Pediatric OSCEs

GOOD LUCK
 Key paediatric questions 
• Feeding –   volume of intake / frequency of feeding
• Vomiting –  frequency / volume / timing – projectile? / bilious? / blood? 
• Fever – confirmed using thermometer vs subjectively feeling hot?
• Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration
• Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly
(intussusception) 
• Rash – any obvious trigger? / distribution? / blanching? 
• Behaviour – irritability / less responsive 
• Cough – productive? / associated increased work of breathing?
• Rhinorrhoea – often associated with viral upper respiratory disease
• Weight gain or loss – check baby book if the parent has it with them
• Sleeping pattern – more sleepy than usual?
• Unwell contacts – often children become infected from unwell siblings
• Localising symptoms – tugging at an ear/ holding tummy 
 Migraine counseling
• make sure they sleep at the same hours nightly, if possible.
• Make sure that they exercise regularly as this reduces stress, anxiety, mood swings and
helps them keep their weight under control (all risks for increasing headaches).
• See to it that they eat on a regular schedule and don’t skip meals. Low blood sugar may
cause headache. Encourage fresh and unprocessed foods whenever possible.
• Commonly used supplements may be helpful in migraine prevention.
• Decrease caffeine intake from soft drinks and iced tea to one dose a day or less.
• Check to be sure that they drink plenty of water, particularly during the summer.
• the approach to treatment depends on the level of disability a child experiences. If the
person experiences mild disability—they miss just an hour of class, do not experience
severe pain reassuring them and get some rest. mild analgesics :acetaminophen.
• moderate to severe disability, such as duration of pain for two or six hours, and prevent
the child from staying in school or participating in his or her usual activities, An over-the-
counter, nonsteroidal option, such as ibuprofen,
• If your child’s migraine is not relieved within one or two hours by analgesics or
combination analgesics, then you may need to consider migraine-specific medications,
such as triptans or dihydroergotamine. The triptan group includes tablets, nasal sprays,
and injectable forms. Currently several triptans: are approved by FDA for use in
adolescents (12 to17 years old)
• If getting a migraine one or two times a week :preventive therapy—medication taken daily
to prevent the onset of a migraine
• If a child has an abnormal neurologic examination, has a new severe headache, or has
 Post gastroenteritis synd
• Infrequently after an episode of gastroenteritis the introduction of normal diet
result in return of watery diarrhea abdomen distention and bloating, and red rash
so but emolient, where temporally lactose intolerance may have developed due to
damage to lining of gut that contain lactase which is an importamt enzyme for
breaking down sugar, confirmed by presence if non absorbed sugar in the stools
giving a positive clinitest
• So return to oral rehydration solution for 24 hr, may need diet that exclude cow
milk, disaccharide and gluten
• Use a low lactose infant formula or LactofreeTM milk –LactofreeTM or other
lactose free brands Plant alternatives e.g. soya, oat, coconut, hemp, nut milks and
products are lactose free.
• Secondary lactose intolerance is temporary. Usually cutting out lactose containing
milk and dairy products from the diet for 8 weeks will give the gut time to heal. The
ability of the gut to produce lactase will build up again and after 8 weeks, the child
should be able to drink milk/ formula and eat regular dairy products.
• It has been shown that lactose increases the amount of calcium absorbed by the
body. Lactose may also encourage the growth of good bacteria in the gut. It is
therefore important to include lactose back in the diet as soon as possible.
 Cyanotic spells
• Exaggeration of cyanosis in child with cyanotic Tetralogy of
Fallot. Occurs once the child is crying or playing, where
rapid cyanosis develops and pallor, irritability, inconsable
crying, due to spasm of pulmonary vessels so it leads to
complete outflow obstruction “no blood flow to pulmonary
circulation. On auscultation no murmur will be heard,’
• Its keep child in knee chest position, if older child in
squatting position, give drugs to relive spasm: o2 morphine,
propranalol, give polus fluid for acidosis and bicarbonate –
then last choice muscle paralysis and artificial ventilation, if
repeated spells do surgery, Blalock Taussing “shunt
subclavian to pulmonary artery”
 Bed wetting counseling
• The term enuresis describes children who wet the bed only during nighttime sleep.
• causes. Some children have smaller bladders, produce more urine throughout the night than others,
or do not wake to triggers of a full bladder, hereditary, or that children who wet the beds do not
produce enough antidiuretic hormone, UTI constipation DM, renal disorders
• NOT caused by poor parenting, toilet-training mistakes, stress, deep sleep, or mental problems.
Understand what is typical. It is not unusually for children to wet the bed up to the age of five . It may
still be frustrating to parents, Do not feel embarrassed. Bed-wetting is a common problem. Clinicians
typically do not think bedwetting is a cause for concern until the child is six-years-old or older
• Visit the doctor if your child experiences burning or pain when urinating, if the child experiences
daytime symptoms, experiences excess thirst, is urinating very frequently, or if the condition has only
started recently; these may be symptoms of another disorder or If the condition is having a significant
impact on the child or family
• A medical check-up can rule out problems such as serious kidney or bladder conditions, or urinary
infections. It is rare that such problems are causing bed-wetting or bowel problems.
• Remember that your child is not trying to wet the bed; never use punishment or shaming
• Discourage any teasing by family members
Encourage regular voiding during the day, ex. every two hours
• Avoid drinks containing caffeine, especially at night
• Ask the child to urinate before going to bed
• Make the bed using alternating waterproof pads and sheets,
• Enuresis alarm, star charts
• Drug treatments
Desmopressin up to 75% of children will respond, and response is usually seen within two weeks.  Do
not give your child any fluids one hour before until eight hours after taking desmopressin
•
Breath holding attacks
Occur in some toddlers when they are upset, the child cries hold breath and goes blue. sometimes
children briefly loss consciousness but rapidly recover fully, drug therapy is unhelpful. Attacks resolve
spontaneously but behavior modification therapy with distraction may help
• It can seem scary, but usually you don’t need to worry these spells are somewhat common and can
happen in healthy children. They can look like seizures, but they’re not. The spells don’t hurt the
children, and many outgrow them by age 6 or 7. After your child passes out, she’ll lie limply on the
floor. She may also:
• Arch her back Become stiff ,Jerk her body a few times, Turn sweaty, Wet herself
• She may or may not gasp when she starts to breathe again.
• Diagnosis
• After your child’s first breath-holding spell, take her to her doctor to rule out any health problems.
• There are no tests to confirm a breath-holding spell. Your pediatrician usually can diagnose it after
hearing what happened.
• Treatment
• If your child has one breath-holding spell, she’ll likely have more. Some children have them several
times a day, while others may have just one in a year.
• There are no drugs or other treatments for these spells. The best thing to do is let your child lie on
her side while she’s out. That helps the blood flow to her brain and gives her a chance to recover
more quickly.
• In very rare cases, a child may not start breathing again after 1 minute. If this happens, call 911. If
she’s still not breathing after 3 minutes, start CPR.
• Prevention
• Your child’s doctor may teach you how to spot triggers that cause the spells, so you may prevent
them.
 Pallor

