Paediatrics Hx & Couns

8/10/2019 Paediatrics Hx & Couns.

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History taking in paediatrics

Ask these questions after taking history of presenting complaint

1. Did you have any problems during pregnancy?

2.

Any problems during delivery?3. Was it a normal delivery?4. Was everything fine just after he was born?5. Is he up to date with all immunisations?6. Are you happy with his development?

P P P P M A F T O S A. An additional history is for paediatric histor y.

P – Presenting complaint

P – Pediatric Questions

P – Past Medical Hx

P – Personal Hx (is the child eating and drinking well? Is he passing urine Ok? Is he playingactively?)

M – Medical Hx

A – Allergy Hx

F – Family Hx

T – Travel Hx

O – Omit

S – Social (is there anyone who smokes in the house?)

A – Anything else



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Celiac Disease

As you know that your child came to us with tummy pain, bloating and diarrhoea

We have done some investigations and we have found that the cause of his symptoms is acondition called celiac disease.

This is a condition in which there is inflammation in the lining of small bowel, which is areaction to the gut to gluten.

Gluten is a part of certain foods – mainly foods made from wheat barley and rye.

This is basically an autoimmune condition which means immune system, which normallyprotects the body from infection mistakenly, attacks itself.

It is a very common condition, meaning that so many people are affected by this condition.

The cause of this is sensitivity to gluten.

What will happen now is that we need to do further investigation which we call biopsy – inwhich we pass a small flexible tube through his mouth, reach the gut and take a smallsample, send to the lab and look at it under the microscope

NB: If no blood test done: then say we suspect a condition called celiac disease. Explainwhat it is and then say

1) We do blood test2) If that blood test is raised then we do a further investigation called biopsy

While we are doing these tests, it is important that your child continue eating everything.

Do not exclude any meals from his diet. Because if he is not eating food which containgluten all the test we are doing will not show anything and in such a case we will not knowif he needs to stop gluten or not.

Management:

The main treatment for celiac disease is not to eat any food that contains gluten for therest of your life

Symptoms usually go within few weeks. The main foods to stop are any food that containswheat, barley or rye.



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Many foods contain these ingredients such as bread, pasta, cakes, and pastries.

Complications:

It is important to follow the above diet as this condition has some complications:

1) Osteoporosis: Thinning of the bones2) Lymphoma: A type of tumour3) Other autoimmune conditions: Type 1 DM, under acting thyroid, dry eyes, liver

problems





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The problem with this is that these medications have got side effects. And forprevention of HIV infection you need to take the medication within 1 hour after yourneedle stick injury. So we need to go now

c) I will also take history from patient to find out if he has got any type of infection and Iwill also take his permission to take blood from him so that we can test for HI andhepatitis B, C infection

d) I will also need to take blood from you for HIV and Hepatitis C and B just like we havedone from a patient

e) We will also need to do blood test for LFT and we need to do a pregnancy test → Justto make sure you are not pregnant

f) We will arrange follow up in clinic to check you are OK and we will do the same withthe patient



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Needle stick injury in a child

A 5 year old child has pricked himself with a needle while playing in the garden. Mother is

very worried that he might have contacted a infection. Please speak to the mum and

address her concerns

1) What time did it happen?2) Did you see the needle?3) What type of a needle was it?

4)

Where was John when this happened?5) Was the needle the one we use for taking blood or the one for sewing?6) Is your child up to date with all immunisation?7) Does he have any medical problems?8) What did you do when it happened?

I squeezed it, allowed it to bleed and washed it under running water.Doctor: Excellent, that is exactly what needs to be done.

9) Is there any type of infection you are worried of?

Management:

From what you are telling me, it is unlikely that your child would have contaminated anyinfection

i) As he is upto date with all immunizationii) The needle must have been lying there for some time and it is unlikely that HIV or

Hepatitis bugs will survive long in that environment

iii) There is no blood test we can do now, to show that he has not contaminatedinfectionBecause even if he has contaminated infection, which is unlikely, it takes about 3months for HIV infection to show in the blood and about 6 – 8 weeks for hepatitisinfection to show up in the blood.And as I said, it is very unlikely.But if you are really worried we can arrange the test in 3 months for your childand you can come to hospital and have the blood tests done.



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And for HIV infection you need atleast 3 blood tests, each 3 months apart,meaning it will take about 9 months before we can say he did not contaminateHIV infectionWith such a very low risk, I do not feel that it is fair for your child.

NB: If the patient still wants the test, go ahead with it, since they are worried

Spleenic Rupture and femur fracture in 9 years old

Jon is a child who has fallen off the bicycle ad sustained spleenic rupture and femur

fracture. Please speak to his dad

Father → How is my child, how is my child, tell me doctor

I’m sorry Mr Sherry, to say your ch ild is in critical condition but do not worry he is beinglooked after by a consultant surgeon and they are very good specialists

My name is Samson by the way; I’m one of the junior doctors

As your child has fallen off the bicycle he has sustained 2 main injuries

1) Firstly he has fractured his thigh bone2) The second injury is that he has ruptured one of the organs in his tummy called

spleen.

This injury is very serious one, because this organ bleeds a lot and you can die from it.

