ..........................................................................................7
PYLORIC STENOSIS (96) ........................................................................................................................................8
BREAST MILK JAUNDICE (160)............................................................................................................................11
BRONCHIOLITIS (148) .........................................................................................................................................13
AOM IN A CHILD (135) .......................................................................................................................................16
FEBRILE CONVULSIONS (45)...............................................................................................................................18
SCENARIO A ......................................................................................................................................................18
HEAD INJURY IN A CHILD (35) ............................................................................................................................22
INTUSSUSCEPTION (7) .........................................................................................................................................25
SCENARIO ...........................................................................................................................................................25
RECURRENT TONSILLITIS IN A CHILD (284) ........................................................................................................27
CHLAMYDIA EYE INFECTION IN A CHILD (271) ...................................................................................................29
FEVER IN AN INFANT – TELEPHONE CONVERSATION (228) .................................................................................32
ECZEMA IN A 15-YEAR-OLD (318) ......................................................................................................................34
URTICARIA IN A 5-YEAR-OLD (329) ....................................................................................................................36
ENURESIS IN A 4 YEAR OLD (341) .......................................................................................................................38
ASTHMA IN A CHILD (258) ..................................................................................................................................40
EXACERBATION OF ASTHMA IN A CHILD (115) ...................................................................................................42
ASTHMA IN A CHILD – TELEPHONE CONVERSATION (260) ..................................................................................46
MILESTONES .....................................................................................................................................................50
DELAYED MILESTONE OF DEVELOPMENT ...........................................................................................................52
Social development ........................................................................................................................................52
Delayed fine motor development ...................................................................................................................52
Gross motor development..............................................................................................................................52
Speech development ......................................................................................................................................52
CHILD DEVELOPMENT (244)...............................................................................................................................53
TWIN WITH LANGUAGE DIFFICULTY (288) .........................................................................................................54
BEHAVIOUR ISSUES IN 3 YEAR OLD (337) ...........................................................................................................56
AUTISM 1ST PRESENTATION (272) .......................................................................................................................58
AUTISM FOLLOW UP (277) ..................................................................................................................................60
VACCINATION IN A 5-WEEK-OLD BABY (299) .....................................................................................................62
MMR VACCINATION (52)...................................................................................................................................64
INFLUENZA VACCINATION IN A CHILD (176) ......................................................................................................67

1
 ASK THESE QUESTIONS IN EVERY PAEDIATRIC CONDITION?

PAMGUD – To Be Ruled Out PAEDIATRIC HISTORY

Pneumonia Pregnancy

• Child have any temperature • How many weeks was the child
• Any cough delivered?
• Any complications during pregnancy?
Acute Otitis Media
• Were you admitted to the hospital?
• Crying and pulling the ear
Birth history
• Any discharge from the ear
• Any complication during birth of
Meningitis
child?
• Child have any temperature • Any medical attention after birth?
• Shying away from light
Immunization
• Do you see any rashes?
• Is the child up to date with his jabs?
Gastroenteritis
Nutrition
• Bowel habit of child
• Is the child eating and drinking well?
UTI
Development
• Does your child run a temperature?
• Crying when passing wee? • Are you happy with the red book? Or
are you happy with the growth of your
Dehydration child compared to the children of the
same age?
• How many nappies have you
changed?
• Were the nappies wet?
• Is the child less playful than before?
• Crying without tears

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 CONSTIPATION IN A CHILD (254)

Scenario

FY2 in. GP surgery. 30-year-old lady made appointment to see you. She has a 2-year-old
child who is constipated. She had visited surgery 2 weeks ago. Abdominal PR and
neurological examination were done. She was advised dietary changes. PR did not show
faecal impaction. Follow up in 2 weeks’ time. Talk to patient and address her concerns.

Patient information

You came two weeks ago b/c you child has constipation you were advised on diet. The child
has been constipated for 2 months. Initially the child used to pass stool every day. Since the
last 2 months its twice a week. In the last few weeks, it has become once a week. 2 months
ago, child had flu like illness with fever cough and runny nose. Child eats cereals for
breakfast, toast for lunch and pasta for dinner. Does not like water, fruits, or vegetables.
Otherwise feeding well. In the previous visit doctor was in a hurry and did not assess child
properly.

APPROACH

GRIPS

PARAPHRASE

H/O constipation

• How many times a week does the child pass stool?

• How does the stool look like?
• Are they like rabbit droppings? (b/c of dehydration)
• Any blood in the stool?
• Pain or distress during passing stool?
• Is it the first time he is constipated?
• Precipitating factors
o Appetite and diet.
o Acute flu like illness
o Anal fissure (Streak of blood in the poop)

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 o Medication – Opioids or antihistamines
o Is the child potty trained?
• Where the child has easy access to the toilet?
• Any problems at home?
• Any change in child’s life – Change of home? School?

Rule out red flags

• PAMGUD
• Constipation in first week of birth? (Hirsprungs)
• Delay in passing meconium. (CF)
• Recurring infection? (CF)
• Stool like narrow ribbons? (Anal stenosis)
• Cow milk introduced in child’s diet.
• Weakness in the legs? Motor developmental delay? (Neuro or Spinal Cord
Abnormality)

PBIND

EXAMINATION

• Observation
• Weight of the child
• Assess developmental milestones
• Abdominal examination
• Neurological examination
• Anal examination

DIAGNOSIS – Idiopathic constipation.

MANAGEMENT

• Dietary advice – increase fluid and fibres

• Laxative drugs – MACRGOL (< 1 year - ½ sachet daily, 1 - 6 year – 1 sachet daily, 7-
12 years – 2 sachets daily)
• Follow up in 2 weeks. If no improvement, refer to paediatrics.
• Consult the seniors. I will take as second opinion from my seniors and if they suggest a
different treatment, I will inform you.

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 NIGHTMARE IN A CHILD (243)

Scenario

You are FY 2 in GP Surgery. A 30-year-old mother has taken an appointment to meet you.
Talk to the mother and address her concerns accordingly.

Patient information

Your son has been waking up in the middle of the night screaming. He wakes up 2 to 3 times
in the night for the past 4 months. His father had told you that he had similar episodes in the
childhood. You are worried that it could be something serious.

Questions

• What is wrong with him?

• Is there anything I should do?
• Do you think he is having nightmares?

Approach

GRIPS

• “How can I help you today?

• History of presenting complaint:
o How long?
o How many times a day?
o Any particular time of the sleep
Is it when he is about to fall asleep?
Or when he is about to wake up?
Or just in the middle of the sleep?
o Has the child been watching some violent movies?
• Differential Diagnosis
o Night terrors.
o Underlying organic-brain disorder: delirium, mental impairment. – PTSD
o Medication or withdrawal from medication

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 o Recurrent febrile illness
o Seizures
o Depressive illness
o REM sleep behaviour disorder
o Obstructive sleep apnoea
• Questions on differential diagnosis:
o Have you witnessed your child having an episode of screaming or thrashing
around?
o Does your child remember what happened in the morning?
o Did you try and comfort him/her? (If so) Did your child recognise you?
o Were his/her eyes open?
• PBIND
• MAFTOSA
o Allergy
o Family History
o Goes to school or not? (Bullying)
• ICE
• Effects of symptoms
• Summarise

EXAMINATION

• Observation

DIAGNOSIS EXPLANATION:

MANAGEMENT:

• Usually nothing needs to be done, it will resolve on its own

• Offer leaflets
• Chat about night terror to know if something worries them
• Maintain sleep schedule
• Arrange a follow up

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 DIFFERENCE BETWEEN NIGHTMARE AND NIGHT TERRORS

Nightmare

• Late at night
• Triggers present
• Child remembers

Night Terrors

• 3-8 year
• Early part of the night
• Family history present
• Triggers -Tiredness, fever , medicine, excitement
• Mx -Mother needs to wait for to child calm down. Intervene only if child gets unsafe

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 PYLORIC STENOSIS (96)

Scenario

You are FY2 in the paediatric department. A 6 week old baby has been vomiting for the past
2 days and the nurses have taken observations which are as follows: Temperature: 36.8,
Blood pressure: 99/66, RR 42, HR 115, Weight 7.6kg, Skin colour: slight dry. Take a focused
history and discuss the initial management with the mother.

