OSCE CAMC CHILD HEALTH PRACTICE QUESTIONS

Child Health Practice Questions 2018 Dr Christine Hammond Gabbadon MBBS; DCH; DM Paeds; MPH

Case Histories 

Elements of the Paediatric History

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Child is behind in immunizations-presents with Immunization card

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Child with asthma

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Child presents with delayed development.

Approach to history, examination and management .

Paediatric vs. Adult History Content Differences ◦ A. Prenatal and birth history ◦ B. Developmental history ◦ C. Social history of family - environmental risks ◦ D. Immunization history

Elements of Paediatric history Chief complaint  History of present illness  Past medical history (hosp., allergy etc)  Pregnancy and birth history  Developmental history  Feeding history  Review of systems  Family/social history  Immunization history 

Case #1 A child is brought to the health centre for his 6 month visit. You ask the mother to show you his immunization card. He has received a BCG vaccine at birth and a DPT/Pentavalent vaccine at 6 weeks. ď‚— Take an immunization history and advise the mother on the current immunization schedule ď‚—

Immunizations ď‚—

Immunizations are useful preventive measures available to infants, children, and adults.

ď‚—

All individuals should be immunized as recommended by individual country guidelines and WHO recommendations

Immunization-minimum recommended (Optional/high risk vaccines marked X) Age

BCG

DPT/Hib/ Hep B/ Polio (IPV/OPV)

PCV

<6 wks

X

6-8 w

X

X

3-4 m

X

X

6m

X

X

1 yr 18m 4 yrs

MMR

Hib Booster

Pneumovax DPT (PPSV23) /DT + OPV

X X

X

X

X X (high risk)

4-6 yrs

X

10-12

DT/

Other vaccine recommendations 

Td/Tdap every 10 years



Hep B



Influenza yearly

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Optional: rotavirus, varicella (chicken pox), pneumococcal, meningitis C

Current OPV recommendations 

Global Polio Eradication initiative

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Removal of all oral polio vaccines (OPVs) in the long term. This will eliminate the rare risks of vaccine-associated paralytic polio (VAPP) and circulating vaccine-derived poliovirus (cVDPV).

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Switch from trivalent OPV (tOPV) to bivalent OPV (bOPV), removing the type 2 component (April 2016 switch day).

Case #2 ď&#x201A;&#x2014;

A 14 year old with a history of bronchial asthma (diagnosed at age 4) presents today with a history of increasing night time cough over the last 2 weeks. He is not wheezing and is not distressed at present. Discuss your management of this patient

What is known about asthma?

Asthma is a common and potentially serious chronic disease that can be controlled but not cured  Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over time in their occurrence, frequency and intensity  Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs 

GINA 2017

What is known about asthma?

Asthma can be effectively treated  When asthma is well-controlled, patients can 

Avoid troublesome symptoms during the day and night Need little or no reliever medication Have productive, physically active lives Have normal or near-normal lung function Avoid serious asthma flare-ups (also called exacerbations, or severe attacks) GINA 2017

Assessment of asthma 1.

Asthma control - two domains ◦ Assess symptom control over the last 4 weeks ◦ Assess risk factors for poor outcomes, including low lung function

2.

GINA 2017, Box 2-1

Treatment issues ◦ Check inhaler technique and adherence ◦ Ask about side-effects ◦ Does the patient have a written asthma action plan? ◦ What are the patient’s attitudes and goals for

Management of asthma-GINA guidelines History: presenting complaint- night time cough, hospitalizations, triggers (exercise, allergens, URTI), asthma meds (rescue, maintenance)  Examination: General, RR, distress, recessions, flaring etc. Presence of clinical broncho-spasm Lung Function (PEFR)  PEFR: Compare with standard for height, Improvement of 20% after bronchodilator 

Levels of asthma control Assess current clinical control:  Controlled  Partly Controlled  Uncontrolled 

Assess future risk (exacerbations etc)  Eg. Frequent exacerbations in past year, admission frequency, high dose meds, cigarette smoke 

GINA assessment of asthma control A. Symptom control In the past 4 weeks, has the patient had:

Level of asthma symptom control Wellcontrolled

Partly controlled

Uncontrolled

None of these

1-2 of these

3-4 of these

• Daytime asthma symptoms more than twice a week?

