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Pediatrics

OSCE

V 4.

BY

Mohammed Nawaiseh

Acknowledgements

First and foremost, i would to thank allah for his never-ending grace,mercy and provision.

Nobody has been more important to me in the pursuit of this project than the members of my family. I would like to thank my parents, whose love, guidance,support and encouragement are with me in whatever I pursue. They are the ultimate role models.

I would like to express my very great appreciation to my Batch “ Doctor 2013 ”

Thanks also to anyone I've forgotten who was instrumental in this project, especially those who contributed to this work in any way over the years.

Acronyms & Abbreviation

Hx History ROS Review of Systems

PE Physical Examination NVD Normal Vaginal delivery

PP Patient Profile CS C-section

CC Chief complaints wt weight

HPI History of present illness ht height

PMH Past Medical History HC Head circumference

PSH Past Surgical History NICU neonatal intensive care unit

DH Drug History # number

FH Family History FNW Fever,night sweats, weight loss

SH Social History N\V Nausea and Vomiting

MSS Musculo skeletal system D\C Diarrhea and constipation

CNS Central nervous system RR Respiratory rate

US Urinary system V\S Vital signs

RS Respiratory system HR Heart rate

CVS Cardiovascular system BP Blood pressure

GI Gastrointestinal system BMI Body mass index

Tx Treatment Temp temperature

Bx Biopsy HA headache

Dx Diagnosis IPPH Introduction,permission, privacy, hand hygiene

Ddx Differential Diagnosis UA Urine analysis

FTT Failure to thrive BWT Birth Weight

Table of Contents

General approach to hx

1. PP
2. CC
3. HPI a. History of time (PC.DOT) i. P → Progression → increase or decrease or constant ii. C → Course + Frequency → intermittent or continuous iii. D → Duration iv. O → Onset → sudden or gradual v. T → Timing
4. Trigger or cause
5. Relieving factors → what causes the pain to become better
6. Exacerbating factors→ what causes the pain to become worse
7. Previous similar symptoms b. SCRS (modified S O CR ATE S ) or character (description) of the symptom i. S → site ii. C → character (description) of the symptom iii. R → radiation iv. S → severity c. Other special questions (related to the case) d. Recent (recent events that may have association with the case) i. Recent sick contact 1. Day care → Is there sick kids with similar symptoms in the daycare 2. Recent animal contact 3. Recent Contaminated food or water ingestion ii. Recent travel iii. Recent trauma iv. Recent FNW + appetite
8. F → fever, chilis and rigors
9. N → night sweats
10. W → wt change (loss or gain)
11. Appetite
12. ROS
13. Pediatric Hx a. Maternal health (birth hx) i. During preg “Prenatal“ 1. Complications → Infection or illness or drugs during pregnancy 2. Alcohol/smoking during pregnancy 3. Routine Check ups and Ultrasound ii. At delivery “Natal”
14. Gestational age → term or preterm
15. Mode of delivery → Normal vaginal delivery (NVD) or C-section (CS) a. Have instruments been used?

3. Complications during delivery iii. After delivery “neonatal”
4. medical problems after birth?"

2. NICU Admission→ neonatal intensive care unit

3. Birth weight?
4. first bowel movement?" b. Growth and development i. first time to
5. Smile?
6. sit up , crawling , walking
7. Talking?
8. learn to dress himself/herself c. Feeding history i. Breastfed Or formula or solid food or mix?
9. When Start eating solid food?
10. formula fortified with iron?
11. pediatric multivitamins
12. appetite? d. Routine pediatric care i. Immunizations up to date? ii. last routine checkup?
13. PMH a. Previous similar episodes b. Hospitalizations c. Blood transfusion
14. PSH
15. DH a. Recent change in medications b. Allergy and drug allergy
16. FH a. Similar episodes in other family members b. Related diseases in the family c. consanguinity
17. SH a. Residency (lives with parents or other) i. Smoking or alcohol ingestion by parents b. parent’s (alive,married or divorced) i. Parents occupation and educational level c. Number of Sisters and brothers

ROS “Review of Systems”

● In the ROS approach all the systems will be asked about, always ask those questions in the same order which will help you to recall the information faster and will prevent you from forgetting important questions.