This is our priority. And because of this your child is being taken to theatre, they will openhis tummy and try stop bleeding from this organ. And if they fail to stop the bleeding theymight need to remove this organ in order to stop bleeding.

And after we have sorted out the bleeding from this organ, the group of home experts willfix his thigh bone.

Because this is quite a big operation and your child was not prepared for it there are risksinvolved with it.

1) We may fail to stop the bleed and therefore there is a risk to life.But do not worry our consultant is a very good specialist and he has done so many ofthese operations before.

2) Risk of infection → we will take due care of this by giving him antibiotics

3) Damage to surrounding nerves and blood channels.4) Risk of clots in leg and lungs



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5) Also specially for the organ we removing the spleenThis organ normally takes part in defending our body from infection and if it is goingto be removed, your child will be prone to infections.Therefore we will give your child 10 vaccinations against 3 main bugsa) Pneumococcal infectionb) Haemophillis Influenzac) Meningococcal infection plus we will give him prophylactic antibioticsd) Also if you go abroad, make sure you see the GP who will arrange all necessary

labs that your child needs before you can take with him abroad.

Are you OK for us to go ahead with this operation?

I will give you a consent form, make sure you read it again and sign it.



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Meningococcemia

A child has come in with a rash. He has been diagnosed with m eningococcal septicaemia.

Please speak to the mum

1) As you know that your child has come to us with a rash and is unwell

2) We have examined your child I’m afraid to say we have found that the cause of his illness

is a condition called meningococcemia

3) Meningococcal septicaemia is an infection of the blood caused by a bug calledmeningococcus. This bug, meningococcus produces very harmful substances in the bloodcalled toxins and can lead to a very serious illness.

Children usually, start by feeling generally unwell and appearance of a rash.

Child may also have a fever and sometimes a rash may not appear at all.

Management:

1) We will start urgent treatment with antibiotic injections

2) We will also need to do some blood test and as well we need to take blood cultures,

send it to the lab and see if we can grow some bugs from it.

3) And we may need to take fluids that surround the spinal cord by doing a procedurecalled lumbar puncture

4) We will give fluids through the blood channels to your child as this infection, commonlykills due to low BP

5) Your child will be treated in intensive care, so that he can have all the support readily

available if necessary

6) In general Mrs William we will support your child as needed by



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→ Giving Oxygen

→ Fluids through his drip

→ And sometimes we do give steroid injection they help with reducing theinflammation

Your child is being looked after by our consultant who is a very good specialist

7) And because this infection can spread we will isolate your child in his own room

8) Also we need to give antibiotics to all those who have been in contact with your child toprevent them from developing this infection. This includes yourself Mrs Williams andeveryone in the house and if you know everyone who has been in contact

9) Do not worry, Mrs William we will give the best available treatment to your child.



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Rectal bleeding in a child

An 8 month old child has been passing fresh blood per rectal. Pl ease speak to the mum

Differential Diagnosis:

1) Intussusception2) Gastroenteritis3) Milk protein allergy4) Polyps5) Volvulus6) Necrotising enterocolitis

7) Anal fissure8) Meckel’s diverticulum 9) Inflammatory bowel disease (over 2 years of age)10) Vascular lesions like haemangiomas or arteriovenous malformations

1) When did you notice bleeding?

2) Is it before or after your child has a pool?

3) What is the colour of the blood? Is it bright or dark?

4) How much is the bleeding?

5) Is the child vomiting?

6) Is your child constipated?

7) Any diarrhoea?

8) Is he running temperature?



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9) Does he cry with his legs pulled towards his tummy?

10) Is there any one at home with diarrhoea and vomiting?

11) Is the child eating and drinking well?

12) Have you noticed any swelling or masses in his tummy?

1) Does he play actively?2) Is he passing wee?3) How many wet nappies have you changed today?4) Does he cry without tears?

1) Was everything fine during pregnancy?2) Was everything fine during birth?3) Did he need any help with breathing when he was born?4) Is he upto date with all immunization?5) Are you happy with his development?6) Is there anyone in the family with tummy problems like tummy pain or bleeding from

the back passage?7) Is the child on any medication?

Management:

1) Blood test2) If drinking & feeding well. Home and follow up in clinic

3) Take photos of any blood if child, has any bleeding.4) We will consider doing a scan of his bowels → we call this scan mickel’s scan, to look

for any pouching in his bowel.

Assess Dehydration

Paediatric Hx



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Vomiting in a 7 year old child7 year old Brown has been vomiting for the past 2 days. Please take history and discuss

differential with examiner

D/D’s :

1) Gastroenteritis2) Intussusception

3) Intestinal obstruction4) UTI5) Ceoliac Disease6) GERD7) Meningitis8) DKA

Questions:

1)→ Is he running any temperature?

→ Does he have diarrhoea?

→ When did he last open his bowel?

→ Any blood or mucus in his stool?

→ How has your child been vomiting?

→ Have you noticed any blood in his vomitus?



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→ Does he vomit all the time or only when you feed him?

2) → Have you noticed any masses in his tummy?

→ Does he have any pain in his tummy?

3) Do you think his tummy is distended?

