OSCE pediatrics (1)

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PEDIATRIC OSCE STATIONS 1 st Edition 2013
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PEDIATRIC OSCE STATIONS
ZUHAIR M. AL-MUSAWI
MBChB, CABP, IBCLC
PROFESSOR OF PEDIATRICS
COLLEGE OF MEDICINE/UNIVERSITY OF KARBALA
CONSULTANT PEDIATRICIAN
KARBALA TEACHING HOSPITAL FOR CHILDREN
KARBALA/IRAQ
CONTRIBUTOR
HAYDER M. AL-MUSAWI
MBChB, CABP, DCH
CHILDREN WELFARE HOSPITAL
BAGHDAD/IRAQ
1st Edition 2013
I
Dedication
This book is dedicated to

our faithful wives,
our mentors, whom we strive to emulate,
our teachers, whom we hope to do proud,
our colleagues, with whom we proudly persevere,
our students, whom we dare to inspire,
and our patients, whom we endeavor to serve.
ZUHAIR AL-MUSAWI
HAYDER AL-MUSAWI
A very special thanks is extended to my son Ali Zuhair

who has helped in the preparation of this book.
Number of Deposition of This Book at Iraqi House of Books and

Documents (Iraqi National Library)
Cover photo of the nice twin (SAJAD and ZAHRAA ZAINI), age one
year, reproduced with kind permission of the parents.
II
Contents
Introduction………………………………………………………………………………IV
Part 1 Static stations 1

A-Case studies with images
Questions…………………………………………………………………………….2
Answers……………………………………………………………………………..67
B-Case studies without images
Questions…………………………………………………………………………..88
Answers……………………………………………………………………………127
Part 2 History taking and management stations 146

Questions…………………………………………………………………………148
Answers……………………………………………………………………………153
Part 3 Communication skills stations 177

Questions…………………………………………………………………………178
Answers……………………………………………………………………………183
Part 4 Clinical stations 204

Cardiovascular system station………………………………………….207
Respiratory system station……………………………………………….209
Gastrointestinal system station………………………………………..211
Neurology stations……………………………………………………………216
Neonatology examination station…………………………………….226
Part 5 Development stations 229

OSCE Tips……………………………………………………………………………….249
References……………………………………………………………………………..251
III
Introduction
The traditional clinical examination, consisting of long cases, short
cases and vivas, has some strengths but unfortunately significant
limitations in terms of validity and reliability. The advent of the
structured performance tests has enabled some of the limitations
to be overcome. The most popular form of these tests is called
OSCE (Objective Structured Clinical Examination).There are many
advantages of the OSCE over the traditional clinical examinations.
Firstly, the OSCE is fairer than the traditional approach due to the
standardization of tasks that have to be performed, an aspect
much appreciated by students. Secondly, the wider sampling of
competencies and the use of structured marking sheets contribute
to improvements in reliability and content validity. However, the
OSCE also has its limitations and should be combined with other
forms of assessment which may more validly test competences not
easily tested within the OSCE format. For example, attitudinal and
behavioral aspects of patient care may be better assessed in
practice-based settings rather than in examination settings. In
addition, there are many aspects of clinical competence that can
be more efficiently tested using a written format.
WHAT IS AN OSCE?
Contrary to popular belief, an OSCE is not a method of assessment

as such. Rather it provides an organizational framework into which
can be incorporated a variety of test methods.
IV
OSCE’s consist of a series of stations around which students rotate.
At each station students are asked to undertake a well defined
task. The criteria on which performance is to be assessed are
carefully defined before the examination takes place. Student
performance is scored on structured rating forms or marking
sheets by examiners (and sometimes patients) whose interaction
with the students is carefully regulated, usually being limited to
providing instructions or asking predetermined questions.
The length of time spent at each station is usually short (5-10

minutes) though in some examinations, may be longer (e.g. 30
minutes). Some OSCE’s incorporate a break between stations for a
variety of reasons. For instance a short time (e.g. 1 minute) may be
scheduled to allow students to move between stations for
examiners to collate marks. Other purposes include a period of
time for students to review material before entering the station; to
record information (e.g. patient notes) after encountering the
patient; or to answer a series of written questions after a patient
encounter about clinical findings, diagnosis or management.
The OSCE format is very flexible allowing a wide selection of tasks

to be assessed, the range being largely limited only by the
ingenuity of those constructing the test. The widespread use of
simulated patients and simulation devices has extended the range
of conditions and skills that can be assessed beyond those one sees
in traditional examinations. However, there are some practical
limitations particularly in the finding and use of real patients with
physical sign.
V
PART 1
Static stations
Static stations do not involve any physical interaction but the tasks
may be very varied. Examples include interpretation of data and
images or writing management plans and prescriptions. Students
complete their tasks and record their responses on a structured
answer sheet which are collected for marking. Such stations may
be included in the OSCE circuit or may be administered at another
time and location. Examiners are not required to observe students
at static stations but are required to mark their responses.
1
PART 1
A- CASE STUDIES WITH IMAGES
QUESTION 1
You are evaluating a term infant in the neonatal intensive care
unit for a seizure that occurred 1 day after birth. Her neonatal
course has been otherwise unremarkable. The only significant
finding on physical examination is an erythematous patch involving
the left side of the face, including the upper and lower eyelids as
shown below
1-What is your diagnosis?

2-What is the most common ophthalmologic finding associated
with this condition?
3-What other features may be seen in this infant?
2
QUESTION 2
The parents of a 2-month-infant who you are seeing for a health
supervision visit relate that a red mass on the infant’s eyelid has
grown and no longer is the flat birthmark seen in the newborn
nursery. Physical examination reveals a hemangioma located on
the upper lid. The visual axis is not obstructed, but the infant is
unable to open her eyelid completely. The remainder of the
examination findings is normal, with no evidence of other
hemangiomas.
1- What is the most important reason for urgent pediatric

ophthalmologic referral for this infant?
2-What 2 interventional procedures should be advised when
there is evidence of this ophthalmologic complication?
3- What lab. Investigation should be ordered before the
procedures?
3
QUESTION 3
A 3-year-old boy is brought to the clinic by his parents due to
concerns about how easily he bruises. They say that since he began
walking at 18 months, he frequently has large, purple bruises that
appear with no known history of trauma. They do not believe that
he falls more frequently than other children his age, and they deny
a family history of easy bruising. On physical examination, the
normally grown child has prominent eyes, a delicate and narrow
nose, and numerous bruises in various stages of healing, primarily
overlying his shins but also scattered elsewhere on his body. He
has translucent skin over the chest, with prominent vascular
markings, and his fingers are slender and hypermobile.
1-Which condition is most consistent with this boy’s features?

2-What is the most common type of inheritance?
3-What advice you should give to the patient and his parents
when they counsel you?
4
QUESTION 4
A 7-year-old girl who has chronic sinusitis presents to the
emergency department with 1 to 2 weeks of headaches that are
worse at night. On physical examination, she is afebrile but seems
uncharacteristically sleepy and exhibits hyperreflexia. Funduscopic
examination shows papilledema.
1-What is the most likely diagnosis?

2-What is the most appropriate diagnostic test?
3-What do you expect to find in the CSF if you are ordered to do
lumbar puncture?
5
QUESTION 5
A previously well 6-year-old boy presents with a rash over his
lower extremities. He has had knee and ankle pain for 3 days that
has caused difficulty ambulating since this morning. On physical
examination, he is afebrile, and his heart rate is 80 beats/min,
respiratory rate is 16 breaths/min, and blood pressure is 108/60
mm Hg. You note bilateral ankle swelling and a purpuric rash over
his lower extremities.
Laboratory findings include:
 White blood cell count,10x103/mcL
 Hemoglobin, 11.5 g/dL
 Hematocrit, 35%
 Platelet count, 410x103/mcL
 Urinalysis shows:
 Specific gravity, 1.025
 pH, 6
 3+ blood
 Trace protein
 20 to 50 red blood cells/high-power field
The random urine protein-to-creatinine ratio is 0.15
1-Is renal biopsy indicated for this

patient?
2-For how long corticosteroids are
given for this patient?
3-Is there any role for ibuprofen in the
management of joint manifestation of
this patient?
6
QUESTION 6
You are evaluating a 5-year-old boy in the emergency department
for lethargy. His mother reports that the boy has been lethargic
since awakening this morning. She adds that he has been
complaining of headaches and has been having morning emesis for
several weeks. She also reports that he has become increasingly
"clumsy" over the past 4 to 6 weeks. On physical examination, the
patient is difficult to arouse; has sluggish pupillary responses; and
has rapid, deep, sustained breaths at a rate of 35 breaths/min. His
C/T scan is shown below
1- What is the most likely cause for this clinical presentation?

2- What is the best step in the initial management of this patient?
3- Describe the C/T findings?
7
QUESTION 7
A 5-year-old previously healthy boy has developed a limp and
right hip pain over the past week. There is no history of trauma,
fever, rashes, or other systemic symptoms. On physical
examination, he has limited internal rotation and abduction of the
right hip; other findings are within normal parameters. A lateral,
anteroposterior, and frog leg radiograph series demonstrates a
crescentic subchondral lucency in the medial aspect of the
epiphysis.

2- Mention 2 implicating factors for this condition?
3-Enumerate 3 differential diagnoses for this disease?
8
QUESTION 8
A 6-month-old boy who lives in a foster home presents with
progressively increased work of breathing and poor feeding. His
past medical history is unknown, except that his biological mother
used illicit drugs during pregnancy. On physical examination, his
temperature is 37.8°C, heart rate is 110 beats/minute, respiratory
rate is 60 breaths/minute, oxygen saturation is 70% in room air,
weight is 7.3 kg (10th percentile), and length and head
circumference are at the 95th percentile for age. He has mild-to-
moderate subcostal retractions, and his lungs are clear to
auscultation. A chest radiograph shows diffuse bilateral interstitial
infiltrates. The white blood cell count is 2.0x103/mcL (2.0x109/L),
with 51% polymorphonuclear leukocytes, 43% lymphocytes, and
6% monocytes. Serum lactate dehydrogenase is elevated at 700
units/L

2- What is the most likely test to yield the diagnosis?
3-What 2 drugs most commonly used in the treatment of this
condition?
4-What is the new name of the causative organism?
9
QUESTION 9
A 14-year-old boy loses consciousness while playing basketball.
He regains consciousness in 30 seconds and is transported to a
pediatric emergency department. Results of head computed
tomography scan, electroencephalography, and echocardiography
are within normal limits. Electrocardiography results are
interpreted as abnormal, with a heart rate of 90 beats/min, PR
interval of 150 msec, and QTc interval of 550
1-What is the most likely explanation for this patient’s syncopal

episode?
2-What risky complications those patients may develop?
3-Enumerate 3 other cardiac conditions causing syncope?
10
QUESTION 10
You are seeing a 6-year-old girl for a health supervision visit. On
physical examination, you note Sexual Maturity Rating (SMR) 3
pubic hair and SMR 1 breast tissue. You noted no pubic hair last
year. She has had a growth spurt in the past 2 years and is
presently at the 75th percentile for height. Her weight is at the
50th percentile for age. Her blood pressure is 90/60 mm Hg. The
remainder of her evaluation is within normal parameters except for
possible clitoromegaly. The radiologist interprets a bone age
radiograph as 8 years.
1- What is the most likely explanation for these findings in this

girl?
2- What is the most helpful diagnostic laboratory blood test?
3-What serum electrolyte findings you expect to see in this
patient?
11
QUESTION 11
You are evaluating an otherwise healthy 3-year-old boy who has
developed a cluster of 5 to 10 flesh-colored, pearly papules, some
of which have central umbilication. He has no prior skin conditions.

2-What is the etiology?
3-What is the most appropriate management?
4-What is the fate of the lesion if untreated?
12
QUESTION 12
You are evaluating a 15-month-old child for mild developmental
delay. He sits well alone, crawls, claps his hands, and waves, but he
does not pull to stand or say any words. His father and paternal
uncle have epilepsy and attended special education classes when
they were in school. You note three hypopigmented macules
scattered over his trunk and arms.

2- Name this skin lesion?
3-What is the significance of this skin lesion?
4-What is the most appropriate next step in this boy’s evaluation?
5-What additional diagnostic testing should be done?
13
QUESTION 13
A 13-year-old girl presents with a 2-day history of fever, sore
throat, and a rash that began on her arms and legs and spread to
her chest and back. Physical examination reveals pharyngeal
exudate; bilateral cervical adenopathy; and a "sandpapery" rash
over her arms, legs, and trunk. A rapid diagnostic test for group A
Streptococcus yields negative results. At 48 hours, a throat culture
is growing small colonies with narrow bands of hemolysis on sheep
blood agar.
1-What is the most likely organism?

2- What is the most appropriate antibiotic for treating this
patient?
14
QUESTION 14
An unimmunized 4-year-old girl presents with malaise, sore
throat, and difficulty swallowing. On physical examination, she has
a temperature of 38.0°C, bilateral cervical adenopathy, and grayish
exudates over the mucous membranes of her tonsils and pharynx.
When you attempt to remove some of the exudate for culture,
bleeding occurs.

2-How it is treated?
3-What is the most appropriate treatment of close contacts of
this child?
15
QUESTION 15
A 6-year-old boy presents with a 2-year history of frequent
pruritic, erythematous eruptions on his arms and legs. The rash
usually worsens during winter but occurs intermittently throughout
the year. His mother has tried various moisturizers, but they have
not been effective in controlling the rash. On physical examination,
you note erythematous patches on his antecubital and popliteal
regions bilaterally.

2- What is the most appropriate initial step in management for
this patient?
3-What are the side effects of the treatment?
16
QUESTION 16
You are treating a 2-year-old girl who has suspected
meningococcal bacteremia and meningitis. Over the past 2 hours,
she has required multiple fluid boluses and inotropic support to
help maintain her blood pressure. She has been intubated due to
respiratory failure. Her temperature is 96°F (35.6°C), and she is
covered in a petechial and purpuric rash. Her most recent
laboratory results reveal a white blood cell count of 1.2x10 3/mcL
(1.2x109/L) with 80% lymphocytes, 10% neutrophils, and 10% band
forms and a platelet count of 32x103/mcL (32x109/L).
1-What is the most likely cause of her laboratory results?