Patient information

You have a 6-week old baby who has been vomiting for the past 2 days. The vomiting is like
a fountain, goes very far (projectile) and looks like fresh milk. The child is constantly asking
for milk. Your child is otherwise fit and well and not on any other medications. Everything
was normal during the pregnancy and child has been gaining weight normally.

Questions

• What is wrong with my child?

• What are you going to do for her?
• Do we need to stay in hospital?
• If the doctor mentions that you have a pyloric stenosis, ask them” what is pyloric
stenosis?
• What is PYLOROTOMY?

Approach:

GRIPS

ODPARA of vomiting

• Whether it goes far or not? Rule out Dehydration

• Colour? o How many nappies have you changed?
• Blood staining? o Were the nappies wet?
• Association with food? o Is the child less playful than before?
o Crying without tears

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Differential Diagnosis

• Pyloric stenosis
• Gastroenteritis
• Dietary intolerance
• Over feeding
• Bronchiolitis
• Intussusception

Red Flags - PAMGUD

PBIND

MAFTOSA

EXAMINATION

• Observation (If the vitals are not given)

• Abdominal examination
• Feed test – ask the mother to feed in front of you and then examine the abdomen. a
palpable mass may be felt in epigastric region.

INVESTIGATIONS

• Abdominal USS
• Blood test - FBC, U&E, ABG and make sure that he has not lost too much salts from
the body.
• Urine examination

Explain the findings :

ICE

EXPLANATION OF THE DIAGNOSIS

From what you tell me about the child and from my investigation it is likely to be something
call Pyloric stenosis. It is the narrowing of the outlet of the stomach. The food your child
takes, it goes to the stomach, but as the outlet of the stomach is obstructed, the food doesn’t

9
go to the bowels. But you would need examinations the tummy of the child especially while
the child is feeding and preform some investigations to confirm it.

MANAGEMENT

• Admit
• Intravenous fluids
• Consult the seniors. I will take as second opinion from my seniors and if they suggest
a different treatment I would inform you.
• Explain that once confirmed the condition usually traded with an operation. This
operation is called a small pyloromyotomy. It is done under general anaesthesia. An
incision would be made at the narrowed part of the outlet of the stomach.

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 BREAST MILK JAUNDICE (160)

Scenario

FY2 at Paediatric Department. 3-week-old baby who has been referred by community mid wife with
jaundice. Child weight: 4 kg. Talk to mother, address her concern, assess child and discuss
management

Patient Information

Jaundice 2 days ago. She is other well. No Fever. Feeding fine. Born at 38 weeks. No problem with
pregnancy. Mother is happy that she is gaining weight. It is their first visit to the hospital. Midwife
noticed jaundice but mother did not.

Questions

• What is wrong with my child?

• Why did it happen?
• What are you going to do?

APPROACH

GRIPS

OPARA of Jaundice

D/D:

• Rule out PAMGUD

• Biliary Atresia: Dark urine and pale stool?
• Breast milk Jaundice: Are you breast feeding? Do you give him extra bottle feeding?

PBIND

MAFTOSA

• Past Medical H/O

• Family H/o
• Allergy

EXAMINATION

• Observation

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INVESTIGATION

• Urine RE
• Specific bilirubin by bilirubinometer (Small device which has light beam, put on child’s skin
and measures amount of bilirubin in child’s skin)
• Heel prick test: Amount of bilirubin

DIAGNOSIS AND MANAGEMENT

Breast milk jaundice – It is quite common in newborn babies and is a condition that causes yellowish
discolouration in the skin and eyes. It happens because the liver in newborn is not mature and I not
ready to deal with pigment called bilirubin. Usually develops in first 2 weeks of life, but if the child is
breast feeding it usually lasts longer. There is nothing to worry, it will resolve on its own without
treatment.

There is nothing to be done at the moment. She can continue breast feeding.

Safety net: Fever, please do come back and let us assess your child again.

Follow up in 1 weeks’ time.

Offer leaflets on breast milk jaundice.

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 BRONCHIOLITIS (148)

Scenario

FY2 in the Paediatric department. Mrs. Sofia Black is 30 years old lady who brought her 8
months baby Michelle with breathing difficulty. Child is currently with the triage nurse.
Observation: O2 Sat: 94%, RR: 26, BP: 99/77, HR: 110. Take a history from the mother and
address her concerns.

Patient Information

• You brought your child to the hospital with breathing problems.

• She has had difficulty in breathing, fever, cough and running nose.
• Michelle had similar attack when he was 3 months
• From last night the shortness of breath and wheeze has got worse.
• She could not sleep at night.
• Last time he had similar problems, she was admitted and given oxygen and nebulisers.
• Child was admitted for a day and then discharge home.
• Child was discharged home on nebulisers
• Once the baby was fine, you stopped giving her the medication.
• You were as well given a spacer device.
• Offer a leaflet about bronchiolitis
• Follow up in one week time

Warning sign

• High temperature
• Rash
• Drowsiness
• If you are ever worried bring the child

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Approach:

GRIPS

PARAPHRASE

History of presenting complaint – ODPARA

Differential diagnosis:

• Viral-induced wheeze.
o Consider if there is wheeze but no crackles, a history of episodic wheeze,
and/or a family or personal history of atopy.
• Pneumonia.
o Consider if temperature is above 39°C and there are persistent focal crackles.
• Asthma.
• Bronchitis.

Questions on differentials

• Any shortness of breath? • Any Cough?

• Any high temperature? • Any Difficulty in feeding?
• Any wheeze? • Runny nose?

• Any allergies?
RED FLAGS:

• Inconsolable cry • Persistent high fever – Apnoea

• Rash • Central cyanosis
• Photophobia • Intercostal recession

MAFTOSA

• Family history of atopy

• Allergy

PBIND

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EXAMINATION

• Chest examination
• Ear, nose and throat examination

MANAGEMENT

• Oxygen
• Nasal gastric tube
• Admit
• Investigations
o Bloods
o Nose Swabs
o CXR To confirm that whether the respiratory syncytial virus is responsible for
the infection.
• Consult the seniors. I will take as second opinion from my seniors and if they suggest
a different treatment, I will inform you.
• May need to stay in hospital for two days (2-3 days).
• ADVICE:
o Keep your child away from other children.
o Paracetamol and ibuprofen to relieve the temperature.
o Drink plenty of fluids – to prevent dehydration.
o Keep your child upright – this may make his breathing easier and may be
useful in trying to feed.
o Keep child away from smoke inhalation.

Bronchiolitis is a common LRTI that affects

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 AOM IN A CHILD (135)

Scenario

FY2 in paediatric department. 10 months old child has been brought to the hospital by her
father with fever. Temp – 39, Pulse – 146 beats/min, BP- 90/77mmHg. Ear examination –
Tympanic membrane is pink in the left ear. Nose and throat examination – Normal. Chest is
clear. Talk the dad, discuss management, and address concerns.

Patient Information

“How is my child doctor?”. Your child has been unwell for the last two days with fever of 39.
Tried to give PCM but temp has been persistent. She has been crying while pulling her right
ear. She has been taking less fluids than usual. She is immunized. Mother of child is at work.
Works as secretary at office. Child is generally fit and never been on meds or hospitalized.
Everything normal at delivery. Normal vaginal delivery.

Questions

• What is wrong with my child?

• Will you admit her?
• What are you going to do for her?

APPROACH

GRIPS

ODPARA for Fever

D/D: Rule out PAMGUD

PBIND

EXAMINATION

• Observation
• Head to toe examination
• Ear examination (of normal followed by diseased ear), nose and throat.

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DIAGNOSIS

From what you have told me, and, on my examination, you child has Acute Otitis Media
which is the infection of her ear.