4) Does he have a burning sensation when passing water?

5) Are you happy with the way he is gaining weight?

6) Is his vomiting worse when he lies flat?

7) Have you noticed any rash anywhere on his body?

8) Has he been feeling very thirsty in the last few days?

1) Is he passing wee?

2) Is he playing actively?

3) Do you find him lethargic?

1) Any problem during pregnancy?

2) Any problem during birth?

3) Are you happy with his development?

4) Is he upto date with all his immunisation?

Dehydration Hx

Paediatric Hx



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Vomiting in a 2 months old

2 months old Peter has been vomiting excessively. Take history and discuss differentials

with the examiner

D/D’s

1) Meningitis2) URTI3) Ear infection4) Gastroenteritis5) Dietary Intolerance6) Celiac Disease7) Pyloric stenosis

8)

Intussusception9) UTI10) Gastro-oesophageal reflux

General Questions:

1) How long has your child been vomiting?

2) How many times does he vomit in a day?

3) Does he vomit always or only when you feed him?



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Questions related to D/D’s :

1) Is he running a temperature?

1) Have you noticed any rash on his body?

2) Does he have any running nose, sneezing or cough?

3) Does he cry while pulling the ear?

4) Does he have diarrhoea as well?

4) Anyone at home with diarrhoea and vomiting?

4) Any Blood or mucus in the poo?

5) What do feed him? Do you breast feed?

6) Anyone in the family with tummy problems?

7) When he vomits, does it go very far? i.e. projectile

7) How far can a vomit go?

8) Does your child cry while pulling legs towards his tummy?

9) Does he cry when passing water?

10) Is the vomiting any worse when the child lies flat?

11) Any burning sensation when passing a wee?

12) Does the wee smell strong?

13) Did you notice any blood in his pool?

1) Is he passing wee?2) How many wet nappies have you changed today?3) Does he cry without tears?4) Do you find him lethargic?5) Does he play actively?

Dehydration Hx

Paediatric Hx



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1) Any Problems during pregnancy?2) Any problem during birth?3) Any problem immediately when he was born?

4) Did he need any help with breathing just after he was born?5) Is he upto date with his jabs?6) Are you happy with his development?

Management of Dehydration in Gastroenteritis

Gastroenteritis is an infection of the gut.

It is a common condition and many children have more than one episode in a year.

A virus is the most common cause of gastroenteritis.

Viruses are easily spread from an infected person to another by close contact.

Symptoms:

The main symptom is diarrhoea often with vomiting as well.

Also crampy pains in the tummy are common

A high temperature may occur sometimes

The main danger with this infection is dehydration:

It is important therefore that you come to hospital if

1) Your child is under 6 months2) If the child has high temperature3) If your child is drowsy4) If there is blood in the stool



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5) If he is not passing wee6) If he is not playing actively

Management:

1) The main treatment is to give fluids to prevent dehydration2) Rehydration drinks → dioralyte which you can buy from any pharmacy or you can

take from the GPThese drinks contain important salts which your child is losing through diarrhoea andvomitingThe best way to do this is by giving small amount of fluids 10ml every 10 minutes.

NB: - If a child is not tolerating any fluids at all → admit

If he is tolerating, can go home with dioralyte (oral solution fluids)

Medication is not usually needed. Once vomiting has settled your child can eat & drink asusual.

Advise about preventing spread of infection

1) Do not share same bath towels2) Regularly clean the toilets with disinfectant especially clean the flush handle3) Make sure you wash your hands after toilet (if he is old enough)4) He should stay off school or nursery until they are 48hrs free of diarrhoea5) Do not let them prepare food for others





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10) Any bleeding from the nose or ear?

11) Any fluid coming out of his ear or nose?

12) Any problem with his vision?

13) Any problem with his hearing?

OK we have examined your child and we have not found anything wrong with him. All theexamination is normal.

What will we do now?

1) We need to observe your child in this department for 4 hours and if he is fine we will letyou go home.

2) When you go home there are certain things I need you to do:

i) First do not leave your child alone for the next 48hrsii) If any drowsiness i.e. he is more sleepy than usual then you should come back to

emergency department

Other things you should look for are:

a) Any vomiting > onceb) Any loss of consciousness, persistent headache, bleeding or fluid leaking from nose

or ears, any dizziness, confusion, breathing problems or new problems in hearing.If any of these problems, you need to come back.

I will give you a leaflet for you to read and it will contain all this information.



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Down ’s syndrome

A 6 week old baby girl has just been diagnosed with Down’s syndrome. Please talk to hermum and address her concerns

As you know that we have done some tests on your child

I have the results with me and I’m ready to discuss them with you.

Would you like to be with someone before we can go ahead discussing?

I’m afraid I do not have good news.

Mrs Williams we have found that you child has a condition called down syndrome

Down syndrome is a genetic chromosome disease, this means it is a disease of buildingblocks and in this condition a child has got one extra chromosome (or extra building block)

Pause here, allow the patient to digest the news



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This means your child will have some degree of learning difficulty and the level varies fromperson to person and some are more affected than others. And it is difficult to say exactlyhow this is gonna be in your child.