11. GI

a. N\ V ,D\ C ,abdominal pain b. Dysphagia or odynophagia c. Heartburn d. Abdominal distension e. Change in stool color ,blood or mucus in stool i. Melena (black tarry stool) and hematemesis ii. Steatorrhea (bulky ,difficult to flush, pale,oily appearance and foul-smelling). f. Jaundice or pale stool or dark urine g. perianal mucositis or sinuses or fistula.

12. US a. Dysuria b. FUN → F requency, U rgency, N octuria c. Change in urine color or amount or characteristic i. Decreased urine output or polyurea → change in the number of wet diapers? ii. Haematuria → red or brown
13. At the start or end or all over the stream of urine iii. Frothy urine iv. Offensive/cloudy urine v. stones d. Loin pain or abdominal pain e. Enuresis → primary (from birth) or secondary (there is previous period of continence)

General

Pediatrics

iii. Hypotonia or muscle weakness iv. Loss of consciousness, Seizures → more in Encephalitis d. Eyes i. colors→ Redness (infection or irritation) ,pale (anemia) ,yellow “jaundice” ii. Periorbital edema e. Ears i. Ear rubbing ,ear pain or discharge* f. Nose i. Runny nose g. Mouth i. Poor feeding \ anorexia (decreased appetite) ii. Mouth sores,mucositis iii. Throat pain iv. Crying h. Endocrine i. Faltering growth → inability to gain wt i. RS i. Cough (dry or productive), SOB, hemoptysis, wheezes,rapid breathing j. CVS → chest pain or neck pain , palpitation k. GI i. N\ V ,D\ C ,abdominal pain

1. If there is abdominal pain → SOCRATES ii. Change in stool color ,blood or mucus in stool
2. Melena (black tarry stool) and hematemesis
3. Steatorrhea (bulky ,difficult to flush, pale,oily appearance and foul-smelling). iii. Jaundice or pale stool or dark urine iv. perianal mucositis l. US i. Dysuria
4. FUN → F requency, U rgency, N octuria→ UTI in older child* ii. Change in urine color or amount or characteristic
5. Amount → Decreased urine output or polyurea
6. Color → Haematuria → red or brown a. If yes → All over the course of urine flow or at the end or start of the flow
7. Characteristic a. Frothy urine or Offensive/cloudy urine b. stones iii. Loin pain or abdominal pain → if yes , ask the SOCRATES iv. Enuresis → primary (from birth) or secondary (there is previous period of continence) ﺳﻠﺲ ﺑﻮﻟﻲ ,اﺳﺄل اذا اﻟﻮﻟﺪ او اﻟﺒﻨﺖ ﺑﻤﺴﻚ اﻟﺒﻮل او اذا ﯾﺘﺒﻮل ﻻإرادي v. Infrequent voiding → as cause not as a symptom vi. Genitalia
8. Ask about , how the genitalia are washed after voiding? Wiping from back to front in girls.? Toilet training?

2. If male → Uncircumcised male? vii. Atypical UTI
3. poor urine flow
4. abdominal or bladder mass
5. Ask about plastic catheters
6. PMH and PSH a. Previous similar episodes → + how many times? b. Previous similar infection or recurrent UTI or Recent upper respiratory tract infection. i. Was he\she admitted to hospital ii. Prophylactic antibiotics was given? iii. TB?
7. DH and allergies a. Prophylactic antibiotics b. Immunization record c. Painkiller,paracetamol
8. FH a. Similar condition with father or mother when were children b. Structural kidney diseases → Vesicoureteric reflux c. Other recent sick family member
9. SH a. Smoking and alcohol in the house b. Residency