2- What is the most important additional laboratory test?
17
QUESTION 17
A 2-year-old girl presents to your office with a 3-week history of a
“barky” cough. According to her mother, the girl has had no fever
or upper respiratory tract infection symptoms, but she has
complained intermittently of a sore throat for the past 2 weeks. On
physical examination, the child appears well and playful. Her throat
is non-erythematous, and her lungs are clear to auscultation.
Because of the persistence of her symptoms, you obtain chest
radiograph.
1-Where is the site of the foreign body?

2-What are the complications if left more than 24 hours?
18
QUESTION 18
A mother brings in her 1-year-old boy for the first time because
she is concerned about his “bowed legs”. The mother is 4 ft 10 in
tall and says she needed to have surgery to straighten out her
bowed legs when she was an adolescent, as did one of her
brothers.
Radiographs of the boy’s long bones are obtained.

2-What are the most likely serum laboratory findings?

2-What are the most likely serum laboratory findings?
19
QUESTION 19
A 17-year-old boy is applying for entry into military service and
requires a complete history and physical examination. During the
interview, he states that he is healthy, although he admits to
being treated for three cases of pneumonia over the past 10 years.
A chest radiograph performed during the last infection showed a
left lower lobe pneumonia, and the patient states that the
infection is “always on that side.” The only finding of note on the
physical examination today is slightly diminished breath sounds
over the left lower lobe.
1- What is the most likely cause for this boy’s recurrent

pneumonias?
20
QUESTION 20
A 3-month-old infant presents to the emergency department with
fussiness and decreased alertness. During triage, he experiences a
seizure. Physical examination reveals somnolence and a bulging
fontanelle. Emergent head computed tomography scan documents
acute and chronic subdural hematomas.

2-What is the procedure that is most likely reveal the cause
of these findings?
3- Is angiography necessary for the diagnosis?
21
QUESTION 21
A 13-year-old boy presents to the emergency department with a
3-day history of severe sore throat and fever. He is having trouble
swallowing due to pain. His past medical history is unremarkable.
On physical examination, he has a temperature of 102.6°F (39.3°C)
and a large left tonsil, with swelling of the left soft palate and
deviation of the uvula to the right. You suspect a peritonsillar
abscess.
1-Mention the bacteria Implicated in this case?

2- What is the most appropriate antimicrobial agent to start
empirically?
22
QUESTION 22
A 10-year-old boy presents to the emergency department with
confusion. He is febrile. While you are examining him, his eyes
glaze over and deviate to the right, he has automatic chewing
movements, and he is completely unresponsive for 30 seconds,
after which he is very sleepy. Emergent head computed
tomography scan shows low density in the right temporal lobe.

2-Discribe the C/T scan finding?
3-What is the most appropriate next step?
23
QUESTION 23
You are evaluating a 15-year-old girl who complains of malaise,
fatigue, and occasional abdominal discomfort. You diagnosed
hypothyroidism due to chronic lymphocytic thyroiditis
(Hashimoto thyroiditis) 6 years ago. She has normal serum
immunoglobulin A concentrations. A tissue transglutaminase
antibody study was negative 1 month before this visit, and free
thyroxine and thyroid-stimulating hormone (TSH) values were
normal at that time. She has normal menses. She reports that she
has been eating poorly and has lost 5 lb since you saw her at the
beginning of the summer, but she obviously has had a good
summer and has a tan.
1-What are the most important laboratory studies to obtain at

this time?
2-What is your most likely diagnosis?
3-What is the cause of her tan?
4-What other endocrine autoimmunities, the girl is at risk to
develop?
24
QUESTION 24
A 5-year-old boy has been ill for 2 days with fever, decreased
appetite, and a rash. On physical examination, you note ulcers on
the tongue and soft palate, but the gingivae are spared. You also
see oval vesicles with surrounding erythema on the hands.

2-What are the causative agents?
3-Enumerate 4 differential diagnoses for the mouth lesion?
25
QUESTION 25
You are evaluating a previously healthy 3-year-old girl for white
spots in her mouth and a worsening rash in her vaginal area. Her
mother states that except for decreased oral intake and
complaints of itchiness in her vaginal area, the child has had no
fever or other systemic symptoms. She has received three different
10-day courses of oral antibiotics in the last 2 months for a throat
infection and otitis media. She completed her last antibiotic course
yesterday. Physical examination shows two small areas of whitish
plaques on her tongue and right buccal mucosa that cannot be
removed easily with a tongue blade. She has no abdominal
tenderness. Her vaginal area is erythematous, with several areas of
excoriation; her hymenal tissue and urethral opening appear
normal. The remainder of her physical examination findings is
normal.
1-What is the most likely causative agent?

2-What is the most likely cause of this patient’s condition?
3-Mention the sites of human body where these organisms
usually found?
26
QUESTION 26
A 3-year-old child presents with a history of intermittent painless
rectal bleeding. Approximately once or twice a week, she passes a
formed stool that contains up to “a teaspoon” of blood.
Physical examination demonstrates no fissures or hemorrhoids.
Hematocrit measurement and results of coagulation studies are
normal. The bleeding persists despite stool softeners.

2-Which test most likely establish the diagnosis?
3-Mention 2 other causes for painless rectal bleeding?
27
QUESTION 27
An 18-year-old boy presents to the emergency department 30
minutes after eating at a seafood restaurant. He states that
approximately 10 minutes into his meal he developed generalized
hives, pruritus, and difficulty breathing. He has a history of shellfish
food allergy, although he had ordered steak and denies eating any
crab, lobster, or shrimp. On physical examination, the patient
appears to have labored breathing, audible wheezing, and diffuse
raised erythematous lesions on his trunk and extremities. His vital
signs include a temperature of 98.5°F (37°C), heart rate of 100
beats/min, respiratory rate of 22 breaths/min, blood pressure of
110/60 mm Hg, and pulse oximetry of 92% on room air.
1-What is the most likely cause for the patient condition?

2-What is the most appropriate immediate action?
28
QUESTION 28
You are working in a refugee camp when a mother brings in her 8-
day-old boy. The mother states he started becoming irritable 2
days ago, and now any loud noise appears to cause him pain, as
evidenced by muscle tightening and back arching causing his head
to nearly touch his feet. Physical examination reveals only a dried
packing on his umbilical cord, as is the local custom. He appears
normal until he is stimulated by touch or a loud noise, and then he
begins to cry, stiffens, and arches his back. The stiffness continues
until he calms down.

2-What is your treatment?
3-How it is prevented?
29
QUESTION 29
A 1-month-old infant presents with freckle like macules over his
face and extremities. The hospital record reveals that he had
multiple papules and pustules distributed over his entire body,
including palms and soles, at birth. The infant appears to be very
healthy and thriving.

2-What are the microscopic findings of the pustules in the
newborn period?
3-Mention 4 other neonatal conditions characterized by pustules
or vesicles and what are their microscopic lesional contents?
30
QUESTION 30
A 4 year-old-boy presents to your clinic with anal itching of 2
weeks' duration. His mother denies itching in other family
members. Tape applied to his perianal skin shows oval structures.
1-What are these oval structures?

2- What is the most appropriate management of this patient?
3- What are the indications for entire family treatment?
31
QUESTION 31
A 16-year-old boy presents with a very swollen, painful right knee.
He is a soccer player, but there is no history of recent injury. During
the interview, you notice the boy has injected conjunctivae.
1-What you expect to find in his urine examination?

3-What dermatologic findings you may also see?
32
QUESTION 32
A 4-year-old boy presents with a history of chronic upper and
lower respiratory tract infections. His weight is 15 kg (25th
percentile), height is 97 cm (10th percentile), temperature is 98.1°F
(36.8°C), and pulse oximetry is 96% on room air. On physical
examination, he coughs intermittently and has mild clubbing. On
nasal examination, you note purulent rhinorrhea and nasal polyps.
Auscultation of the heart reveals a regular rate and rhythm, with
the point of maximal impulse displaced to the right.
1- What is the most likely diagnosis?

2-What other characteristic finding you may see?
3-How can you prove your diagnosis?
33
QUESTION 33
A 14-month-old girl is brought to the emergency department with
a 12-hour history of fever and rash. Her mother became frightened
when it was difficult to arouse the girl after her nap.
Findings on physical examination include a temperature of 104°F
(40°C), a heart rate of 164 beats/min, a respiratory rate of 42
breaths/min, and a blood pressure of 75/45 mm Hg. There are
petechiae and purpura on the chest, arms, and legs.

2-What is the most appropriate initial therapy?
34
QUESTION 34
You are evaluating a newborn boy who has lax abdominal
musculature and bilateral undescended testes. Other findings on
physical examination are normal.

2- What is the most likely urologic abnormality in this boy?
3-What is the renal outcome of this disease?
35
QUESTION 35
A child presents for her 2-week evaluation after being delivered
by a midwife at home. The parents are concerned that they have
never seen her turn her head, which makes it difficult for her to
feed at the breast. They also note that her back does not appear
normal. On physical examination, her hairline appears low
posteriorly. You confirm that she does not turn her head, and when
placed prone, does not turn her head to the side. Her right scapula
appears to be higher than the left, and you note that the spine
does not appear to be perfectly straight, suggesting congenital
scoliosis. You obtain an anteroposterior radiograph of the cervical
spine, which shows multilevel segmentation anomalies in the mid
to lower cervical spine.

2- What other associated defects may be seen?
36
QUESTION 36
A 4-month-old is brought to clinic by his parents for evaluation of
bilateral droopy eyes. His mother believes this has developed just
over the last week. The child recently started taking cereal in
addition to breastfeeding and has been constipated. Physical
examination reveals droopy eyelids and 1+ deep tendon reflexes
diffusely.

2-Enumerate 3 neuromuscular causes for ptosis?
37
QUESTION 37
A 3-year-old girl is brought to your office for re-evaluation of a
fever that began 6 days ago. Her mother tells you that her
daughter's temperature has been as high as 102.2°F (39°C). Her
physical examination was unremarkable when you examined her 3
days ago, but today you note injected sclera; cracked, red lips; a
strawberry appearance of her tongue; and a swollen, nontender,
cervical node.

2-What important test should be done at time of diagnosis and
why?
3-What treatment you should order?
38
QUESTION 38
You are seeing a 6-month-old boy for a health supervision visit.
On physical examination, you note bilateral, nontender scrotal
swelling. The scrotum transilluminates. The remainder of the
physical examination findings is normal.

2-What is the fate of this condition?
39
QUESTION 39
A 17-year-old boy presents for a sports physical. He has a learning
disability and is shy. His height is at the 75th percentile, and his
body mass index is at the 85th percentile. Physical examination
findings include minimal facial hair, bilateral gynecomastia (breast
>4 cm in diameter), and small testes (testicular volume of 6 mL).
1- What is the most likely cause of this patient's gynecomastia?

2-Mention 3 conditions causing gynecomastia?
3- Mention 3 drugs causing gynecomastia?
40
QUESTION 40
You are called to the newborn nursery to examine an infant who
appears dysmorphic. On physical examination, the baby is normally
grown and vigorous. You note over folded pinnae, deviation of the
nose to one side, and a small chin. The feet are maintained in
dorsiflexion, but can be corrected passively.
1- What are the causes of this baby’s features?

2- What is the difference between these features and
malformations?
3-What is the fate of these features?
41
QUESTION 41
A 6-year-old girl is brought to your office for clumsy gait of 3 days’
duration. On physical examination, she is afebrile and ataxic. She
has a full right facial palsy. Deep tendon reflexes are hard to elicit
at the knees and absent at the ankles. Results of her examination
are otherwise normal.

2- What is the most appropriate next step in the evaluation of
this child?
42
QUESTION 42
During the health supervision visit of a 2-week-old boy, his
mother states that the neonate’s left eye constantly tears and that
lights seem to bother him. On physical examination, the left eye
appears larger than the right, with mild conjunctival injection.

2- What is the most appropriate next step?
3-Why early diagnosis is important?
43
QUESTION 43
A 6-month-old infant who is new to your practice presents for a
health supervision visit. Review of his medical records reveals that
he was born at term after a reportedly uneventful pregnancy. He
was diagnosed with tetralogy of Fallot soon after birth, for which
he has undergone surgical intervention. He has been hospitalized
once subsequently for failure to thrive. No gastrointestinal
abnormalities were found, and he was discharged on 24-kcal/oz
formula. Chromosome analysis reveals a normal 46,XY karyotype.
The family history is negative for other individuals who have birth
defects or mental retardation. On physical examination, the boy’s
weight is 5.8 kg (3rd percentile), length is 62 cm (10th percentile),
and occipitofrontal circumference is 42 cm (10th percentile). There
is a right facial droop, and the left ear is protuberant, with
underfolding of the pinna. There is an iris coloboma on the right.
1- What is the most likely diagnosis for this child?

2-What other associated features you should look for?
44
QUESTION 44
A 2-year-old boy who had a history of recurrent episodes of dry,
scaly, pruritic eruptions on the face and extensor surfaces as an
infant now presents with multiple pustules that are oozing and
crusting. The pustules do not resolve with hydration, emollients,
moderately potent topical corticosteroids, or calcineurin inhibitors.
1- What is the most likely diagnosis for this child?

2- What is the most appropriate next step in the management of
this patient?
45
QUESTION 45
A 15-year-old boy who has cystic acne has experienced a frontal
headache for 1 week. He reports that the only drug he takes is
isotretinoin. Last night he presented to the emergency department
for headache. Computed tomography of the head was obtained
and normal; he was given meperidine and discharged home. He
presents now to your office for follow-up. The boy has
papilledema, but his physical examination findings are otherwise
normal.

