Pediatrics Flashcards
You are a Hospital Medical Officer (HMO) in an antenatal clinic, seeing a 28-year-old woman for her antenatal visit at 35 weeks of gestation. She wants to discuss infant feeding with you. She has heard a lot about the benefits of breastfeeding, but her mother told her recently that babies grow better with formula feeds. She is uncertain whether she should breastfeed or formula-feed her baby.
TASKS:
▪ Discuss the advantages and disadvantages of breast-feeding and formula-feeding with her.
▪ Outline the steps involved in safe formula-feeding.
APPROACH
▪ I appreciate that you came here to take advice regarding feeding your baby. I will explain to you important concepts about both breastfeeding and bottle feeding. If you have any questions along the way, just stop me anytime.
▪ Breastfeeding has its advantages both to the baby and the mother.
§ For the baby:
□ It protects against bugs for example, rotavirus and there is increased resistance of the baby to infection, from immunological constituents in breast milk including lymphocytes and antibodies
□ It decreases the risk for celiac disease, and inflammatory bowel disease
□ Babies who are breastfed, are protected from allergic reactions, as opposed to babies who are formula fed who can have allergies from the contents of the formula.
§ For the mother:
□ It increases the bond between the mother and the baby
□ It has less economic burden to the family
□ it is available every time and you are able to feed almost whenever and wherever the baby wants it without having to prepare formula, carry bottles around and without problems with sterility
□ It also helps in the weight reduction to pre-pregnancy state because when baby starts suckling the breast, a hormone called oxytocin gets released which helps in bringing the uterus size back to pre-pregnancy size
□ It decreases the level of some hormones like cortisol in the blood thereby decreasing incidence of mood disturbances after delivery in mother.
□ It acts as a protective factor for breast cancer
□ Exclusive breastfeeding can also to some extent act as a contraception
▪ At the beginning, you should breast feed your baby on demand until the baby gets adjusted gradually within 48-72 hours. After that, you can feed her every 2-5 hours.
▪ However, if you are taking medications during breast feeding you need to contact your GP regarding it, as some medications can go to the baby through the breast milk.
▪ If you are worried about a cracked nipple, there are some special classes at the hospital to prepare the nipple during the last 2 months of pregnancy.
▪ Also, if you are working, you can still continue breastfeeding. You can express your milk and keep the milk in fridge for 1-2days, 2 weeks in freezer and for 3 months in deep freezer.
▪ While breastfeeding is the optimal method of feeding the human infant, and that the majority of mothers successfully breastfeed, a variety of reasons may prevent breastfeeding in practice, including:
§ illness in the mother
§ failure to establish lactation, which may be hormonally based
§ possible illness in the baby (e.g. cleft palate)
§ prematurity, which requires the mother to express regularly to maintain her supply
§ previous extensive breast surgery in the mother
§ heightened anxiety in the mother
▪ If one of these conditions are present or if for some reason breastfeeding is unsuccessful, formula-feeding is a safe and very effective alternative. Formulas are designed to contain the same nutritional components as breast milk, but that exact reproduction is difficult as the concentration and components of breast milk change throughout each feed to provide all the essential nutrients the baby needs. In the morning it contains more water and towards the afternoon, it contains more fat.
▪ However, there is no advantage of formula feeding over breastfeeding.
▪ In preparing bottle feeds, you need to remember the following:
§ sterility in preparing the bottle feeds is essential
§ Bottles should be washed clean with a bottlebrush to ensure that all residue is removed
§ Bottles and teats should be stored in solution (Milton) to ensure continuing sterility, but the bottles need to be rinsed free of this solution prior to use
§ the fluid used to make the formula and to rinse the bottles should be cooled boiled water
§ Each can of formula has explicit makeup instructions on the side of the can or packet and if followed these will produce the exact required concentration. There is no place for any added scoops, which can be harmful
§ the day’s requirements are best made up at the one time, although each feed can be made separately. If the former, the day’s feed should be stored in the refrigerator.
§ only one day’s feed at a time should be prepared in advance and each feed should contain approximately 30 ml more than it is anticipated the baby may take, and any excess discarded at the end of the feed.
▪ It is important for you to understand that weight gain is not the only criterion for success as excess weight gain in the first 12 months of life may in fact be detrimental in later life.
KEY ISSUES
▪ Empathic answering of this young mother-to-be’s questions.
▪ Recognition that she is uncomfortable with what her mother has told her but is seeking reassurance and support for her own view which she feels is accurate.
▪ Satisfactory explanation of the advantages and disadvantages of the different methods of feeding.
▪ Candidates should know how formula feeds are prepared.
IMPORTANT POINTS FROM THE COMMENTARY
Ability to discuss impartially and accurately the relative merits, indications, contraindications and techniques of infant feeding by breastfeeding and by formula-feeding is a requisite for all medical graduates as outlined and is an area where good communication skills are paramount.
A young couple, the wife pregnant with their first child, have come to see you in general practice to discuss with you the place of routine neonatal circumcision if their baby is a boy.
TASKS
1. Discuss with the couple the perceived risks and benefits of the procedure.
APPROACH
▪ I understand that you are here to discuss with me regarding the possibility of doing circumcision for your child right after delivery. Can you tell me more about it?
▪ If it’s okay, may I know how much you know about circumcision?
▪ As your GP, I am here to provide you a background of the procedure and why it is usually done. Usually, many parents are unaware of the actual process of circumcision, and may ask this to be done usually more as a ritual. As parents, I strongly advise you to consider the advantages and disadvantages of this procedure before making a decision for your child.
▪ Explain what is circumcision (ILLUSTRATE)
○ Normally, the tip of the penis is surrounded by a part of the skin called, the foreskin. This foreskin serves as a protection of the sensitive tip of the penis called the glans. Circumcision involves the removal of the foreskin to expose the tip/glans of the penis. It is usually done under local anesthesia, or under general anesthesia if done after 6 months of age, and is basically a pain-free procedure.
▪ Explain background of why circumcision is usually done
○ As I mentioned earlier, it is usually performed on baby boys mainly because it is requested by their parents, often for religious and cultural reasons.
○ Generally, circumcision is not a routine procedure in newborn babies. Initially the foreskin seems tight, but initially it frees up by the age of 5 years and it can usually be pulled back. And when it can be pulled back, any debris or cheesy material present underneath the foreskin may be gently washed away. And as a general rule, the foreskin should only be retracted by its owner to prevent injuries.
○ But in some cases, circumcision may be necessary for medical reasons, but this is quite uncommon.
§ STATE MAIN INDICATION
□ In some boys the foreskin may be very tight, which leads to a very small opening causing problems in passing the urine, and this tend to become prone to swelling and infection. This is condition is known as phimosis, and when it does not respond to conservative measures, circumcision is usually done.
▪ Explain advantages
○ There are perceived advantages of routine circumcision of the newborns which include the following:
§ Reduced incidence of urinary tract infections, although routine circumcision is not necessary to achieve this. Circumcision may assist those suffering recurrent UTIs and is usually done at a later age.
§ Minimizes the risk of subsequent development of penile cancer. However, infection by a sexually transmitted infection, the HPV virus, is the major contributor in development of the disease. Cancer is still rarely seen in men who can retract and clean their foreskin regularly
§ There’s divided opinion regarding its advantage in reducing the incidence of sexually transmitted infections. But there is some evidence that suggest that the risk of HIV is lessened by this procedure.
▪ Explain disadvantages and complications
○ The recognized complications and disadvantages of this procedure include the following
§ Hemorrhage, which is deemed to be the most common
§ Infections, leading to septicemia, or infection in the blood
§ Ulceration of the tip of the penis
§ Injury to the urethra–the urine passage
§ Too much skin removed leading to unsatisfactory cosmetic appearance
§ Secondary phimosis
○ But under the experienced hands of the specialist, these complications are very rare
▪ Explain ABSOLUTE CONTRAINDICATIONS TO CIRCUMCISION
○ However, there are still conditions wherein newborn circumcision is not advised for a patient. And in case these are present in your child, I’m afraid circumcision may not be the best procedure for him
§ Hypospadias and epispadias – this is when the urethra, or the urine passage, is not present at the tip of the penis. Rather, it is located on the other parts of the penis (ILLUSTRATE)
§ Chordee - a condition in which the head of the penis curves upward or downward
§ Buried penis - a condition where the penis is partially or completely hidden below the surface of the skin
§ Sick infants, including jaundiced infants
§ Family history of bleeding disorder, or known recognised familial bleeding disorder possibility
§ Inadequate expertise and facilities
▪ Do you have any questions so far?
▪ I have reading materials for you about circumcision, to give you more insight to this procedure.
▪ I hope this consult gave you more insight to guide you in making the best decision for your child. Thank you very much.
KEY ISSUES
1. The ability to discuss in an unbiased manner the perceived advantages and disadvantages of routine neonatal circumcision
2. Capacity to summarize that the recommendations of various national and international pediatric and pediatric surgical associations, who have extensively reviewed the literature on the subject, do not support routine neonatal circumcision
3. Critical error: none defined
IMPORTANT POINTS FROM THE COMMENTARY
▪ Many young parents are unaware of the issues involved about this procedure, as they request circumcision without any information about the procedure
▪ Decision should be left to the parents after a full and accurate discussion.
You are working in a community health centre. Your next patient is a 10 month old female infant, baby Helena, seen with her mother, who has been referred by the local child health nurse. The pregnancy and delivery were normal. The child presented to the nurse six weeks ago for review and general screening including hearing. The nurse was concerned that the baby has a hearing problem and wanted her checked by a doctor. The child’s parents have never had cause to worry about her hearing. She is the third child in a healthy family and has been well apart from a few upper respiratory infections.
She is crawling, does not walk yet, but pulls herself up to standing beside a small table.
Initial examination findings
A busy infant girl who objects to being restrained by her parent. She babbles during assessment. Otoscopic examination is normal. No abnormal physical signs are present on general examination. The parents are puzzled at the need for referral and seek information about further investigation and management.
TASKS
1. Ask the parent for additional relevant and focused history
2. Counsel the parent after you have obtained a further history
3. Explain possible causes of any suspected hearing loss to the parent
4. Discuss your plan of management with the parent.
APPROACH
▪ I understand from the notes that you have been referred here by the local childcare nurse for a suspected hearing loss in your daughter. I am happy you’ve come, I am here to help you, but I just need to ask a few questions, is that alright with you?