History taking
• Meets greets and introduces. demography
• Elicit symptoms of anemia : fatigue, dizziness, palpitation, weakness,
breathlessness,
• Establishes history of bleeding P/R, gums, haemoptysis, melaena,
haematuria, any petechia or rash in the body
• Ask if there is any perenial itching at night ( indicates worms)
• If yes  ask if she notice any worms in the child’s stool
• Is there any signs of malabsorption( like there is no gaining in the weight)
• Ask about Diet ( iron , B12, folate )
• Chronic infections - infections such as infective endocarditis ,osteomyelitis,
renal disease can lead to anaemia of chronic disease
• Drug history - certain drugs can trigger haemolysis in G6PD deficiency
• Past medical history >> any hematological disorders /neonatal history.
• Past surgical history
• Recent travel / allergy history / immunization
• Family history  for inherited anaemias.
Acute Diarrhea(Child)

History taking
• Meets greets and introduces. Demography
• Diarrhea: Duration, onset, timing, frequency, progression, stool color consistency,
mucus or blood, relation to food
• any associated symptoms : Fever ,rash, irritability, lethargy, vomiting, low urine output,
thirst
• Relevant Past Medical/ Family history/BIND
• examination finding: Temp, pulse, BP, hydration status, abdomen, other sources of
infection
• Explore parent’s concerns regarding antibiotic, investigation and anti-diarrheal drugs
• Advice: continue breast feeding/soft diet, ORS, avoid juices
• ORS: How much to give/ calculated for child weight, not to make in fruit juice and other
commercial beverages(ORS 75 ml/kg in first 4 hrs)
• Re assessment after 4 hrs. discuss the Red flag symptoms for immediate referral
• Health education: hand hygiene /explain safety netting. Re assessment/ Appropriate
follow up
 Constipation history
Introduce yourself with a friendly greeting.
Ask (personal history) , which is:
Name , age , gender , order of birth , address
Ask about the main problems that made her/him went to see the doctor
Ask about the onset, duration aggravating and relieving factors.
Ask about other symptoms of the relevant and relating systems.
Abdominal distension , pain , nausea , vomiting , dysuria ,rectal prolapse ,soiling
Red Flag (signs & symptoms)
Failure to pass meconium within 24 h of life
Failure to thrive
Gross abdominal distension
Abnormal lower limb neurology or deformity
Sacral dimple above natal cleft, over the spine
Abnormal appearance/ position/patency of anus
Perianal bruising or multiple fissures
Any similar episodes in the past.
Other medical problems or conditions.
History of drug intake: ,History of drug allergy.
Family history:
Social history Diet Diary
 Rickets

History taking
• Meets greets and introduces your self
• Ask about  Name, age ,….
• Ask about chief complaint
• When do u notice this problem ( onset)
• Elicit symptoms of rickets ( delayed dentition, delay closure of
ant.fontanelle, failure to thrive, short stature , delay in development ……)
• Ask about the causes of rickets like :
– decreased exposure to sunlight,
– diet low in Ca, vit D
– any malabsorption disease like celiac, cystic fibrosis
– Is there any medical diseases like renal or liver disease
• Does it affect his life , daily activities, and his intellectual learning process
• Past surgical history
• Allergy history / Drug history
• Immunization / Neonatal history
• Family history
Asthma
Counseling
• Meets greets and introduces your self
• So, first tell me what do you know about your child condition?
• Then ask about the symptoms that child has to know the
severity of asthma
• Give brief introduction about:
– What is asthma
– the trigger factors that elicit asthma attack
– how it will affect the Child’s health if not controlled
• Explain the management of asthma ( stepwise approach) and
mention about side effects
• Don’t forget to ask if they know how to use MDI or spacer
• Ask if any of the parents are smoker to quite
• Emphasize the importance to adhere to the t/t
Counseling of febrile fits
After the detailed examination of your son and the investigations we think that
he has what we call febrile convulsions. 

Do you know anything about them? 

This is a seizure brought on by fever and is usually appeared in a child aged

between 6 months and 5 years. The child becomes unconscious and usually
stiff with jerking of the arms and legs. 