Yes No • Any night waking due to asthma?

Yes No • Reliever needed for symptoms* more than twice a week?

Yes No • Any activity limitation due to asthma?

Yes No

B. Risk factors for poor asthma outcomes • Assess risk factors at diagnosis and periodically the patient’s • Measure FEV at start of treatment, after 3 to 6 months of treatment to record © Global Initiative for Asthma GINA 2017 Box 2-2B (1/4) 1

Achieve control Step up Rx until control achieved  Step down if control maintained at least 3 months  Follow up after 1 month then every 3 months 

Steps to control Step 1: as needed rapid acting B2 agonist  Step 2: add Controller: Low dose inhaled glucocorticoids (ICS)or Leukotriene modifier (montelucast)  Step 3: Choice of low/ med/ high dose ICS +/long acting B agonist/ leukotriene modifier/ sustained theophiline  Step 4: add long acting agonist to med or high dose ICS  Step 5: add oral glucocorticoid (lowest dose , Anti IgE Rx 

Stepwise approach to control asthma symptoms and reduce risk Diagnosis

Symptom control & risk factors (including lung function)

RE

Symptoms Side-effects

W

ENT ADJUST TREATM

RE VI E

Exacerbations

Patient preference

SS SE AS

SP O

N SE

Inhaler technique & adherence

Asthma medications Non-pharmacological strategies

Patient satisfaction

Treat modifiable risk factors

Lung function

STEP 5 STEP 4 PREFERRED CONTROLLER CHOICE

STEP 1

STEP 3

STEP 2

Low dose ICS/LABA**

Low dose ICS Other controller options

Consider low dose ICS

RELIEVER

REMEMBER TO...

SLIT added as an option GINA 2017, Box 3-5 (1/8)

Leukotriene receptor antagonists (LTRA) Low dose theophylline*

Med/high dose ICS Low dose ICS+LTRA (or + theoph*)

As-needed short-acting beta2-agonist (SABA)

Med/high ICS/LABA

Refer for add-on treatment

e.g. tiotropium,* anti-IgE, anti-IL5*

Add tiotropium* Add low dose High dose ICS OCS + LTRA (or + theoph*)

As-needed SABA or low dose ICS/formoterol#

•

Provide guided self-management education (self-monitoring + written action plan + regular review)

•

Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety

•

Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of sensitizers where appropriate

•

Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first

•

Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is >70% predicted

•

Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.

Ceasing ICS is not advised.

© Global Initiative for Asthma

Asthma education, Environment control

Asthma Control plan  Teach how to use Peak Flow meter  Teach how to use MDI (spacer)  Asthma control test You tube demos: https:// www.youtube.com/watch?v=Rdb3p9RZoR4 https:// www.youtube.com/watch?v=ma_cmlU9Dx U https:// 

Case # 3 

A young mother comes to see you with her 2 year old son. She is concerned about his development

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Take a focused history to address the mother’s concerns and discuss a plan of action

Focused history ď&#x201A;&#x2014;

Touch briefly on the elements of the paediatric history, but focus more on the presenting complaint and developmental history

ď&#x201A;&#x2014;

Management includes the history, examination, investigations and treatment

PHYSICAL DEVELOPMENT FIRST YEAR o Most

babies double their birth weight by 6 mths gaining an average of 0.5oz to 1oz every day for the first 6 months of life.

o Birth

weight usually triples sometime between 9 and 12 months of age.

COGNITIVE DEVELOPMENT ď&#x201A;&#x2014;

This is the process by which babies develop the abilities to learn and remember.

ď&#x201A;&#x2014;

Babies begin to recognize and interact with loved ones and start to understand that people and objects still exist even when they are out of sight (object permanence).

EMOTIONAL AND SOCIAL DEVELOPMENT. 

In the first month, newborns express emotion mainly by crying and grimacing or displaying an alert and bright face.

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By about 4 months, they learn to smile, coo, and move their arms around when excited.

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By 5 months, babies show a clear preference for a loved one. In the following months, "separation protest" and

LANGUAGE DEVELOPMENT. 

By about 3 to 6 weeks, babies develop a different crying sound to show a specific need (such as hunger or discomfort).

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By around 2 months of age, they begin to interact with caregivers by cooing and smiling, which proceeds to babbling and chuckling within about 6 months.