2-What is the most appropriate next step in the evaluation of this
patient?
3-What are the causes of this condition and mention the specific
cause in this patient?
46
QUESTION 46
You are called to the nursery to evaluate a term newborn that has
dysmorphic features. The baby is normally grown and vigorous.
You note a small, symmetrically receded mandible as well as
posterior positioning of the tongue and a cleft palate. The baby’s
22-year-old mother was born with similar features; she has no
health problems at the present except for severe near sightedness.

2- What risk this infant may develop if untreated?
3- What is the most likely diagnosis of the mother?
47
QUESTION 47
A 2-week-old infant is brought to your clinic for her first health
supervision visit. She has been doing well at home, but her mother
is concerned that sometimes her hands and feet “turn blue.” On
physical examination, she appears alert and well. Her heart rate is
140 beats/min and respiratory rate is 40 beats/min. Her pulses are
strong and equal, and there are no cardiac murmurs. Her hands
and feet have a bluish tint, but her lips are pink.

3-What is the prognosis?
48
QUESTION 48
As the doctor for the high school basketball team, you are asked to
evaluate a student, who injured his right index finger on the rim
while dunking the basketball. During your evaluation, you note a
hematoma on the finger, but normal range of motion and no
broken skin. He has minimal tenderness. You also note
arachnodactyly and hypermobility of his thumb joints. He wears
glasses, has a pectus carinatum, and after a detailed measurement,
his arm span relative to his height is 1.15. He tells you that he can
play without pain and is looking forward to the state playoffs later
in the week. His parents tell you that basketball offers his best
chance of attending college.

2-Why he wears glasses?
3-What is the first investigation to be done?
4-What is your best advice to the patient?
49
QUESTION 49
You are evaluating an 8-year-old girl who recently moved to your
area from South America. She complains of a sore left knee and
tells you that yesterday her left ankle was sore and swollen. On
physical examination, she is alert and cooperative. Her resting
heart rate is 120 beats/min and respiratory rate is 20 breaths/min.
Her left knee is exquisitely painful and tender with motion, mildly
swollen, and erythematous. Her left ankle is mildly tender but
otherwise normal, although she tells you that on the preceding
day, it felt and looked like her knee does now. You notice a pink,
macular, erythematous rash on the trunk that has central
blanching.
1-What is this skin lesion?

50
QUESTION 50
A previously healthy 10-year-old girl presents to the emergency
department with the acute onset of gross hematuria, headache,
and facial swelling. About 2 weeks ago, she had a sore throat that
resolved without therapy. Vital signs include:
temperature of 99.3°F (37.4°C), heart rate of 94 beats/min, and
blood pressure of 147/92 mm Hg. On physical examination, you
note periorbital edema but no other abnormalities. Her serum
creatinine is 1.0 mg/dL (88.4 mcmol/L).

2-What is the cause of hypertension in this patient?
3-How you treat his hypertension?
51
QUESTION 51
A 3-year-old boy presents with a complaint of a swollen finger .
He was playing with the family cat yesterday, and the cat bit him.
Within 24 hours, the mother noted redness and swelling of
the finger. Physical examination reveals a temperature of 101°F
(38.3°C) and an erythematous area surrounding two puncture
marks on the palm of his right hand. The palm is very tender to
touch. The mother reminds you that he is allergic to penicillin.
1-What are the most likely causative organisms?

2- What is the best choice of initial antimicrobial therapy for this
child?
3- Where the infection rate is higher, in cat or dog bite and why?
52
QUESTION 52
While evaluating a newborn, you note absence of a red reflex.
Subsequent evaluation by an ophthalmologist reveals bilateral
cataracts. The infant also has failed the neonatal hearing screening
test, with results suggestive of severe hearing loss.
1- What is the most likely cause of the findings in this patient?

2-Enumerate 4 other causes for leukocoria?
3-What other findings you may see in this infant?
53
QUESTION 53
You are called to the nursery to evaluate a newborn who has
multiple anomalies. The baby was born at 37 weeks’ gestation to a
34-year-old primigravida and was delivered by cesarean section
due to breech presentation. Birth records reveal that there was a
short, two-vessel umbilical cord. On physical examination, the
infant appears pink and cries vigorously with manipulation of his
joints. You note flexion contractures at the elbows, wrists, hips,
and knees.
1-What is wrong with the newborn?

2-What is the primary cause of this infant’s contractures?
3- What is Pena-Shokeir phenotype?
54
QUESTION 54
A 15-year-old girl presents with a 4-day history of a temperature
to 102°F (38.9°C), a progressively worsening sore throat, right-
sided neck pain, and trismus. On physical examination, the
apprehensive adolescent has difficulty opening her mouth and
swallowing because of pain. Her pharynx is very swollen and
erythematous, with a small amount of mucopurulent exudate on
the left tonsil, and her uvula is deviated to the right. Tender 1 x 2-
cm cervical lymph nodes are palpable in her left neck. Laboratory
tests demonstrate a peripheral white blood cell count of 16 x
103/mcL (16x 109/L), with a differential count of 75%
polymorphonuclear leukocytes, 5% band polymorphonuclear
leukocytes, and 20% lymphocytes.

2-Which bacteria are usually isolated?
3- What are the most appropriate antibiotics to use in the
management of this patient?
55
QUESTION 55
A woman brings her 4-year-old son to see you because she is
concerned that he bruises easily. He has been well except for
having had a cold 2 weeks ago. He is behind on his immunizations.
On physical examination, you note that he is normally grown, but
he has diffuse joint hypermobility. There are paper-thin scars over
both knees where he previously sustained abrasions. The skin is
soft and stretchy. There are multiple bruises in various stages of
healing on the forehead, arms, and shins.
1-What is the most likely diagnosis for this child?

2-What cardiac complications he may develop?
3-What are Beighton criteria?
56
QUESTION 56
A 4-year-old boy has chronic nasal congestion, poor weight gain,
and frequent otitis media. There has been no improvement with
oral antihistamines, topical decongestants, or topical corticosteroid
sprays. Physical examination of the nares reveals bilateral polyps.
1-What is the most appropriate next study?

2-Enumerate 5 diseases associated with nasal polyposis?
3-What is your therapy?
57
QUESTION 57
A 9-year-old girl comes into your office for a health supervision
visit. You notice that in the last year, she has grown less than 1 in
(1.5 cm) and has gained 5 lb (2.2 kg). Her mother tells you that she
is doing well in school, but has been a little more tired in the past
few months than previously. She appears pale but otherwise well.
1-What is the most likely reason for the growth attenuation?

2-What other features you expect to see in this patient?
3-Mention 4 other causes of growth attenuation?
58
QUESTION 58
A 4-year-old girl has a 6-month history of right-sided ear drainage
that has continued despite several courses of oral and topical
antibiotics. Physical examination reveals purulent material in the
external auditory canal as well as a white mass on the tympanic
membrane.
1- What is the most likely cause of these findings?

2-What is your management?
59
QUESTION 59
A 30-month-old boy presents with multiple blotchy, brown
macules over the trunk and upper extremities. His parents report
that a few red lesions first appeared at 9 months of age, and
occasionally these lesions develop into”blisters.” The boy has
continued to develop new lesions on his chest, back, and arms. On
physical examination, stroking an individual lesion results in tense
edema within the lesion and an erythematous flare surrounding
the lesion.

2-What sign is demonstrated in the right photo?
60
QUESTION 60
A 3-year-old girl is hospitalized because of the sudden passage of
three maroon-colored stools. On physical examination, the child is
alert, with a pulse of 100 beats/min and a blood pressure of 80/60
mm Hg. Her abdomen is soft, with no tenderness. Rectal
examination demonstrates guaiac-positive stool. An abdominal
radiograph appears normal. A technetium-99 pertechnetate scan
shows an area of uptake in the right lower quadrant.

2- What is the most appropriate next step?
3- Mention 3 less common presentations of the disease?
61
QUESTION 61
A 3-year-old boy is brought to the office with complaints of
intermittent abdominal pain for 2 days. His mother notes that he
also had a limp and a faint rash on his legs for 1 day. He has been
afebrile and otherwise well except for an upper respiratory tract
infection a few weeks ago. On physical examination, he is alert and
complains of mild abdominal tenderness on palpation. His left
ankle is swollen and tender, and a few 4- to 5-mm nonblanching
lesions are visible on his thighs bilaterally.

2-What is primary cause of long-term morbidity?
62
QUESTION 62
A 10-year-old child presents to your office 1 hour after being
struck in the left eye by a thrown baseball. There was no loss of
consciousness, and he has not vomited since the incident. On
physical examination, the periorbital region appears swollen and
bruised diffusely. Extraocular motion is intact. Pupillary responses
are normal. The disc margins are sharp. Vision is slightly diminished
in the affected eye. You note bright red blood settling in the
inferior aspect of the anterior chamber up to the inferior margin of
the pupil.

2- What is the most appropriate next step in this patient’s
management?
63
QUESTION 63
The parents of an 18-month-old boy are concerned because he
has only two small, pegged teeth. He also has thin hair. The mother
reports she had late dental eruption as a child.
1-What is the most likely diagnosis in this patient?

2-What is the usual presentation of this patient?
3-Enumerate 3 other causes for late dental eruption?
64
QUESTION 64
You are evaluating a 16-year-old boy who has a 3-month history
of bilateral leg pain and lower back pain. He also reports occasional
low-grade fever and a 5- to 10-lb (2.25- to 4.5-kg) weight loss over
the last 3 months. He denies rashes or other symptoms. His
physical examination reveals loss of mobility of the lower spine
when bending forward and tenderness of both knees, hip
radiograph was ordered. The remainders of the examination
findings are normal.

2- What other features you may see in this patient?
3- What finding you see in the hip radiograph?
65
QUESTION 65
A 4-year-old boy presents with a 3 d history of jaundice and a
florid rash. He has had orange urine and there is no change in his
stool colour. There is no history of blood transfusion or sexual
abuse. The grandmother was recently diagnosed with hepatitis B.
On examination he is well, apyrexial and mildly jaundiced with
cervical and axillary lymphadenopathy. He has an extensive papular
rash over the face, extremities and trunk. There is 3 cm
hepatomegaly with no splenomegaly or ascites.
Examination is otherwise normal.
Initial investigations are as follows:

Total bilirubin 66 μmol/litre (0–15)
Conjugated bilirubin 23 μmol/litre (0–10)
Alanine aminotransferase (ALT ) 2033 IU/litre (0–35)
1. What is the name of this rash?