I know Mrs.------- that was a very frightening experience for you, however
febrile convulsions are not as serious as they look. 

Is there anything you want to ask me before proceeding? 

this point I would like to tell you what you should do to prevent febrile
convulsions. If your child is having fever, don’t over cloth him or over heat the
room, try to keep him cool! Give him plenty of fluids to drink and also don’t
forget paracetamol medicine to get his temperature down. 
• When your child is fitting you should lay him flat on ground , take any thing that
surround him to protect him from any injuries , give him paracetamol suppository,
do for him sponging by tap water . and you can bring him to the hospital . Note
the time and wait for the fit to stop. If the fit doesn’t stop in 5 minutes we will
give you medicine which is called diazepam and you have to insert it in the child’s
back passage. This should stop the fits in 10 minutes.

• And don’t worry The risk of having another gets rapidly less after the age of -6
years----

• Febrile convulsions lasting less than 30 minutes will never cause permanent brain
damage
DEVELOPMENTAL DELAY

history taking
 YOU HAVE TO KNOW THE MILESTONES OF EACH AGE

• onset ? from birth or at certain age? Progression? Duration?

• Then ask about the proper milestone for age
( Go through all 4 aspects of development)
 
• If not achieving it, step down till you know in which age are the
milestone of the child compared to his actual age
 
• Associated with any neurological symptoms? ( seizures, ataxia,
chorea, …)
• A slow, floppy or irritable baby?
• Did the child feed well?
Pregnancy and Birth history :
• During pregnancy? Antepartum haemorrhage or hypertension
• Was the child a full-term normal delivery?
• Prematurity and intrapartum asphyxia should ( cerebral palsy)
• prenatal Dx ( down syndrome)
• Infections ( TORCH)
• Exposures ( fetal alcohol syndrome)
Postnatal history:
• APGAR scores
• infections ( group G strep)
• Seizures
• deep jaundice? ( severe jaundice can lead to kernicterus)
• Hearing test performed
• newborn screening performed
PMH and drugs:
• Ototoxic antibiotics ( Gentamicin)
• Frequent otitis media
• meningitis
Behavior since birth:
• Aggression, depression, anxity, hyperactivity, poor social skills
FH:
• Relatives with Developmental delay , genetic abnormalities,
syndromes
• Consanguinity
Social History: neglect or abuse?
 Epilepsy drug counselling (sodium valproate)

Epilepsy is a neurological disorder characterized by unpredictable

fits due to spontaneous abnormal electrical discharge in any
part of the brain. It is a chronic disease and the drugs should
be taken daily unless withdrawal can be considered if the child
is free of seizures 2 years consecutively
• give drug regularly so that they have fewer seizures
• start as small amount, increase the dose bit by bit  to get used to
• It may take a few wks to work properly
• Continue to give the medicine in the way that you have been told to
• Do not stop the drug suddenly
• Do not change the dose w/o doctor advice

If vomits < 30 minutes after the dose give them the same dose again
If vomits > 30 minutes after the dose  do not. Wait the next dose
 If you forget a dose, you can give it within 6-7 hrs, if after
this plz  Wait until next normal dose
 Side effects :
take them to hospital straight away if 
 If your child gets bad stomach pains or starts being sick
(vomits) often, or both (pancreatitis)
 If has stomach pains, is very sleepy, gets jaundice or has more
seizures than usual (liver disease )
--------
Contact your doctor if :
 Your child’s hands may shake
 If you notice any unusual bleeding or bruising
--------
Continue to give, if : (takes wk to months)
 Sleepy/ change in behaviour
 Hungrier, bcz he will put weight later
 vomit/feel sick/loss of hair (wks to month)
Pyloric stenosis
• Good afternoon mam, im ….., im here to help you
• May I know you name?
• How can I help you today? e.g my child has vomiting
• Since when s/he is vomiting?
• how many times?
• Can you tell me how much was it? Is it much like a cup or a table
spoon
• What its color? Content? Consistency ( how it looks like)?
• Did you noticed any blood with the vomitus?
• How was it? Is it effortless, forcefull, projectile?
• Is the vomiting occur before or after taking food
• What happened after s/he vomited? Did s/he feels hungry? Feels
tired? And lost interest in feeding?
• Did you notice any weight loss?
• Is it the first time?
• Anything associated with this vomiting? Fever, diarrhea, abdominal
pain, color change
 Management of nephrotic syndrome
• Meets greets and introduces. Demography
• Could I know what brings you to here today?
• What do you know about your child condition?
• NS: is condition which causes the kidneys to leak large amounts of protein into
the urine. This can lead to swelling of body tissues and a high risk of infections
 In the management :
• Your child will be admitted in the ward till his urine protein become zero
• Initially we are giving oral corticosteroids (60 mg/m2/day of prednisolone
After 4 wks, reduce it to 40 mg/m2 on alternate days for 4 wks and then stopped
• We will monitor him by ( daily weight, urine albumin, BP, intake and output
chart, any evidence of infection)
• after discharge, we request you to check the protein level in your child
urine by dipstick daily in the morning at least for 3 days, if it is positive or
you notice any relapse in your child condition like edema please do bring
him to the hospital
• Try to restrict salt and increase protein in diet
• Make sure you attend the vaccination appointments ( because your child
is at increased risk of developing infections like chickenpox)
• If your child did not respond by 4–8 wks, will require a renal biopsy
 Diabetes History
• Have you been very thirsty? Do you drink a lot?
• Have you been urinating more than usual?
• Has the child had any bedwetting episodes?
• Has there been any recent weight loss?
• Have you been feeling tired lately?
• Have you noticed an increased appetite lately?
• Has the child had more frequent minor skin infections?
• Predisposing factors:
• Type 1 DM:
• Have you had any viral infections recently any other
disease( autoimmune disease) ?
• Type 2 DM:
• What kinds of exercise do you participate in on a regular basis? How
frequent do you exercise? How long do you exercise each time?
• How many hours a day do you spend watching TV, using the
computer, and play video games?
•  What do you normally eat? What is the portion size? How many
meals do you have per day? Do you normally eat out or home
cooked meals? Do you eat as a family? Do you eat at the table or in
front of the tv?
• Family history:
• Type 1 DM:
• Are there any family members with insulin-dependent diabetes
mellitus?
• Are there any family members with autoimmune conditions?
• Type 2 DM: Any of your family has diabetes?
Diabetes