▪ Possible causes/risk factors for hearing loss:
○ Is there a family history of deafness?
○ Did you have any problems during pregnancy especially infections?
○ Were there any health problems with the baby during or soon after birth?
○ Was hearing test done after birth?
○ Is the baby growing and thriving?
○ Does the child have fever? Is she irritable? Pulls on ear?
▪ Assess for evidence of hearing loss:
○ Does the baby respond to sounds, including loud sounds?
○ Does the baby respond when called by her name?
○ Does the baby turn towards the sources of the sounds?
○ Does the baby respond to television?
▪ Assess for evidence of developmental delay: (child is 10 months)
○ Do you have any problems with her growth and development?
○ Do you have any concerns with her development as compared to other kids of her age?
▪ Counselling:
Hearing loss is common among pre-schoolers, and most cases are mild and transient and is usually due to conductive hearing loss or a problem in the mechanical transmission of the sound in the ear due to a blockage in the ear passage. The most common cause of hearing problems is a ‘glue ear’, which is a build-up of sticky fluid in the middle ear following middle-ear infections. The outer ear can get blocked with things such as wax and foreign objects put in there by the child.
However in your child, she does not exhibit signs of infection, so this is quite unlikely.
Hearing loss can also be due to a problem in the nerve for hearing but it is far less common, but it is important to detect it as early as possible. Possible causes for this include a genetic cause, infections acquired by the mother during pregnancy like rubella, HSV, CMV, maternal diabetes, or prematurity. If the child also acquired infections after birth such as measles, chicken pox, mumps, it can also cause hearing loss in the child.
The distraction tests that were done to your child by the local health nurse is only a screening tool, but it does not diagnose deafness. Usually, it is the parents who notice that there is something wrong with the hearing of their child, however, it is important to follow-up this concern because if there is indeed a problem, the earlier we diagnose this, the better. I am going to refer you to a pediatric audiologist so that a formal hearing assessment by an audiogram can be done. I will give you some reading materials about hearing problems in children for further insight. I will review you after the audiogram is done. If we find a problem with the result of the test, I will refer you to the specialist for further evaluation. If the results are normal, then I will review your child’s hearing and language development in about three months. I will give you reading materials for further insight. Do you have questions at this point?
KEY ISSUES
▪ Appropriate history relevant to deafness.
▪ Counselling with reference to early definitive screening for hearing.
▪ Providing appropriate level of support and reassurance.
CRITICAL ERROR
▪ Failure to refer for specialist assessment (audiogram) for definitive diagnosis.
IMPORTANT POINTS FROM THE COMMENTARY
▪ Proceed from the cue of ‘possible hearing loss’ to assess whether other evidence, such as failure to turn to sound, is present to support this diagnosis
▪ Inquiry regarding features suggesting associated developmental delay is appropriate
▪ Given a working hypothesis of possible hearing loss, features in the history which could be causative, such as maternal illness in pregnancy, perinatal problems such as jaundice or drug administration, should be evaluated
▪ The importance of early diagnosis and treatment of significant hearing deficit in this age group make referral for definitive diagnosis mandatory despite no other concerning features being present
You work in general practice. You are counseling the family of a four-month old male infant who was rushed to the emergency department of the local hospital the day before but was dead on arrival. The provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a coronial autopsy.
You had seen him for the first time two months previously, with his single mother, when he was thriving and developing normally and had commenced immunisations. Two days before his death, you saw him again, this time with mild upper respiratory snuffles which were causing minor difficulties with breastfeeding. However, over the next two days, he apparently improved, and his mother had advised you that he appeared normal and fed well from the breast just prior to his death. You are unaware of any suspicious circumstances surrounding the death.
The family members have attended to seek details of why the baby died and why an autopsy is necessary. The spokesperson for the group is the mother’s sister, the aunt of the infant. The mother is also present, but is too distressed to ask any questions herself.
TASKS
1. Answer the questions of the aunt relating to the death of the infant
2. Counsel the aunt and family
APPROACH
▪ I am so sorry to hear about Andrew’s death. Please take my deepest condolences. I can imagine how this must be very hard for you and for your family. I understand that you are all here to discuss the occurrence surrounding his death, and why an autopsy is necessary. I will do my best to answer any questions or concerns you may have with regard to this.
▪ We can’t understand why Andrew has died!
○ I’m so sorry to hear that. As of now, we are still doing our best to identify the specific cause of his death. However, at this point It seems that most likely the cause of his death is what we call as Sudden Infant Death Syndrome (SIDS), or commonly called as “cot-death”. This is a major cause of death for infants under 1 year, and this is often seen in infants at about four months of age, and sadly there are no certain causes are known to predispose anyone of this condition. Usually there is a need to exclude other possible causes, such as a severe infection, which is unlikely in Andrew’s case because his snuffles were not warning signs that suggest a an overwhelming infection. Other conditions, such as metabolic and genetic causes also need to be excluded. And that is why in any cases of sudden or unexplained death, just as in Andrew’s case, the police and the coroner must be notified to assist us in identifying the cause of his death.
▪ Why do the police have to be involved? Do they think my sister killed her baby?”
○ I can see that you are getting very upset during this difficult time. But let me reassure you that we don’t mean to let you feel that way. Nobody suspects your sister to harm her child. The police are here to assist the coroners to help identify the cause of Andrew’s death. BY law, they are required to interview all the people concerned, including you, me, and the doctors in the hospital, to provide information to the coroner. Let me reassure you that all police officers and coroners who work with SIDS cases are specially trained to conduct their work in a manner that will provide comfort to the family.
▪ Why does he have to undergo an autopsy?
○ There is a need for an autopsy in all cases of SIDS to identify the cause and to exclude other possible causes of his death. It is a medical examination of the body and organs, and it is usually performed on the next working day after the child’s death. It is performed like a surgical operation, by a very experienced pathologists and will ensure care in the manner of the proceeding with the examination. In order to identify the cause of SIDS, they will have to remove tiny tissue samples from the body in order to examine it under the microscope, and they might also send it for chemical and microbiological analysis. Do you understand so far?
▪ When will we get further information and results of this/ When can we arrange a funeral?
○ Usually the full results of the autopsy will be available after 6 weeks from the day of the procedure. However, I can try to find out the initial findings after the autopsy has been performed. Nevertheless, the coroner’s office will contact your sister at a later date to provide further information regarding the full results. I will follow him up.
○ The coroner usually decides if an inquest needs to be held, but with SIDS this is generally not necessary. Once the autopsy is complete, you can arrange his funeral. A social worker can assist you in arranging his funeral. If you wish to see or hold Andrew after the procedure, I will try to arrange for this as well
▪ We feel so alone. Is there anyone we can talk to about this?
○ I can imagine how distressing this must be for all of you in the family. As of now, what I can offer you are these contacts of SIDS support groups which can help you get through this. The support groups often hold meetings with other bereaved parents, and hopefully you can think about taking part of it. I am here to help you too. Please don’t blame yourself (to the mom) because you are not responsible for Andrew’s death. It is not related to his mild infection and medical treatment of the snuffles will not change the outcome.
▪ CLOSING
○ Again, please don’t blame yourself as this is not your fault. We are all here for you to assist you and support you in this whole process. I will arrange another review with you to check up on your situation, and also follow-up the coroner’s office to confirm the diagnosis. I will contact you immediately once I have the results of the autopsy. Do you have any other concerns?
KEY ISSUES
▪ Appropriate empathetic explanation
▪ Ability to explain the involvement of appropriate authorities and support groups
▪ Offering to arrange for continuing follow-up, contact, and support with the family
CRITICAL ERRORS
▪ Failure to display empathy in counselling
▪ Failure to recognise and explain need for coronial notification and autopsy
IMPORTANT POINTS FROM THE COMMENTARY
▪ Empathy in communication
▪ Knowledge of legislative requirements
▪ ALL UNEXPLAINED DEATHS must be reported to the coroner and the police must take statements
▪ The caring practitioner will offer to liaise with the coroner on behalf of the parents, and in this way is often able to receive preliminary reports if the coroner is agreeable to them being released.
▪ Offer to keep contact with the grieving family until confident that this tragic event has been accepted.
A nine year old boy, Roger, is admitted to the pediatric unit to which you are the HMO. This is his first presentation of insulin-dependent Type 1 diabetes mellitus. His general condition is satisfactory, not requiring intravenous resuscitation, and he has already commenced insulin therapy and has stabilized with good blood sugar control.
As the ward HMO, his mother has asked you for further information about his ongoing care in relation to his diabetes from now on.
TASK
1. Answer the queries the mother has, related to the ongoing care of Roger’s diabetes.
APPROACH
▪ I understand that Roger has been diagnosed with an insulin-dependent Type 1 diabetes mellitus and he is now on insulin therapy. I know that this might be quite distressing or upsetting for you, but do not be too stressed, I am here to help you. Do you have some questions about this?
▪ Will he need insulin injections each day from now on?
○ Yes, Roger will need life-long injections of insulin, because in his condition, there is absolutely no production of this hormone in the body that is why we need to give it to him externally. There are different types of insulin, rapid acting, short acting, intermediate acting and long acting insulin. At this time, he will need twice daily insulin injections which consists of a combination of a short-acting insulin and an intermediate-acting insulin so that his blood sugar can be controlled for the whole day. You should remember to assist Roger in taking the right amount and right frequency of insulin injections and not to miss his meals so that his blood sugar level will not drop to very low levels. However, if at any time he experiences dizziness, shaking, sweating, nervousness or a rapid pulse, these may be signs of a low blood sugar level. He should immediately take in at least 15 grams of a quick acting carbohydrate such as some glucose tablets or high-sugar options like candy, or fruit juice or non-diet soda to help stabilize his blood sugar and reduce symptoms. Within 15 minutes, he should feel better. If he doesn’t get better, he could take another 15 grams, but if he still doesn’t improve, you should bring him to the ED for further management.
▪ Who is going to be giving Roger’s insulin from now on?
○ It is best if you and your husband and if possible an older sibling can assist Roger in giving his insulin injections. Do not worry about this because the Pediatric unit staff and educators will ensure that you will be educated on the proper drawing up and administration of insulin before discharge so you would be confident to do it at home. Also if necessary, or if you need further assistance, we can also arrange help for you at home from the district nursing service after discharge.