INVESTIGATION: Urine RE

MANAGEMENT

• Start antibiotics – AMOXICILLIN f/b CLARITHROMYCIN

o Age < 2 years
o Symptoms for > 3 days
o High grade fever, systemically unwell
o Both ear infected
o Smelly discharge from ear
• Continue for PCM for the fever
• Advice
o Plenty of fluids
• Safety netting
o Drowsiness
o Develops rash
o Worsening fever
o Photophobia
• Follow up in 3 days with GP

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 FEBRILE CONVULSIONS (45)

SCENARIO A

You are a FY 2 doctor in the Paediatric department. Mrs. Melanie Carl has brought her 2-
year-old child, Jenny Carl. Jenny had a fit at home, which lasted 2 minutes. Her temperature
is 38.5 C. On examination, there is redness over the left the eardrum. The rest of nose and
throat are normal. Please talk to the mum, take a focused history, discuss management of the
child and address her concerns.

Patient Information

• You are Mrs. Melanie Carl; you have brought your 2-year-old child because the child had
a fit at home 2 hours ago.
• This is the first time it has happened
• You have got 2 children at home. You were in the kitchen and the 2 children were in the
living room. Then the older child who is 6 years old called you to say that John was
having a fit. Jenny is years old.
• After the seizure the child went floppy and pale.
• On the last 24 hours Jenny has been touching the ear vividly and there has been discharge
from the ear.
• The child is up to date with all immunisation
• Child was pulling and touching the ear but not crying.
• No other past medical history, no allergies, no regular medications
• You are worried about meningitis because your neighbour child had meningitis OR you
read in the news that there are many children now getting meningitis.

Scenario B

• The child woke up this morning pulling the ear.

• The child was on the mum’s lap when she had a fit.
• Child is feeding and developing well.
• Child is with the nurse at the moment.
• Temperature: 39.4

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 Scenario C

• The child had a seizure when you were walking in the garden
• The child never had any immunisation, because you did not know that you are supposed
to take him for immunisation.
• The fit lasted less than 30 seconds.
• The child was running a temperature but you did not measure
• You gave paracetamol to the child
• The child has been pulling the ear in the last 24 hours.
• The child was able to eat and drink
• Child is allergic to amoxicillin

Approach:

GRIPS - How can I help?

History of seizure:

• How long did the seizure last?

• Did you witness the seizure?
o Before the fit:
Fever or feeling unwell
o During the fit:
Any tongue biting?
Any urinary incontinence?
Faecal incontinences?
Did he hit the head to anything?
o After the seizure:
Was he drowsy?
Any vomiting?
• Differential Diagnosis:
o Hypoglycaemia o Family history of febrile
o Epilepsy convulsions
o Febrile convulsions

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PBIND

MAFTOSA

Rule out dehydration, PAMGUD

RED FLAGS:

• Inconsolable cry • Persistent high fever – Apnoea

• Rash • Central cyanosis
• Photophobia • Intercostal recession

EXAMINATIONS:

• Observation – Check temperature

• (This is given) Check the ear closely - he has red ear drum.

EXPLAIN DIAGNOSIS

Febrile convulsions. This is a condition in which children develop a fit when they have high
temperatures. Seizure usually develops with a temperature of 38 degree or more. The cause is
known due to ear infection. It usually develops between 6 months and 6 years. It may happen
again child is likely to be free of having febrile convulsion after the age of 6 years. Febrile
convulsion is not epilepsy, but unfortunately it has been linked with an increased risk of
temperature.

MANAGEMENT:

• If child is Feeding well and not dehydrated – Send back home or else Admit.
• Give antibiotics for acute otitis media (Amoxicillin for 5 days if no allergy)
• Advice:
o Paracetamol and ibuprofen to reduce temperature
o Light clothing
o Tepid sponging or excessive cooling is not recommended

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• What to do when child is having seizure:
o Remove dangerous things away from the child
o Put him in the recovery position
o Do not put anything in the mouth
o Call an ambulance if the seizure lasts more than 5 min. - Always take child to
the doctor for assessment
• Safety netting:
o Non blanching rash
o Drowsiness
o Persistent crying
o Child is unwell or if you are worried about your child
• Offer leaflet about febrile convulsion and ear infection.
• Follow up with GP in 3-5 days

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 HEAD INJURY IN A CHILD (35)

Scenario

You are working in the Paediatric Department as a Foundation Year 2 doctor. Your next
patient is Jenny, a 9-month-old baby who fell down at home. She has a bruise on her head. At
the moment, the child is well and actively playing in the department. Please talk to her mum,
Lucy. Take a history and discuss management.

Patient information:

You are Mrs Lucy Lopez, a 31 year old lady. You have brought your 9 month old child Jenny
to the hospital who has had a fall.

• You were changing the nappy of a 2 year old child when Jenny, 9 months fell down from
the sofa.
• It happened one hour ago
• Jane is up to date with all vaccinations
• No past medical history
• The child goes to the nursery
• Jane vomited once

Questions:

• Are u sure everything is okay doctor?

• Yes I Know there is a Bruise on the Head
• You are very distressed
• What should I do next?
• Doctor, you will not perform a CT scan now?
• Why not CT Scan? how will you know she will be fine?
• What should be done about it?

22
Approach:

GRIPS - How can I help?

History about the fall

• When
• Where
• How
• Who witnessed the fall.

History of Incident

• Before
• During (LOC, vomit, seizure)
• After

Rule out Non Accidental Injury

• Has this happened before

• Any other injury?
• I am sorry to ask this but is your partner the father of the child?

Rule our PAMGUD

MAFTOSA

PBIND

ICE / Summarise

Red flags

• Slept and couldn’t wake up; • Vomited

drowsy • Seizure
• CSF from nose or ear • Bruise, laceration, swelling > 5cm
• Loss of consciousness (CT Scan)

23
Examination

• Observation
• Examine the ears, nose and throat.
• Examine the bruise closely

Explain the diagnosis to the mother: Child has mild head injury

Management

• CT Scan is not required because it’s a mild head injury and will expose the child to
unnecessary radiations.
• Observe for 4 hours in the department, if child is playing and active, then you can go
home.

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 INTUSSUSCEPTION (7)

SCENARIO

FY2 in paediatric department. Your next patient is 18 months old child, who has been
referred to the hospital by GP. Child is with the nurse in the next room. Take focused history
and discuss management with the mother

Patient Information

You are the mother, 30-year-old lady. Referred to the hospital by GP with 18-month-old
child. Your child has been crying for the last 10 hours. He would cry continuously for 5
minutes and stop for 1 minutes and start again. He is crying by pulling his legs towards his
tummy. He has had diarrhea with blood in it. YOU CHILD HAS BEEN lethargic and not
able to drink and eat properly. He is your first child through normal delivery. Child passes
coloured stools. He is up to date with vaccination. Development normal. No past h/o no
allergies. Stool is jelly like.

Questions

• What is wrong with my child?

• What are you going to for him?
• Will you admit him?
• What investigation will you do?
• What is air enema?
• What if that does not work?

APPROACH

GRIPS: Confirm relation to the child.

PARAPHRASE

ODPARA for crying complain

Rule out PAMGUD

PBIND

Examination on GP letter: Swelling on tummy, Increased heart rate.

25
Investigation

• Observation

DIAGNOSIS

From what you have Intussusception. It is a condition in which one part of the bowel slides
into another part like a telescope. Which causes the bowel to become blocked.

MANAGEMENT

• Admit
• Oxygen if required
• IV fluids
• NG tube
• Analgesics
• Investigations:
o FBC, UnE, LFT, Blood glucose level.
o USG of Abdomen
• Reduction by air enema (usually successful in 8-9/10 patients). In this small tube is
passed through the back passage of the child and then air is pushed into the bowels
using this tube. This air helps reversing the telescoping of the bowel. Continuous
monitoring and Xray is needed to watch is blocked is relieved or not. If not succeeded
with air enema, he might need operation.
• Consult my seniors and inform parents if there is any change in treatment plan.
• Offer leaflet for intussusception.

26
 RECURRENT TONSILLITIS IN A CHILD (284)

Scenario

FY2 in GP Surgery. Patricia Jones has come to see you and talk to you about her son, who is
9 years old. He was referred to ENT by another GP for tonsillectomy for her son 2 weeks
ago. Specialist has seen the son and refused to perform the procedure. He has sent her back to
the GP. Past Medical H/O 3 episodes of tonsilitis in last 6 months. Treated with antibiotic.
Talk to the mother, take focused history, and address her concerns.