counseling
 Counseling in diabetes
• diabetes is a chronic condition affecting many organs.
• These can be avoided if the child adheres to treatment
and controls his/her diabetes well.
• Treatment is insulin
• Injection sites are – subcutaneous tissue of upper arm,
anterior and lateral aspects of thigh, buttocks and
abdomen.
• Rotation is important.
• Pinch skin upto 40 degrees before injecting.
• Explain dosage of insulin (next slide)
• In the case of an illness insulin must be
continued, and test urine by a dipstick for
ketones and monitor blood glucose levels.
Seek treatment if ketones and glucose keep
increasing.
• If exercise planned, dose of insulin should be
reduced and ensure child takes in more food
or has a small snack with him/her at all times.
• Together with treatment it is important to follow a
diet rich in complex carbohydrates such as brown rice,
brown bread and low fat. Increase foods which are
high in fibre.
• Regular blood glucose monitoring is essential.
• Explain the signs of hypoglycemia(last slide) and to
feed the child anything containing glucose. (fruit juices
or candy)
• There are diabetes support groups that the child could
take part in.
 Drugs in diabetes
• 0.5 U /kg/day
• 2/3rd of the total dose- (intermediate-
isophane (30 mins before dinner) or long
acting- glargine and determer) given before
dinner
• 1/3rd of the total dose- rapid acting (lispro,
aspart, glulisine) 15 min before a meal or
immediately after a meal.
 Signs of hypoglycemia
glucose (<2.6mmol/l)
• Shakiness.
• Dizziness.
• Sweating.
• Hunger.
• Headache.
• Irritability.
• Pale skin color.
• Sudden moodiness or behavior changes, such as
crying for no apparent reason
 Ambu bag
A self-refilling bag-valve-mask unit with 250 ml capacity,
used for artificial respiration
for the non-intubated patient, is effective for ventilating and
oxygenating intubated patients,
allowing both spontaneous and artificial respiration.
 Ambu bag
INDICATIONS:
Cardiopulmonary arrest
Increased metabolic demand for oxygen .. Hypoxia
Apnea .. Inadequate respiratory effort
CONTRAINDICATIONS:
Severe facial trauma
Diaphragmatic hernia
Complete, irreversible airway obstruction
Foreign material in the airway should be removed first

EQUIPMENT:
Equipment required to deliver supplemental oxygen
Oxygen tubing
Oxygen source
https://www.youtube.com/watch?v=EgH0J4hKL2w
Complications:
Aspiration
Pneumothorax
Hyperventilation
Barotrauma
Enuresis .. History taking
• Onset? primary vs. secondary
• Nocturnal vs. daytime ?
• Frequency and severity (during daytime and night time)
– number of episodes/night ?
– number of nights/week ?
• Urination pattern – dribbling, dysuria, hesitancy, urgency,
quality of stream
• Bowel habits? ( constipation as a cause)
• Associated symptoms
– Lower back pain? Abdominal pain (suggests UTI)? Bad dreams?
• Fluid intake and dietary habits (Caffeinated beverages) ?
• Past history of UTI ?
• History of other medical problems (such as lower back CNS
trauma, diabetes mellitus, neurological problems like epilepsy) ?
Children with diabetes insipidus, diabetes mellitus, and chronic
renal disease may have a polyuria with a compensatory
polydipsia.
• History of stressful events (including abuse) ?
• How is family coping with the enuresis: punishing the child?
Embarrassed? Understanding?
• Medications? ( as a cause)
• Developmental history ?
• Family history of enuresis ?
• Any treatments or techniques previously attempted to resolve
enuresis?
G6PD deficiency counseling
• After the detailed examination of your son and the investigations we
think that he has what we call G6PD deficiency

Do you know anything about it ? 

•
G6PD deficiency does not go away and is a lifelong condition. It is an
inherited disease .
• It is more common in males and is usually passed on to male children
from their mother, even though she has had no symptoms herself..
• Most people with G6PD deficiency have a completely normal life as
long as they avoid certain foods and drugs.
• Some people with the condition will get anaemia.
• Anaemia can make children look pale and have less energy. This may
happen after taking one of the drugs or eating the foods listed below,
or during an illness such as an infection
Signs and symptoms
• Child should be checked by a doctor whenever any of the following
symptoms develop:
• pale skin (pallor(
• persistent and/or severe tiredness
• dark coloured urine (wee)
• jaundice (yellow skin or eyes).
Care at home
1-Foods  Avoid Fava beans - also called broad beans
2-Hena
3-Chemicals
o napthalene balls
o Methylene blue 
 
You should always check with your doctor or pharmacist before giving any
medication to your child.
Do you have any question?
 