3- What is the best means of management?
66
A- CASE STUDIES WITH IMAGES
ANSWER 1
1- Sturge-Weber syndrome.
2- The most common ophthalmologic finding associated with this
condition is glaucoma.
3- Affected infants may have seizures, and some children have
developmental delay, learning disabilities, and intellectual
disability.
ANSWER 2
1- The infant described is at risk for amblyopia or diminished visual
acuity because of potential obstruction of vision by a hemangioma.
Thus, urgent ophthalmologic referral is indicated.
2- If ophthalmologic evaluation reveals evidence of amblyopia,
laser therapy or intralesional corticosteroids may be used to
reduce the size of the hemangioma.
3- Platelets count to exclude Kasabach-Merritt syndrome.
ANSWER 3
1- Ehlers-Danlos syndrome.
2- Most types of EDS are autosomal dominant, but autosomal
recessive and Xlinked forms also are described.
3- My advice is to avoid activities that can place affected
individuals at increased risk for arterial rupture, such as collision
sports, weight training, and heavy lifting.
ANSWER 4
1- Brain abscess.
2- The most appropriate diagnostic test is head computed
tomography scan with contrast.
3- A lumbar puncture should not be obtained prior to imaging
because removing CSF and reducing pressure below the foramen
67
magnum can cause expanded intracranial contents to herniate
downward.
ANSWER 5
1- The patient does not require renal biopsy at this point because
the urinalysis does not yet show evidence of significant proteinuria.
2- Corticosteroid therapy is not indicated for joint symptoms or
purpura.
3- Ibuprofen should be used with caution in children at risk of renal
disease, and they should be avoided in this patient, who already
has microscopic hematuria, to prevent further progression of early
renal involvement.
ANSWER 6
1- The clinical presentation and medical history of the child
described in the vignette is very concerning for an underlying brain
tumor.
2- Emergent intubation and control of the airway is indicated
before obtaining diagnostic imaging because the child is at
significant risk for brainstem herniation and respiratory arrest.
3- Computed tomography scan demonstrate a large posterior fossa
mass (medulloblastoma) with associated hemorrhage, obstruction
of the 4th ventricle, and dilation of the lateral and 3rd ventricles.
ANSWER 7
1- Legg-Calvé-Perthes Disease.
2- Passive exposure to smoking both prenatally and during
childhood has been associated in some studies, possibly by
affecting vascular development. Thrombophilia associated with
abnormalities of protein C and protein S also has been implicated.
3- *Slipped capital femoral epiphysis.
*Toxic (transient) synovitis.
*Septic hip.
68
ANSWER 8
1- Pneumocystis pneumonia.
2- The most likely test to yield the diagnosis is bronchoalveolar
lavage.
3- Trimethoprim-sulfamethoxazole is effective and generally well
tolerated and is the drug of choice for both treatment and
prevention. Children who cannot tolerate trimethoprim-
sulfamethoxazole can be given intravenous pentamidine.
4- Pneumocystis jiroveci (previously P carinii).
ANSWER 9
1- The most likely explanation for this patient’s syncopal episode is
long QT syndrome.
2- Patients who have long QT syndrome are at risk for life
threatening ventricular tachycardia, torsades de pointes, and
ventricular fibrillation.
3-* Complete atrio-ventricular block.
* Hypertrophic cardiomyopathy.
* Supraventricular tachycardia due to Wolff-Parkinson-White
syndrome.
ANSWER 10
1- The most likely explanation for these findings in the girl is
congenital adrenal hyperplasia (CAH).
2- The most helpful diagnostic laboratory blood test is
measurement of 17-hydroxyprogesterone.
3- Electrolyte abnormalities are not found in late-onset CAH.
ANSWER 11
1- Molluscum contagiosum.
2- They are caused by a DNA pox virus called molluscum
contagiosum virus (MCV).
69
3- Because of its benign nature and ultimate self-resolution,
observation is frequently the best approach for healthy children.
4- Without treatment, individual lesions usually resolve in 6 to 9
months, and the infection clears within 1 to 4 years. Molluscum
contagiosum often behaves differently in patients who have HIV
and resists treatment more than in healthy children.
ANSWER 12
1- Tuberous sclerosis complex (TSC).
2- Hypomelanotic macule, sometimes called ash leaf spot or
Fitzpatrick patch.
3- The presence of three or more hypomelanotic macules is a
major criterion for the diagnosis of TSC.
4- Cranial magnetic resonance imaging is necessary to determine
the presence of brain hamartomas.
5- Additional diagnostic testing should include ophthalmologic
evaluation, neurodevelopmental testing, echocardiography, and
renal ultrasonography. Although the boy’s delayed speech suggests
the need for audiology evaluation.
ANSWER 13
1- Arcanobacterium (formerly Corynebacterium) haemolyticum.
2- Erythromycin is the drug of choice for treating pharyngitis
caused by A haemolyticum.
ANSWER 14
1- Membranous pharyngitis caused by Corynebacterium
diphtheria.
2- The mainstay of therapy is diphtheria antitoxin and antimicrobial
therapy to stop toxin production, eradicate the organism, and
prevent transmission. Acceptable regimens include erythromycin
orally or IV for 14 days, penicillin G procaine intramuscularly (IM)
for 14 days, or penicillin G IM or IV for 14 days.
70
3- Close contacts of patients who have diphtheria, regardless of
their immunization status, should receive a single IM dose of
penicillin G benzathine or 10 days of oral erythromycin.
ANSWER 15
1- Atopic dermatitis, also called eczema.
2- Topical corticosteroid therapy.
3- Regular use of topical corticosteroids is associated with
hypopigmentation, bruising, acne, and thinning of the skin.
ANSWER 16
1- Disseminated intravascular coagulation (DIC) associated with
septic shock.
2- Measurement of fibrinogen.
ANSWER 17
1- Esophagus.
2- Although less than 1% of esophageal foreign bodies cause
significant morbidity, complications have been reported, including
esophageal erosion and perforation, esophageal stenosis,
aortoesophageal or tracheoesophageal fistula, and death. Because
most of the complications have been noted when foreign bodies
are retained for more than 24 hours, current guidelines
recommend removal of most foreign bodies within this time frame.
ANSWER 18
1- Familial hypophosphatemic rickets of either the autosomal
dominant or sex-linked type.
2- The typical laboratory findings in this disorder are normal
serum calcium and low serum phosphate values.
ANSWER 19
1- Pulmonary sequestration.
71
2- Surgical lobectomy generally is curative.
ANSWER 20
1- The most common cause of subdural hematoma in an infant is
“shaken baby” or “shaken impact syndrome.”
2- Retinal examination can identify retinal hemorrhages to support
the diagnosis.
3- Subdural hemorrhages result from trauma to veins traversing
the subdural space, making angiography unnecessary.
ANSWER 21
1- The bacteria that are involved most commonly are group A
Streptococcus and mixed oropharyngeal anaerobes.
2- Antimicrobial therapy must cover group A Streptococcus and
oral anaerobes, and clindamycin is a good choice.
ANSWER 22
1- Focal encephalitis.
2- Hemorrhagic necrosis.
3- Administration of intravenous acyclovir.
ANSWER 23
1- Measurement of cortisol and adrenocorticotropic hormone.
2-Addison disease (the presence of both autoimmune
hypothyroidism and suspected adrenal insufficiency in this girl
suggests the diagnosis of autoimmune polyglandular syndrome
type 2).
3-Skin pigmentation is increased by high concentrations of
adrenocorticotropic hormone.
4-The girl is at risk for other endocrine autoimmunities, including
ovarian failure and diabetes.
72
ANSWER 24
1- Hand-foot-and-mouth disease.
2- Coxsackievirus A16 or enterovirus 71, although other Coxsackievirus
types and echoviruses have been implicated.
3- Aphthous ulcers. herpangina, herpetic gingivostomatitis, and thrush.
ANSWER 25
1-Candida albicans, which is a normal commensal organism in
human.
2-The repeated courses of antibiotic have created the conditions
for Candida organisms to become pathogens.
3-The skin, throughout the entire gastrointestinal (GI) tract, in the
female genital tract, and in the urine of patients who have
indwelling Foley catheters.
ANSWER 26
1-The patient described has small-volume, painless rectal bleeding
that persists despite stool softeners. There is no fever or signs of
systemic illness to suggest an infection. The clinical presentation is
more consistent with a colonic polyp.
2-colonoscopy is the most likely test to identify the polyp.
3-Painless rectal bleeding generally is caused by anatomic rather
than inflammatory lesions. Meckel diverticulum is an extra piece of
intestine, typically located in the distal ileum that can ulcerate and
cause large-volume painless rectal bleeding. In toddlers, excessive
numbers of lymph nodes in the colon (lymphoid nodular
hyperplasia) sometimes may present with rectal bleeding.
ANSWER 27
1- The adolescent described in the vignette most likely is
experiencing an adverse food reaction, specifically anaphylaxis to
shellfish.
73
2- The rapid (<30 min) onset of urticaria and wheezing in a
shellfish-allergic patient who is eating in a seafood restaurant is
likely anaphylaxis and warrants prompt administration of
intramuscular epinephrine.
ANSWER 28
1- Tetanus (caused by a neurotoxin from the anaerobic bacterium
Clostridium tetani).
2- Treatment includes the use of human tetanus immune globulin
(TIG), oral antimicrobial agents (metronidazole or penicillin) for 10
to 14 days, and other supportive measures (e.g., ventilator
support, decreased external stimuli such as loud noises). In
addition, all infected wounds should be cleaned properly and
debrided.
3- Tetanus is prevented best through immunization with tetanus
toxoid. Tetanus toxoid is available:
1) in combination with diphtheria toxoid and acellular pertussis
vaccine (DTaP) to provide basic immunity against tetanus,
diphtheria, and pertussis;
2) as part of a double antigen (DT) for children up to 6 years of age
who cannot receive the pertussis component of the DTaP; and
3) as a single antigen (tetanus toxoid) (TT) to immunize pregnant
women and women of childbearing age to prevent tetanus in their
newborns.
ANSWER 29
1- Transient neonatal pustular melanosis (TNPM) is a disorder of
unknown cause that begins in utero. At birth, affected infants may
exhibit pustules or small hyperpigmented macules surrounded by
a rim of scale, the remnant of the pustule roof.
2- A Wright-stained preparation of the pustular contents reveals a
predominance of neutrophils.
74
3- The vesicles of erythema toxicum contain eosinophils, the
pustules caused by staphylococcal folliculitis contain gram-positive
cocci, the vesicles of herpes simplex virus infection contain
multinucleated giant cells, and the pustules of congenital
candidiasis contain pseudohyphae and budding yeast.
ANSWER 30
1-Eggs of roundworm Enterobius vermicularis.
2- The treatment of pinworm infections is a single dose of
mebendazole, pyrantel pamoate, or albendazole. A repeat dose
should be administered 2 weeks after the first dose in case of
reinfection.
3- The entire family should be treated if multiple infections or
repeated infections occur.
ANSWER 31
1- A finding of leukocyte esterase on a urine dipstick from a
male patient suggests the presence of urethritis and is confirmed
by the presence of 10 or more polymorphonuclear leukocytes per
high-power field in the centrifuged sediment of a first morning
void.
2- Reiter syndrome (RS).
3- Dermatologic findings of RS are common and include balanitis;
painless ulcers on the tongue, palate, pharynx, and buccal mucosa;
onycholysis; and vesicles and papules that mimic psoriasis
(keratoderma blennorrhagicum).
ANSWER 32
1- The chronic sinopulmonary infections, nasal polyps, and right-
sided heart (dextrocardia) described for the boy in the vignette are
virtually diagnostic for primary ciliary dyskinesia (PCD).
2- Approximately 50% of patients who have PCD have situs
inversus, a reversal of the visceral organs (Kartagener syndrome).
75
3-The diagnosis can be confirmed by identification of abnormal
cilia orientation or missing dynein arms by electron microscopy.
ANSWER 33
1- Sepsis due to Neisseria meningitides.
2- Vancomycin plus ceftriaxone.
ANSWER 34
1- Prune belly (Eagle-Barrett) syndrome (PBS) is a relatively
uncommon condition resulting from poorly developed abdominal
musculature.
2- Hydronephrosis is a common anomaly associated with PBS. The
hydronephrosis usually is obstructive and due to PUV or
vesicoureteral reflux and ureteropelvic junction obstruction.
3- The renal outcome is generally poor, and most children who
have PBS develop renal insufficiency.
ANSWER 35
1- The Klippel-Feil syndrome involves the fusion of cervical
vertebrae and occurs in approximately 1 in 42,000 births, with a
65% female predominance. It is usually a sporadic event. Due to
neck immobility, affected individuals are at risk of cervical spine
injury.
2-Associated defects may include deafness (conduction or
sensorineural, occurring in up to 30% of patients), congenital heart
defects (usually ventricular septal defect), rib
defects,hemivertebrae, Sprengel anomaly (elevation of the
scapula), scoliosis, and renal anomalies.
ANSWER 36
1- The bilateral ptosis, combined with constipation and diminished
reflexes, all developing during the introduction of solid foods
described for the infant in the vignette is classic for botulism.
76
2- Neuromuscular causes for ptosis that have a new-onset
neuropathic or myopathic basis include myasthenia gravis,
mitochondrial disease (chronic progressive external
ophthalmoplegia), and toxin exposures, such as botulism,
diphtheria, tick paralysis, insecticides, and vincristine.
ANSWER 37
1- Kawasaki disease (KD) is believed to be a multisystem illness
characterized by vasculitis of small- and medium-size blood vessels,
including the coronary arteries.
2- Echocardiography usually is performed at the time of diagnosis
to assess for the presence of a subclinical myocarditis, to evaluate
for coronary arteritis, and to serve as a baseline for future studies.
3- Intravenous gamma globulin during the acute phase and high-
dose aspirin therapy (80 to 100 mg/kg per day) is administered
until the patient is afebrile for 48 hours, at which time the dose is
decreased to 3 to 5 mg/kg per day for 6 to 8 weeks or until platelet
concentrations normalize.
ANSWER 38
1- Hydrocele (Failure of the processus vaginalis to obliterate
proximally results in fluid accumulation around the testes).
2- Most hydroceles resolve within 1 year; persistence beyond 1
year of age warrants surgical evaluation.
ANSWER 39
1- Adolescent males, who are tall and have gynecomastia and small
testes probably have Klinefelter syndrome (impaired androgen
production).
2- Liver and kidney disease, hyperthyroidism, androgen
insensitivity syndromes, and neoplasms.
3- Spironolactone, ketoconazole, digitalis, anabolic steroids,
and cimetidine.
77
ANSWER 40
1- Causes of fetal deformation are many and include
oligohydramnios, prolonged breech positioning, a small or
malformed uterus, fibroid tumors of the uterus, and multiple
gestations. Often, the affected infant has a pugilistic facies, with
deviation of the nose to one side. Limb positioning defects are
common.
2- Unlike malformations, which occur due to intrinsic problems
within a developing structure, deformations are due to mechanical
forces acting on an otherwise normally developing embryo or
fetus.
3- The appearance of the affected infant typically normalizes
over time.
ANSWER 41
1- The ataxia plus areflexia reported for the girl, paired with a facial
palsy, are virtually pathognomonic for Guillain-Barré syndrome.
2- Lumbar puncture will reveal albuminocytologic dissociation, with
an increase in protein and no pleocytosis.
ANSWER 42
1- Congenital or infantile glaucoma.
2- Children who exhibit these findings should be referred
immediately to an ophthalmologist for measurement of intraocular
pressure (IOP) to confirm the diagnosis.
3- Clinicians who care for children need to know the signs and
symptoms of glaucoma because delay in making this diagnosis may
lead to permanent visual loss.
ANSWER 43
1- The infant has features consistent with CHARGE association.
2- Traditionally, however, CHARGE has been considered an
association in which C=coloboma, H=heart defect, A=atresia
78
choanae, R=retardation of postnatal growth and/or development,
G=genital anomaly/ies, and E=ear malformation(s).
To meet criteria for the diagnosis of CHARGE, an individual
must have at least four of the above-delineated features, with
at least one of those being coloboma, choanal atresia or
stenosis, or malformation of the inner ear.
ANSWER 44
1- The child described suffers from atopic dermatitis (AD) and has
failed to improve despite use of several appropriate interventions.
Therefore, secondary bacterial infection by Staphylococcus aureus
should be considered.
2-Administration of an oral antistaphylococcal antibiotic would
promote resolution of this exacerbation.
ANSWER 45
1-Pseudotumor cerebri.
2-Lumbar puncture should be the next test performed in the
patient to determine opening pressure and exclude infection,
aseptic meningitis, or pseudotumor cerebri.
3-Multiple causes of pseudotumor cerebri have been reported, and
the clinician should exclude the possibility of these coexisting
conditions. Metabolic disorders (hyper- or hypovitaminosis A,
Addison disease, hypoparathyroidism,pseudohypoparathyroidism),
hematologic disorders (iron deficiency, polycythemia), infections
(otitis media and mastoiditis), systemic lupus erythematosus, and
pregnancy all can lead to pseudotumor cerebri. More frequently in
children, the disorder can be associated with obesity or drugs
(isotretinoin and other retinoids, tetracycline, minocycline,
corticosteroids, nalidixic acid, nitrofurantoin, oral contraceptives).
This boy’s isotretinoin should be discontinued to eliminate
definitively his pseudotumor cerebri.
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ANSWER 46
1- The newborn described has the Pierre-Robin sequence (PRS),
also known as Robin sequence.
2- Corpulmonale is a well-documented complication of PRS due to
hypoxia, chronic carbon dioxide retention, and elevated pulmonary
vascular pressure.
3- The syndromic diagnosis with which PRS most commonly is
associated is the Stickler syndrome , an autosomal dominant
connective tissue disorder characterized by micrognathia, malar
hypoplasia, and rapidly progressive, high myopia. The mother most
likely has Stickler syndrome.
ANSWER 47
1- Acrocyanosis.
2- Acrocyanosis is the transient bluish discoloration of the hands
and feet in response to vasomotor instability or a cold
environment.
3- Acrocyanosis is believed to be due to vasoconstriction of small
arterioles and generally is a benign phenomenon that resolves in
the first few postnatal months.
ANSWER 48
1-Marfan syndrome is a connective tissue disorder that typically
is inherited in an autosomal dominant pattern.
2-He may have ectopialentis or lens dislocation.
3-Echocardiography is essential to evaluate for the possibility of
cardiovascular involvement.
4-Patients in whom Marfan syndrome has been diagnosed or
is highly suspected should be counseled to avoid participation
in competitive contact sports. Avoidance of contact sports is
important because there is an increased risk of cardiac,
skeletal, and ophthalmologic problems resulting from injury.
Specifically with respect to the cardiovascular system, there
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can be tearing of the weakened, abnormal aortic wall, which
can lead to a catastrophic outcome.
ANSWER 49
1- Erythema marginatum.
2- Rheumatic fever.
ANSWER 50
1- Postinfectious acute glomerulonephritis (PIAGN).
2- The elevated blood pressure is related primarily to salt and
water retention by the kidney due to a reduced glomerular
filtration rate (GFR). Intrarenal renin levels may be elevated.
Because renin induces salt (and, therefore, water) reabsorption in
the kidney, this appears to be a likely major mechanism yielding
elevated blood pressure in patients who have acute
glomerulonephritis (AGN).
3- A variety of medications have proven efficacious in lowering
blood pressure in AGN. For mild-to-moderate elevations in blood
pressure, the most efficacious agents are usually “loop diuretics”
such as furosemide, which block salt and water reabsorption in the
distal nephron. Angiotensin-converting enzyme inhibitors (ACEI)
also have some efficacy in AGN by inhibiting the effects of renin.
Although medications such as nitroprusside and diazoxide are
effective in patients who are experiencing a hypertensive
emergency, the blood pressure of the child described in the
vignette can be managed initially by diuretics followed by ACEI.
Another vital strategy to treat the hypertension is to restrict fluid
intake, generally to one half to two thirds of maintenance
requirements.
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ANSWER 51
1- Patients who have been bitten by a cat or dog and develop signs
and symptoms of infection within 24 to 48 hours most likely have
an infection with Pasteurella multocida.
2- Since the patient described is allergic to penicillin, which makes
clindamycin and trimethoprim-sulfamethoxazole the appropriate
therapy. The clindamycin is required for coverage of
Staphylococcus aureus, which is common in animal bites;
the trimethoprim-sulfamethoxazole kills the Pasteurella.
3- The infection rate associated with cat bites is nearly double that
of dog bites because most cat bites result in puncture wounds,
while dogs tend to rip and tear the flesh when biting. Puncture
wounds are more difficult to clean and, therefore, are more likely
to become infected.
ANSWER 52
1- Congenital rubella.
2- A number of different conditions are associated with
leukocoria, including neoplastic conditions (eg, retinoblastoma),
retinal abnormalities (eg, retinopathy of prematurity),
developmental abnormalities (eg, chorioretinal coloboma),
inflammatory conditions (eg, toxocariasis), and other conditions,
such as cataracts.
3- Common findings in infants who have congenital rubella include
eye abnormalities, such as cataracts, congenital glaucoma, and
retinopathy, as well as sensorineural hearing loss, heart disease
(peripheral branch pulmonary artery stenosis, patent ductus
arteriosus), and mental retardation. Affected infants often also
have intrauterine growth retardation, hepatosplenomegaly,
thrombocytopenia, and purpuric skin lesions (blueberry muffin
rash).
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ANSWER 53
1- The newborn described has multiple joint contractures or
arthrogryposis multiplex congenita.
2- The primary cause of arthrogryposis multiplex congenita is
decreased fetal movement (fetal akinesia), which often is
idiopathic.
3- Fetal akinesia may be associated with a number of other
findings, including facial anomalies, hypoplastic lungs, short
umbilical cord, and intrauterine growth restriction. This
constellation of features, along with arthrogryposis, is referred to
as the Pena-Shokeir phenotype.
ANSWER 54
1- Peritonsillar abscess or quinsy.
2- The most common aerobic bacterial pathogens isolated include
Streptococcus pyogenes, beta-hemolytic group C streptococci,
and Staphylococcus aureus; the most commonly isolated
anaerobes are anaerobic streptococci and Prevotella, Bacteroides,
and Peptostreptococcus sp.
3- Because of the high frequency of a mixed polymicrobial etiology,
patients should be treated with an antimicrobial agent that covers
both aerobic and anaerobic bacteria, such as ampicillin/sulbactam,
clindamycin (especially if methicillin-resistant S aureus is
suspected), or oral amoxicillin/clavulanic acid.
ANSWER 55
1- Ehlers-Danlos syndromes (EDSs) (group of genetic connective
tissue disorders that are characterized by hyperextensibility of skin,
hyperextensibility of joints, and poor wound healing.)
2- Recent studies have shown that individuals who have both the
classic and hypermobile types are at increased risk for dilatation or
rupture of the ascending aorta.
3- It is recommended that joint hypermobility be determined
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using the Beighton criteria. A score of 5/9 or greater is necessary to
diagnose hypermobility using the following
maneuvers/observations:
1) Passive dorsiflexion of the 5th fingers beyond 90 degrees from
the horizontal plane (1 point for each hand)
2) Passive apposition of the thumb to the flexor aspect of the
forearms (1 point for each hand)
3) Hyperextension of the elbow beyond 10 degrees (1 point for
each elbow)
4) Hyperextension of the knee beyond 10 degrees (1 point for each
knee)
5) Forward flexion of the trunk with knees fully extended so that
the palms of the hand rest flat on the floor (1 point).
ANSWER 56
1- The boy described has nasal polyps associated with poor weight
gain, chronic otitis media, and nasal congestion. Any child who
presents with nasal polyps should be evaluated for cystic fibrosis
(CF) with a sweat chloride test.
2-Allergic fungal sinusitis, allergic rhinitis, aspirin sensitivity (Samter
triad ), chronic sinusitis, Kartagener syndrome, non-allergic rhinitis,
and Churg-Strauss syndrome.
3- Therapy for nasal polyps includes an initial investigation for the
underlying cause. Medical and surgical interventions have included
topical and systemic glucocorticoids, functional endoscopic sinus
surgery, and aspirin desensitization.
ANSWER 57
1- The most common endocrinologic reason for growth attenuation
is hypothyroidism.
2- Symptoms and signs of hypothyroidism include pallor, fatigue,
goiter, dry skin, hypochromic anemia, hair loss, carotenemia, easy
bruising or menorrhagia, edema, and hyperlipidemia. Rarely,
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pericardial and pleural effusions may occur.
3- Celiac disease, Cushing disease, growth attenuation before
puberty, and growth hormone deficiency.
ANSWER 58
1- Cholesteatomas are saclike structures within the middle ear or
on the surface of the tympanic membrane. They consist of trapped
epithelial tissue and squamous debris that grow beneath the
surface of the tympanic membrane.
2- The treatment is surgical removal. If they are not removed, they
will continue to enlarge, becoming locally destructive and possibly
invading the inner ear and intracranial cavity. Approximately 50%
of patients have associated hearing loss at the time of diagnosis.
ANSWER 59
1- Urticaria pigmentosa (UP) is one of four clinical manifestations
of mastocytosis that may be observed in childhood: solitary
mastocytoma, UP, and less commonly, bullous mastocytosis and
telangiectasia macularis eruptive perstans.
2- Stroking of pigmented lesions results in an erythematous flare
surrounding tense edema within the lesion (Darier sign).
ANSWER 60
1- The girl described presents with painless rectal bleeding, and
findings on the nuclear medicine study are consistent with a
Meckel diverticulum.
2-Surgicalconsultation should be obtained for resection of the
Meckel diverticulum.
3- Less common presentations include Meckel diverticulitis (which
can mimic appendicitis), intestinal obstruction from
intussusception or herniation, and (rarely) perforation from an
ingested foreign body trapped in the diverticulum.
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ANSWER 61
1- Henoch-Schönlein purpura (HSP).
2- Nephritis is seen in up to 50% of affected children and is the
primary cause of long-term morbidity.
ANSWER 62
1- The boy described has a hyphema, a collection of blood between
the cornea and iris that occurs after severe ocular trauma.
2- Treatment generally includes the use of a cycloplegic agent such
as atropine or homatropine to minimize iris movement and
decrease discomfort. In addition, topical steroids frequently are
used to minimize inflammation. Restricted activity is critical, which
is why most children are admitted initially to the hospital and
placed at bedrest, with the head of the bed elevated 45 degrees.
The eye is shielded, but not patched, to minimize the likelihood of
further trauma.
ANSWER 63
1- Hypohidrotic ectodermal dysplasia.
2- Because of the inability to sweat, affected children often have
heat intolerance and unexplained high fevers.
3- Calcium deficiency, hypopituitarism, and hypothyroidism.
ANSWER 64
1- Ankylosing spondylitis, one of the diseases categorized as
spondyloarthropathies, or more recently, enthesitis-related
arthritides.
2- Other features, including anterior uveitis, renal involvement, and
rarely aortic insufficiency, have been described in adolescents who
have this disease.
3- Hip radiographs show evidence of sacroiliitis.
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ANSWER 65
1- Gianotti–Crosti syndrome is a distinct, self-limiting rash,
commonly associated with viral infections in children between 2
and 6 years of age. It presents as multiple, pink to red−brown
papules or papulovesicles, which may be pruritic and can become
confluent. Gianotti and Crosti initially described the exanthema as
associated with hepatitis B virus, and they termed it papular
acrodermatitis of childhood. It can occur in several viral diseases,
e.g. hepatitis A, B and C, coxsackie viruses and cytomegalovirus.
2- Hepatitis B.
3- Patient and family education with consideration of antiviral
agents.
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PART 1
B- CASE STUDIES WITHOUT IMAGES
QUESTION 1
A 3-year-old girl presents with a 4- to 5-day history of diarrhea,
increased fussiness, and decreased urine output over the previous
day. On physical examination, her temperature is 37.5°C, heart rate
is 120 beats/min, respiratory rate is 24 breaths/min, and blood
pressure is 126/84 mm Hg. In addition, she has slightly pale, moist
mucous membranes and a II/VI flow murmur, but no gallop or
edema. Laboratory evaluation shows:
 White blood cell count, 24.2x103/mcL
 Hematocrit, 18.5%
 Blood urea nitrogen, 60 mg/dL
 Creatinine, 2.9 mg/dL