▪ How do I assess the day to day control of his diabetes?
○ Roger’s blood sugar levels will need to be monitored several times daily by a glucometer (show details of glucometer to the parent). These levels are usually assessed before each meal and before bed at night. This will allow us to be able to review the blood sugar levels and to recognize if adjustment in the insulin dosage is required depending on the trend of his blood sugar levels over several days.
If the blood sugar levels are persistently high, or if Roger will be unwell for any reason, we could also test his urine for ketones which will tell us that Roger’s body is not able to use glucose for energy, and the insulin might need adjustment. [In normal states these ketones will be completely metabolised so that very few, if any at all, will appear in the urine. If for any reason the body cannot get enough glucose for energy it will switch to using body fats, resulting in an increase in ketone production making them detectable in the blood and urine.]
▪ What do I need to do about his school?
○ The school should be notified about Roger’s condition. After his discharge, the ward diabetic educator will be with you to visit Roger’s school so that relevant school staff can be instructed and educated about possible complications that Roger might experience while in school, most importantly if he experiences symptoms of a very low blood sugar level, and how to detect and manage it. You should also take every opportunity to review these important aspects of care with the school staff and ensure that any new staff are made aware of Roger’s condition. We could also give the school a list of phone numbers which include your number, your GP’s number, and the hospital/children’s ward number, so that they could contact you if needed in cases of an emergency.
▪ Will he be able to go to school camps? What should I do about them?
○ The aim of our treatment and education program is to allow Roger to live as normal a life as possible, and he should be encouraged to participate in all school activities and social activities. However, some arrangements should be made prior to allowing Roger to attend the school camp. If it would be possible for you, you and your husband or any one of you can attend the camp as camp parents so that you could also supervise Roger while he is at camp. However, if this is not possible, his teacher can be educated about Roger’s condition and its management so that you would be confident and comfortable with the teacher’s knowledge in looking after Roger. If the camp would be situated in a distant town, I would also provide a letter for the local medical practitioner explaining Roger’s diagnosis and providing details of his insulin regimen, blood sugar levels and telephone contacts.
▪ He went to his first sleepover party a few weeks ago — could he still go on these now?
○ Yes, as I mentioned, our aim is to let Roger live a normal life as possible. He should be encouraged to participate in social activities such as this. However, it is better if Roger will be staying in the home of a family whom you know very well so that a frank informative discussion on the management of Roger’s condition can be done. Also, it is better if the sleepovers are done in a home close to your home, if not in your own home, so that if necessary, you can come over and do the blood test as well as give the insulin in the evening and the next morning until Roger is old enough and reliable enough to do these by himself.
▪ Can he play sport?
○ Of course. I would like to assure you that there is no reason why Roger cannot play most sports. However, you should remember that his insulin dose needs to be adjusted prior to partaking in the sport since there would be increased glucose metabolism with physical activity. But again, I would like to emphasize that we should allow Roger to lead a normal life and enjoy activities as much as possible.
▪ Do you have any other queries at this point? I would give you some reading materials about Diabetes for your further insight. When he gets discharged, I will also give a letter to his GP so he can regularly follow you up.
KEY ISSUES
▪ Ability to answer the specific questions of the parent accurately and sensibly
CRITICAL ERROR
▪ Failure to discuss symptoms and treatment of insulin-induced hypoglycaemia
IMPORTANT POINTS FROM THE COMMENTARY
▪ The scenario is designed to assess both the knowledge of the topic and the candidate’s ability to provide accurate information in a reassuring manner to a parent who is trying to cope with a diagnosis, which to most parents is initially devastating and upsetting.
▪ The emphasis in many of the answers should be allowing the child to lead as normal a life as possible, so that school and social activities should be maintained wherever possible.
Baby Helen is brought to see you in a general setting, as her mother is concerned about her continuing jaundice. Helen is now two weeks old and was born at term by easy vaginal delivery weighing 3.7kg. APGAR scores were 9 and 10 (at 1 and 5 minutes respectively).
She became jaundiced in the neonatal period starting on day three. Investigations then revealed no blood group incompatibility, both mother and baby being group O positive and no red blood cell (including enzymes) abnormality. The infant was treated with phototherapy for two days. Since discharge from hospital at eight days of age the jaundice has persisted and the mother is concerned. Baby is feeding well from the breast. Current weight is 3.9kg.
Examination findings
The baby was active and clinically normal apart from the jaundice when you saw her yesterday. You arranged investigations as set out below. The mother has now returned with the baby to discuss the results and your advice about treatment.
Investigation results
Serum bilirubin Total: 250 umol/L
Conjugated Less than 10umol/L
Neonatal thyroid screening Normal
Urine culture Sterile
Full blood examination normal
TASKS
1. Obtain any further necessary history you require. You should not take more than 2-3minutes to do this.
2. Discuss the results of investigations with the mother.
3. Explain the diagnosis to her and advise about future management
APPROACH
▪ Congratulations again on becoming a new mother. Helen is a very beautiful child.
▪ I understand that you are concerned about Helen’s skin, and is here to discuss Helen’s lab results with me. But before we talk about it, is it alright if I ask you a few clarifying questions to help me assess her further?
▪ HISTORY
○ Is she your first baby? How is her general health so far?
○ Well Baby Questions
§ Is he crying too much, sleeping too much or difficult to wake up?
§ How is he feeding? How many feeds has he been taking for the past few days?
§ After every feed, did he produce a wet nappy? How many wet nappies have you changed so far? Any changes? Is it foul smelling?
○ Rule out sepsis and conjugated hyperbilirubinema symptoms
§ Any fever, rash, vomiting, and lethargy?
§ Have you noticed any fast breathing? Has he been breathing harder than the usual?
§ What’s the color of his stools and urine? Has it turned dark or pale colored?
○ Did she have a heel prick test done?
○ Mother
§ How is your general health so far? Are you taking any medications? Do you smoke, drink alcohol, or engage in recreational drugs?
§ Do you enjoy your motherhood so far?
▪ DISCUSS INVESTIGATION RESULTS
○ There can be several factors that could have led to the yellowish skin color of your child, and medically we call it as jaundice, that is why we ran some investigations to identify what is causing this. Infections can be ruled out as the full blood examination and urine culture tests turned out to be normal. Thyroid conditions can also be ruled out because the thyroid neonatal screening turned out to be normal as well. However, we can see here that the serum total bilirubin is increased. Bilirubin is a pigment in the baby’s blood which is usually absorbed by the body in the gut. However, in some conditions there seems to affect its absorption, making it accumulate and deposit in the skin and some organs, causing it to manifest as a yellowish tinge in the skin. There can be several causes of it–like a blood disorder or anything that causes obstruction in the part of the gut which tend to prevent this bilirubin absorption. In your baby’s case, the conjugated bilirubin is low, which means we can easily rule out the conditions causing obstruction in the gut, and point our diagnosis towards the blood-breakdown related or absorption causes of jaundice.
▪ DIAGNOSIS AND FUTURE MANAGEMENT
○ However, based on the history and examination findings, most likely she has a condition called, breast milk jaundice. Have you heard about it? Sorry for the medical terms but let me explain the condition to you. There are some factors within the breast milk that increases the absorption of the pigment in the blood called bilirubin in the baby’s gut, and accumulation of this pigment then causes the yellowish tinge in your baby’s skin. It is a benign condition and does not require treatment. I can tell this because your baby is gaining weight well, feeding well, and active, and she has normal physical examination findings except for her yellowish skin. Just as your baby is still developing, her organs are also still adjusting to the milk that you give her, and in time as she grows more, she will then eventually be able to metabolize/digest/use this pigment and subsequently the yellowish tinge of her skin will disappear.
○ There is nothing wrong with your breastmilk, and you can continue breastfeeding. It can persist for as long as three months of age, but the baby will remain active and gain weight. We can confirm the diagnosis by temporarily suspending breastfeeding for 24-48 hours which results in the fall of the bilirubin levels in the body. After which, the breastfeeding can be continued.
○ During the time of this temporary suspension, please express your breastmilk in order to maintain lactation. I can refer you to the lactation nurse who can teach you more about this method.
○ However, if you will see that the jaundice is progressing, where it already includes her palms and the soles, or if she becomes overly sleepy or irritable, or if not feeding well, please report back immediately so that we can check her again.
○ I will arrange regular reviews with you to check for Helen’s progress.
○ Here are some reading materials that I can give you to give you more insight to your child’s condition and about breastfeeding. Do you have any questions?
KEY ISSUES
▪ Establishing that urine and stools are of normal color
▪ Accurate interpretation of important pathology results
▪ Reassurance to the mother that her milk is not harmful to her baby
▪ Accurate explanation of the possible causes of jaundice and logically excluding other important diagnoses
CRITICAL ERRORS
▪ Not appreciating the significance of predominant unconjugated hyperbilirubinemia and insisting that the baby has biliary atresia or hemolytic disease
▪ Insisting that the breastmilk is unsatisfactory for the baby and recommending permanent cessation of breastfeeding
IMPORTANT POINTS FROM THE COMMENTARY
▪ Jaundice very common affecting at least 50% of full term babies, and a significantly higher proportion of premature infants
▪ Physiological Jaundice
○ Adaptation process to the extrauterine life that takes some days to mature
○ Resolves by end of the first week in term infants
○ Up to 10 days to a fortnight in preterms
○ Usually appears on day three on term infants, and late day two in preterms
▪ Pathological jaundice = appears within 24 hours of life
○ Hemolytic process (ABO incompatibility) = most common cause
§ Hereditary spherocytosis
§ G6PD
§ RH isoimmunization - usually known prior to birth due to screening
▪ Prolonged jaundice
○ Conjugated vs unconjugated = determined by blood levels
○ Breast milk Jaundice = unconjugated, but should only be considered as a diagnosis by exclusion
§ CLIN FEAT (MUST BE ASKED IN HISTORY)
□ Babies are breastfed, thriving, gaining weight well
□ Bowel motions and urine are normal in color
§ PE is entirely normal except for jaundice
§ Benign, requires no treatment except explanation and support
§ Breastfeeding SHOULD NOT BE INTERRUPTED, although it is usually interrupted to confirm diagnosis
□ This is rarely necessary and tends to give a wrong message to young mothers that their breast milk is harmful to the infant
§ Cause is unknown, but it is thought to be due to a factor in the breast milk that causes increased enteric absorption of bilirubin.