History of limp
• Onset (acute of not)
• Is it painful ?
• History of trauma
• Which joints is affected?
• Presence of infection (UTI, resp
infection,…..etc)
• Associated fever ( transient
artheritis, septic artheritis
malignancy)
• Presence of rash
• Birth injury
• Pain during night ( growing pain,
malignancy>ostiod osteoma)
• Associated morning stiffness
• Aggrevating and relieving factors
• Soft tissue
injury( injection,vaccination)
• Obese?? ( slipped capital
femoral)
• Past medial history
• Is it a 1st episode
• His of hospitalization
• History of infection
• His of recent injection or
vaccination
How to approach child with GERD ?
• Name / age
• The onset
• Ask about vomiting related questions( frequency , quantity ….)
• Any other associated symptoms?
• Is he term baby?
• Wight at birth( to see if he is thriving or not)
• When is the vomiting before or after the food?
• The color and volume of the vomit?
• Is it projectile (come out strongly )?
• Contain food particles or blood?
• Is changing the position after feeding (upright position ) improve the case?
• When you start introduce solid food, is there any improve?
• Then as usual ask about past medical history , feeding history , family history
Lumbar Puncture (COUNSELLING)
• Lumbar puncture is a helpful procedure to know if your
child has infection of the coverings of his/her brain or not.
• It is done by inserting a needle in your child lower back
between two vertebrae. A sample is removed from the
fluid that surrounds brain and spinal cord.
• It is done in the treatment room, your child will lie on
his/her side with his/her knees drawn up to chest, the
area of his back will be cleaned, then the needle will be
inserted, a sample taken out and the puncture site is
covered with a bandage.
• Then, your child will be returned to the ward
 yes its painful but its important for your child
• If the mother ask about sedation !
 Tell her that he may not require sedation, only they will hold him/her in one side
 Sedation might be used in small babies
• If the mother ask you about complications !
 Tell her there is always a small % of complications, your child may have some headache,
bleeding or infection, which can be dealt with safely and avoided by performing good
procedure.
• If the mother ask you about the time of the procedure !
 Tell her it will take about 10-15 minutes
 Indication: suspected meningitis, encephalitis, therapeutic
CI: local infection,, Increased ICP, coagulaopathy, CV and RS instability
Complication if not done: hearing loss, inflation of vessels, local cerbral infraction, abcess,
collection of pus, hydroephleous,
neonatal jaundice:

History taking
• History of Present Illness
– Onset and progression of jaundiced skin
– Feeding: breast milk or formula?
– Current weight compared to birth
weight. Gaining weight appropriately?
– Number of wet diapers per day?
(Indicator of hydration status)
– Consistency and colour of stool and
urine?(pale stool implies poor bili
excretion)
• Family History:
– Infections or fever?
– History of pruritus?
– History of drug intake Medications?
(newborn or mother)
– General activity: irritable? lethargic?
– Gender & ethnicity? (Males, Asians, and
Blacks have some increased risk
• Perinatal History
– Maternal blood group
– Maternal illnesses or infections
– Results of antenatal screening tests
– Maternal medicine or drug intake
– Delayed cord clamping (could indicate
polycythemia)
– Birth trauma with bruising
– Results of newborn screening tests
– Previous siblings with neonatal jaundice
– Other family members with jaundice
– Anemia or blood disorders
– Splenectomy
– Bile stones or gallbladder removal
• PMH / PSH
• Immunization
• Allergy history
 neonatal jaundice counseling
Introduce yourself with a friendly greeting.
Ask (personal history) , which is: Name , age , gender , order of birth , address
Ask about the main problems that made her/him went to see the doctor
Ask about the onset, duration aggravating and relieving factors. other symptoms
1. this common condition is caused by high levels of bilirubin in the blood.
2. Your child's skin and sclera (whites of his eyes) will look yellow.
3. Some newborns need to be treated before they leave the hospital.
4. Others may need to go back to the hospital when they are a few days old.
5. Treatment in the hospital most often lasts 1 to 2 days.
6. To help break down the bilirubin to water soluble, your child will be placed under bright
lights (phototherapy) in a warm, enclosed bed.
7. Possible side effects of phototherapy are watery diarrhea, dehydration, and skin rash that
will go away once the therapy stops.
8. The infant will wear only a diaper and special eye shades. Your baby may have an
intravenous (IV) line to give them fluids.
9. Rarely, your baby may need treatment called a double volume blood exchange transfusion.
This is used when the baby's bilirubin level is very high.
10. your child will be able to feed (by breast or bottle) normally. Your child should feed
every 2 to 2 ½ hours (10 to 12 times a day). To avoid dehydration
11. Your child's bilirubin level will need to be checked i, 24 hours after therapy stops,
12. After discharge , continue breastfeeding , come back if you notice increase yellowish
color , or they baby cry a lot
• Jaundice in a newborn is common in babies and is not the same as jaundice
in adults. The medical term for jaundice in babies is neonatal jaundice. If
your baby has jaundice they need to be seen by a health care provider. Your
baby may look jaundiced on their first or second day of life. Often you will
not see it until the second or third day. Most times the jaundice will go
away over one to two weeks (3 weeks for preterm babies) and does not
cause any longterm problems for most babies. Sometimes the jaundice
needs to be treated Breast milk jaundice may develop 5–7 days after birth
and is a harmless type of jaundice. There is no need to stop breastfeeding.
Check with your health care provider if you think your baby has breast milk
jaundice. What causes a baby to be jaundiced? Before your baby is born
they have a lot of red blood cells to carry oxygen from the placenta. After
birth they don’t need as many of these cells. The red blood cells are broken
down in the liver and are passed in their stools/poo (bowel movements).
Your baby looks jaundiced (yellow) when there is a build up of the broken down
red blood cells (bilirubin) in their skin. There is more chance of your baby getting
jaundiced and needing treatment if they:  Are born before full term  Are not feeding
well  Had a brother or sister who was jaundiced  Have a different blood group from
you (their mother)  Became bruised during their birth  Have an infection There are
also other reasons your baby may be jaundiced which your health care provider will
discuss with you if required.
• There are two ways to measure the jaundice level. A special
meter can be placed on your baby’s skin to check the jaundice
level. If it is high using the meter, or the hospital doesn’t use the
meter a blood test can help decide if treatment is needed.
Jaundice is measured by taking a small amount of blood from
your baby’s heel to check the level of bilirubin
• Phototherapy is a special bright light that shines on your baby to
help breakdown the bilirubin in their skin so that it can be
passed in their stools. Phototherapy is given from an overhead
light. Your baby is placed under or on the special lights in their
cot or in an incubator. They only wear a nappy. Eye shields are
used to protect their eyes from the bright overhead lights.
• if your baby is not treated they may have some problems with
their development. This may include seizures and muscle
spasms, delays in development, deafness and physical and
intellectual disability