2-What is the most useful diagnostic test in this clinical setting?
3-Enumerate 3 indications for dialysis in this case?
4-What are the indications for platelet transfusions?
QUESTION 2
You are caring for a 15-year-old girl who has been hospitalized for
3 months for treatment of burns over 65% of her body suffered in a
house fire. For several weeks, she has required hyperalimentation
because of problems in consuming food. Routine laboratory
studies reveal a serum calcium of 12.1 mg/dL (3.0 mmol/L) and
phosphorus of 4.6 mg/dL (1.5 mmol/L). Serum electrolyte values
are normal.
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1-What is the most likely cause of this girl’s hypercalcemia?
2-Enumerate other 3 causes for hypercalcemia?
3-How a low-magnesium hyperalimentation formula affects
serum calcium?
QUESTION 3
You are evaluating a 7-week-old infant for persistent jaundice. She
was born at term, following an uncomplicated pregnancy and
delivery, weighed 3.2 kg at birth, and has been exclusively
breastfed. She was first evaluated for jaundice at 3 weeks of age.
The total bilirubin concentration was 16.0 mg/dL (273.7 mcmol/L),
and abdominal ultrasonography demonstrated "a collapsed gall
bladder without dilatation of the intrahepatic or extrahepatic bile
ducts." You diagnosed breast milk jaundice and on follow-up visits
every few days you noted a gradual reduction in total bilirubin.
Physical examination demonstrates an alert, icteric infant whose
weight is 4.2 kg. She has a firm liver edge palpable 1.5 cm below
the right costal margin and a spleen tip palpable 2 cm below the
left costal margin. You obtain the following laboratory data:
 Hemoglobin, 9.5 mg/dL
 Total bilirubin, 8.5 mg/dL
 Direct bilirubin, 4.5 mg/dL
 Alanine aminotransferase, 140 units/L
 Aspartate aminotransferase, 70 units/L
 Alkaline phosphatase, 450 units/L
1-What is the most appropriate next diagnostic test?