Patient Information

“My referral was rejected”. Son is 9 years old. You want his tonsils to be removed. You feel
NHS is trying to save money and that is why tonsillectomy is being refused. He had 3
episodes in last 6 months and 5 episodes in last 12 months. You only took your son to the GP
for the last 3 episodes but did not mention the previous episodes to the GP. Whenever the
child has these episodes. She takes child off school but doesn’t mention it to the GP. He is
immunized. Normal development.

Questions

• Why was the procedure not done?

• What are you going to do now?
• Maybe the specialist doesn’t want to do the procedure because I don’t have much money.

APPROACH

GRIPS - “How can I help you today.”

PARAPHRASE – “I understand you were referred to the ENT, shall be go through

everything to be on the same page.”

• When was she referred? • Effect on his life –

• What did the ENT say? o School?
• How many episodes in 1 year? o Sleep – Snore at night?
• Age at onset of tonsilitis o Tired all the time? Sleepy
• Symptoms in episode during the day?

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PBIND

Past medical/surgical History

Allergy History

ICE / Summarise

ANSWER TO MOTHERS CONCERN

I apologize you were referred early for tonsillectomy as your child has had only 5 episodes
and doesn’t meet criteria for surgery. Tonsils are important defence organs of our body. If
you remove them, he may fall victim to infections. We do not remove them till it is
absolutely necessary.

Criteria for tonsillectomy

• > 7 episodes in 1 year

• > 5 episodes in 2 consecutive years
• > 3 episodes in 3 consecutive years

Advise the mother:

• To inform GP about every episode of Tonsilitis so it can be well documented.

• During episode give plenty of fluids to prevent dehydration
• Avoid hot drinks as it may worsen pain
• Salt-water gargle
• Use PCM or Ibuprofen for fever and pain.
• Child doesn’t need to skip school once the fever subsides. He can be sent back to
school.

28
 CHLAMYDIA EYE INFECTION IN A CHILD (271)

Scenario

You are a FY2 in a GP Surgery. A 18 year old lady who delivered 10 days ago has made an
appointment to see you. When the child was 7 days old, he was found to have eye infection
and the eye swab taken showed chlamydia infection. Child was treated with chloramphenicol
eye drops and is now fine. Take a history and address her concerns.

Patient Information

• You have been with your partner for the last 2 years.
• You never had PID infections.
• Your partner never complained of any STI symptoms.
• You do not have any symptoms of PID.
• You have been in this stable relationship for the last 2 years.
• You do not have any other partners.
• Your child was diagnosed with chlamydia eye infection but he is now fine.

Questions

• How did the child get the eye infection?

• Did I get this infection from my partner?
• Do you think he is cheating on me?

Approach

GRIPS - How can I help you?

History

• Ask about how the child is doing.

• Any eye discharge in the child?
• Any redness, fever?

29
MAFTOSA

• Sexual history
o Married or stable relationship?
o Practice safe sex?
o Any symptoms like discharge or lower abdominal pain?
o Any STIs in the past screened or treated?
o Any symptoms in the partner?
o Has her partner ever been diagnosed with sexually transmitted infection?
o How long has she been with the partner?
o Is there any chance you could have any other partners?

ICE / SUMMARISE

RED FLAGS

EXAMINATION

• Observations
• Abdominal examination
• PV exam

DIAGNOSIS - Child is likely to have contract chlamydia infection from the mother during
delivery. Explain that sexually transmitted infections in women can be silent which means
you can have these infections without having any symptoms. It is a sexually transmitted
infection which means you got it from your partner but what I cannot say is whether you got
it from the current partner or not.

“But doctor I have had 1 partner for the last 2 years.”

I think any one in your situation would ask the same question but I think it is some- thing that
you can discuss with your partner. In terms of going forward, we can arrange some swabs for
STIs from you and start some treatment. Sometimes, even if you have got a PID, the swabs
can still come back negative. So as soon as we take the swabs, we can start you on treatment
anyway. Do you think you can discuss with your partner? If you can talk to your partner and
have a discussion, he can also come and get treated.

30
Management

• Refer them to the GUM clinic.

• Explain that it is important to screen for other sexually transmitted infections such as
Hepatitis B and HIV.
• Explain that she needs to use a barrier method of contraception such as condoms
until both herself and the partner have completed treatment.
• Explain that future use of barrier method of contraception with greatly reduce the risk
of reinfection and other STIs.
• Explain that it is important to complete the treatment once it has been started to pre-
vent long term complications such as PID, infertility, ectopic pregnancy and chronic
pelvic pain.
• Advise to use contraception.
• Offer leaflet about sexually transmitted infection

31
 FEVER IN AN INFANT – TELEPHONE CONVERSATION (228)

Scenario

FY2 at GP Surgery. A 30-year-old lady, registered on the trial list for telephone consultation.
She wants to speak to you about her 10-month-old child. No known Past history or present
illness. No allergies. Talk to mother and address her concerns.

Patient Information

“Can you come home and see my child? He isn’t feeling well.” Child has fever. Temp is 39-
40. Ibuprofen given. No effect. Cough and runny nose for 24 hours. Not feeding well for past
24 hours. Not changed the nappy because he hasn’t passed any urine. Prior to that he was fit
and well. Immunized. Not able to take the child to the hospital because of lack of
transportation

Questions

• Can I bring her to GP surgery instead of hospital?

• Can you prescribe antibiotics?

APPROACH

GRIPS

Confirm who are speaking to. How can I help you?

TELEPHONIC INTRODUCTION.

• Confirm relationship with child

• Ask where the number can be called back on in case of call drop or any other
number?
• Confirm name of child, date of birth, and address
• Ask if anyone is taking care of the child while he speaks?
• If someone is not, ask to be put on speaker and take care of the child?

ODPARA of Fever and Cough

Rule out PAMGUD

32
Rule out Red Flags

PBIND

MAFTOSA

DO NOT GIVE DIAGNOSIS

I am sorry to tell you that the fever of your child is too high, and he is dehydrated as he has not
passed urine for a while. So, the child needs to be assessed by a doctor and I think it would be
better for the child, for you to go to the hospital than come to the GP practice. If you can’t
reach the hospital because of lack of transportation, we can arrange an ambulance for you.

Meanwhile when you are waiting for the ambulance

• Do not leave the child alone

• Continue giving small sips of water
• Give PCM to lower temperature

Call her back in 10 – 15 minutes to see if the ambulance has arrived or not.

33
 ECZEMA IN A 15-YEAR-OLD (318)

Scenario

FY2 at GP Surgery. James, 15-year-old boy has come to the GP with his mom. James has
asthma. Talk to the mother, assess James, and address the concern.

Patient Information

James was diagnosed with asthma since he was 7 years of age. James’s father and sister also
have asthma. He takes blue inhaler, and his asthma is well controlled. 2 weeks ago, he got a
rash behind both his knees. Which is itchy and has been preventing him from sleep at night.
Because of which his school performance is suffering. James tried E-45 cream which he got
from the pharmacy. But no effective improvement. A couple of year ago he had a similar rash
and had similar cream and it got resolved.

Questions

• How will you help us?

• What is wrong with my son?
• Is it his asthma?
• You will be given picture of eczema of both knees.

Approach

GRIPS

H/O Skin lesion

• When did you notice the rash?

• Which part of the body did you notice it on?
• Anything that makes it worse?
• Is it getting bigger?
• Is it itchy?
• Anyone else in the family with similar rash?
• What do you think starts this rash? Dust? New soap? New clothes?
• Have you used anything for the rash?
• How have you been using the cream? How do you apply it?

34
 • How frequently have you been using it?