§ Jaundice may persist for up to three months, but baby thrives and remains well
Benjamin, a 14 month old boy has been brought in to the hospital Emergency department by his parent following as episode at home the previous evening. His parent explains that he had been unwell all day with a high fever (40C), and while he was being cuddled, he was staring and did not respond to his name. They noted that his body twitched all over for several seconds and the whole episode lasted 60 seconds. He then went off to sleep and slept for the rest of the night.
Examination findings
Benjamin is alert and normal neurologically. He has a low grade fever and sings of an upper respiratory tract infection.
TASKS
1. Take any further history to ascertain the most likely cause for this episode.
2. Explain your diagnosis and subsequent management to the child’s parent.
APPROACH
▪ I understand form the notes that you are worried about Benjamin because he had a twitching episode last night. Can you tell me more about it?
▪ Okay, I understand that he also had been unwell all day with a high fever, he had a period of staring and unresponsiveness, then the twitching episode came which lasted for about a minute, but he seems to be better now.
▪ Is this the first time this kind of episode happened? Has he ever had this episode without the fever? Did you notice any abnormal behavior before the twitching episode happened? Was it a generalized twitching episode? Did he have any injury to the head?
▪ Well Baby questions:
a. Mental state of the baby: has he been really irritable, or has been hard to wake up?
b. Eating/Drinking: has he been eating and drinking fine?
c. Wet nappies: Has he not been producing wet nappies for the last 8 hours? (very dehydrated), change in the number of wet nappies?
▪ Rule out risk factors for epilepsy:
a. Birth history
i. Antenatal: what was your age when you had your child? Did you have any infections or any medical condition during pregnancy? Did you take any drugs or medication, or had any trauma?
ii. Delivery: was he a term baby? What is the mode of delivery? What is the reason for the mode of delivery? Did he require resuscitation or did he cry immediately after birth?
iii. Postpartum: did he spend any time in special nursery? Was heel-prick test done?
b. Developmental history
i. How do you think he is growing compared to kids of his age group? Are you concerned about his development when you compare him with kids of his age group?
c. Family history
i. Do you have a family history of epilepsy? How about a family history of febrile convulsions?
▪ Closure
a. Immunizations: Is the immunizations up to date?
b. Nutrition: is he breastfed or bottle-fed? When did you start weaning? Any concerns about it?
c. Social history: Does the child have any siblings? Do they have the same symptoms? Any family member with the same problem?
d. Medications: Do you give your child any medications?
e. Allergies: Does he have any allergies?
f. Past history: Does he have any previous medical or surgical illness?
▪ From the history, most likely the episode that happened last night is a simple febrile convulsion. Do you have an idea what this is? A febrile convulsion is a fit or seizure caused by a fever. They are caused by a sudden change in your child’s body temperature and are usually associated with a fever above 38°C. Almost always, the fever is caused by a viral infection, which would usually manifest as an upper respiratory tract infection in adults, but in children, their brain is immature so it is susceptible to effects of high fever. This is a common reaction to fever in children, about 3% of the population have a seizure associated with fever. This condition commonly runs in families, as in your case wherein your sister had episodes of febrile convulsions in her childhood.
During a febrile convulsion, your child will usually lose consciousness, their muscles may stiffen or jerk, and your child may go red or blue in the face. The convulsion may last for several minutes but when the movements stop, your child will regain consciousness but will probably remain sleepy or irritated afterwards.
Remember that during a convulsion, there is nothing you can do to make the convulsion stop. The most important thing is to stay calm and don’t panic. Place your child on a soft surface, lying on his or her side or back. Do not restrain your child and do not put anything in their mouth, including your fingers. Try to watch exactly what happens, so that you can describe it to the doctor later and time how long the convulsion lasts. Do not put your child who is having a convulsion in the bath. After the first twitching episode, there is a 30% chance of recurrence especially in the first 24 hours. Do not give your child any medication, except Panadol for the fever along with tepid sponging to bring the fever down.
Do not stress yourself, this is generally a benign condition and the convulsions do not cause brain damage nor cause an increased risk for subsequent epilepsy.
However, if the convulsion lasts more than five minutes or your child does not wake up when the convulsion stops or if your child looks very sick when the convulsion stops, please see your GP immediately or go the ED. Do you have any questions at this point?
KEY ISSUES
▪ Appropriate questioning and history-taking.
▪ Appropriate education and reassurance.
▪ Advice on preventive measures.
CRITICAL ERROR
▪ Suggesting on the strength of this episode of a brief febrile convulsion that he has epilepsy.
IMPORTANT POINTS FROM THE COMMENTARY
▪ The dominant cue is the recognition of the change in sensorium in this child while he has a high fever. Pattern recognition leads to the likely diagnosis and should allow the candidate to make a definitive diagnosis.
▪ The scenario tests not only knowledge of a common condition, but also skill in being able to impart a logical explanation in language that the parent can understand without causing alarm. It also requires reassurance and confidence in the diagnosis.
▪ While epilepsy may be raised as a possibility, the clinical features at the time, the normal appearance of the child when examined and absence of risk factors, make this highly unlikely at this stage. The candidate should therefore recognise this as a simple febrile convulsion with an excellent prognosis.
▪ A simple febrile convulsion is a common condition and candidates must be aware of risk factors that would suggest an alternative diagnosis of epilepsy should be considered: prolonged convulsion lasting greater than 15 minutes; a focal element to the seizure; a family history of epilepsy; or abnormal neurological behaviour in the child prior to the seizure. Any of these features would throw doubt on the diagnosis of simple febrile convulsion. None of these features is present in this child and hence the diagnosis is clearly most likely to be a simple febrile convulsion.
You are seeing a 6-year-old boy, Jonathan, for the first time with this mother, who complains how active he is. He is in his second year at school, and his teacher has commented that he is disruptive and loud in class.
TASKS
1. Take a focused history from the mother to determine the possible causes for the child’s presentation
2. Indicate to the mother your probably diagnosis and a brief plan of management.
APPROACH
▪ I understand that you are here with Jonathan as he has certain behavioral concerns in school. Can you tell me more about it?
▪ HISTORY OF PRESENTING CONDITION (MIX WITH SOCIAL HISTORY)
○ What do they mean about being “active, disruptive, and loud”? What exactly is his behavior?
○ Since when was he noted to be this way?
○ Is this kind of behavior only observed in school or is it also noted in other places as well?
○ When did he start school for this year (rule out separation anxiety at home)
○ Is he bullied in school?
○ What interventions has been done in the class? How did Jonathan respond to it?
○ How is his academic performance?
○ ATTENTION QUESTIONS
§ Can he give you his full attention when you call him?
§ If he gives you this attention, can he maintain it for a long time?
§ Can he concentrate on what he is doing?
§ Does he like to do homework?
§ Can he finish his task?
§ Is he often forgetful?
○ HYPERACTIVITY QUESTIONS
§ Can he stay still on his chair when you eat a meal? Or can he stay still on his chair when asked to?
§ In the supermarket (or other scenarios), can he wait for his turn when in a line?
§ Is he talkative?
§ Does he often interrupt others when other people are talking?
§ Is he sleeping well? How many hours does he sleep in a day?
§ Do you think he is aggressive towards other kids?
○ HOME SITUATION (add confidentiality statement if patient is initially uncooperative)
§ How is he at home? Who does he live with? How is his relationship with others? How is the relationship of the family members to one another?
§ Are there recent changes in your home situation?
§ How about you and your partner, how is your relationship with one another?
§ Can you say that you are a generally a happy family?
○ R/O DDX
§ Any concerns about his vision and hearing? Has he ever done any formal vision or hearing assessments?
§ Any episodes of staring blanky or day dreaming?
§ How is his general health? Any previous history of trauma to the head, fever, cough, colds, ear pain?
○ BINDS
§ BIRTH: Any complications during your pregnancy with him? Have you taken any medications during your pregnancy with him (r/o meds that may cause deafness in utero)? Any concerns during his delivery? Was a hearing test done on him?
§ Immunisations up to date? (if not, I will arrange another review with you to address this issue)
§ Nutrition: Does he often eat meat, green leafy vegetables, nuts, fruits?
§ DEVELOPMENT: Do you have any concerns about his growth and development compared with other children? At his age, can he speak full sentences and express himself thoroughly?
§ Social History*** (already asked)
○ Any previous history of other medical or surgical illnesses? Does he take any regular medications? Does he have any allergies?
○ Any family history of a similar problem, behavioral, or mental health problems? Medical or surgical illnesses?
▪ EXPLANATION AND FURTHER MANAGEMENT
○ From history, it seems that most likely your child has a behavioral disorder. The condition which most commonly presents this way is Attention Deficit Hyperactivity Disorder or ADHD. I still need to confirm it that is why I will refer him to the specialist for further assessment. They will consider checking his vision and hearing, and they might consider doing something called psychosomatic testing best done by a specialist child psychologist. They will send questionnaires to the family and to the school to try and figure out that he is exhibiting this behavior both in school and at home. This might take several months of observation and assessment of your child before a certain behavioral condition is diagnosed. But do not be stressed about this, as we will continually provide you support, and arrange regular reviews with your child throughout the way.
○ Once it is confirmed, he will be started on behavioral modification therapy. These are classroom strategies to help with his learning and improve his concentration span. The specialist might also consider starting him on medications to stimulate the areas in the brain for impulse control and concentration (RITALIN, methylphenidate). These medications may have certain side effects like nausea, vomiting, rash, but the specialist will taper the dose which is appropriate to the weight and age of your child to minimize the occurrence of these side effects.
○ We have a lot of support available for you and your family. If you need one, I can refer you to a counselor/centerlink/etc.
○ For now I will also arrange basic blood investigations for him just to rule out other possible causes of this change in behavior, which would include an FBE, UEC, ESR/CRP. I will arrange another review with you once the results are available. If he ever develops nausea, vomiting, headache, ear pain, please report back to me so that we can check him again. Here are reading materials that I can share with you to give you more insight about your child’s condition.
○ Do you have any questions?