2- Define direct hyperbilirubinemia?
3- At what age you get the best surgical outcomes for infants who
have biliary atresia?
4- Mention 2 drugs which enhance bile flow in the postoperative
period of Kasai procedure
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QUESTION 4
A 14-year-old boy in the 9th grade presents with a complaint of
abdominal pain. He describes the pain as being in both the right
and left upper quadrants and explains that it occurs at any time of
the day or night. He also complains of recent left hip and leg pain.
Physical examination demonstrates a cooperative, alert adolescent
whose height is 137 cm and weight is 28 kg. A firm liver edge is
palpable 4 cm below the right costal margin, and the spleen is
palpable 6 cm below the left costal margin.
Initial laboratory data include:
 Alkaline phosphatase, 650 units/L

2-How you confirm it?
QUESTION 5
A 4-month-old male infant presents with abdominal distention,
vomiting, and poor weight gain. His temperature is 37.3°C, heart
rate is 110 beats/min, respiratory rate is 32 breaths/min, and blood
pressure is 96/56 mm Hg. On physical examination, you note
abdominal distention, with a palpable mass above the pubic
symphysis.
Results of laboratory studies include:
 Sodium, 136 mEq/L
 Potassium, 7.2 mEq/L
 Chloride, 110 mEq/L
 Bicarbonate, 16 mEq/L
90
 Blood urea nitrogen, 25 mg/dL
 Creatinine, 1.3 mg/dL
 Calcium, 9.5 mg/dL
 Magnesium, 1.8 mg/dL
 Phosphorus, 5.5 mg/dL

2-What is the next best step in the management of this patient’s
electrolyte abnormality?
3- Enumerate 2 causes of pseudohyperkalemia?
QUESTION 6
A 3-year-old boy presents with abdominal discomfort and
occasional vomiting. The only finding of note on physical
examination is a blood pressure of 104/58 mm Hg.
Urinalysis reveals:
 pH, 6
 3+ blood
 Negative for protein, nitrite, and leukocyte esterase
 10 to 20 red blood cells/high-power field (hpf)
 Fewer than 5 white blood cells/hpf
Upon further questioning, the mother states that she has a history
of "blood in her urine" and two maternal uncles required dialysis in
their teenage years.
1-What is the most likely cause for this patient’s urinary findings?
2-What is the mode of inheritance which you conclude from the
above scenario?
3- Mention 2 differential diagnoses?
91
QUESTION 7
You are caring for a 16-year-old girl who has juvenile idiopathic
arthritis. Her musculoskeletal symptoms have come under good
control using naproxen sodium. Recently, however, she has
been complaining of vague abdominal pain and occasional loose
bowel movements. Physical examination demonstrates an alert,
cooperative adolescent in no distress whose vital signs are
normal for her age. She has mild, direct tenderness in the
epigastric region, and rectal examination produces a scant amount
of brown stool that is positive on fecal occult blood test.
Laboratory data include:
 Erythrocyte sedimentation rate, 25 mm/hr
 Albumin, 3.4 g/dL

2-What is the most appropriate additional medication for this
patient?
QUESTION 8
You are called to see a 16-year-old girl who underwent scoliosis
surgery 6 days ago. She is receiving parenteral nutrition via
peripheral vein and morphine for pain. This morning she began
complaining of severe upper abdominal pain and vomiting. Physical
examination demonstrates a well-developed adolescent in
moderate distress whose temperature is 38.7°C, heart rate is 90
beats/min, and blood pressure is 130/66 mm Hg. Her abdomen is
mildly distended, with moderate fullness and tenderness in the
right upper quadrant and epigastrium.
Laboratory data include:
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 Gamma-glutamyl transpeptidase, 180 units/L
 Amylase, 70 units/L
 Lipase, 80 units/L
1-What is the most likely cause of these findings?

2- What is the most appropriate diagnostic test?
QUESTION 9
A previously healthy 11-year-old girl has had a dry hacking cough
for 3 months associated with fatigue, occasional fevers
(temperature of 38.4°C), and a 4-kg weight loss. On physical
examination, the tired-appearing child has multiple firm,
nontender posterior cervical, axillary, and inguinal nodes; her
respiratory rate is slightly elevated; and she has occasional
wheezes. Small nodules are visible along the iris-pupil margin, and
an ophthalmologist recently diagnosed anterior uveitis.
Laboratory findings of note include:
 Erythrocyte sedimentation rate, 32 mm/hr
 Calcium, 12.3 mg/dL
 Serum angiotensin converting enzyme, 110 units/L (normal, 5
to 89 units/L)
A purified protein derivative test is negative. Chest radiography
shows bilateral hilar adenopathy but no obvious parenchymal
disease

2-What is the most useful test(s) for establishing the diagnosis?
93
QUESTION 10
The mother of a 6-year-old girl reports during a health supervision
visit that her daughter has nighttime wetting and occasional
daytime accidents with urgency. She has no history of constipation,
and no one else in the family has suffered enuresis.
Her urinalysis reveals:
 pH, 7
 2+ blood
 Trace protein
 Positive for nitrites
 3+ leukocyte esterase
 5 to 10 red blood cells/high-power field (hpf)
 20 to 50 white blood cells/hpf
1-What is the most likely cause of her symptoms?

2-What is the best diagnostic test to perform for this patient and
why?
3-What is your suggested treatment?
QUESTION 11
A 15-year-old girl presents to the emergency department with
right upper quadrant pain for 2 days that is severe enough to keep
her out of school. Her appetite is decreased and she has nausea
but no vomiting or diarrhea. She has mild discomfort with urination
but no vaginal discharge. The only medication she is taking is
combined oral contraceptive pills. Her last menstrual period was
heavier than usual. Laboratory tests reveal:
• White blood cell count, 7.4x103/mcL with 64% segmented
neutrophils and 26% lymphocytes
• Total bilirubin, 0.4 mg/dL
• Alanine aminotransferase, 14 units/L
• Aspartate aminotransferase, 16 units/L
94
Her urine has 7 white blood cells per high-power field.
Abdominal ultrasonography reveals a normal liver, spleen,
gallbladder, and kidneys.

2-What is the cause of her pyuria?
3-What are the most likely recovered organisms?
QUESTION 12
A 14-year-old girl presents with a 2-month history of joint pain
that is responding poorly to over the-counter anti-inflammatory
medications. She reports some sores in her mouth and mild
swelling around her eyes and ankles. On physical examination, her
temperature is 37.0°C, heart rate is 76 beats/min, respiratory rate
is 14 breaths/min, and blood pressure is 130/86 mm Hg.
She has oral ulcers, mild periorbital and pretibial edema, and mild
swelling of her wrists and knee joints. Laboratory findings include:
• Sodium, 136 mEq/L
• Potassium, 4.8 mEq/L
• Chloride, 100 mEq/L
• Bicarbonate, 22 mEq/L
• Blood urea nitrogen, 24.0 mg/dL
• Creatinine, 1.3 mg/dL
• Albumin, 2.5 g/dL
• Hemoglobin, 10.1 g/dL
• White blood cell count, 3.0x103/mcL
• Platelet count, 190x103/mcL
• Urinalysis: 3+ blood, 3+ protein, with 20 to 50 red blood
cells/high-power field
• Antinuclear antibody titer: 1:1,280
• Anti-double-stranded DNA titer: 1:640
95
2-What is the next best step in management?
3-What tests are used to monitor the patient?
QUESTION 13
You are called to the emergency department to evaluate a 1-year-
old girl who was rescued from a house fire by paramedics. She was
found unconscious at the scene and had soot around her nares. On
arrival to the emergency department, she is able to open her eyes
but still appears sleepy. Her temperature is 37.0°C, heart rate is
150 beats/min, respiratory rate is 30 breaths/min, and blood
pressure is 90/60 mm Hg. Her oxygen saturation by pulse oximetry
is 97% on 100% oxygen administered at 8 L/min via a
nonrebreathing facemask. The nurse asks if you would like to
reduce the oxygen because the girl’s oxygen saturation is greater
than 95%. You explain to the nurse that the pulse oximetry findings
are unlikely to be reliable in this patient.
1-What is the most likely reason for inaccurate pulse oximetry

results in this patient?
2-Mention 3 conditions in which pulse oximetry can yield falsely
low saturations?
3-How pulse oximetry works?
QUESTION 14
A 3½-week-old male infant presents to your office with a history
of 2 to 3 days of vomiting. He was born at term and his birth weight
was 3,250 g. He is breastfed. He has been exhibiting no bilious
vomiting after each feeding, and according to his mother, the
emesis now appears to "shoot out of his mouth." After vomiting,
he seems eager to resume feeding. Over the past 24 hours, his
mother has noted fewer wet diapers and fewer stools than usual.
The baby has experienced no diarrhea or upper respiratory tract
96
symptoms. Physical examination demonstrates an alert, afebrile
infant who weighs 3,550 g and is sucking vigorously on a pacifier.
His skin turgor is normal. The remainders of the examination
findings are unremarkable, except for slight abdominal distention.
You refer the baby to the local emergency department and
order measurement of serum electrolytes. Results include:

2-Mention 3 differentials diagnoses?
3- What is the most appropriate initial treatment for this infant?
QUESTION 15
A 5-year-old girl has a 2-year history of intermittent, poorly
localized abdominal pain. She now presents with a recurrence of
crampy pain, and she has vomited after each meal for the past 24
hours. She has no history of fever or diarrhea. The child woke
frequently last night because of pain, and she seemed more
comfortable lying on her side in a knee-chest position. The family
history is negative for gastrointestinal disease. Both parents are 42
years of age, and the child’s father underwent a coronary artery
bypass procedure last year. The girl is difficult to examine,
complaining of pain wherever her abdomen is palpated. Initial
laboratory data include:
• Amylase, 240 units/L
97
• Lipase, 700 units/L
• Aspartate aminotransferase, 60 units/L
• Alanine aminotransferase, 70 units/L

2-What is the test that most likely demonstrates the underlying
cause of this girl’s illness?
QUESTION 16
A 6-year-old child presents for a health supervision visit. On
physical examination, his weight is 18 kg, height is 102 cm (<3rd
percentile), pulse rate is 90 beats/min, respiratory rate is 18
breaths/min, and blood pressure is 134/88 mm Hg. Of note, he has
pale conjunctivae and mild edema. Among the results of laboratory
evaluations are:
• White blood cell count, 6.0 x103/mcL
• Mean cell volume, 82 fL
• Reticulocyte count, 0.4%
• Blood urea nitrogen, 94 mg/dL
• Serum creatinine, 12.1 mg/dL
The stool is negative for occult blood.
1- What is the most likely explanation for this patient’s anemia?

2-What are the causes of low reticulocyte count and anemia?
QUESTION 17
An 18-month-old female presents with failure to thrive,
polydipsia, and photophobia. Her weight is 8 kg and height is 70 cm
(both <5th percentile). On physical examination, she appears pale
and small for stated age, and she closes her eyes when you
attempt to perform ophthalmoscopy.
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She has tacky mucous membranes and capillary refill of 2 to 3
seconds. Pertinent findings on laboratory evaluation include:
• Calcium, 8.4 mg/dL
• Phosphorus, 2.1 mg/dL
• Magnesium, 1.4 mg/dL
Glucose, 102 mg/dL
1- Mention the abnormal laboratory findings in this case?

3-What is the best clinical test to establish the diagnosis?
QUESTION 18
A mother brings in her 3-year-old daughter because of daytime
urinary incontinence and abdominal pain. The mother explained
that the girl was toilet trained at 2 years of age. On physical
examination, growth parameters and vital signs are normal,
although the girl has mild suprapubic tenderness without
associated costovertebral angle tenderness or sacral dimples.
Urinalysis shows a urine specific gravity of 1.025, pH of 6.5, 2+
blood, 1+ protein, 3+ leukocyte esterase, and positive nitrite. Urine
microscopy demonstrates 5 to 10 red blood cells/high-power
field, 20 to 50 white blood cells/high-power field, and 3+ bacteria.
1-What is the most likely etiologic agent?

2-Mention 2 conditions in which nitrite test may be negative even
in the presence of a UTI?
99
QUESTION 19
A 4-year-old female presents with fever, chills, and vomiting. She
has had abdominal pain and dysuria for 3 days. Her temperature is
104.2°F (40.1°C), and she has left-sided costovertebral angle
tenderness. Laboratory evaluation reveals a white blood cell count
of 18.7 x 103/mcL with 85% neutrophils, 5% bands, 7%
lymphocytes, and 3% monocytes. On urinalysis, the urine specific
gravity is 1.025 and pH is 6.5, and there is 2+ blood, 1+ protein, 3+
leukocyte esterase, and positive nitrite. Urine microscopy
demonstrates 5 to 10 red blood cells/high-power field, 50 to 100
white blood cells/high-power field, and 3+ bacteria. Findings on
renal/bladder ultrasonography are normal. After a 3-day
hospitalization for administration of intravenous antibiotics,
discharge with a prescription for oral antibiotics is planned.

2-What is the most appropriate study to complete this child’s
evaluation?
3-What are the anatomic abnormalities which can be detected by
renal/bladder ultrasonography in this patient?
QUESTION 20
A 3,200-g term infant has an abnormal finding on newborn
screening that was obtained at 36 hours of age. The thyroxine (T4)
value was 3.5 mcg/dL (45.2 nmol/L) (normal, >7 mcg/dL [90.3
nmol/L]). The thyroid-stimulating hormone (TSH) value was
reported by the screening laboratory as within the normal range.
1-What is the most likely reason for the low T4 value?

2-How it is inherited?
3-How it is diagnosed?
100
QUESTION 21
A term newborn is delivered by emergent cesarean section
because of intrauterine growth restriction, oligohydramnios, and
non reassuring fetal heart rate monitoring in labor. Delivery room
resuscitation includes endotracheal intubation and assisted
ventilation with 100% oxygen, chest compressions, intravenous
epinephrine, and volume expansion. Apgar scores are 1, 2,
and 3 at 1, 5, and 10 minutes, respectively. An umbilical cord
arterial blood gas measurement documents a pH of 6.9 and a base
deficit of 20 mmol/L. At 12 hours of age, the infant demonstrates
tonic-clonic convulsive activity of the arms and legs with
a concomitant decrease in heart rate and bedside pulse oximetry
saturation.
1-What is the most likely cause for this infant's seizure?

2- What you conclude from the umbilical cord arterial blood gas
measurement?
3-Enumerate other 5 causes for neonatal seizure?
QUESTION 22
A worried grandmother brings her 2-year-old grandchild to the
emergency department immediately upon finding the boy with an
open bottle of 81-mg chewable aspirin (which is used by the
grandfather for coronary artery disease prophylaxis). She is unsure
of the number of tablets in the bottle prior to ingestion, but the
original number was 30, and there are now three remaining. The
child has vomited once and is fussy and lethargic. Physical
evaluation reveals a 12-kg child who has tachypnea and
tachycardia. Laboratory results include a pH of 7.45, carbon
dioxide of 25 mEq/L (25 mmol/L), and bicarbonate of 18 mEq/L (18
mmol/L). A salicylate measurement result is pending.
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1-What is the next best step in the management of this child?
2- What are the toxic effects of salicylates?
3- Is syrup of ipecac indicated for this patient?
QUESTION 23
An 11-year-old Caucasian boy who has no significant past medical
history presents to the emergency department with a 3-day history
of brown urine. He reports no dysuria, urgency, frequency, or
abdominal or flank pain. His vital signs reveal: temperature, 99°F
(37.2°C); blood pressure, 141/84 mm Hg; heart rate, 92 beats/min;
and respiratory rate, 24 breaths/min.
Significant findings on physical examination include moderate
periorbital and leg edema. His urinalysis reveals moderate blood
and 4+ protein. The serum complement 3 (C3) and C4
concentrations are both low.
1-What is the most likely cause of his hematuria?