D/D:

• Eczema – Flexural Rash

• Urticaria
• Psoriasis – Extensor Rash
• Allergy
• Fungal Infection

R/F of eczema:

• Family History
• Auto-immune conditions
o Asthma
o DM type 1
o Hyperthyroidism

MAFTOSA

ICE / Summarise / Effect of symptoms in patients’ life / Mood

EXAMINATION OF AFFECTED AREAS

DIAGNOSIS

“…Eczema. It is a chronic inflammation of skin leading to dry and itchy skin usually
affecting the inner part of the knees and elbows.”

MANAGEMENT

“As you have already used E45 ointment, I would like to give you Dermol. You can use it as
cream, lotion, and soap substitute. It should be used frequently and regularly, during or after
washing as well. Skin should be gently dried and applied while the skin is still moisturised. It
should be used in the direction of hair growth. Do not rub it. They should avoid using soap,
detergents, and bubble bath. No follow up is required. If it does not respond, you can always
come back. We will then start him on weak steroids”

SAFETY NETTING - Bacterial infection – any redness or oozing.

35
Refer the patient in case of psychological problem. Keep a diary for the occurrence of rash.

URTICARIA IN A 5-YEAR-OLD (329)

Scenario

FY2 in GP surgery. 30 year old came in with some concerns about her 5 year old child. Take
to the mother and address her concerns.

Patient Information

5 year old girl developed rash 2 days ago after taking hot shower. But rash went away after
few hours. Rash was all over the body and pink in colour. Few hours ago, she developed rash
again, after she came back from playing outside. She was with her grandmother at the
moment. You are concerned that this may keep on happening. She is generally fit and well.
Immunized. Has no allergies.

Questions

• Could it be contagious?
• Is it meningitis?

Approach

GRIPS

RASH H/O:

• When did you notice the rash? Is it the first time?

• Which part of the body did you notice it on?
• Is the rash like wheels?
• Anything that makes it worse?
• Is it itchy? Is it painful?
• Does she have any allergies?
• Anyone else in the family with similar rash?
• What do you think starts this rash? Dust? New soap? New clothes? Eating food?

D/D:

36
 • Allergic rash: runny nose, sneezing, watering eyes.
• Anaphylaxis: SOB, Noisy breathing or wheeze, swelling of face.
• Meningitis: Fever, generally unwell, shying away from light.
• Bleeding disorder: Any history or any family history of rash or bleeding problems?
• Insect Bite: Is there any chance she could have been bitten by an insect?
• Eczema: Rash on flexor part of joint.

Rule out PAMGUD

PBIND

EFFECT OF SYMPTOM

EXAMINATION OF RASH

DIAGNOSIS

“…the rash is like wheels, it appears to be a condition called Urticaria. It is a type of allergic
rash.”

MANAGEMENT

“I would advise you to look for the cause of the rash and avoid it. Once specific allergen is
found, we can do a test called Patch testing on the next follow up. It is test in which we attach
a small amount of allergen to the skin for 48 hours so see its effect. I would tell you that it is
self-limiting and will resolve itself. You can keep a diary for the rash, mentioning the
occurrences of rash, how long it lasts, number of wheels and any other symptoms you might
see. It is not at all contagious.”

Give antihistaminic for rash.

Safety net : Advice to bring child to hospital next time she develops a rash. So we can see
and have a better understanding of the rash or if she becomes unwell in any way.

Follow up when she gets rash the next time.

37
 ENURESIS IN A 4 YEAR OLD (341)

Scenario

FY2 at GP surgery. 30 year old lady brings her 4 year old with some concerns. Talk to the
patient, address her concerns and discuss initial management.

Patient Information

C/o bedwetting only at night since birth. No day time bed wetting. Child is toilet trained.
Going to nursery and happy to attend it. No evidence of abuse or stress at home or nursery.

Questions

• What is wrong with my child?

• What will you do for my son?
• Is there any medications for it?

APPROACH

GRIPS

“How can I help you?”

H/O Bed wetting:

• How long has he been wetting himself?

• Is it during the day, night or both?
• Was he previously dry? If yes, for how long?
• Is there any pattern for bed wetting?
• Does he wake up after wetting?
• Is there adequate fluid intake during the day?
• Is there easy access to toilet at night?
• How many times a night and how many nights a week does he wet the bed?

PBIND

• Stress at home or Nursery?

• Change of house or Nursery?
• Is the child toilet trained?

38
MAFTOSA

No examination required

MANAGEMENT

“This is normal for this age group. There are certain things that can be tried to reduce this:

• Avoid caffeine drinks before bed time.

• Encourage to go to toilet before bed.
• Ensure adequate but not excess fluid intake during the day.
• Make sure the child’s room has enough light.
• Make sure the child has easy access to toilet.
• Make sure child does not watch scary TV programmes during the day.
• DO NOT lift the child and taking him to the toilet.”

Other treatment

• Reward system
• Enuresis alarm

Primary enuresis – Never been dry.

• If child is < 5 years old and only night enuresis

• If child is > 5 years old
o If more than 2 times a week
Short term treatment – Desmopressin
Long term treatment - Enuresis alarm
o If less than 2 times a week – Reassure

Refer child for further management.

• Primary enuresis with treatment failure after 2 cycles of treatment (1 week)

• Secondary enuresis
• If > 2 year old and < 5 year old with both day and night bed wetting.

39
 ASTHMA IN A CHILD (258)

Scenario

FY2 in paediatrics department, 7-year-old boy presented with chest tightness and wheeze. RR high,
SpO2 – 94%.. Talk to mother and address her concerns.

Patient information

For the last 3 days the child has cough, sneezing. In the last 24 hours he has wheeze and SOB.
Wheeze started at night. Diagnosed with asthma 2 years ago. Child development normal. Up to date
with immunization. Father had asthma.

Questions

• How is the child doing?

• Can we go home?

Approach:

GRIPS - Confirm relationship to the child. ‘May I know how are you related to George/
Emmy?’

Paraphrase the scenario

Check their understanding: “What have you been told about George condition?”.

History taking: ODPARA for SOB and Chest tightness

Red Flags:

• Slept and couldn’t wake up; • Vomited

• CSF from nose or ear • Seizure
• Loss of consciousness • Worsening of symptom

MAFTOSA

• Past Medical History -Asthma

o Can I ask you some questions?
o How long has he had asthma for?

40
 o What medications is he taking?
o Since he has been diagnosed with asthma how many times has he been to the
hospital due to exacerbations of asthma? Let’s say in the last one-year.
o Is there anything you think could be the cause of these exacerbations?
• Drug - NSAIDs
• Family History of Atopy, Allergies.

Triggers of asthma:

PBIND

EXAMINATION

• Observation
• Chest examination
• PEFR

MANAGEMENT:

From what you have told me I feel like he has another attack of asthma due to the chest
infection. As the child has fever cough for 3 days.

• Admit child
• O2 supplementation
• Not responding to inhalers – Nebulization
• If he responds well – discharge with inhalers and oral steroids
• Follow with GP in 2 days.
• Advice
o Ask if she knows how to use spacer
o Explain triggers
• Give leaflets about exacerbations
• Safety Net:
o Slept and couldn’t wake up; o Vomited
drowsy o Seizure
o CSF from nose or ear o Worsening of sym
o Loss of consciousness

41
 EXACERBATION OF ASTHMA IN A CHILD (115)

Scenario

You are FY2 in Paediatric department. A 4 years old child George who was admitted with an
exacerbation of acute asthma. George is a 4 years old child who is known to have asthma. He
has had recurrent exacerbation of asthma. Talk to mum and determine the cause of
exacerbations of asthma. Explain to the mother how to use the spacer device.

Patient information

• You are Lesley white

• A 30 years old lady
• Your child George was diagnosed with asthma one year ago.
• For the 1 year he has had to come to the hospital with acute exacerbation every month, so
6 times in the last 1 year.
• When you are giving inhalers to your child but he is not always cooperative. He fights a
lot and he does not like the spacer.
• You feel that you have done everything you have been asked to do but still he keeps
getting the attack of asthma.
• You have removed the carpet at home.
• You do not smoke.
• You do use perfume at home.
• You do fry food in the kitchen from time to time.
• You had to give your pet (cat) to your neighbours because you thought it could be the
cause.
• You have got another child 7 years’ old who is fit and well.
• You use yellow spacer and you have got 6 of them at home
• You scrub the spacer to clean it
• Too many puffs

Questions

• Why is he keep getting the exacerbations of asthma?