• Follow up within 1 to 3 days of leaving hospital

Headache :

History taking
Regarding the HA itself:
• Onset (how long has the HA been present)
• Nature (episodic versus continuous)
• Frequency (per week, per month, per year)
• Duration (minutes, hours, days, etc.)
• Severity (pain scale or documentation of loss of normal
functioning)
• Character of Pain (stabbing, squeezing, pulsatile)
• Location (unilateral, bilateral, fronto-temporal, occipital)
• Radiation
• Associated symptoms (Fever ,weight loss, night sweats,
anorexia, nausea or vomiting)
• Disabilities (Waking the child consistently from sleep )
• Associated neurologic features (especially if present in between the headaches) -
cognitive or behavioral regression - worsening speech - worsening gait pattern -
worsening vision, double vision or transient loss of vision
• Aura (specify what type)
• Aggravating Factors (photophobia, phonophobia, physical exertion)
• Alleviating Factors (including medications used, sleep, position change, etc.)
• Ask about RED FLAGs ( like torticollis, abnormal gait, coordination)
• Recent head injury
• Past medical history :
• First episode or not
• History of HIV, cancer or neurocutaneous disorder
• Drug use
Personal history:
• Sleep quality and quantity
• Eating habits Caffeine intake
• Physical Exercise
• Life stressor or concomitant mood disorder
Family History
• Migraine ?
 
Febrile Seizure

History taking
• Meets greets and introduces.
• Details of Seizure: Generalized or focused jerky movement/ duration/ association
with incontinence of urine or stool, rolling of eyes upward/tongue bite
• Fever : Intensity and duration, Fever source: cough/ ear or nasal discharge /
vomiting / rash/ urinary or bowel symptoms
• After seizure history of unconsciousness/ drowsiness
• Past medical history/ Birth history/Immunization
• Family history of Epilepsy

• Reassure the mother regarding the diagnosis of Febrile fits. Responds to her
concern
• Advice Management for fever with paracetamol/ tepid sponging
• Management at home if seizure reoccurs: turn the patient on sides, do not put
anything in mouth and bring him to the clinic for evaluation
 Whooping cough
• Meets greets and introduces. Demography
• Since when you have cough
• Is it gradually develop or start with you suddenly?
• Is cough productive, about sputum; amount, color, odor and
consistency.
• How you describe this cough ? Has special character or the
normal one?
• Timing, aggravating and relieving factor
• Do u have associated symptoms:
– fever(chill, rigor), allergies, URTI, GERD, weight loss, hemoptysis,
chest pain, night sweat or Vomiting
• Do you complain of runny nose or fever before the cough?
• Is there any chest tightness
 Epistaxis
 Meets greets and introduces. Demography
 May I know what bring you here?
 Since when you have this problem?
 Severity, Frequency, Duration, Laterality of the nosebleed. 
 Is it after exercise or during sleep?- Is it associated with a migraine?
 Is there any hematemesis or melena? (Picture of posterior bleeding )
 Methods used to stop the bleeding. 
 History of trauma
 Foreign bodies insertion 
 Nasal discharge
 Ear problems 
 Throat problems 
 Precipitating and aggravating factors
PMH  Medications 
– Aspirin
– Previous epistaxis – NSAIDs
– DM – Warfarin
– Heparin
– Hypertension – Dipyridamole
– Hepatic or other Family history 
systemic disease – Bleeding disorders
– Easy bruising – Leukemia 
– Anemia 
– Prolonged bleeding Social history 
after surgery – Smoking 
– Alcoholism 
– Work place .. hot environment?
 Acute chest syndrome
 Is a vaso-occlusive crisis of the pulmonary vasculature commonly seen in
patients with sickle cell anemia
  Commonly manifests with pulmonary infiltrate on a chest x-ray