He may have delay in developing speech and motor development like sitting, crawling,

walking etc can occur.

Your child will eventually learn to do all of these things but may just take longer than otherchildren who do not have down syndrome.

Someone with Down’s syndrome will tend to have a low level of intelligence th an otherpeople who do not have this condition.

This condition is quite common and 1 out of 1,000 babies born in the UK have this

condition

This condition is commonly associated with other medical problems like heart problems.

We need to do a scan of his heart to make sure there are no other medical problems.

We will also arrange a hearing test

Management:

There is no treatment that can cure Down’s syndrome. It is something you have for life.

Many people with Down syndrome are able to go to a usual school with other childrenwhile others may need to go to a special school which will take care of their special needs.

As they get older, people with this condition are able to cope with some kind of job.

But do not feel that you are alone, because great support and advice for parents who havea child with Down’s syndrome is available through Down’s syndrome Association and a

number of other support groups.I will give you leaflet and websites



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Irritable hip.

Mother of a 2 year old child has brought a 2 year old boy with difficulty in walking. All

investigations were done and were found to be normal.

1. May I know what brings you to hospital?2. When did you notice that your child is limping?3. Does he runny any temperature?4. Has he lost any weight?5. Is he able to put weight on that leg?6. Is there any chance he could have hurt himself?7. Did he have any fall?8. Any running nose o sneezing?



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From what you are telling me most probably your child has a condition called irritable hip.

What we gonna do now is that we will do an x-ray of his hips and do blood tests.

This is to make sure that its not infection of his hip joint and there are no other causes

If the blood tests and x-rays are fie then your child most likely as I said before has acondition called Irritable hip which is simply inflammation of the hip joint.

The cause is not known It usually follows a simple cold It leads to accumulation of small amount of fluids in the hip joint This condition usually resolves with few weeks We will give your child pain killers like ibuprofen

We will also see you in clinic to see how your child is doing We will also arrange an US scan of the hip to check for any fluids

Irritable Hip

As you know your child has come to us limping with pain in his hip

We have done the test and the good news is that all the blood tests are normal.

And we have found that the cause of this is a condition called irritable hip syndrome.

This is a condition in which there is inflammation in other words swelling of the lining thatcovers the hip joint. The cause of this inflammation is not clear.

This condition is common after child has had a viral illness for example common cold orviral gastroenteritis. But there is no infection in the hip itself.

This condition usually resolves within 2 weeks, therefore we advise that the child has gotcomplete rest for the next 2 weeks. And if he is feeling better he can therefore start

bearing some weight on this leg.



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We will give you crutches to help him walk to places like toilet.

After 4 weeks he should be able to return to sport but that again depends on how he feels.

We will follow you up in clinic in 6 weeks time to see how the child is doing.

Your child can take rest from school for two weeks, just to make sure that the leg is rested.We will give you pain killers called Ibuprofen to use for this pain. This medication you canbuy over the counter as well.

Important:

1) Irritable hip is a transient synovitis2) No infection in the hip3) X-ray, blood test U&S may be done to rule out other causes.4) It resolves on is own5) Frequently follows viral infection somewhere else not the joint for example viral

gastro-enteritis

Idiopathic Thrombocytopenic purpura

A child has come with bruises for the past 2 days and also had 2 episodes of bleeding from

the nose. Please take history from mum and discuss differentials with the examiner

D/D’s:

1) ITP2) HSP3) HUS4) NAI5) Leukaemia6) Coagulation disorders7) Medications



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Questions:

1) → Is your child well?

→ Is he playing actively?

→ Is he feeding well, eating + drinking ok?

→ Did he recently (in the last few weeks) have any infection like sore throat or commoncold?

→ Has he had bleeding from the nose?

→ When did the bleeding start?

→ And when did the rash appear?

2) → Any problem with his wee?

→ Have you noticed any blood in his wee?

→ Diarrhoea? or blood in his stool?

3) Who looks after the child normally?

4) →Have you noticed any swellings anywhere on his body?

→ Has he lost weight recently which you cannot explain?

5) Is there anybody in the family with bleeding problems?

6) Is the child on any medication?

Diabetes Mellitus

A 5 year old boy has been diagnosed with IDDM. Please talk to the mum and address her

concerns.

Defination:

This is a condition in which the blood sugar levels in your child are constantly high.

The reason this is happening is that in our body we have an organ called the pancreas; this

organ produces the hormone called Insulin



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In the case of your child this organ is not producing enough Insulin. And without thisInsulin, our body cannot sugar and as result it’s constantly high.

This is what is making your child thirsty and hungry all the time and to be weeing all thetime.