KEY ISSUES
▪ Obtaining a logical and focused history to exclude various possible causes for Jonathan’s behavior
▪ Showing empathy with the parents’ frustration
▪ Having a clear approach to the management plan
CRITICAL ERRORS
▪ Coming to a premature conclusion of ADHD and recommending stimulant medication, without having explored the history for other causes
IMPORTANT POINTS FROM THE COMMENTARY
▪ Important history points
○ Past history
○ Current developmental status
○ Family and school situation
▪ Monitoring progress OVER SEVERAL CONSULTATIONS may be required to give a positive diagnosis of ADHD
▪ Majority of children presenting this way have MAJOR FAMILY DYNAMICS PROBLEMS
○ However, the current scenario is designed to indicate that a diagnosis of ADHD is by EXCLUSION of all other causes for this symptom
○ Stimulant medication is NOT THE IMMEDIATE TREATMENT NEEDED
○ The doctor is often under great pressure to prescribe these medications at first visit and this should be resisted
▪ No specific tests available to make a diagnosis of ADHD
○ Diagnosis is made from the pattern of behavior, confirmed by psychometric testing
○ Parents often already arranged this prior the consultation, and often tried a variety of exclusion diets which may be helpful, but overall are not
▪ Support parents when they are trying exclusion diets if they are keen to institute them, but you should monitor progress and make a critical appraisal as to the success or otherwise of this treatment and support the parent accordingly.
You are working in a general practice. A 4-year-old boy has been seen with his mother. He was taken to another doctor with a cold whilst the family were on holidays and a soft cardiac murmur was heard. His parents were asked to bring him to see the family doctor, to decide if anything further needs to be done. His general health and exercise tolerance are excellent and he is on the 50th centile for height and weight. He has never been cyanosed. There is no history of heart disease in the immediate family but a cousin had a hole-in-the-heart operation. His parents feel he has no concerning symptoms. On examination you have confirmed a soft vibratory mid-systolic murmur (grade 2/6) located between the lower left sternal edge and the apex, which varies with respiration. Full physical examination is otherwise completely normal. You have finished your history-taking and examination and are about to discuss things with the child’s mother.
TASKS
1. Explain your diagnosis and further management to the child’s mother.
APPROACH
▪ I understand that you are concerned about your son as a soft cardiac murmur was heard on examination by the other doctor. Is it alright if I confirm some information with you?
▪ When you took him to the doctor when he had a cold, did he also have fever at that time?
▪ Are there any problems with his growth and general health?
▪ Is he able to perform his activities well and able to tolerate exercise?
▪ Did he ever had episodes where his skin turned blue?
▪ Was he ever diagnosed of a heart disease?
▪ Is there a history of heart disease in the family?
▪ From the history and examination, most likely the extra heart sound or murmur that is heard on your child is what we call an innocent murmur.
▪ A heart ‘murmur’ is a sound heard when listening to the heart with a stethoscope. It occurs between, or in addition to, the normal ‘heart sounds’ and results from some turbulence (‘eddies’) resulting from the flow of blood through, or close to, the heart. Murmurs are sometimes described as “whooshing noises” produced with each heart beat.
▪ Whilst some murmurs can indicate the presence of a heart abnormality, the commonest murmurs are not due to any heart problem at all. These so-called ‘Innocent murmurs’ are detected in many normal children. They result from minor turbulence in the flow of blood, which occurs in entirely healthy children and even in adults.
▪ This is most likely because there are no concerning signs and symptoms present in your child. He is within the normal growth percentile, his general health is good, he is able to tolerate exercise well, he had no previous episodes of turning blue, and his physical examination is all normal. Also the characteristics of the murmur that is heard which are soft with no diastolic component, varies with respiration and is only heard on part of the chest all points more to a functional or innocent murmur.
▪ During that time that you took him to the doctor while he was having a cold and fever, the murmur was easily detected because innocent murmurs are often rather louder, and hence more easily detected, during an illnesss associated with a raised temperature (fever). As the heart works harder when the body temperature is high, this makes the turbulence in blood flow increase and the murmur is louder.
▪ If you would prefer, I could arrange for a chest x-ray and ECG which is unlikely to show any abnormality which may be reassuring for you.
▪ If you would still prefer, I could also refer you to the specialist who might consider doing an echocardiography.
KEY ISSUES
▪ Ability to assess confidently the features of an innocent heart murmur.
▪ Avoidance of unnecessary extensive investigation.
IMPORTANT POINTS FROM THE COMMENTARY
▪ Cardiac murmurs in young children are very common. It is estimated that careful auscultation under ideal circumstances will detect an innocent soft murmur in over 50% of normal four-year-olds. Hence medical facilities would be overwhelmed if all of these murmurs were referred for specialist assessment.
▪ Primary care physicians should be confident in distinguishing innocent functional murmurs from those that are associated with an organic heart lesion.
▪ Rheumatic fever in our community is unusual these days unless practising in areas where large numbers of Aboriginal or Torres Straight Islander peoples are treated.
So the usual task is to differentiate an innocent murmur from one due to an organic heart lesion, most likely of congenital origin.
You are asked to see an infant, Jessica, born 24 hours ago, for jaundice. She is the first child of a healthy mother, whose pregnancy was normal. Delivery was at term, by a midwife, and was uneventful. The infant weighed 3700 grams at birth. Jaundice was noticed soon after birth, within the first 24 hours. The infant has been sucking well at the breast. The mother wants to go home as soon as possible.
Examination Findings
The infant is clinically jaundiced but otherwise well and active with no hepatosplenomegaly or other abnormal physical signs
You have obtained all relevant findings on history and examination.
TASKS
1. Ask the observing examiner for results of any investigations you consider necessary
2. Advise the parent on diagnosis and management
APPROACH
▪ Congratulations on having your baby. What a beautiful baby girl!
▪ I understand that you really want to go home right now, and that your Obgyn may have said that you could immediately go home after your delivery. However, I am just really concerned about the progressive change in Jessica’s skin color since she was born. Have you noticed this yellowish tinge in her skin? In some cases, this could be a sign of certain conditions that we need to catch earlier on to be able to treat it well to avoid life-threatening consequences for the child. That is why we ordered some investigations to identify certain conditions that could explain this. Will it be alright with you if I go check on the results of her blood works first, just to ensure that everything is okay with her, and then we’ll see how we can manage Jessica from there?
▪ Examiner, I would like to know the results of the following investigations: Blood typing with RH typing for both the mother and the child, Direct coombs test, Full blood examination, peripheral blood smear, total bilirubin and conjugated bilirubin levels
○ INVESTIGATION RESULTS
○ Mother’s blood Group O Rh positive
Infant’s blood Group A Rh positive
Direct coombs test Strongly positive
Infant’s Hb 170g/L
Blood film/Peripheral blood smear Microspherocytes
Bilirubin (Total) 250 umol/L
Bilirubin (Conjugated) 6 umol/L at 24 hours
○ Feedback from biochemist: this is abnormal, but below the range at which exchange transfusion is indicated
▪ ADVISE ON DIAGNOSIS AND MANAGEMENT
○ I got her blood results back, and based on history and examination and these results, it seems that most likely Jessica has got a condition called ABO INCOMPATIBILITY. Sorry for the medical jargon, but let me explain this to you.
○ [ILLUSTRATE] The red blood cells in our blood got a special protein in their surface called antigens, and we have special proteins in our body called antibodies which help fight off infections. Your blood group is O positive, and in people with O+ blood group, they have no antigens in the surface of their RBCs, whereas they have ANTI-A and ANTI-B antibodies which are the proteins that fight off against infections or foreign RBCs. Your baby has got A+, and it has A antigen, and ANTI-B ANTIBODIES. Now sometimes during the third stage of labor or during delivery, there is silent exchange of blood between the mother and the baby, Now since you got antibodies (Anti-A) which reacted to the baby’s antigens (A antigens), that lead to the breakdown of the RBCs of your baby, leading to the accumulation of a pigment which causes Jessica to become jaundiced.
○ Unfortunately, this is a serious condition, because if it is left untreated, this pigment can damage the baby’s brain, leading to long term neurological deficits, hearing impairment, learning disabilities, and mental retardation, a condition called kernicterus.
○ I’m afraid that you may not be able to go home right now, as she needs to be admitted in the hospital to receive urgent treatment to avoid all these complications. I will refer her to a specialist who order a treatment called phototherapy, where we will keep Jessica under a special type of light which will help in excreting this pigment from the body through her urine and feces. It can be done in a room where you can also stay in the hospital so that you can conveniently feed her as well.
○ There are some side effects of this treatment, first is retinal and genital damage that’s why we are going to cover her eyes and her genitals while we do the treatment. The second complication is dehydration, that is why we will make sure she’s under the lights only when she’s sleeping, and not during feeding. Third, green colored stools may be noted, which can suggest that the treatment is working and that she’s removing the pigment from her body already. It
○ If this treatment is given immediately, most babies recover well from the condition, and it has an excellent prognosis.
○ We’ll continuously monitor her pigment levels (bilirubin levels) in her blood. If this levels keeps going up despite this treatment, we’ll consider other treatment modalities called exchange transfusion, where we will try to exchange the baby’s blood with a fresh blood.
○ I can only imagine how distressing it is for you to be here and to see your child this way. We will be here for you and give you support, and rest assured we will do all that we can to look after Jessica the best way we can.
KEY ISSUES
▪ Recognition of hemolytic disease of the newborn and its immediate treatment
▪ Empathetic but realistic communication with the new parent
▪ Ability to relate to mother’s disappointment with need for medical intervention
CRITICAL ERRORS
▪ Failure to recognize hemolytic disease of the newborn and failure to advise phototherapy
IMPORTANT POINTS FROM THE COMMENTARY
▪ Dominant cue in this case: neonatal jaundice in the FIRST DAY OF LIFE
○ Indicates a PATHOLOGICAL AND POTENTIALLY DANGEROUS rise in the bilirubin levels
▪ Hemolytic disease is the most common cause of potentially dangerous neonatal jaundice.
○ Jaundice on the FIRST DAY OF LIFE is hemolytic UNLESS PROVEN OTHERWISE
○ Readily treatable, complications avoidable
○ Early diagnosis is MANDATORY
○ Hyperbilirubinemia is likely to reach a maximum level around the third day of life
▪ Seek evidence confirming the existence of hemolysis and defining the degree of hyperbilirubinemia
○ Hepatosplenomegaly may or may not be present
▪ CRUCIAL lab tests: blood grouping of mother and the infant, and direct coombs test
○ Positive direct coombs = CONFIRMS that the infant’s red cells have been sensitised by antibodies and establishes diagnosis due to an ABO incompatibility
▪ Deciding further management depends on estimation of SERUM BILIRUBIN LEVELS (direct and indirect).