42
Approach:

GRIPS - Confirm relationship to the child. ‘May I know how are you related to George/
Emmy?’

Paraphrase the scenario: “I understand that George was brought to the hospital be- cause he
was unwell.”. Check their understanding: “What have you been told about George
condition?”. Explain that he has an exacerbation of asthma and you were wondering what
could be the cause of his exacerbation.

History taking

• Can I ask you some questions?

• How long has he had asthma for?
• What medications is he taking?
• Since he has been diagnosed with asthma how many times has he been to the hospital
due to exacerbations of asthma? Let’s say in the last one-year.
• Is there anything you think could be the cause of these exacerbations?

Triggers of asthma:

• Ask about triggers of asthma

• Recurrent chest infections?
• Is he taking the inhaler? Do you use a spacer?
• Which type of spacer is he using?
• Is he cooperative while taking the medication? Do you face any problems while
giving the inhalers? Does he tolerate the spacers well?
• How do you give him the brown inhaler? Is he taking the brown inhaler regularly?

Safety Net:

• Slept and couldn’t wake up; • Vomited

• CSF from nose or ear • Seizure
• Loss of consciousness • Worsening of symptom

43
MAFTOSA

• Past Medical History

• Drug
• Family History of Allergies.

PBIND

MANAGEMENT:

From what you have told me I feel like he is not taking all the medications in. Explain that
she needs to use the correct spacer device according to the age of the child and needs to use a
mask (Only say this if the mother is not using the correct spacer)

• Red spacer 0-1 year

• Yellow spacer 1-5 years
• Blue spacer with or without a mask – 5 years and above.

Explain some of the triggers why someone could have some exacerbations of asthma. If the
feeding is not good, the child may not take the appropriate dose of medications.

Or maybe the dose is not adequate, it needs to be revised or a new medication might need to
be prescribed.

Demonstrate how to use an inhaler and explain how to use a spacer:

• Ask which spacer do you use?

• Apply a tight seal around the mouth.
• Give one puff and place it around mouth and nose for 5-6 seconds. - Give a 30
seconds break.
• And then give another puff.

Taking care of spacers:

• How often do you wash?

• Wash it 2-3 times a week or if it is visibly dirty.

44
 • When washing it, use soap and water, but just under running water. - You do not need
to scrub.
• Please also do not remove the mask when washing the spacer.

Helpful tips:

• Put it tight around the mouth and nose

• What does he like to watch on the TV?
• Try to distract the child by putting TV on channel which he/she likes
• Use the rewarding technique approach by telling your child that if you take the
medication we will give you something
• Turn on his favourite programme
• Also you can decorate the spacer so that it is attractive to him/her
• So try to make it as playful as possible.

Explain the importance of a preventer inhaler.

Address any triggers of asthma in the station

Consult the seniors. I will take as second opinion from my seniors and if they suggest a
different treatment, I will inform you.

Arrange follow-ups in 2 weeks’ time

Give leaflets about exacerbations

Safety Net:

• Slept and couldn’t wake up; • Vomited

drowsy • Seizure
• CSF from nose or ear • Worsening of symptom
• Loss of consciousness

45
 ASTHMA IN A CHILD – TELEPHONE CONVERSATION (260)

Scenario

You are FY 2 in a GP Surgery. The father of a 9 year old has telephoned the practice and
would like to talk to a doctor, as his son has not been well. Talk to the father over the phone
and address his concerns.

Patient information

• Your child has had cough, fever and cold for the last 3 days and is running a temperature.
You have given him paracetamol but the temperature is still high.
• In the last 24 hours, he has developed shortness of birth and you have given salbutamol,
inhaled steroid and Montelukast but he is still short of breath.
• Your child was diagnosed with asthma 4 years ago and is on salbutamol regular inhaled
steroid (brown inhaler) and Montelukast.
• At the moment, he is drowsy, not eating much, short of birth, not very active and is
sleeping on the sofa.
• Child is up to date with all vaccinations and there were no problems during pregnancy or
after delivery.
• He doesn’t have any known allergies.

Questions

• What should I do?

• Can you prescribe him some oral steroid may be he will improve?
• I will come and collect the steroid as the last time (6 months ago) he had similar problem,
the doctor prescribed him steroids

46
Approach

Confirm who is talking on the other side of the phone.

GRIPS

• Confirm relationship with child

• Ask where the number can be called back on in case of call drop or any other
number?
• Confirm name of child, date of birth, and address
• Ask if anyone is taking care of the child while he speaks?
• If someone is not, ask to be put on speaker and take care of the child?

History of the presenting complaint:

• Ask what is wrong with the child?

• Is the child breathing?
• Is the child sitting up?
• Is he drowsy?

History of SOB:

• Onset
• Duration
• Exacerbating and relieving factor
• Associated symptoms
o Chest pain (tightness)?
o Cough?
o Runny nose?
o Fever?
o Wheeze?

Long term treatment for asthma:

• What medications is the child on?

• Does he take inhalers?

47
 • Does he take any steroid tablets?

Treatment of acute episode:

• Have you given him salbutamol? Have you used spacer?

• How many puffs did you give him?

Rule out PAMGUD

Questions on differential diagnosis:

RED FLAGS

• Drowsy • Vomited
• CSF from nose or ear • Seizure
• Loss of consciousness • Worsening of symptom

MAFTOSA

ICE / Effects of Symptoms

SUMMARISE

Explanation of the Diagnosis - Infective exacerbation of asthma - Likely to have viral

infection which has made his asthma worse. From what you tell me, you child seems severely
dehydrated and seems to need admission. At the hospital I would like to examine and treat
accordingly.

MANAGEMENT

• Please remove all the objects from around the child

• Place the child in a sitting position but reclining backwards, it will help with breathing
• Check airway patency
• Stay with the child
• Keep giving him salbutamol via spacer and we will call the ambulance for you

48
• If he loses consciousness please lay him on the left side. Ask if can visit the hospital
or else suggest arranging for ambulance.
• Call back after calling the ambulance to check where the ambulance has arrived

49
 MILESTONES

History of concern

Milestone history

• Smile • Talking
• Walk • Crawling
• Following with eyes • Walking with support
• Laughing with other people

Does he cry ok?

PBIND

Up to date with vaccinations?

Social History

Differential Diagnosis :

• Constitutional delay (never started walking, family history)

• Trauma
• Cerebral palsy (difficult birth, breathing problems after birth)
• Duchenne muscular dystrophy (walked since birth but then stopped, climbs on
himself, increase in the size of calf muscles)
• Congenital hip dysplasia (clicking sound from hip while changing nappies)
• Infections e.g. septic arthritis (fever, swelling, redness, tenderness)
• Perthes disease (avascular necrosis of the femoral head; pain, limping, age 3-14)
• Irritable hip (history of infection a few days back)
• Non accidental injury (bruises of different ages)
• Polio (not up to date with his vaccinations)
• Rickets (bowing of legs, knock knees, malnutrition)

50
Questions on differential diagnosis

• After how many days did you go home after delivery?

• Did the child need any special care after delivery (cerebral palsy)?
• Has he ever suffered from any infections?
• Is there anyone in your family who had delayed walking (familial)?

51
 DELAYED MILESTONE OF DEVELOPMENT

SOCIAL DEVELOPMENT

• No smile – 8 weeks
• No eye contact – 12 weeks

DELAYED FINE MOTOR DEVELOPMENT

• No holding objects – 20 weeks

• No reaching objects – 24 weeks
• No transferring objects – 36 weeks

GROSS MOTOR DEVELOPMENT

• Can’t sit unsupported – 48 WEEKS

• Can’t walk – 72 WEEKS
• Can’t run – 120 weeks

SPEECH DEVELOPMENT

• No single meaningful word – 72 weeks

• No sentence of two to three words in 120 weeks

52
 CHILD DEVELOPMENT (244)

Scenario A

You are FY 2 in GP Surgery. A 30-year female has made an appointment to see you. Talk to
her and address her concerns accordingly.