Main Points:

1) The cause for this condition is not known2) Treatment is replace the insulin which is lacking in his body3) Do not blame yourself, the cause is not known4) So many people are affected with this condition

5) Make sure the school nurse, and GP know, we will write a letter to the GP toinform him about this

6) You can see your GP if you have any questions or if your insulin has run out7) It is important to monitor the sugar levels in the blood of your child and for this

we will give the diary and device what we call glucometer8) I will ask the nurse to explain to you when and how to check sugar levels. Usually

it is before meals9) Please take medication as prescribed10) This condition after many years of having it, may lead to kidney, heart and eye

damage. The better the sugar level controlled the less damage to these organs11) We will also give you a bracelet which our child needs to wear at all time so

that if he needs help, people will know quickly how to help him12) Sometimes the insulin after injecting can make the sugar levels in the blood so

low that it can cause a condition called hypoglycaemia, this can make someonefeel hungry, shaking and sweaty

13)

I will ask the nurse to demonstrate a hypoglycaemic attack to you14) Always make sure your child has a sweet drink wit him, so that you can give

him in case his sugar level becomes low15) Do not worry, this condition can be controlled16) To give this medication you will be injecting it yourself, but don’t worry its a

small needle and he will learn how to do it himself or if it’s a young child the

parents will have to do it.



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Hypoglycaemia in a child

A 9 year old boy who is a known diabetic has just had a fit. Please talk to the mum and

address her concerns

Points:

1) Take history to find out how this happened2) Check given medication3) Advice better the insulin to be given by one person as you can give 2 times by

mistake4) Child must eat after taking insulin

5) How long has the child been diabetic?6) Did anybody witness it?



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7) What happened?8) Talk about

Questions:

Mrs Jones I understand your child has had a fit Can you tell me what happened OK and I understand he is diabetic Who usually gives him Insulin? Did you give him Insulin today? Did he eat anything just before or immediately after giving him Insulin? Do you normally record in the diary the amount of Insulin given and at what time it

was given?

Counselling:

1) From what you are telling me most probably your child has got what we callhypoglycaemic attack

2) Do you know anything about this?

3) This is a condition in which the blood sugar levels are low which leads to the child toloose consciousness and to have fits

4) To avoid this from happening please make sure you feed your child either just before orimmediately after Insulin injection

5) It is important that only one person gives Insulin to the child to avoid mistakes

6) A well to be on a safe side make sure your child wears a diabetic bracelet all the timeand carry with you a sugary drink all the time

7) Explain hypoglycaemic attack (shaking, sweating), check blood sugar, give a drink if BSL islow



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Neonatal Jaundice

A 3 year old baby has jaundice. Please talk to the mum and address her concerns

NB: - Neonatal jaundice

1) Appears on day 2 – 32) Disappears by day 143) Does not raise above 200 m4) Baby remains well5) Jaundice less than 24hrs old is abnormal/pathological and after 2 weeks is abnormal6) Common in breast fed children



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Questions:

1) May I know what brings you to hospital today?

2) When did his skin start to turn yellow?

3) How old is your child now?

4) Is he well? Playing actively?

5) Any temperature?

6) Whats the colour of his poo?

7) Is he feeding well?

8) Do you breast feed your child?

Counselling:

i) Most probably it is physiological jaundice

ii) This is because the organ in our body called the liver is still not mature and it is notdealing with this pigment called bilirubin which has now coloured the skin yellow

iii) The skin usually return to normal within the next 14 days

But as for now we will do the blood test to check the level of this pigment in the blood ofyour child.

If the pigment is within the recommended level then we will let you go home and the skinof your child should be able to return to normal within 2 weeks.

If we will let you go home please observe your child and if any problem or the jaundice isbecoming worse or you are just worried please bring your child back.

IF it is above the recommended levels then we will give your child treatment calledphototherapy , during which we will shine light onto your child. This light will break downthe pigment.

If this does not help we may need to exchange his blood to help clear these pigments fromhis blood, which can damage the brain



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As I said it is likely your child has physiological jaundice, but we are just checking to be on asafe side.

By doing the blood test we will also rule out other things which could cause yellowishdiscouration of your skin

Obesity in a child

A 10 year old child has been found to be obese. Please speak to the mum and address her

concerns

NB: - Do not be judgemental in your conversation. Be very supportive to the parents.

1) While examining your child we have found that the weight of John is slightly on thehigher side

2) Let me explain this with a chart



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3) Now before we go ahead, can I ask you a few questions? Is it alright?

i) What do you normally give your child to eat for breakfast and dinner?

ii) What does he like to do?

iii) Does he go to school?

iv) Who else lives at home?

Main points:



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1) If your child continues to be overweight then he may develop problems when he/shegrows up.These are like DM, HTN, IHD, joint problems

2) You can help your child to loose and maintain weight by:- Adding fruits and vegetables to diet- Avoid fatty and fast food- Encourage him/her to do exercise e.g. riding a bicycle, running, playing football,

swimming.- Its important that everyone in the house eat the same type of food so that the

child does not feel left out.- Give him gifts if he does well on certain exercise- Try not to feed him late at night

- I will refer you to the dietician who will give you more advice about this.- A lot of people do manage to lose weight with these methods only- I will refer you to a programme called MEND: (mind, exercise, nutrition-it is a

programme where people go twice a week to exercise their mind, body and learnabout healthy foods)

Febrile convulsion

3 year old child Lucy has just had a fit and her mum Mrs Jones has just brought her to

hospital. You are the junior doctor in the department please address her concerns.

Hi mum, Can I as you a few questions.