○ BILIRUBIN - derived from the catabolism of heme proteins produced in the breakdown of red blood cells
§ Unconjugated (indirect) bilirubin - converted in the liver to the Conjugated (direct) bilirubin, and is excreted into the bile.
§ Conjugated is NOT reabsorbed once it enters the intestinal tract.
□ Thus in THIS CASE SCENARIO, the level of bilirubin is INSUFFICIENT to warrant an exchange transfusion, but the level of unconjugated hyperbilirubinemia exceeding 240umol/L confirms the need for PHOTOTHERAPY
▪ DEGREE of hemolysis should be defined by measuring the INFANT’S HEMOGLOBIN
Your next patient is baby Laura brought by her mother to a general practice at six weeks of age, as part of routine postnatal follow-up. Laura is the couple’s first child. The baby is breastfed and gaining weight normally. Her mother wants to know what you would advise about immunisation because she and her husband have recently heard conflicting views expressed in the media. General examination of the baby reveals no abnormality. She was given her first hepatitis B vaccination soon after birth.
TASKS:
1. Outline the current immunisation protocol you would recommend and what diseases the programme is protecting against.
2. Discuss any concerns the parents have about immunisation.
You will not be expected to take any additional history or ask for examination findings.
APPROACH
▪ I appreciate that you have come to discuss about it, what do you know about immunization?
▪ I will be explaining to you what immunization is. If you do not understand anything along the way, please don’t hesitate to stop me and ask.
▪ We have white blood cells in our body which fights against infections. Whenever there is an infection by the bug, these cells release some chemicals called antibodies that will kill the bug. However, this process takes a long time. By the time your body have produced these antibodies, the bug has already caused substantial damage to the body. There are also special type of white blood cells called memory cells, which are specially-trained white blood cells which can recognize infection by the same bug when infected in the future. So, if the child gets infected by the same bug in the future, the memory cells are already trained to attack them immediately. This is the type of cell which we utilize when we do immunizations. What we is we introduce a weakened bug or parts of the bug which are chemically treated, to the child at regular specific intervals, so that the child’s white blood cells will be trained to act against the bug if he encounters it in the future. This is what we call as vaccines. Please do not be stressed, the vaccines are not harmful as the bugs injected are chemically treated and only produce a mild response in the body, just enough for the body to produce antibodies and not the full blown infection.
▪ Immunization is offered at certain times starting at birth and then at 2, 4, 6, 12 and 18 months. Later doses are usually at preschool age. Usually, more than one dose is required for complete protection. With the development of immunization program in majority of the countries of the world, a number of serious and lethal disease have been eradicated. That is why, immunization is recommended for all children all over Australia. Within the government’s program, the diseases that are covered are chickenpox, rotavirus that produces diarrhea, Hib, polio, infections like measles, mumps, and rubella, hepatitis B, pneumococcal vaccine that prevents respiratory and brain infections, meninggococcus vaccine that prevents against brain infections and DPT vaccine that prevents against whooping cough, tetanus, and diphtheria or grey membrane infection of the throat.
○ At birth: Hepatitis B (hep B)
○ At 2 months and 4 months: Acellular diphtheria, tetanus, pertussis (DTPa); H.influenzae type B (Hib); oral or inactivated polio vaccine (O/IPV); hepatitis B (hep B); 7-valent pneumococcal conjugate vaccine (7VPCV)
○ At 6 months: Acellular diphtheria, tetanus, pertussis (DTPa); oral or inactivated polio vaccine (O/IPV); (hepatitis B [hep B] in NSW, QLD, SA. NT); 7-valent pneumococcal conjugate vaccine (7VPCV)
○ At 12 months: Measles, mumps, rubella (MMR); H.influenzae type B (Hib); meningococcus (MenC): (hepatitis B [hep B]) in VIC, WA, TAS)
○ At 18 months: Varicella zoster virus (VZV); 23-valent pneumococcal polysaccharide vaccine (23VPPV)
○ At 4 years: Acellular diphtheria, tetanus, pertussis (DTPa); measles, mumps, rubella (MMR); oral or inactivated polio vaccine (O/IPV)
▪ As you know, all medications have side effects. Majority of vaccines have a few insignificant side effects like local skin reaction (pain, redness, and swelling of the skin), sometimes especially with DTPa the child can develop high-grade fever, but we usually give antipyretics half an hour before the vaccine to prevent that. This side effect is sometimes accompanied by excessive, inconsolable high pitched crying (because of pertussis component). But do not be too stressed, the side effects are rare and with the use of acellular pertussis vaccine, these side effects have been minimized.
▪ There are some contraindications for these vaccines. Absolute Contraindications include encephalopathy or a neurological illness within seven days of a previous DTP-containing vaccine or an immediate severe or anaphylactic reaction to vaccination with DTP. A simple febrile convulsion or pre-existing neurologic disease are not contraindications to pertussis vaccine. Children with minor illnesses, i.e. without systemic illness and providing the temperature is less than 38.5 “C, may be vaccinated safely. With a major illness or a high fever, the vaccination should be postponed until the child is well. Live vaccines (MMR, oral poliomyelitis, rubella, chicken pox) should not be administered to immunocompromised patients like a child with HIV, on chemotherapy, or on treatment with high-dose steroids (>2mg/kg) for more than 2 weeks. An anaphylactic reaction to egg is not a contraindication to MMR vaccine, but many authorities recommend that in such a case it should be administered in an area where resuscitative equipment is available and the child be observed for 4 hours.
Patient questions:
▪ Is it true that MMR vaccine is related to Autism?
○ There have been a report of association of measles vaccination with autism. However, no association has been convincingly demonstrated and several studies show no link at all between these.
▪ I have heard a lot about homeopathic vaccination.
○ Up till now, there has been no evidence within the medical literature that supports efficacy of homeopathic vaccination. However, the decision is still yours.
▪ What if I travel in between and my son misses a dose?
○ There is a special catch-up schedule for children who have missed their doses or who come to Australia from overseas.
▪ I am going to give you written material that will tell you exactly when to bring the child for each vaccination. It is important to maintain a record for your child (blue/yellow book).
KEY ISSUES
▪ Knowledge of basic principles of current immunisation regimens.
▪ Explanation and accurate information regarding benefits of immunisation
▪ Exploration of parental concerns.
CRITICAL ERRORS
▪ Candidate provides wrong advice regarding contraindications to immunisation.
▪ Recommendation or acceptance of sublingual homoeopathic vaccines.
IMPORTANT POINTS FROM THE COMMENTARY
▪ This scenario is concerned with counselling a young mother on the advantages and disadvantages of immunisation. This requires of candidates a sound knowledge of the topic and an ability to give the information to the parent in a manner that gives a balanced overview, without domineering with their own personal feelings.
This is a very common situation in general practice where patients will often attend to discuss with the doctor, beliefs they have, or to seek further information on a topic. Doctors should not hesitate to admit that they do not know a particular answer but should offer to seek the answer and communicate it at a later date.
▪ Updated immunisation schedules such as the one illustrated are available from paediatric hospitals.
▪ Candidates should be aware of the absolute contraindications to the standard vaccinations and also the false contraindications which are so often quoted.
A five year old boy is brought to the emergency department because of swelling around the eyes. He has only been passing small amounts of urine, which is dark in color. In the past 12 hours, he has become restless and irritable.
The child had school sores (impetigo) three weeks ago, treated successfully with a topical antibiotic cream, but has had no other prior illnesses.
Both parents are well. The child is an only child and has always kept in good health.
TASKS
1. Ask the examiner for the relevant physical exam findings you wish to elicit
2. Discuss with the parent your provisional diagnosis
3. Advise details of any investigations that are required and advise the parent of the treatment that will be needed.
You do not need to take any further history.
APPROACH
▪ PHYSICAL EXAMINATION
○ GA: pallor, jaundice, lymphadenopathy, edema (where exactly is the edema present? Involving which parts of the body? Periorbital edema/pretibial-thyroid/bipedal), signs of dehydration (CRT, moist lips and oral mucosa, skin turgor), rashes?
○ GROWTH CHART
○ VS: BLOOD PRESSURE with Postural Drop*, pulse, RR, O2 sat, temp
○ ENT: fundoscopy (papilledema?), periorbital edema? Nasal/pharyngeal congestion? Exudates on the posterior pharyngeal wall (r/o strep throat), palpable thyroid, tenderness? Any carotid bruits or thyroid bruits?
○ CVS: heart sounds distinct? murmurs?
○ Respi: Breath sounds? Any crackles (pleural effusion)?
○ Abdomen: any visible masses or striae? Ascites present?
§ Masses, tenderness (liver edge palpable)?
§ Kidney ballotable?
○ Back: costovertebral angle tenderness?
○ Genital exam, with consent: check for scrotal edema as well
▪ OFFICE TESTS: Urine dipstick (blood and protein), BSL, 12L ECG
▪ RELEVANT PHYSICAL FINDINGS TO BE GIVEN TO THE CANDIDATE ON REQUEST
○ Resting blood pressure: 145/90 mmhg, no postural hypotension
○ Temperature 36.5C
○ Pulse: 90/min, regular
○ Periorbital edema: no edema elsewhere, no ascites or pleural effusions
○ Cardiovascular system: normal
○ Liver edge: palpable just below the costal margin
○ Optic fundi: normal
○ ENT examination: normal
○ Urine dipstick: Strongly positive (++) for blood and protein
▪ EXPLAIN PROVISIONAL DIAGNOSIS and MANAGEMENT
○ From history and examination, it seems that most likely your child has a condition called Post-Streptococcal Glomerulonephritis. Sorry for using the medical terms, but I’ll do my best to explain these to you. Normally our kidney serves as the main filtering organ of our body, which tends to help us remove wastes such as urine, and also helps maintain our water and our salt balance. Sometimes, when the body is affected by any infection, like a skin infection as in your child’s case, the body tends to respond by creating factors in the blood that fight off these infections (antibodies). However for some unknown reasons, these antibodies also tend try to attack our own cells in the body. In your child’s case, the antibodies that fought off against the bug called streptococcus which caused the skin infection tend to have the propensity to attack the kidneys. Because of this, we could see blood in his urine manifested by his dark urine, and also a salt and water imbalance in his body causing decreased urination, retention of his fluids manifested by swelling of his eyes and high blood pressure. In medical terms, we call this condition as post-streptococcal glomerulonephritis.