Patient information

You have a 14-month old son who has not yet started to walk independently. He can walk
with support around the table but cannot walk independently whereas his friends of the same
age group are already walking. Your child can say few words, laugh, smile, interact with
other siblings and can follow with his eyes. He plays well with toys and you have no other
concerns in terms of other developments.

Questions

• Why can’t he walk doctor?

• Do we need to see the specialist?
• Does he need any investigations?

Approach GRIPS

• H/O complain
• Differential Diagnosis
• Red Flags
• MAFTOSA
• Effects of Symptoms / Summarise

EXPLANATION

• Explain that it is normal for a child still not to walk at 14 months of age.
• Reassure he will walk
• Arrange a follow up in 2 months’ time
• If not walking by then, we will send you to a specialist.
• Offer information in terms of what a child can do and what he cannot do at certain age

53
 TWIN WITH LANGUAGE DIFFICULTY (288)

Scenario

FY2 in GP surgery. 35 year old lady, has come to see you. Talk to her and address her
concerns.

Patient Information

She has twins. Michela can say only 2-3 words, while Lucy can say 8-10 words. Michela can
only say Mumma, dada. Both were delivered at 36 weeks via normal vagina delivery. They
are vaccinated. You are satisfied with development. Normal smile, eye contact. Sitting at 7
months and crawling at 9 months. He is interactive. Can stand with support.

Questions

Will he be able to speak later?

APPROACH

GRIPS

“How can I help you?”

H/O speech delay

• How many words can Michela say at the moment?

• What type of words can she say?
• Does she respond to her name?
• Does he point at things?
• Does he smile?
• Does he make eye contact?
• Does he interact with other siblings?

PBIND

Any other medical illness?

Any medications?

Allergies?

54
ADVICE TO PARENT

“It is okay not to be able to say so many words at this age. We should start thinking of her seriously if
she can’t say more than 6 words at 18 months. It is quite normal for one of the twins to be a bit ahead
than the other. Don’t worry he will catch up. Try and interact with her more, both verbally and non-
verbally. They tend to learn from what they see and hear. Twins are generally slower in picking you
language than single baby. It could be that the other twin might be getting more attention. Make sure
to give each equal attention. Concentrate on the child you are taking to. Encourage other family
members to talk to twins individually. Turn off the TV for at least 30 minutes each day. So that your
babies can listen to voices around them.”

NO referral required right now.

Offer leaflet.

“If the child doesn’t speak by 18 months twins and multiple birth association (TAMBA). They
can refer you to language and speech consultant who can help michela catch up with the
language.”

55
 BEHAVIOUR ISSUES IN 3 YEAR OLD (337)

Scenario

FY2 in GP surgery. 41 year old mother has made an appointment to see you. Talk to the
mother and address her concerns.

Patient Information

You have come to the GP today because your 3 year old child is behaving strangely. When
you give him food, playing with food and not eating. You feed him 5-7 times a day. When
you put your child in bed, he doesn’t sleep, instead he runs around. He smiles, keeps eye
contact, is very talkative, speaks well. He hugs, started going to the nursery, plays with other
children, shares toys, no screaming episodes, no aggressive behaviour, no repetitive
behaviour. He is your first child.

Questions

• Why is he not eating?

• Why is he not sleeping?
• What will you do for us?
• Is it autism?

APPROACH

GRIPS

H/O CONCERN : NOT EATING, NOT SLEEPING

ASK ABOUT MILESTONE HISTORY:

• Does she respond to her name?

• Does he point at things?
• Does he smile?
• Does he make eye contact?
• Does he walk with support?
• Does he resist when you try to cuddle him?
• Does he have any repetitive behaviour like playing with the same toys?
• What does he like to eat?
• How many times does he eat?

56
PBIND

Rule out PAMGUD

MAFTOSA

• Medical and medication History

• Allergy
• Family

DIAGNOSIS

“…There is nothing wrong with your child. Sometimes children need attention, give you child some
more attention like stay in bed with him, read stories to him, give him food he likes. Trying eating
with him and take care not to overfeed him.”

Offer leaflet on behaviour issues.

57
 AUTISM 1 ST PRESENTATION (272)

Scenario

FY2 at GP Surgery. 41 year old lady has made an appointment to see you. Talk to her and
address her concern.

Patient Information

You have come to the GP, because your 3 year old child has not been able to speak until now.
He likes playing by himself. He is your only child. You do not know when a child should be
able to speak. He has a habit of playing with the same toys every time. He doesn’t like to
change the toy. He is not able to speak any words but he makes screaming sounds. You have
no other problem with other milestones. He doesn’t smile much to others. Recently, you and
your partner took him to the day care and that us when you noticed that other children of his
age are able to talk. The day care teacher also mentioned that he doesn’t like to play with
other children. At the age of 12 months he had MMR vaccination and he is up to date with all
other vaccinations. He is the only child you have.

Questions

• Why is he not able to talk?

• What is wrong with him?
• Do you think he will be able to talk?
• What will you do for him?
• If the doctor says that your child has autism, ask the doctor “Do you think that it is the
MMR vaccine that got him?”

APPROACH

GRIPS + H/O Concern – Not able to speak

• When did you notice it? • Does he make eye contact?

• How did you notice it?
• Has anyone else noticed?
• Does he respond to his name?
• Does he point at things?
• Does he smile?
• Does he interact with others or
laugh with others?
• Does he like to be alone?
• Does he like to repetitive things?
• Does he play with other kids?

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PBIND

Rule out PAMGUD

MAFTOSA

D/D

• After how many days did you go home after delivery?

• Did the child need any special care after delivery?
• Did he suffer any infections?
• Anyone in your family with similar problems?

DIAGNOSIS

“…probably your child has a condition called autism. It is the condition in which his brain
works in a different way and affects how he interacts or communicate with others.
Unfortunately it is a lifelong condition. And the child may have learning difficulties,
language impairment and mental health issues.”

MANAGEMENT

• Refer immediately (same day) to Autism team or Paediatrician or Psychiatrist.

• Once the diagnosis is confirmed, child will need to be managed by multi-disciplinary
team which includes – Occupational Therapy, Speech and language therapist,
Behaviour therapist and Psychologist.
• Tell the mother, that her child would need a special school for education.
• Refer mother to Autistic societies.
• Offer leaflet.

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 AUTISM FOLLOW UP (277)

Scenario

FY2 at GP. 3 year old boy has come for follow up. 3 weeks ago, he has presented to your GP
Surgery with Speech and Learning difficulties. He was referred to the autism team and a
diagnosis of Autism Spectrum Disorder has been confirmed. He has been referred back to
your practise for follow up. Talk to the mother and address her concerns.

Patient Information

Questions

• What will happen now?

• Is there anything I have to do for my baby?
• Is it because of MMR Vaccine?
• Should I give MMR vaccination to my baby?

APROACH

GRIPS

PARAPHRASE

“I understand you were referred to the autism team and you here for a follow up now.”

Ask brief history about symptoms of Autism

• “What type of behaviour do you find most challenging while dealing with him?”
• “Does he have any problem with sleeping?”
• “Does he eat well?”
• “Can he say when he wants to eat?”
• “Does he respond to his name?”
• “Is he able to tell you if he wants something? How does he express himself when he
wants something?”
• “Does he respond to you?”
• “If you talk to him does he understand?”
• “Does he know his name?”
• “Does he respond to your smile or hug?”

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 • “Does he scream a lot?”
• “Does any of his behaviours cause harm to him?”

MANAGEMENT

• The child may have Learning and Speech difficulties. Because of this we will need to
refer him to multi-disciplinary team which includes – Occupational Therapy, Speech
and language therapist, Behaviour therapist and Psychologist.
• Occupational Therapist will teach him skills which will allow him to practise a
vocation.
• Speech and language therapist and Behaviour therapist will manage his Speech and
Behavioural problems.
• Mental and Psychological problems will be taken care of by Psychologist.
• Parents should make reasonable adaptation for the child
o Rooms should be cream coloured not white or yellow.
o Should have a noise free safe environment.
o No harsh lights.
• Tell the mother, that her child would need a special school for education.
• Refer mother to Autistic societies like National Autistic Society Charity and
Ambitious about Autism Charity. They will help with learning environment of the
child as well as offer financial support.
• Offer leaflet.