1. What brings you to hospital today?

2. What time was it?3. Did the whole of his body jerk or it was only on part of his body?4. Did he lose consciousness5. How long did e have a fit for?6. Did he wet himself?7. Did he pool himself while having a fit?8. Has this happened before9. How old is your child now?10. Is there anyone in the family with similar problems as a child?



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11. Did he have any temperature?12. How high was the temperature?13. Did he/she have any headache or sneezing?14. Have you noticed any rash on any part of his body15. Does he cry when he passes wee?16. Does your child have any medical illness

17. Does he have epilepsy, Diabetes (High blood sugar) , asthma, heart problems.

18. Any one in the family who had similar problem as a child?

Counselling

From what you are telling me most likely your child has a condition called febrileconvulsion. Do you know anything about?

Definition: This is a condition in which children develops a fit if they have a hightemperature.

1. A febrile seizure in its self is not a dangerous, but child can sustain an injury duringthe fit and sometimes this can be as bad as head injury.

2. Children recover fully from a fit.3. Common condition which causes high temperature are conditions like meningitis,

water works infection, common cold, ear infection.4. You can prevent febrile fit by

- Keep your child lightly dressed- Give him/her paracetamol when he /she has a temperature- Give him a lot of cool drinks.

5. Only one seizure occurs in most cases, but a child may have a repeat seizure.Recurrent seizure is more likely if there is family history of febrile convulsion.

6. During a seizure remove all dangerous objects around the child and make him lie onhis side.

7. Febrile convulsion does not lead to epilepsy. These 2 conditions are totally different.8. Emergency help.

- Call an ambulance if seizure last more than 5 minutes or if a child has difficulty inbreathing or if your child develops a repeat seizure immediately after the first

one.- Otherwise bring your child to hospital immediately after a seizure.



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Infantile colic

Mrs Mirrian Jones has to emergency department because her 1 month old baby has been

crying excessively for the past 2 days. Please speak to her and address her concerns.

1. May I know what brings you to hospital today?2. How many hours a day does he cry?3. Is he running any temperature?4. Is he passing wee?5. Do you find him lethargic?6. Is he feeding well?7. Do you find him lethargic?8. Does he cry while drawing her legs towards his tummy?



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9. Have you noticed any blood in his pool?10. Any vomiting or diarrhoea.11. Have you looked at his/her private parts is everything fine ?12. Have you noticed any rash on his body?13. Does he /she cry while pulling the ears?

From what you are telling me, most probably your child has a condition called infantilecolic.

This is when children who are otherwise well cry repeatedly. This is a very commoncondition. The cause for this condition is not clear. There is not treatment for thiscondition. This condition normally settles after few months.

Try to burp your baby after feeding because trapped wind in the stomach can make thiscondition worse.

Try also to respond quickly the moments he starts to cry.

Soothing a baby usually helps.

Taking turns in looking after the child will help you cope better and have enough sleep.

Is there anyone at home who can help you look after your child?

As I said usually this condition settles with time, but if you find your child lethargic or looksunwell please bring your child and we will have a look at him again.

NB: make sure you rule out intussusception and testicular torsion.

If intussusceptions or torsion admit , blood tests and refer to specialist.

Foreign Body ingestion

A 5 year old child has just swallowed a coin. He has come with her mother, please speak to

them and address her concerns



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Hello! Mum. My name is Nevan, I’m one of the junior doctors in the department.

I understand your child has swallowed the coin, can you please tell me how it happened.

Mum: The child was playing in the sitting room, I left him for a few minutes and I found himcoughing and I saw coins on the floor.

Doctor: Did you see him swallow a coin?

Mum: No

Doctor: So when you saw him cough, did he lose consciousness? Did he turn blue?

OK

1) What we need to do now is that we will do an x-ray of his chest ad tummy in order tocheck where the coin is.

2) If the coin is above the diaphragm, which is the narrow place of the food pipe thenwe will have to put your child to sleep and take the coin out with a telescope.

3) If the coin is below the diaphragm, then it’ gonna pass in the p oo.

Examiner:

X-ray done doctor and the coin is below the diaphragm

Excellent

SO Mrs Jones the coin has passed the narrowest part of the gut. It is very likely thereforethat it passes with the poo.

What you need to do is to let your child have poo in the closet, wash poo with water so youcan see the coin remain behind

You need to do this for the next 48hrs

If your child does not pass the coin within the next 48hrs, please come back to the hospitalwe will do another X-ray to fnd where the coin.

Also bring your child to hospital if any vomiting or excessive crying or if he develops tummypains

Peanut Allergy



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A 9 year old John has been brought to Emergency department by her mum who noticed that

John had developed rash over his skin, itching and shortness of breath immediately after

eating peanuts.

Speak to the mum and address her concerns

1. Can you please tell me what brings you to the hospital?2. When did this happen?3. Did it develop immediately after eating peanuts?4. Is this the first time this has happened?5. Did he develop swelling in the face and neck as well?6. Any difficulty in breathing?7. Any rash and was he scratching?

8. Does your child have any other medical problems like Asthma?9. Does he have any other allergies?

From what you are telling me most likely your child is allergic to peanuts.

This is a very common condition.