○ This is not usually uncommon. But generally this condition has a good long term prognosis, and with the proper treatment that we’ll give now he will be able to recover well.
○ As of now he needs to be admitted in the hospital to where careful monitoring of his BP and urine output and intake of fluids will be done until his fluid balance in the body will be restored. He will be referred to a specialist who might do further investigations to confirm the diagnosis which includes blood tests such as UEC, Inflammatory markers such as C3,C4,ASOT, DNAse B, FBE, and urine samples fpr urine microscopy and culture.
○ Aside from that, strict fluid balance will be observed by restricting his fluid intake, measuring his daily weight, and having a low protein, low salt/high carbohydrate diet. He might also be given antihypertensive medications which will depend on specialist advise.
○ Once discharged, your GP would have to monitor your son’s blood pressure, renal function initially weekly, and then as needed as he recovers. Regular urinalysis will also be done to monitor the blood present in the urine as sometimes it may persist for even up to 2 years.
○ I can give you reading materials to give you more insight to his condition.
KEY ISSUES
▪ Diagnosis of acute PSGN
▪ Ability to specify appropriate plan of investigations
▪ Development of coherent treatment plan
CRITICAL ERRORS
▪ Failure to admit to hospital
IMPORTANT POINTS FROM THE COMMENTARY
▪ Scenario involves diagnosis, from clinical signs and appropriate investigations and an empathetic explanation of the treatment.
▪ Candidate should be able to arrive at the correct diagnosis, investigate, and treat appropriately. FAILING to do so puts the patient at risk!
Peter, a five-year-old boy is brought to you in a general practice setting by his parent with a fever of 40 °C that developed overnight. He complains of an intensely sore throat and finds it sore when he swallows food or fluid, although he is able to do so.
TASKS:
▪ Indicate to the examiner the clinical examination you would perform to diagnose the problem. The examiner will give you the results of the physical examination.
▪ Discuss with the parent any investigations you feel are necessary.
▪ Explain your diagnosis and suggest management to the mother.
You do not need to take any further history
APPROACH
▪ Doctor, I would like to know the physical examination findings of the child.
▪ What is the general appearance of the child? Is there any pallor, lymphadenopathy, rash?
▪ What are the vital signs? Temperature, blood pressure, respiratory rate, pulse rate
▪ What is the appearance of the tonsils? Is it erythematous and inflamed? Does it have exudates?
▪ What is the appearance of the pharynx? Is it erythematous?
▪ What is the appearance of the tympanic membrance? Is it red and bulging?
▪ Is there neck stiffness?
▪ CVS/Respiratory/Abdomen
▪ From my examination, most likely your child is having a condition called acute tonsillitis, probably due to a bug called streptococcus. But I still need to confirm this that is why I would like to arrange for a throat swab before we start with antibiotic treatment. A swab will be taken from your child’s throat to detect what bacteria is present which is causing the infection.
▪ Your tonsils are the two small pads of glandular (lymphatic) tissue located each side of the back of your throat. They are part of your immune system. They make antibodies and white blood cells (lymphocytes) to attack germs inside your mouth. This makes the tonsils part of your first line of defence against bacteria in food or air.
▪ Tonsillitis occurs when your tonsils become infected, and can be caused by either bacteria or viruses. In your son’s case, I suspect bacterial tonsillitis because he’s markedly unwell, and has tender, enlarged tonsillar lymph glands.
▪ The symptoms of tonsillitis include white or yellow spots of pus on the tonsils, sore throat – although some children complain of pain in their tummy rather than a sore throat, swollen lymph glands under each side of the jaw, pain when swallowing, and fever, as what is happening in your child.
▪ Tonsillitis can lead to a number of complications, including:
▪ Chronic tonsillitis which is the infection of the tonsils which does not clear up. The person may go on feeling unwell and tired
▪ Secondary infections because the infection can spread to the person’s nose, sinuses or ears
▪ Glue ear (otitis media) – the adenoids which are lymph nodes located in the throat behind the nose are part of the same group of lymph nodes as tonsils. When the adenoids swell up (usually when the tonsils are also large), they can block the Eustachian tube, which goes from the back of the throat to the middle ear. This is the thin tube that you push air along when you ‘pop’ your ear. If this tube stays blocked most of the time, sticky fluid forms in the middle ear which interferes with hearing. This is called a glue ear.
▪ Quinsy – if the infection spreads into the tissue around the tonsils, an abscess can form in the throat, also known as a peri-tonsillar abscess. This causes severe pain and can interfere with swallowing and even breathing.
▪ However, with appropriate treatment, acute tonsillitis should resolve completely. If the child doesn’t have any allergies to medications, I will prescribe an antibiotic (phenoxymethylpenicillin) for 10 days (or erythromycin if allergic). You can also give him paracetamol to relieve pain and fever. Please also give him plenty of fluids.
▪ Most children with tonsillitis do not feel well and it hurts them to swallow. Try cool drinks (cold drinks can hurt), ice blocks and ice cream. Don’t worry if the child stops eating for a day or two. Usually, they pick up quickly when the infection has gone.
▪ If he is more lethargic, can’t drink, doesn’t wee or starts vomiting, you need to go to the hospital. Otherwise, I will see you in 2-3 days to check up on improvement. If there is no improvement, the child needs to continue antibiotic for a total of 10 days to prevent possible complications, and we will proceed with investigations such as FBE, ESR/CRP, EBV serology to find out other causes of the child’s condition.
KEY ISSUES
▪ Appropriate examination interpretation, with appropriate diagnosis.
▪ Adequate treatment plan.
▪ Appropriate explanation.
CRITICAL ERRORS
▪ Failure to consider streptococcal tonsillitis as the diagnosis.
▪ Failure to discuss followup and screening for other conditions if there is no initial improvement.
IMPORTANT POINTS FROM THE COMMENTARY
▪ This scenario assesses the ability of the candidate to come to a logical conclusion as to the most likely diagnosis (acute bacterial tonsillitis) in this situation based on the information provided and knowledge of the natural history of disease processes.
▪ The scenario tests diagnostic acumen by showing how several conditions can be safely excluded because of the history and the time frame and gives scope to considering other diagnoses if the provisional diagnosis is not confirmed.
Mark, a five-year-old boy, is brought to see you in general practice setting, because for the past six weeks he has been soiling his pants, with increasing frequency, with foul smelling semifluid feces. It is now happening almost every day and he is being teased at school.
His parent cannot tell you much about his bowel habits as he now attends to his own toilet needs when he feels like it.
TASKS
1. Take a further focused history from the parent
2. Ask the examiner for the appropriate findings on examination of the child which would be relevant to your diagnosis
3. Explain your diagnosis to the parent and advise on management
APPROACH
▪ [if parent is not calm] I know you have a tough time washing all of Mark’s clothes, and I know you are very concerned about him. But before we do anything to him, I need to ask you a few questions first to assess him further, and then we can formulate a plan to help him. Will that be alright with you?
▪ [if parent is just ok] I can see from Mark’s notes that he’s been soiling his pants recently. Can you tell me more about it?
▪ HISTORY
○ Fecal incontinence
§ Since when is he soiling his underpants? How often? When did you first notice it?
§ How frequently does he usually open his bowels?
§ Can you describe to me how his poop is? Is it loose or hard stools? Is it associated with any blood or mucus?
§ Does he complain of any tummy pain or pain elsewhere (anal pain) while passing stools recently?
□ If yes, Pain questions
§ Does he have any previous episodes of constipation/hard stools/difficulty passing stools/pain during passing stools? Any previous history of diarrhea?
§ Is he toilet trained / I know he is toilet trained but did he have any similar problems before?
□ Did you have any difficulties during his toilet training before?
○ Associated features
§ Any nausea or vomiting or fever noted?
§ Problems with his water works? Is he dry at night?
§ How is his appetite? Any weight loss/weight gain?
○ BINDSMA
§ Birth (relevant): was he able to pass meconium (first stool) right after birth? / do you remember if he had delayed passage of his stools after he was born?
§ Immunization - not that relevant in this case.
§ Nutrition: What does his diet usually consist of? Does he take a lot of fiber, vegetables, and fruits? Does he drink a lot of water or not?
§ Development: any concerns about his growth and development?
§ School/Social: I’m sorry to hear that he’s been being teased in school because of this condition. Could you tell me more about it?
□ If not sharing, you can reassure by using a confidentiality statement
□ How long has this been going on?
□ What does he usually do to cope with this?
□ How is he as a student? Does he get along with his peers? Does he enjoy school?
□ How is your situation at home? Who else lives with Mark? How is his relationship with him? Any concerns at home?
§ Medications: does he take any medications or supplements?
§ Allergies: does he have any allergies?
○ PMH: Does he have any other medical or surgical illnesses?
○ FHx: Any family history of bowel conditions?
▪ PHYSICAL EXAMINATION
○ GA: PICCLED, does he look active/lethargic/withdrawn?
○ Growth Chart**
○ VS: temperature*, HR, RR, O2 sats
○ FOCUSED ABDOMINAL PE: any distention or visible masses or peristalsis? Any palpable masses or tenderness or rigidity? Any organomegalies?
○ RECTAL EXAM with the parents’ consent and with a chaperone?
§ Inspection: any visible lacerations, fissures, bleeding, skin tags, discharge, fecal staining?
§ Per rectal exam: any palpable masses or tenderness? Is there blood on the examining finger?
○ OFFICE TEST: UDS, BSL
▪ PE FROM THE CASE
○ A shy boy
○ Normal height and weight on the 50th centile
○ Abdomen is soft
○ Fecal masses are felt in the lower quadrants
○ No other abnormality
○ Anus appears normal, with some fecal staining adjacent
○ No anal fissure apparent
○ On rectal examination, the rectum is packed with firm feces
▪ DIAGNOSIS AND MANAGEMENT
○ From history and examination, it seems that most likely your child has a condition called ENCOPRESIS, have you heard about it? it is a condition where there is an unknowing passage of fecal material in the underpants.