2-Enumerate 5 other causes of gross hematuria?
QUESTION 24
You are asked to review a case for morbidity and mortality
conference. The infant was born at term to a 19-year-old gravida 1,
para 1 woman by normal spontaneous vaginal delivery. The mother
was known to be group B Streptococcus-negative, but she did have
genital warts. The Apgar scores were 9 at 1 minute and 10 at 5
minutes. On the seventh postnatal day, the infant developed a
temperature of 103°F (39.4°C) and was brought to the emergency
department. At this time, the infant was in shock and required
mechanical ventilation. Physical examination revealed scleral
icterus and hepatosplenomegaly but no skin lesions. A lumbar
puncture could not be performed. Laboratory results include:
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• White blood cell count of 2.34x103/mcL, with 32% lymphocytes,
41%neutrophils, 8% bands, 15% monocytes, 3% eosinophils, and
1% basophils
• Hemoglobin of 7.1 g/dL
• Hematocrit of 21%
• Platelet count of 40x103/mcL
• Prothrombin time of 41.2 seconds
• Activated partial thromboplastin time of >106 seconds
• Aspartate aminotransferase concentration of 3,086 U/L
• Alanine aminotransferase concentration of 456 U/L
• Total bilirubin of 4.4 mg/dL
The chest radiograph demonstrated diffuse interstitial infiltrates
bilaterally. The patient did poorly over the next 3 days and died
despite aggressive management in a pediatric intensive care unit.
1- What is the most likely cause of this patient's death?

2-How you treat?
3- What are the causes of neonatal shock like symptoms during
the first 7 to 10 days after birth?
QUESTION 25
An obese 14-year-old boy who has been receiving a course of
prednisone for asthma is brought to the emergency department
comatose and responding only to pain. His mother states that he
has been drinking juice and carbonated beverages to quench his
thirst. This morning he became increasingly lethargic, refused
fluids, and finally became unresponsive. On physical examination,
his blood pressure is 120/50 mm Hg, pulse is 100 beats/min, and
respiratory rate is 20 breaths/min. His lungs are free of wheezes,
with good air exchange. He appears 10% dehydrated.
Initial laboratory studies reveal:
• Glucose, 1,200 mg/dL
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• Serum osmolality, 334 mOsm/kg H2O

2-What serious complication the patient may develop if he is
resuscitated rapidly?
3-What is the cause of his hyponatremia?
4-What is your general plan for fluid therapy in this patient?
QUESTION 26
A 3-week-old breastfed infant presents to the emergency
department with irritability, fever, jaundice, and hepatomegaly. A
laboratory evaluation shows a normal complete blood count and a
bilirubin concentration of 6.5 mg/Dl. A urinalysis is positive for
reducing substances. A blood culture is positive for
Escherichia coli.

2- What is the most appropriate dietary management of this
patient?
3- What is the cause of positive urinary reducing substances?
QUESTION 27
A 4-year-old boy presents to the emergency department with a
3-week history of daily abdominal pain and vomiting. His mother
states that he also has appeared pale. On physical examination, the
boy is quiet and has a soft abdomen. The stool is dark and
guaiac-positive. The boy’s pulse is 130 beats/min, and his blood
pressure is 90/60 mm Hg. Among the laboratory findings are:
• Hematocrit, 23%
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• Platelet count, 275 x 103/mcL
• White blood cell count, 6.7 x 103/mcL
• Alanine aminotransferase, 25 U/L
• Amylase, 50 U/L

2- What is the most appropriate diagnostic procedure?
QUESTION 28
You are evaluating a newborn in whom intrauterine renal
ultrasonography results were abnormal. The child appears very
edematous but requires resuscitation with fluids for initial
respiratory distress and hypotension. One day later, the child
appears more edematous. He has excellent urine output.
Measurement of serum electrolytes reveal:
Albumin concentration is 0.9 g/dL. His urinalysis reveals no
blood and 4+ protein, with a random urine protein-to-creatinine
ratio of 43.5.
1- What is the most likely cause of this child’s clinical status?

2-Why they are at risk for malnutrition and failure to thrive
during infancy?
QUESTION 29
A 17-year-old girl presents with a 5-day history of jaundice. She
has a 3-year history of anxiety and depression and has seen a
neurologist because of tremor and slurred speech. On physical
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examination, the girl is responsive but withdrawn and has scleral
icterus. Her liver is slightly enlarged, but there is no splenomegaly.
Her total serum bilirubin is 12.0 mg/dL, direct bilirubin is 1.0
mg/dL, and hematocrit is 25%.
Serum albumin is 3.0, and total protein is 6.5 g/dL. The peripheral
blood smear demonstrates schistocytes and burr cells.
The prothrombin time is 23 seconds, partial thromboplastin time is
60 seconds, and serum ammonia concentration is 80 mcg/dL.

2- What laboratory test most likely identifies the cause of this
girl’s liver dysfunction?
3-What clinical test help to establish the diagnosis?
QUESTION 30
You are asked to evaluate a 1-year-old boy who has failure to
thrive and whose weight is at the 5th percentile and height is
below the 5th percentile. On physical examination, you find a blond,
blue-eyed, fair-skinned boy who does not bear weight on his legs
and never has walked. His legs appear markedly bowed, and the
mother reports that the bowing has been worsening over the past
several months.
Laboratory tests reveal:
• Serum calcium, 9.6 g/dL
• Serum phosphate, 1.7 g/dL
Urinalysis reveals glucose, no blood, and 2+ protein.
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1- What is the most likely cause of the boy’s leg bowing?
2- What is the cause of rickets in this patient?
3-Is there any role for medical treatment?
QUESTION 31
A 14-year-old girl presents with a 2-month history of joint pain
that is responding poorly to over the-counter anti-inflammatory
medications. She reports some sores in her mouth and mild
swelling around her eyes and ankles. On physical examination, her
temperature is 37.0°C, heart rate is 76 beats/min, respiratory rate
is 14 breaths/min, and blood pressure is 130/86 mm Hg.
She has oral ulcers, mild periorbital and pretibial edema, and mild
swelling of her wrists and knee joints. Laboratory findings include:
• Albumin, 2.5 g/dL
• Urinalysis: 3+ blood, 3+ protein, with 20 to 50 red blood
cells/high-power field
• Antinuclear antibody titer: 1:1,280
• Anti-double-stranded DNA titer: 1:640

2- What is the next best step in management?
3- How you monitor renal progression in this patient?
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QUESTION 32
You are evaluating a 14-year-old girl during a health supervision
visit. On physical examination, her weight is at the 50th percentile,
height is at the 75th percentile, temperature is 36.8°C, pulse
is 72 beats/min, respiratory rate is 14 breaths/min, and blood
pressure is 160/96 mm Hg.
Laboratory evaluation reveals:
• Normal urinalysis findings
Renal ultrasonography shows a normal right kidney that is 10.5 cm
in length and a left kidney that is 7.0 cm in length (greater than 2
standard deviations below the mean for age). Both kidneys are of
normal echotexture and have no cysts, calculi, or masses.
Echocardiography reveals moderate left ventricular hypertrophy
but an otherwise structurally normal heart.
1-What abnormalities you noticed in his laboratory results?

2-What is the most likely cause for this patient’s elevated blood
pressure?
QUESTION 33
A 3-year-old girl presents with a 2-day history of vomiting and
diarrhea. Her mother explains that although the girl has difficulty
keeping down fluids, she has managed to take sips of water and
eat popsicles. On physical examination, her temperature is 37.0°C,
heart rate is 140 beats/min, respiratory rate is 14 breaths/min,
blood pressure is 106/60 mm Hg, and weight is 15 kg. She has dry
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mucous membranes and a capillary refill of 3 seconds. Laboratory
evaluation reveals:
• Glucose, 70.0 mg/dL
Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 3+ ketones,
and no blood or protein.
1-What is your conclusion of the patient laboratory evaluation?

2-What is the most likely cause of the patient clinical condition?
3-What is the most appropriate intravenous fluid order for
immediate management?
QUESTION 34
A 10-day-old boy presents to the emergency department with a 1-
day history of lesions on his lips. He was born at 38 weeks by
Caesarean section because his mother had previously had a
Caesarean section. The pregnancy was uneventful; in particular
there was no history of Group B Streptococcus or herpes simplex
virus infection. The baby was discharged home on day 2, feeding
well. He developed sticky eyes on day 4, which his mother treated
with over the-counter medication. Otherwise, there had been no
concerns and he continued to feed well. On the morning of
presentation, his mother had noticed yellow crusty lesions on his
upper lip and at the angle of his mouth.
At triage, his observations were as follows:
 Axillary temperature 36.4 0C
 Heart rate 140 beats per minute
 Central capillary refill time less than 2 s
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 Respiratory rate 35 breaths per minute.
Clinical assessment revealed the baby to be unsettled, and he
disliked being examined. Cardiovascular, respiratory and
abdominal examination was unremarkable. He had a yellow crusty
lesion at the angle of his mouth and a small one on his central
upper lip. There was yellow discharge from both eyes, but his
conjunctivae were normal. His skin was diffusely erythematous and
seemed to be tender. He was well hydrated.

2-What is the most likely pathogen?
3-What would be the most appropriate treatment?
4-What is the usual natural progression of this condition if
treated appropriately and promptly?
QUESTION 35
A 19-year-old primiparous woman develops toxemia in her last
trimester of pregnancy and during the course of her labor is
treated with magnesium sulfate. At 38 weeks’ gestation, she
delivers a 2100-g (4-lb, 10-oz) infant with Apgar scores of 1 at 1
minute and 5 at 5 minutes. Laboratory studies at 18 hours of age
reveal a hematocrit of 79%, platelet count of 100,000/μL, glucose
41 mg/dL, magnesium 2.5 mEq/L, and calcium 8.7 mg/dL. Soon
after, the infant has a generalized convulsion.
1-What is the most likely cause of the infant’s seizure?

2-What is the mechanism behind the seizure?
3-How you treat?
QUESTION 36
A previously normal newborn infant in a community hospital
nursery is noted to be cyanotic at 14 hours of life. She is placed on
a face mask with oxygen flowing at 10 L/min. She remains cyanotic,
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and her pulse oximetry reading does not change. An arterial blood
gas shows her PaO2 to be 23 mm Hg. Bilateral breath sounds are
present, and she has no murmur. She is breathing deeply and
quickly, but she is not retracting.
1-What is the most likely cause of this infant deterioration?

2- While you are waiting for the transport team, what urgent
intervention you should do?
QUESTION 37
You are asked to evaluate a 4-year-old boy admitted to your local
children’s hospital with a diagnosis of pneumonia. The parents
state that the child has had multiple, intermittent episodes of fever
and respiratory difficulty over the past 2 years, including cyanosis,
wheezing, and dyspnea; each episode lasts for about 3 days. During
each event he has a small amount of hemoptysis, is diagnosed with
left lower lobe pneumonia, and improves upon treatment. Repeat
radiographs done several days after each event are reportedly
normal. His examination on the current admission is significant
for findings similar to those described above, as well as digital
clubbing.

2-What is the most appropriate primary recommendation and
what you expect to find?
3-Is there any place for diet modification?
QUESTION 38
A 15-year-old girl is admitted to the hospital with a 6-kg weight
loss, bloody diarrhea, and fever that have occurred intermittently
over the previous 6 months. She reports cramping abdominal pain
with bowel movements. She also reports secondary amenorrhea
during this time. Stool cultures in her physician’s office have shown
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only normal intestinal flora. A urine pregnancy test was negative,
while an erythrocyte sedimentation rate (ESR) was elevated. Her
examination is significant for the lack of oral mucosal ulcerations
and a normal perianal examination. Anti-Saccharomyces
cerevisiae antibodies (ASCA) are negative, while anti-neutrophil
cytoplasm antibodies (p-ANCA) are positive.

2- What is the most serious complication of her disease and how
it is presented?
QUESTION 39
An 11-month-old boy has a hematocrit of 24% on a screening
laboratory done at his well-child checkup. Further testing
demonstrates: hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte
count 12,200/μL with 39% neutrophils, 6% bands, 55%
lymphocytes; hypochromia on smear; free erythrocyte
protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole
blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-
cell preparation negative; stool guaiac-negative; and mean
corpuscular volume (MCV) 64 fL.

2-What is the most appropriate recommendation?
3-Mention another type of anemia with increased free
erythrocyte protoporphyrin (FEP) level?
QUESTION 40
The parents of a 1-month-old infant bring him to the emergency
center in your local hospital for emesis and listlessness. Both of his
parents wanted a natural birth, so he was born at home and has
not yet been to see a physician. On examination, you find a
dehydrated, listless, and irritable infant. Although you don’t have a
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birth weight, the parents do not feel that he has gained much
weight. He has significant jaundice. His abdominal examination is
significant for both hepatomegaly and splenomegaly. Laboratory
values include a total bilirubin of 15.8 mg/dL and a direct bilirubin
of 5.5 mg/dL. His liver function tests are elevated and his serum
glucose is 38 mg/dL. Serum ammonia is normal. A urinalysis is
negative for glucose, but it has a “mouse-like” odor.