This is caused by over reacting of the body’s immune system, which normally fight infection

People who are allergic usually develop

i) Tingling in the mouth and lipsii) Swelling of the faceiii) Rashiv) Colicky pain in the tummyv) Tightness in the throat

Severe reaction can cause:

i) Wheezeii) Difficulty in breathingiii) Swelling of the whole neckiv) Swelling of the tongev) Horseness of voice

Treatment:

1) Main thing is to avoid nuts- By checking the labels on the food package



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- Take care when you are not preparing the food yourself

2) If allergy reaction starts:

- Give anti-histamine- If severe allergy give him the medication called Adrenaline injection → the nurse

will explain how to use it.

We will give you a medication called Adrenaline which is stored in a device called epipen (itlooks like a pen). Use it only if it’s severe reaction

Whether your child has a mild allergic reaction you need to bring him to hospitalimmediately and if he has developed severe reactions please call ambulance immediatelyby calling 999.

Also make sure your child wears a bracelet all the time to indicate that he/she is allergic topeanut and if he/she develops a reaction people may know how to help him/her



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MMR Vaccination

A father has brought a 4 month old child who is due to have MMR. The father is worried

that MMR causes autism. Please address his concerns

1) A dose of MMR is usually given to children age 12 – 13 months2) Second dose is usually given between 3 years 4 months and 5 years3) MMR vaccination is very safe and is not linked with autism or bowel diseases4) MMR stands for Measles, Mumps and Rubella

5)

The vaccine is used to immunise measles, mumps and rubella infection are all givenin one injection

6) Even if your child has already had one of these diseases, your child should still haveMMR immunisation

7) Children are perfectly well after having a dose of MMR vaccination8) However some children develop a mild fever (temperature) and a faint rash 7 – 10

days later. This should only last upto 2 – 3 daysA few children develop mild swollen face about 3 weeks later. Any swelling will

gradually go downNone of these reactions is serious

9) It is safe to give even if you are allergic to eggs10) These infections we are trying to prevent are serious infections

a) Mumps → causes swelling of glands around the face- Pancreatitis- Orchitis- Meningitis- Encephalitisb) Rubella (German measles):- Rash, sore throat, swollen glands- If pregnant becomes infected then the virus can cause damage to the unborn

child e.g. damage to the heart brain, eyes, hearingc) Measles:- Encephalitis → seizures → Brain damage

- Pneumonia, bronchitis



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It would be very helpful if you can vaccinate your child. I’m sure you would like your childto be in position of not having any of these infections.

UTI in a child A 10 year old child has been diagnosed with UTI. Please speak to the Mum and address her

concerns

As you know that Tom came to us with burning sensation when passing water.

We have found that the cause of that is that he has got water work infections

It is a very common infection in children and in most cases children make full recovery

Water works infection are caused by bacteria (germs) that get into the urine

Most of these germs are those that live in your own bowel

These bacteria cause no problem in the bowel but can cause infection in other parts of thebody; in this case they have cause infection of the water works

In most cases it just happen and there is nothing to account for it

In Some Cases:

1) Constipation cause urine to be retained in the bladder by obstructing the flow → thislead to urine to be infected

2) An abnormality to the urinary tract for example flowing back of the urine frombladder into the kidney can cause infection

Children can have different symptoms e.g. fever, vomiting, crying, jaundice, blood in urine,

tummy pain, becoming generally unwell

NB: - It is very important that we treat this infection with antibiotics → because theseinfections can lead to kidney damage.

Usually a course of antibiotic clears the infection

We will also do the scans of his kidney and water works to make sure that he has got noproblems that is making him suffer from the urine infection and also to make sure that

there is no kidney damage or flowing back of urine into his kidney tubes





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Re-apply the same treatment 7 days after first application. This helps make sure all mitesare killed.

So in general everyone in your house should apply this medication twice.

Remember to include awkward places such as the back, soles of feet, between the fingersand toes, under the finger nails and genitalia.

1) If you wash your hands or any other part of your body during the treatment period,you should re-apply the cream or lotion to the washed areas

2) Cloth, towels and bed linen should be washed in the machine at 50 ᵒC or above, afterfirst application of treatment

3) Any items of the clothes that could not be washed should be placed in a plastic bagfor atleast 72 hours until they die

4) Once you apply the permethrin cream you should leave it for 12 hours and if youhave used malathion you should leave it for 24 hrs

5) We will also give you the medication which you will take through the mouth to stopitching. The medication is called piriton.

6) Children should stay off school during the period of treatment.7) Sometimes the skin can get infected and if you suspect infection of the skin please

see your GP.

Vaginal Discharge in a 8 year old child

An 8 year old child has come with vaginal discharge. Take history and discuss differential

diagnosis with examiner

D/D’s :

1) Child abuse2) UTI3) Foreign body4) Trauma

Questions:



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1) Do you think the child is behaving strangely?→ Is there anyone at home other ten you and the child?→ Is there any bleeding from down below?→ Is there any staining of her underwear?→ Who normally looks after her?

2) Is she running a temperature→ Does she complain of burning sensation when passing water?→ Does she pass wee more frequent than usual?

3) Is there any chance there could be a foreign body down below?4) Is there any chance she could have hurt herself?5) Is the discharge smelly?6) What is the colour of the discharge?