 Present with
–  Fever to >38.5
– Chest Pain
– Hypoxemia relative to baseline
– Tachypnea
– Wheezing
– Cough
– Increased work of breathing
 Pathogenesis
– Three primary mechanisms
1. Pneumonia/systemic infection:
– Respiratory infection induces excessive inflammatory lung injury
response in susceptible SCD pt as compared to  infection in non-SCD pt
2. Fat embolism more prevalent in adults
– Generally involves multiple bones
» Most often pelvis and femur
» Results in infarction and edema of marrow compartment, with
necrosis of marrow compartment and spillage of contents into
bloodstream which are carried to and occlude the pulmonary
vasculature
– More severe course with systemic complications
3. Direct pulmonary infarction from HbS-containing
erythrocytes (prevalence unknown)
 Investigation
CXR: At any sign of respiratory symptoms CXR should be obtained
serially every 24-48 hours
CBC w/ diff, reticulocyte ct:
Low Hgb/drop from baseline may indicate acutely worsening tissue hypoxia
Acute drop in platelet count often precedes ACS event
Functional asplenia manifests in baseline thrombocytosis>400K
Drop to <200K is risk factor for multi-lobar ACS and mechanical ventilation
Obtain arterial blood gas if significant respiratory distress present
Type and cross-match for transfusion
Obtain blood cultures if febrile
LFTs and BUN/Cr to assess and monitor hepatic and renal function
Chest x ray to confirm the diagnosis
 Acute Management
• Fluid management
– Hypovolemia can increase sickling
• IV crystalloid followed by liberal PO hydration
• Pain control
– Increased pain and high dose morphine are both associated with ACS
• Balance pain control and associated respiratory depression
• Respiratory Support
– O2 supplementation to maintain sats>92%
– Incentive spirometry to prevent atelectasis
– Bronchodilators may be helpful in asthmatics and those with RAD
• Antibiotic treatment
– Guided by regional resistance patterns and season
• Coverage for atypical bacteria
• Seasonal influenza
• Transfusion
– Transfusion acutely increases Hgb oxygen saturation
• Has been demonstrated to prevent ACS during major surgery
• Average increase in oxygen saturation from 86% to 93%
• Simple and exchange transfusion result in similar improvements
– Simple transfusion for pts with Hgb<10 g/dL
» 2-4 units in first 24 hrs followed by maintenance to keep >10
– Exchange transfusion for severe/rapidly progressing illness

• Fever control
– Acetaminophen
– Beware of NSAIDs if renal involvement
• Corticosteroids
– Side effects of avascular necrosis, VOC, association with hemorrhagic stroke
– Limited support for use
• Nitrous oxide
– No effect on duration of pain crisis, narcotic use, pain scores, development
of ACS
– Limited support for use
 prevention Complications
• Pre-operative blood • Neurologic complications most
often associated with respiratory
transfusion in surgical
failure
patients – In children can include reversible
• Maintenance asthma and posterior leukoencephalopathy
syndrome, cerebral infarcts, acute
compliance to therapy for necrotizing encephalitis
asthmatic children • Respiratory failure, especially in pts
• Maintenance with a  h/o cardiac disease
• Widespread hypoxemia can cause
hydroxyurea therapyI
additional sickling and vaso-
• ncentive spirometry during occlusionà multi-organ failure
acute VOC hospitalizations • Death
 CT explanation to the parents :
Good morning Mrs.---- my name is Dr……………. I am one of the doctors
doing the clinics today. You are worry about the CT which we need to
do it for your child , no thing to be worry about it --
CT is a series of X-ray images taken from different angles-cross-
sectional images Of bones, blood vessels and soft tissues

And the doctors want to reach to the definitive diagnosis for your child
regarding ( headache, seizure, ---- (whatever diagnosis you mention )
CT scans are painless and, The whole procedure typically takes about
30 minutes.

About the procedure may be asked to:

Take off some or all of your clothing and wear a hospital gown
Remove metal objects, such as a belt, jewelry,
Refrain from eating or drinking for a few hours before the scan
And a special material ( contrast dye “iodine based dye” might be
given to you:
{ By mouth. If your esophagus or stomach is being scanned
By injection. through a vein in your arm to help your gallbladder,
urinary tract, liver or blood vessels stand out on the images
By enema. visualize your intestines.
This procedure can make you feel bloated and uncomfortable}
Sedation :to keep him calm and still. Because the movement blurs the
images and may lead to inaccurate result
After the CT scan: can return to your normal routine
you may be asked to wait for a short time before leaving to ensure
that you feel well. you'll likely be told to drink lots of fluids to help your
kidneys remove the contrast material from your body
I agree with you that CT has risk of exposure to a high amount of
radiation. But CT scans have many benefits that outweigh this small
potential risk.
May a contrast material through a vein in may cause allergic reactions,
itching,rash, N/v. If it happen easy to manage .
Cyanosis
• Onset
• Is it sudden or gradual( foreign body )
• Is s/he blue all the time
• Where did you notice the discoloration
• Any associated symptoms : breathing difficulty, choking,
cough , difficulty on lying down , palpitation , edema
• Any history of Fainting
• Any difficulty in feeding
• Aggrevating factores : with exertion, emotions, and/or
bearing down
• Any sign of failure to thrive
• Past medical history :
• Any previous episode
• Any medical problem ( genetic ,-- )
• Drugs
Gestational History and Family History
 
Prenatal screening is important as many genetic
syndromes are associated with congenital cardiac
malformations
Maternal illness: diabetes, rubella, teratogenic
medications.
Birth history : apgar , need for O2 , scapo admission ---
Any murmur detected ---
 
Family history of congenital cardiac disease is important,
as more and more individuals with congenital heart
disease are living into their reproductive age.
How to use SPACER
Both spacer and aero chamber can be used with or without the
mask depend on the age of the child and the ability to follow
instruction given, e.g 10yrs old child can understand the instruction
to use the spacer without the mask but, 5yrsold child cant
The use of them is to concentrate the drug and not waste it the
surrounding air

 To Use a Spacer without the mask:

1. Shake the inhaler well before use (3-4 shakes)

2. Remove the cap from your inhaler, and from your spacer, if it has one
3. Put the inhaler into the spacer
4. Teach the child how to breathe deeply and slowly
5. Breathe out, away from the spacer
6. Bring the spacer to your mouth, put the mouthpiece between your teeth
and close your lips around it
7. Breathe in and out deeply 5-7 times, Press the top of your inhaler once as
the child breathing in
Cleaning Your Spacer
To clean your spacer, follow the instructions that come
:with it. In most cases, they will advise you to
Take the spacer apart.
Gently move the parts back and forth in warm water using
a mild soap. Never use high-pressure or boiling hot water,
rubbing alcohol or disinfectant.
Rinse the parts well in clean water.
Do not dry inside of the spacer with a towel as it will
cause static. Instead, let the parts air dry (for example,
leave them out overnight).
Put the spacer back together.
:Taking an Inhaled Treatment spacer/ aero chamber with a mask

1. Hold the mask to the face so that both the nose and mouth are covered. It is important
to create a good seal between the face and mask so that all medication will be delivered
to the airways.
2. Press the inhaler once. The medication will be delivered into the AeroChamber.
3. Breathe in and out at least 6 times. The diaphragm should move with each breath.
4. Remove the mask from the face.
5. Repeat steps 1-4 when more than one puff is prescribed.
6. If young child, make the child cry or gasp to take deep breathing

?What is a Diskus inhaler

1. a flat, round deviceused to deliver asthma medicines

2. powder form
3. has a dose counter window starts at 60 doses. Each time a
dose is taken, the counter will count backward by 1 dose
4. appropriate for children who are about 8 years old or over.
 How to use a Diskus inhaler
Step 1: Open the Diskus
Hold the Diskus inhaler in one hand.
Put the thumb of your other hand into the thumb grip, which is a
hollow spot that fits your thumb tightly.
Push your thumb away from you until you hear a click. You should
be able to see the mouthpiece and the tab beside it.

Step 2: Get the medicine ready

Hold the Diskus inhaler in one hand.
With your other hand, put your first finger in the thumb grip and the
thumb on the tab.
Slide the tab away from you, toward your first finger, until you hear a
click. This means the medicine is ready.
To prevent the dose from getting lost, do not drop or bang the Diskus
inhaler.
Step 3: Take the medicine
Breathe out.
Wrap your lips tightly around the mouthpiece of the Diskus inhaler.
Breathe in quickly and deeply.
Take the Diskus inhaler out of your mouth.
Hold your breath while you count to 10 slowly.
Breathe out slowly through your nose.

Step 4: Close the Diskus

Close the Diskus inhaler by holding it in one hand.
With the other hand, put the thumb back into the thumb grip.
Slide the thumb grip toward you until you hear a click.
 breastfeeding
Benefits of breastfeeding (examples include infantile nutrition, protection from
common childhood diseases, food allergies, chronic diseases, maternal-child
bonding) Comments: 9. Common concerns in early postpartum breastfeeding
(examples include sore nipples, not enough milk, sleepy baby, pumps or milk
storage) Comments: 10. Educated me about how to optimize baby’s attachment to
breast • “C” hold of breast • Proper alignment of infant, mouth at nipple level •
Mother tickles infant’s lower lip • Cheeks not sucked in • Cradle, football, and side
by side • Bring baby to breast instead of bringing baby to nipple • Clicking sounds
means baby is not properly attached • Comfortable sitting position Yes = 3 or more
mentions YES NO Comments: 11. How to avoid sore, cracked nipples YES NO
Comments: 12. Timing (examples include how often baby should breastfeed, how
long on each breast, use of both breasts) Yes = 2 or more mentions YES NO
Comments: 13. Avoidance of use of formula unless medically advised

Solid food recomened to be introduced after 6 moth of age.. Graudally intailly small
quantities of pureed fruit root vegatbles or rice, if weaning before 6 montgh sof age,
egg wheat and fish avoidied, high salt and sugar food and honey not to be given
before 1 year of age , breast mild insufficent aftre 6 month of age (energy vit, iron)
hold the baby so that he/she is facing the nipple
keep your fingers away from the area to be drawn into the baby's mouth,
allowing the baby to draw in the entire nipple and as much of the areola as
possible
press your fingers slightly towards your ribs to keep the nipple extended as much
as possible
guide and insert the areola by centering the nipple in the baby's mouth and
pointing it toward the top back section of the baby's mouth
hold the baby in close to your body

The baby must:

face the mother's body
open his/her mouth wide (like a big yawn)
draw the nipple in to the upper back part of his mouth
place his gums beyond the nipple, taking in as much of the areola as possible
have his tongue out, over his lower gum, "cradling" the nipple and areola
 Urine collecting bag

Remove the infant’s nappy and ensure the genital area is clean, dry and free from
cream/talc. 2) Boys: Place the urine collector over the penis with the tip of the penis
inside the bag. With the long section of the bag hanging downwards, gently press the
adhesive onto the skin to seal. Girls: Place the opening of the urine collector bag over
the vulval area. With the long section of the bag hanging downwards, gently press
the adhesive onto the skin to seal. Slightly pull the bag out to create a ballooning
effect. 3) A nappy may be loosely fitted if desired. 4) After the infant has voided, hold
the surrounding skin taut whilst gently removing the bag, ensuring the bag is kept
upright so the urine sample is pooled at the bottom. Press the adhesive edges
together to form a seal. 5) Transfer the urine sample into a yellow top container. To
do this, hold the collection bag over the open container and cut a small hole in the
end of the bag, allowing the urine to completely drain into the container. 6) Replace
the lid of sample container and seal tightly. The label of the container then needs the
following information recorded: – Infant’s full name – Date of birth – Date and time of
collection – Referring doctor
Here are different
topics notes