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Also by 6 months, most babies have learned all of the basic and distinct sounds of their native language.

SOME KEY MILESTONES FOR PRESCHOOLERS 24+ MONTHS Runs easily  Climbs well  Imitates adults and playmates  Learns to use potty follows a 2-3-step command  Able to say name, age, gender  Tells stories  Learns how to treat others by how he/she is treated 

GROWTH AND DEVELOPMENT AGES 2 TO 5 YEARS 

Physical development. stronger and starts to look longer and leaner.

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Physical growth is slower than in the first 2 years of life, but the outward changes can be dramatic.

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Cognitive development. Able to think and reason. Learn their letters, counting, and colors. Their play becomes more creative as they learn to imagine.

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Emotional and social development. Gradually learn how to manage their feelings. They begin to feel ashamed or guilty when they do something wrong. By age 5, friends become important.

GROWTH AND DEVELOPMENT AGES 2 TO 5 YEARS ď&#x201A;&#x2014;

Language. The ability to use words grows quickly in these years. By age 2, most children can say at least 50 words. By age 5, a child may know thousands of words and be able to carry on conversations and tell stories.

ď&#x201A;&#x2014;

Sensory and motor development. By age 2, most children can walk up stairs one at a time, kick a ball, and draw simple strokes with a pencil. By age 5, most can dress and undress themselves; draw a person with a head, body, arms, and legs; and write some small and

Case # 4 A 25 year old mother brings her first baby who was found to have Sickle Cell Disease on neonatal screening. The repeat test for Hb electrophoresis confirms Hb SS disease. ď&#x201A;&#x2014; Provide information on the disease itself and develop a management plan for the baby ď&#x201A;&#x2014;

Sickle Cell Disease

Some Forms of Sickle Cell Disease Hemoglobin SS  Hemoglobin SC  Hemoglobin Sβ0 thalassemia  Hemoglobin Sβ+ thalassemia  Hemoglobin SD  Hemoglobin SE 

Sickle Cell Anaemia Sickle cell anemia is an inherited blood disorder (includes Homozygous SS and SB0 thalassemia).  It causes:  Chronic destruction of red blood cells, causing severe anemia  Episodes of intense pain  Vulnerability to infections  Organ damage  In some cases, early death- this has been 

Sickle Cell Anaemia People who have SCD inherit two abnormal hemoglobin genes, one from each parent.  In all forms of SCD, at least one of the two abnormal genes causes a person’s body to make hemoglobin S.  When a person has two hemoglobin S genes, Hemoglobin SS, the disease is called sickle cell anemia. This is the most common and often most severe kind of 

Sickle SS inheritance .

Symptoms Fatigue, shortness of breath, pale skin and fingernails due to anemia  Recurrent bouts of pain in the abdomen, chest, back, arms or legs  A yellowing of the skin and whites of the eyes  Slowed growth and delayed puberty in children  Frequent infections  Eye problems, including blindness  Leg ulcers (adults) 

Prevention of infections-SCD Additional immunizations:  4th Hib  Prevnar 13  Pneumococcus 23 (Pneumovax)(age 4)  Penicillin prophylaxis age 4 months to 4 years 

Advice to parent Keep regular appointments and follow recommended immunizations and penicillin prophylaxis  Keep warm. Avoid chills (eg beach/ exposure to elements)  Nutrition: balanced diet including fruits and vegetables, plenty water  Keep analgesics at home. Extra fluids with painful crisis  Ensure regular school attendance 

Case # 5 A one year old infant is brought to you with a 2 day history of fever and irritability ď&#x201A;&#x2014; Take a focused history and outline your management plan ď&#x201A;&#x2014;

Child with fever Essentials-history, examination, investigations, management/referral  Look for neck stiffness, evidence of UTI, source of infection (eg RTI), ear infection (otitis media)  Investigations- CBC, blood culture, urine culture, CSF culture (spinal tap)  Appropriate treatment when source of infection identified  Referral to hospital for ill child and if meningitis or pneumonia etc suspected 

References 

http://www.patienteducationcenter.org/arti cles/sickle-cell-anemia /

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http://ginasthma.org/

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http:// ehlt.flinders.edu.au/education/DLiT/200 0/Motor%20Dev/stages.htm