Cover the P4MAFTOSA

Ear Infection / URTI

A 4 year old child has come with fever. He is accompanied by his father who thinks he has

ear infection as he had an ear infection in the past. Please speak to the dad and address hisconcerns

Hi! My name is Samson I’m one of the junior doctors.

Questions:

1) May I know what brings you here today?2) What makes you think your child has an ear infection?



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3) Have you checked temperature of your child?4) Does he complain of pain in the ear?5) Does he complain of any discharge from the ear?6) Does he have cough and is he sneezing?

From what you have told me, my assessment is that your child has an upper respiratorytract infection and not a ear infection.

It occurs usually because of a bug called virus and no antibiotics are needed for it.

Don’t worry your child will be well soon. I will give you paracetamol for the fever

Bring him back to us

If you feel that the ch ild’s condition is no improving If your child develops high temperature If you notice any rash on his body or If he becomes drowsy

Anything else you want to ask?

If you worried of any thing please bring your child to us.

Blood Transfusion A 3 week old child is deeply jaundiced. You have planned to exchange transfusion but his

parents are Jehovah’s Witness, they are not giving their permission. Please speak to the dad

Hi! My name is Samson I’m one of the junior doctors.

As you know your child has jaundice and he needs exchange transfusion

Dad: I am sorry but my religion does not permit



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Dr: Yes, but this is to save the life of your child

Dad: There has to be some other way to treat my child

Dr: I am afraid this is the best possible management, which is required, because of the levelof the harmful pigment has reached to a level where there is no other treatment optionother than this . We need to replace the baby’s blood w hich contains the harmful pigments

We do respect your beliefs but we feel this is very important for your child. Should Iarrange an appointment with the hospital chaplain, may be they will help you inreconsidering your decision?

Keep repeating the same thing till 4:30 min, at 4:30 if you are unable to convince, then say Iam sorry I have been unable to convince you, I’ll arrange a meeting with my consultants to

talk to you, is it alright?

Is there anything else you want to know?

Thank you very much

Needle stick Injury in a medical professionalWhile taking blood from a 5 year old child, you pricked yourself. Talk to the mom and

explain that you need to take blood from the child to check for communicable disease

Hi! I’m Dr ... I am one of the junior doctors here

As you know that I had to take some blood from Tommy’s blood channels today and send itfor tests. While doing so I pricked myself.



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When such a thing happens what we need to do is to take a small amount of blood fromthe patient and send it to laboratory to check for any communicable diseases.

So I need to take some blood, just a few mls, from little Tommy’s blood channels

Please don’t be upset. I know this is hard for you but the thing is that we need to know iflittle Tommy has any communicable disease.

I am not saying that Tommy has a communicable disease, but what I am trying to say is thatthere might be a possibility of him having a communicable disease and since I a doctor hereand am taking care of many other children like tommy.

I may transfer a communicable disease to other little ones, if little Tommy is been infected.So just for the safety of other little ones, we are bound to do so.

This is our hospital protocol that if a doctor is pricked by a patient’s needle then thepat ient’s blood has to be checked for communicable diseases, so that if the patient hasone, the doctor can be given prompt treatment, so that he does not spread it to otherchildren. So I am here to follow the hospital protocol.

You do not need to worry because it will be done quickly and only small amount (a few mls)of blood will be taken for this purpose.

If mum not convinced:Say I am sorry I am not able to convince you, I will arrange meeting with my seniors andthey will address your concerns and try convincing you.

Non-accidental injury-telephone conversation with the examiner

2 year old boy has been brought to emergency department with bruises all over her body. X-

rays has been done.

Discuss the case with your consultant on the phone.



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Find who you are speaking to: Hello, can I speak to Dr Williams the consultantpaediatrician on call.

Consultant: Yes speaking.

Apologise for disturbing: Hi, Dr Williams, I am really sorry to disturb at this time my nameis Samson. I am one of the junior doctors in paediatrics.

Can I discuss the patient with you please?

Situation: I have a 2 year old child who has been brought by her mother with multiplebruises of different ages and child has got humeral fracture on the x-ray.

Background : So this is a 2 year old child who lives with her mum and step father, themother gives history fall from a sofa 2 days ago.

Assessment Upon examination –the child has got bruises of different ages, the lefthumerus is deformed and swallow. Otherwise the child is ok.

X-ray of the left humerus has shown a transverse fracture of the left humerus, it’s a closedfracture, undisplaced but angulated, neurovascular intact.

Diagnosis : I feel this is a case of non accidental injury.

Management:

1. I have admitted the child2. I have done good clinical skeletal survey on him3. I have checked the child name on protection registrar and I think we will need to

contact the social services.4. Is there anything else you would like me to do?5. Would you please come and help in the further management of the patient.

Anaesthesia in an IDDM child

A 7 year old child is planned for ankle surgery under general anaesthesia. Please assess if

the child is fit for anaesthesia



Hi my name is Samson; I’m one of the junior doctors

I understand that your child has been scheduled for an operation on his ankle

Can I ask you a few questions?

1) When did he last eat or drink something?2) In the last few days or so did he have any illness?3)

Documents

Paediatrics Hx & Couns