○ [ILLUSTRATE] The common cause is constipation or fear of pain during defecation. In your child’s case, a few months back he was constipated and had anal fissures which was causing the pain on defecation. Even though the fissures were treated, David still fears that it’s going to be painful again if he goes to the toilet. So as he is refusing to go to the toilet, he is now becoming constipated again. Do you understand so far?
○ Because of this chronic collection of feces in the bowel, there is formation of liquid stools and it tends to leak around the hard stools causing his soiling. However, the bulky hard stools still remain inside, aggravating his constipation.
○ Don’t be stressed, it is a manageable condition. At this time the treatment is to empty his bowel now by giving an enema. Once he empties his bowel, we can start him on stool softeners.
○ I also encourage you to start toilet training him again, and encourage him to go to the toilet right after meals for a set period of time. You may use an egg timer for this.
○ I can only imagine how distressing it is to wash his clothes every day but please do not scold him. This takes a long time to get better, and needs a lot of patience on your part. You can start a star chart to motivate him to empty use the toilet when necessary.
○ I would also like you to talk to his teacher about his condition, and to address about bullying. Please give him extra clothes which he can wear whenever he has soiling episodes in school.
○ Please do not scold the child, and talk to the teacher about bullying. This takes a long time to get better and needs patience on your part.
○ I will arrange a regular review with him to ensure that his constipation is not recurring.
○ However, If the he develops severe pain, nausea, vomiting, or different pain from what he feels now, please come back immediately for a review. Here are some reading materials which can give more insight about your child’s problem. Do you have any questions?
KEY ISSUES
▪ Explanation of diagnosis
▪ Initial emptying of the rectum and colon
▪ Need for prolonged treatment and follow-up
CRITICAL ERRORS
▪ Suggesting that sigmoidoscopy or colonoscopy is required at this stage.
IMPORTANT POINTS FROM THE COMMENTARY
▪ Majority of constipation cases are non-organic, that is they are related to an episode, in many cases associated with the passage of a hard tool which may make the child wary of passing a bowel motion subsequently
▪ Can be associated with a mucosal tear or anal fissure which distresses the child, further compounding the problem.
○ Recognize the pattern early and treat it with fecal softeners allowing the fissure to heal
▪ If the child remains fearful of going to the toilet because of anticipation of pain, this compounds the situation which may lead to chronic constipation, toilet refusal, and in many cases, overflow encopresis.
▪ Young children may develop fear of the toilet during toilet training if they are required to perch on a toilet seat without support and this also may lead to subsequent constipation
▪ Constipation can also be secondary to emotional upset or trauma.
▪ AIMS OF MANAGEMENT
○ Exclude any possible organic pathology
○ Explore any precipitating features
○ Provide adequate explanation of the processes involved for both parent and child with a plan of action to alleviate the problem
▪ History SHOULD INCLUDE
○ Thorough enquiry into the child’s environment
§ Diet, general health, growth pattern, the family dynamics, progress at school, relationship with peers, and the like.
○ Hirschprung disease at this age has usually presented with a history of constipation from birth, often with a delay in the passage of meconium.
§ If there is suspicion, referral to pediatric surgery should be sought to include bowel biopsy
▪ Treatment
○ Careful reassurance, explanation of the nature of the condition
○ Comprehensive explanation about how constipation has developed, preferably with illustrative drawings
Johnny, a five-year-old boy, is brought to see you in a general practice by his mother because of a bed-wetting problem, which occurs nightly. He has been fully continent by day since he was three years old: and has previously been treated unsuccessfully with nightly amitriptyline (Tryptanol®). The wetting exasperated his parents initially, but they now accept that it is involuntary and both parents are keen to help him in any way possible.
TASKS:
1. Ask the mother for any further relevant history.
2. Tell the examiner what relevant examination findings you would seek.
3. Advise Johnny’s mother how you will further assess and manage his condition.
APPROACH
▪ History
○ I understand that Johnny has again started to wet his bed nightly. I know that you have prior experience about this and he has been treated, thought unsuccessfully, with a medication before. I appreciate and applaud you that you understand that this is not Johnny’s fault, and are very keen to help Johnny. I appreciate that you have come to me so we can all work together to help Johnny about this problem. I just have a few questions, is that okay?
○ When did this start? How does he react to it? How is his general health?
○ UTI questions: Any pain/burning, sensation while passing pee, any change in colour or blood? Frequent small passage of urine?
○ Any polydipsia or frequent thirsts? Any polyuria or frequent passing of urine?
○ Bowel: any loose stools? constipation?
○ Any problems with growth and development?
○ How is his fluid intake?
○ I would just like to ask some personal questions. But I would like to assure you that whatever we talk about here will be private and confidential unless it poses a risk to you or to others. Will that be okay?
○ How is the family situation?
○ Any stress in the family? How is your relationship with your husband? How is your relationship with Johnny? How is his relationship with his siblings?
○ How is he at school? Does he have a lot of friends? Does he experience bullying in school? Any problems reported by his teachers?
○ Any family history of a similar condition?
▪ Physical Examination
○ General appearance
○ Growth charts
○ Vital signs: BP
○ ENT and LN examination
○ Systemic examination
○ Genital examination
○ Office test: UDT, BSL
▪ I would also like to send a urine sample for urine microscopy and culture.
▪ Explanation:
Most likely your child is having a condition called nocturnal enuresis or bedwetting. From my history and physical examination, I have found no physical problem and emotional stressors in your child. Bedwetting is common in young children and is part of their physical and emotional development. Usually the cause is unknown, but some may be due to genetic tendency which means that bedwetting does tend to run in families. If one or both parents wet the bed when they were children, then it is quite likely to occur in their children. Also when we are in sleep and our bladder fills, it sends signals to the brain commanding to say that we need to get up to pass urine. But sometimes in children, the response does not occur as they are in deep sleep, and lead to involuntary passage of urine in the child.
Bedwetting isn’t a disease, a psychological problem or a response to allergies. It isn’t caused by laziness or naughtiness either, so punishing a bedwetting child doesn’t do any good at all. I understand that it is distressing to be doing excessive washing of bedclothes and pyjamas, but I am enthusiastic with your interest in trying to help Johnny. It is important to be patient and sympathetic, since your child can suffer distress and embarrassment about bedwetting.
At this stage, we do not need to start him on medications.
One way to help your child become aware of urinating during sleep is to use a pad and bell. With this simple system, a bell rings and wakes the child once the pad is wet. Over a period of a few weeks, the child gains greater bladder control until they are consistently waking up to go to the toilet. The bell or alarm can be obtained through hiring or buying from pharmacies or through some Community Health Centres or Children’s hospitals.
The bell consists of a rubber pad that is placed in the bed under where the child’s bottom will be, and it is connected by a wire to a box with a battery powered alarm bell. The system operates at low voltage and there is no risk to your child. The pad should be placed on the bed on top of the bottom sheet and should be covered with a piece of thin material, e.g. an old sheet that has been cut up into strips just big enough to cover the pad and long enough to tuck in on either side of the bed. The wires should be plugged into the box, which should then be placed as far away from the bed as the wire will allow. When going to bed, your child should switch on the bell and get into bed. It is best if he or she only wears a pyjama jacket and underpants rather than pyjama trousers or a long nightdress.
When your child wets the bed, a loud bell will sound. He or she should get out of bed as quickly as possible, turn off the bell and go to the toilet to finish emptying his or her bladder. Then your child should dry the pad using the piece of material, put a new piece of material over the pad, turn the bell back on and get back into bed. You may have to help your child with some of this, at least for the first few nights and especially if he or she is a very deep sleeper. Within a week or two your child should start to have some dry nights. This may happen because he or she wakes up and goes to the toilet before wetting the bed, or because he or she learns to hold on all night. However, even with the alarm it may be some weeks before success is achieved and the alarm should be persisted with for up to three months.
Your child needs to be very involved in the treatment plan if it is to work. The success rate is very high is the child is also motivated. And as is the case with Johnny, it is good that he is also motivated to help himself. As the treatment progresses, your child will probably have some good nights and some bad nights. Be very positive on the good nights, and try not to be negative on the bad ones. It can be helpful to keep a record chart of wet and dry nights. Your child should make the chart themselves and choose how to complete it. Some children like to put stars or stickers on for dry nights or to colour it in or draw pictures. Choose something that fits in with your child’s interests. Most children don’t need rewards to encourage them to take part in treatment - the prospect of a regular dry bed is usually enough. Some small treats along the way may be a good idea, but don’t promise them in advance. Rather, give them as a little surprise if your child is making some progress. Certainly don’t offer big rewards (e.g. a new bike) because this can add to the stress associated with treatment, and can be very disappointing if your child doesn’t become dry.
It is important for your child to drink plenty of fluid spreads evenly throughout the day. Although lifting and restriction of fluids have not been shown to be effective generally, if you are keen to continue this, you may feel free to do so as it occasionally does help some children. However, don’t give drinks containing caffeine (e.g. coffee, tea, hot chocolate, caffeinated soft-drinks like Coca-Cola etc.) late at night.
Remember, bedwetting is not a behavioural problem. Most children have no lasting problems from bedwetting. However, many will feel embarrassed or ashamed. Family members of children who wet the bed need to be supportive and not critical.
If asked: ○ During school camps or sleepovers, he could use a medication in the form of a nasal spray called arginine vasopressin when it is important to remain dry and to avoid any embarrassment. It helps a child's body make less urine at night, therefore reducing the risk of the child's bladder overfilling during sleep. It is safe provided you never exceed the recommended dose and avoid excessive fluid intake in the evening after dinner. ○ The success rate with amitriptyline (Tryptanol®) is low. It can be a dangerous drug in overdose and is rarely used now.
KEY ISSUES
▪ Empathy, support, and encouragement to both child and parent.
▪ Enquiry about a family history of enuresis.
▪ Exclusion of emotional stress at home or school.
▪ Exclusion of organic pathology by the history and by arranging simple urine testing.
▪ Advice about plan of action should be logical and clear.
CRITICAL ERRORS
▪ Suggesting a probable organic cause for the wetting and the need for invasive investigations.
IMPORTANT POINTS FROM THE COMMENTARY
▪ This scenario describes a five-year-old boy with persistent primary bed-wetting from three years of age. He is otherwise well, has no daytime wetting or any other symptoms to suggest a pathological cause for his wetting. The candidate should appreciate that the boy himself is very keen to be dry, and that his parents are willing to help him achieve this