Physical Examination

1. General a. Well or sick? b. Level of Consciousness i. Irritability ,Lethargy c. Color → pale, mottled, or cyanosed d. Rash e. mouth sores
2. Vital signs a. RR, HR ,BP, Temp,capillary refill → look for signs of shock and fever i. Tachypnoea → pneumonia
3. CNS a. Focal neurological signs b. Brudzinski/Kernig signs? c. Neck stiffness (not always present in infants) d. Raised intracranial pressure - reduced conscious level, abnormal pupillary responses, abnormal posturing, Cushing's triad (bradycardia,HTN, abnormal pattern of breathing) e. Late signs – papilloedema (rare), bulging fontanelle in infants, opisthotonus (hyperextension of head and back)
4. RS → air entry (bilateral, symmetrical) , Ears and throat ,Always examine tympanic membranes in febrile children,Erythema or exudate on the tonsils? ,chest recession, abnormal auscultation.

i. dipstick testing

1. Nitrite → for bacteria in urine
2. Leukocyte esterase → for white blood cells
3. Glucose ,protein , blood ii. Urine culture “UC” and microscopy
4. Clean catch → >10^5 CFU of a single organism per millilitre
5. catheter sample or suprapubic aspirate → Any bacterial growth of a single organism per millilitre b. Imaging i. US → for urinary system ii. DMSA “Dimercaptosuccinic acid” → after 3 months of UTI , for scarring iii. MCUG “micturating cystourethrogram”
6. Management a. Treatment i. < 3 months of age
7. intravenous antibiotic therapy (e.g. co-amoxiclav) for at least 5–7 days then→ oral prophylaxis ii. > 3 months and children with acute pyelonephritis/ upper UTI (bacteriuria and fever ≥38° C or bacteriuria & loin pain/tenderness even if fever is <38° C)
8. oral antibiotics (e.g. trimethoprim for 7 days); or
9. IV antibiotics, e.g. co-amoxiclav, for 2–4 days followed by oral antibiotics for a total of 7–10 days. iii. Children with cystitis/ lower UTI (dysuria but no systemic symptoms or signs)
10. Oral antibiotics such as trimethoprim or nitrofurantoin for 3 days. b. Prevention i. High fluid intake → Regular voiding, double micturition ii. Prevent or treat constipation iii. circumcision in boys iv. anti-VUR surgery in severe VUR v. Good perineal hygiene vi. Lactobacillus acidophilus → probiotic vii. Advise to check urine culture if develops clinical features suggestive of nonspecific illness viii. If renal scarring or reflux on investigation, or develops recurrent UTIs:
11. Consider low-dose antibiotic prophylaxis → Trimethoprim (2 mg/kg at night) or nitrofurantoin or cephalexin
12. Monitor blood pressure, proteinuria, renal growth and function Meningitis\Encephalitis
13. Investigation a. Blood: i. CBC with differential ii. electrolytes and Urea iii. blood culture iv. Blood glucose and blood gas (for acidosis) b. Lumbar puncture “LB” for CSF unless contraindicated c. KFT (BUN, Cr), LFT (AST, ALT)

d. Coagulation screen, C-reactive protein e. Culture of blood, throat swab, urine, stool for bacteria f. Rapid antigen test for meningitis organisms (can be done on blood, CSF, or urine) g. Samples for viral PCRs (e.g. throat swab, nasopharyngeal aspirate, conjunctival swab, stool sample) h. PCR of blood and CSF for possible organisms i. Consider CT/MRI brain scan and EEG j. If TB suspected: chest X-ray, Mantoux “ PPD” test and/or QuantiFERON-TB, gastric aspirates or sputum for microscopy and culture (and PCR if available)