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 VACCINATION IN A 5-WEEK-OLD BABY (299)

Scenario

FY2 in GP Surgery. 30 year old has brought her 5 week old baby for nonurgent appointment.
She has some concerns about vaccinations. Talk to the mother and address her concerns.

Patient Information

She is worried about the vaccination at 2 months. He baby is due to take vaccination in 3
weeks’ time. It is 6 in 1 vaccine. She wonders why they can’t be given separately. She is
scared her baby will be very sick after the vaccination. Normal Paediatric History.
Development good. PAMGUD negative. No dehydration. Normal number of diapers.
MAFTOSA insignificant. Normal systemic review.

Questions

• What are the vaccination at that age

• How many times will he will be injected?
• Are there any side effects at injection site?
• What if he doesn’t take vaccination?

APPROACH

GRIPS

“How can I help you today? I can see that you are concerned about the vaccination, and I
understand why you feel so. I am sorry, we got you worried. Vaccination in children is routine.
It is absolutely safe and done to protect them. Let me ask you a few questions so that I can give
you better advice about your baby.”

GENERAL HEALTH

• Is he fit and well?

• Is he feeding well?
• Does he have any medical problems?
• Is he on any medication?
• Has he had any issues after birth?

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SYSTEMIC REVIEW

• Cough
• Runny nose
• Fever
• Sneezing
• Diarrhea
• Vomiting
• Is the baby passing poo and wee normally?

PBIND

ADDRESS CONCERN

What are the vaccination at this age? How many times will he be injected?

• 6 in 1 vaccine 1st dose – usually one injection

o Site - Given in the thigh.
o Side effects – Swelling at injection site for 2 – 3 days, fever for 1 – 2 days.
• Pneumococcal vaccine + Rotavirus vaccine + Men B vaccine

Advantage of vaccine

o Protect you and your child from many serious and potential deadly diseases
o Protect other people in your community – by helping to stop diseases
spreading to people who cannot have vaccines
o Get safety tested for years before being introduced – they’re also monitored
for any side effects
o Reduce or even get rid of some diseases – if enough people are vaccinated.
o Do not cause autism – studies have found no evidence of a link between the
MMR vaccine an autism
o Do not overload or weaken the immune system – it’s safe to give children
several vaccines at a time and this reduces the amount of injections they need

Contraindication of vaccination : Allergy to the vaccine, Fever at time of vaccination,

Poorly controlled epilepsy or Neurological conditions worsening – Wait till seen by specialist.

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 MMR VACCINATION (52)

Scenario

FY2 doctor in the GP. An 11 months old girl is due for Immunisation next week. Please talk
to her mum Jane and address her concerns.

Patient Information

Opening statement: “ Doctor I read in the newspaper /magazine/ article that MMR
vaccination can cause autism and it is linked.” You are Mrs. Jane Jones, a 30-year-old lady.
You have an 11-month-old girl, Rachel, who is due for her MMR vaccination next week.
You are worried that MMR vaccination is not safe. One of your nephews has got autism and
you are concerned that MMR vaccine can cause autism in your child. Your child is well, able
to eat and drink. She has got no allergies. At the end of the day you do not agree to the
vaccination, you say that you want to think about it. You do not know much about MMR
Vaccination. You are happy to receive a leaflet about MMR Vaccination.

Questions

• Is there a link between MMR and autism?

• Can you tell me about the MMR vaccine?
• Is it given in one go or can I take it separately? Mumps, rubella and measles? Tell me
what does MMR stand for?
• Why do you give it?
• When do you normally give it?
• I read there is connection between MMR and autism.
• Is it linked to a bowel condition? Which condition is it?
• Why is there a still rubella infection if you are giving vaccine?
• When MMR is usually given?
• Is there any alternative to MMR vaccination?
• Are there cases of these infections in the UK?
• Do you think it is really important to do this vaccination?
• Are there any complications of MMR vaccination?
• Are there any side effects of this vaccination?

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APPROACH:

GRIPS

How can I help you?

History taking:

• Do you have any other concerns regarding other vaccinations?

• Have you been able to take your child to other vaccinations?
• Do you feel you will be able to take your child for vaccinations?
• Summarise for the mother
• Explain to mother that MMR is safe.

MMR stands for mumps, measles and rubella:

• 1st dose is offered between 12 to 13 months, because antibody from mothers start
disappearing by this time.
• 2nd dose 3 years 4 months of age, at this age the child starts going to play school.
• These are highly infectious condition that can cause serious complications such as
meningitis, encephalitis and deafness.
• No option for separate dose (3 in 1).
• Not linked to autism.
• Not associated with any bowel condition.

Why is rubella still in the UK?

• Not everyone is vaccinated.

• Go to other countries and get infected.

Alternative: There are no alternative forms of MMR vaccine.

Side Effect of MMR:

• Pain, swelling and reddening at the site of an injection.

• Fever – mild fever may develop a few days after immunisation.
• Parotid swelling (swelling of gland in face).

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Advice:

• TO DO:
o Protect you and your child from many serious and potential deadly diseases
o Protect other people in your community – by helping to stop diseases
spreading to people who cannot have vaccines
o Get safety tested for years before being introduced – they’re also monitored
for any side effects
o Sometimes cause mild side effects that won’t last long – some children may
feel a bit unwell and have a sore arm for 2 to 3 days
o Reduce or even get rid of some diseases – if enough people are vaccinated.
• NOT TO DO:
o Do not cause autism – studies have found no evidence of a link between the
MMR vaccine an autism
o Do not overload or weaken the immune system – it’s safe to give children
several vaccines at a time and this reduces the amount of injections they need

Immunisation schedule:

• 2ndmonth: DPT + Hep B + H. influenza + Polio

• 3rdmonth: 5 + Rotavirus + meningococcal
• 4thmonth: 5 + Rotavirus + meningococcal
• 12 months: Rotavirus and MMR

Contra-indications:

• Acute illness e.g. URTI, otitis media and Allergy to neomycin

• Patients with egg allergy CAN be given MMR vaccination

If missed a dose

Visit GP and ask about missed dose

If given in adults

Avoid getting pregnant for 1 months after the dose

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 INFLUENZA VACCINATION IN A CHILD (176)

Scenario

FY2 in GP Surgery. Patient wants to talk to you about her son who is 3 years old and is due
for flu vaccine in a weeks’ time. Talk to her and address her concerns.

Patient Information

Child is up to date with all immunization. I want to know about influenza vaccine. I am
scared about the vaccine. One of your neighbours children had flu vaccine and developed fit
in one month.

Questions

• Is it good for my child?

• Can flu vaccine cause fit? (NO)
• Will my child get a flu after influenza vaccine?
• How will I differentiate side effect of vaccine from the flu?

APPROACH

GRIPS

“How may I help you?”

Take H/O current condition of child

• Is he fit and well?

• Is he feeding well?
• Does he have any medical problems?
• Is he on any medication?
• Has he had any issues after birth?

SYSTEMIC REVIEW

• Cough
• Runny nose
• Fever
• Sneezing
• Diarrhea

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 • Vomiting
• Is the baby passing poo and wee normally?

PBIND

PAST MEDICAL AND MEDICATION HISTORY

ALLERGIES

C/I OF FLU VACCINE

• Severe asthma
• Weak immune system
• Allergy to Neomycin and Eggs
• Active Infection

How will you give the vaccine?

• Single dose in each nostril. Between 2 – 3 years of age.

• Reassure mother, that it is completely safe.

Side effects of flu vaccine

• Headache.
• Mild flu like symptoms.
• Mild body ache.
• Loss of appetite.

Complications if not vaccinated

• Pneumonia
• Bronchitis
• Ear infection

How will I differentiate side effect of vaccine from the flu?

• Flu infection will be much more severe than the side effects of the vaccine.

Ask mother is she is comfortable to give her child the vaccination?

Provide leaflet for vaccination.

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