2. Management a. Antibiotics i. cefotaxime (<1 month ) ii. ceftriaxone (>1 month ). iii. vancomycin is added to cover G +ve iv. In infants <1 month of age, ampicillin is added to cover Listeria infection. v. Acyclovir→ (HSV) encephalitis vi. IM benzylpenicillin immediately → any fever + purpuric rash vii. ceftriaxone/vancomycin (just in case of strep-resistance) b. Antipyretic i. paracetamol or ibuprofen

Pneumonia

1. Investigation a. Chest X-ray (Fig. 17.18, look below) may confirm the diagnosis but cannot reliably differentiate between bacterial and viral pneumonia. b. Nasopharyngeal aspirate c. Blood tests, including full blood count and acute-phase reactants are generally unhelpful in differentiating between a viral and bacterial cause.
2. Management a. Most affected children can be managed at home b. but indications for admission include i. oxygen saturation <92% ii. recurrent apnoea iii. grunting and/or an inability to maintain adequate fluid/feed intake. c. General supportive care → oxygen for hypoxia and analgesia if there is Pain. d. Intravenous fluids should be given if necessary to correct dehydration and maintain adequate hydration and sodium balance. e. Physiotherapy has no proven role f. Antibiotics (determined by the child’s age and the severity of illness) i. Newborns → broad spectrum intravenous antibiotics. ii. Older infants → oral amoxicillin, with broader spectrum antibiotics such as co-amoxiclav reserved for complicated or unresponsive pneumonia. iii. children over 5 years of age → either amoxicillin or an oral macrolide such as erythromycin is the treatment of choice. iv. There is no advantage in giving intravenous rather than oral treatment in mild/moderate pneumonia.

DDx ● Neonatal sepsis ● Skin a. Measles (or other viral exanthem),Rubella, Roseola, Varicella → Chickenpox b. Fifth disease → Group A strep c. Scarlet fever ● CNS → Meningitis / encephalitis

● RS

a. Pneumonia b. URI, Acute otitis media ● GI a. Gastroenteritis (viral, bacterial, parasitic) b. Food poisoning c. Intussusception, Volvulus ● US a. Upper UTI → Pyelonephritis , Lower UTI → cystitis or urethritis

● Rash or purpura → meningococcal infection ● Fever + Abdominal pain or loin pain + dysuria + hematuria → UTI ● Fever + HA+Photophobia,nuchal rigidity → meningitis ● Fever + Irritability, Lethargy ,Drowsiness,sleepy, Hypoactivity → meningitis ● Fever + Loss of consciousness, Seizures → Encephalitis ● Fever + chills and rigors + dyspnea → pneumonia ● Fever + vomiting and diarrhea → Gastroenteritis ● Fever + ear rubbing → otitis media ● Fever + bone pain → osteomyelitis ● Fever + joint pain → septic or reactive arthritis ● Dysuria alone is usually due to cystitis, or vulvitis in girls or balanitis in uncircumcised boys. ● UTI may involve the kidneys (pyelonephritis), when it is usually associated with fever and systemic involvement, or may be due to cystitis, when there may be no fever. ● all febrile neonates(<4 wks) should be: ○ Admitted ○ Given empirical IV antibiotics ○ Evaluated with a full sepsis work-up ● Most common infections in neonates (< 4 weeks) are caused by: ○ Gram –ve bacteria ○ Group B strep ● Choice of ABx should cover these groups. Therefore, start the patient on: ○ Ampicillin + cefotaxime ○ Ampicillin + gentamicin ● Indications for Admission: ○ If WBC >15,000 or < 5000, OR ○ Urine culture is +ve, OR ○ CXR is positive ○ Invasive diarrhea ○ Premature ○ Prior antibiotic treatment The most common pathogens causing pneumonia vary according to the child’s age: ● Newborn – organisms from the mother’s genital tract, particularly group B streptococcus “GBS” , but also Gram-negative enterococci and bacilli. ● Infants and young children – respiratory viruses,particularly RSV , are most common, but bacterial infections include Streptococcus pneumoniae or H. influenzae. Bordetella pertussis