2-what other features you expect to see in this infant?
3-What simple test can be of help in the diagnosis?
4-What is your treatment?
QUESTION 41
A 20-week anomaly scan was performed on a 20-year-old woman
and revealed exomphalos, macroglossia, bilateral enlarged kidneys
and an umbilical cord cyst in the fetus. Amniocentesis confirmed a
normal male karyotype. The baby was delivered at 38 weeks. He
was found to be macrosomic, with a birthweight of 5.34 kg, and
had macroglossia and transient hypoglycaemia.
1. What is the most likely diagnosis?

2. What other associated features maybe noted in infancy?
3. What long-term follow-up would you arrange for an infant with
this condition?
QUESTION 42
A 14-month-old child presented with a 2-week history of
diarrhoea and vomiting but no fever. She had not been drinking
well and had dry nappies so was taken to the emergency
department by her mother. Mum said that the baby had had a
distended abdomen since birth but that it had become increasingly
distended, especially on the left side. The baby had not been eating
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well and had lost some weight over the previous 2 months. On
examination, she was noted to be pale. She had no dysmorphic
features. She had a temperature of 37.6 0C, a mild tachycardia and
a blood pressure of 147/ 97 mmHg. On palpation, a left-sided
abdominal mass was evident, and a CT scan showed an intrarenal
mass with calcification and a single pulmonary nodule.
The results of the investigations were as follows:
 Haemoglobin 10.2 g/dl
 White cell count 31X109/l (neutrophilia)
 Platelet count 899X109/l
 Urea and electrolytes Normal
 Liver function tests Normal
 Prothrombin time Normal
 APTT Prolonged
 D-dimers Normal
 Fibrinogen Normal
 Urine noradrenalin Normal
 Urine dopamine: DOP Normal
 Urine HMMA Normal
 Urine HVA Normal

2. What is the cause of her prolonged APTT?
3. Which is the most appropriate treatment for her hypertension?
QUESTION 43
A term male is delivered by Caesarean section for a prolonged
second stage of labour. This is his mother’s fifth pregnancy and she
has had no antenatal care. His APGARS are 6 at 1 min and 8 at 5
min. At 35 min of life he is tachypnoeic and occasionally grunting.
On admission to the neonatal unit some dysmorphic features are
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noted. He has low set ears, broad epicanthic folds, abundant neck
skin folds and bilateral simian creases. Examination of his
cardiovascular system is unremarkable. A 5 cm liver and 2 cm
spleen are palpable. A chest X-ray shows bilateral perihilar
markings, with some fluid visible in the horizontal fissure.
A full blood count shows:
 Haemoglobin (Hb) 12 g/dl
 White Cell Count (WCC) 58X109/l
 Platelets 27X109/l
1-What is the most likely explanation for the above findings?

2-What first-line investigation should be performed to elucidate
the aetiology of the leucocytosis?
3-What is the management of choice in this case?
QUESTION 44
A 6-year-old boy is admitted with a 5-day history of fever,
lethargy, anorexia, jaundice and dark urine. On examination he is
pyrexial, pale, mildly icteric with lymphadenopathy and tender
hepatosplenomegally.
Initial investigations show:
 Hb 5.5 g/dl
 WBC 12.0 × 109/l (N 41%, L 47%, M 11%, atypical lymphocytes
1%)
 Platelets 212 × 109/l
 Bilirubin 37 mmol/l
 Transaminases normal
 A coagulation screen is normal

2- Which specific complications should be considered?
3-What further investigations may be considered?
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QUESTION 45
A 9-year-old girl is referred by her general practitioner because of
a progressive deterioration in speech and gait. She is usually fit and
well, but her parents report that she has become increasingly
unsteady on her feet for the past 4 weeks. Although usually a shy
girl, they also say that she is more reluctant to talk and often
appears to have difficulty getting her words out.
Examination in clinic reveals a shy, pale child, with no jaundice or
skin rashes. Her pulse is 70 beats/min, blood pressure
110/65mmHg, and temperature 37.3 1C. She has a 2 cm liver edge,
fine intention tremor, difficulty in articulating her speech and a
rather ataxic gait.
Blood tests reveal:
 Hb 9.6 g/dl
 WCC 11.8×109/l
 Platelets 413×109/l
 Na 141 mmol/l
 K 3.9 mmol/l
 Urea 3.5 mmol/l
 Albumin 17 g/l
 AST 600 U/l
 GGT 92 U/l
 Alkaline phosphatase 310 U/l

2- Which single investigation is diagnostic?
3- What treatment options are there?
QUESTION 46
A 7-year-old boy who has a history of seizures presents with
headaches and increased confusion. His complex partial seizures
are being treated with carbamazepine. Physical examination
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reveals a weight of 34 kg (50th percentile), with all other findings
within normal limits, including results of the neurologic
examination and funduscopy.
Laboratory tests reveal:
Urinalysis shows a specific gravity of 1.030; pH of 5.5; and negative
findings for blood, protein, ketones, nitrite, and leukocyte esterase.

2-What is the cause?
3-What is the most appropriate treatment for the patient’s
condition?
QUESTION 47
A 6-month-old boy is brought to the emergency department for
evaluation of a 2-day history of a temperature to 39.8°C, increasing
irritability, constant crying, decreased activity, and emesis. His
mother states that everyone in the house has been ill with colds
and that the baby has had a runny nose and nasal congestion for
the past week. He has only had his 2-month set of immunizations
because he has been ill each time he is brought in for his vaccines.
On physical examination, the infant has a temperature of 40.0°C,
appears ill, and is extremely irritable. His anterior fontanelle is full,
and he has a stiff neck. Studies obtained on his cerebrospinal fluid
show:
• Glucose, 5.0 mg/dL
• Protein, 170.0 mg/dL
• White blood cell count, 550/mm3
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• 2 red blood cells
Gram stain is positive for many white blood cells and gram-positive
cocci.

2- What is the most appropriate empiric antibiotic regimen for
the treatment of this patient?
QUESTION 48
A1-year-old boy was referred to the hospital by his GP with a
short history of polyuria and ‘drinking the bathwater’. His mother
also suffered with similar symptoms and received treatment for
this. On examination, the child appeared very well apart from a
sticky left eye. Initial blood and urine results showed:
 Serum Sodium 154mmol/l
 Potassium 3.9mmol/l
 Bicarbonate 27mmol/l
 Urea 2.1mmol/l
 Creatinine 25 mmol/l
 Glucose 4mmol/l
 Osmolality 309mOsm/kg
 Urine Osmolality 283mOsm/kg
1- What are the two most likely diagnoses?

2- What investigation is required to confirm the diagnosis and
reliably distinguish the two?
3- What are the modes of inheritance?
QUESTION 49
A 12-year-old girl presents with a 4-month history of feeling tired
with headaches, nausea and stomach cramps. Over the past month
she has struggled to get to school and she is generally only able to
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attend school 1 or 2 days a week. She finds it hard to get off to
sleep at night but denies that worries keep her awake.
Her mother says it takes her over an hour to wake her up in the
morning. She is not on any medication. There is no past medical
history of note. In the family, her mother has myalgic encephalitis
(ME) and has been unwell for about 8 years.
Examination including full neurological examination is entirely
normal. The results of the following tests (FBC, U&E. LFTs, CRP,
ESR/viscosity, thyroid function, coeliac screen, calcium, ferritin,
creatine kinase, random glucose. Urine for protein, blood and
glucose) were normal.

2-What other symptoms you expect to find in this patient?
3- How should you manage this patient?
QUESTION 50
Salwa is 4.5-year-old girl who has been complaining of headaches.
They are recurrent and occur every 10 weeks almost to the day.
Her mother is able to predict the recurrence of her headache by
looking at the diary. She always wakes up at around midnight with
the headache, says she feels nauseous and then proceeds to lose
her colour, have dark rings around her eyes and commences to
vomit. She will wake up, call her mum, complain of a spinning
head, a distaste in her mouth and then she will go very quiet,
prefer to lie in a dark room with photophobia. She often describes
seeing ‘coloured smarties’ in front of her eyes. The headaches are
occipital in nature and thought to be very severe as she will hold
her head and thrash about. She vomits profusely and then remains
bed-bound for up to several days. She does not have any eye-
watering or redness. On examination there were no abnormalities
to find whatsoever, she was not ataxic and did not have any
nystagmus.
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She has no neck stiffness, her blood pressure is normal for her age
and her height, weight and head circumference are within normal
limits. In between her bouts of headache she is fit and well, attends
school and is making developmental progress. She is prone to
car sickness. There is no family history of migraines.
1- What is the most important diagnosis to exclude initially?

2- What investigation would you aim to do urgently?
4- What are the differential diagnoses?
QUESTION 51
A term male infant born to consanguineous parents is assessed at
24 h of age due to poor feeding, profuse yellow watery diarrhoea
and irritability. He weighed 3.2 kg at birth and delivery was
uneventful. There was no polyhydramnios. He has been breastfed
since birth. On examination he is pale with a non tender, but
distended abdomen and reduced bowel sounds.
His weight is 2.75 kg and he looks dehydrated. Examination is
otherwise normal.
Initial investigations (normal values in parentheses) showed:
 Sodium 149 mmol/litre (135–145)
 Potassium 3.7 mmol/litre (3.5–5.0)
 Urea 6.5 mmol/litre (2.5–7.5)
 Creatinine 147 μmol/litre (40–110)
 Chloride 119 mmol/litre (95–105)
 Haemoglobin 17.2 g/dl (14.0–20.0)
 White blood cell count 8.0 × 109/litre (10.0–26.0)
 Platelet count 302 × 109/litre (150–400)
Arterial blood gas:
 pH 7.20 (7.30–7.45)
 PCO2 2.3 kPa (4.6–6.0)
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 Bicarbonate 6.8 mmol/litre (22.0–26.0)
 Base excess −18.6 mmol/litre (−2.0 to +2.0)
 Lactate 5.9 mmol/litre (0.6–2.4)
An abdominal X-ray shows distended bowel loops, with
no intramural thickening or pneumoperitoneum.
He was given nil by mouth and received intravenous fluids
and antibiotics. His dehydration improved but the metabolic
acidosis and diarrhoea persisted despite receiving no enteral
feeds and the commencement of total parenteral nutrition.
Blood and stool cultures were negative.
1- Describes the results of the lab. Investigations?

3- What is the investigation of choice?
QUESTION 52
A 10-month-old boy presents with 3 weeks of vomiting and
constipation , he is passing hard stools every 2–3 days. He has
fallen from the 9th to below the 0.4th centile in the last 6 weeks.
He passed meconium within the first 24 h of life.
On examination, he looks pale and there are some dysmorphic
features , a short nose, long philtrum and wide mouth. He has
normal heart sounds with a grade 3 ejection systolic murmur,
loudest at the upper right sternal edge. Examination is otherwise
normal.
Initial investigations are as follows:
 Haemoglobin 9.1 g/dl (11.3–14.1)
 Total white blood cell count 12.4 × 109/litre (6.0–17.0)
 Platelet count 407 × 109/litre (150–400)
 Sodium 144 mmol/litre (135–145)
 Potassium 3.7 mmol/litre (3.5–5.0)
 Urea 7.8 mmol/litre (2.5–7.5)
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 Creatinine 78 μmol/litre (45–120)
 Albumin 52 g/litre (35–50)
 Corrected calcium 3.84 mmol/litre (2.38–2.63)
 Phosphate 1.67 mmol/litre (0.99–1.57)

2- Which investigation would be most useful in establishing the
diagnosis?
3-How you treat such patient?
QUESTION 53
A 10-week-old baby presented with 1 week’s history of vomiting.
He was born at 32 weeks gestation, needed ventilator support with
oxygen for 1 day after birth, two doses of surfactant and 2 days of
phototherapy for moderate jaundice of prematurity. He was
formula fed from birth (the first 2 weeks via nasogastric tube). He
tended to vomit after feeds and was started on formula milk at 4
weeks of age. The health visitor had advised a change of milk the
week before.
The baby’s weight was on the 9th centile, length on the 50th
centile and head circumference on the 75th centile. Ward urine
test showed a trace of proteinuria, but was otherwise normal.
Investigations showed:
 Hb 149 g/L
 white count 12.8×109/L (30% neutrophils)
 platelets 301×109/L
 Na 137 mmol/L
 K 3.5mmol/L
 urea 6.0 mmol/L
 Creatinine 50 mmol/L
 Chloride 95 mmol/L
 CRP 7 mg/L
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 pH 7.43
 pO2 7.9 kPa
 pCO2 4.7 kPa
 HCO3 29.6 mmol/L (capillary sample)
1- What is the most likely cause of the vomiting?

2- What is the next step in diagnosis?
3-What management strategy should be used next?
QUESTION 54
A very concerned mother brings a 2-year-old child to your office
because of two episodes of a brief, shrill cry followed by a
prolonged expiration and apnea. You have been following this child
in your practice since birth and know the child to be a product of a
normal pregnancy and delivery, to be growing and developing
normally, and to have no chronic medical problems. The first
episode occurred immediately after the mother refused to
give the child some juice; the child became cyanotic, unconscious,
and had generalized clonic jerks. A few moments later the child
awakened and had no residual effects. The most recent episode
(identical in nature) occurred at the grocery store when the child’s
father refused to purchase a toy for her. Your physical examination
reveals a delightful child without unexpected physical examination
findings.

2-How you treat such child?
3-What is the prognosis of such condition?
QUESTION 55
A child has a 2-week history of spiking fevers, which have been as
high as 40°C (104°F). She has spindle-shaped swelling of finger
joints and complains of upper sternal pain. When she has fever, the
123
parents note a faint salmon-colored rash that resolves with the
resolution of the fever. She has had no conjunctivitis or mucositis,
but her heart sounds are muffled and she has increased pulsus
paradoxus.

2-What is the cause of the upper sternal pain?
QUESTION 56
You are asked to evaluate an infant born vaginally 3 hours
previously to a mother whose only pregnancy complication was
poorly controlled gestational diabetes. The nursing staff noticed
that the infant was breathing abnormally.
On examination, you find that the infant is cyanotic, has irregular,
labored breathing, and has decreased breath sounds on the right
side. You also note decreased tone in the right arm. You provide
oxygen and order a stat portable chest radiograph, which is
normal.
1-What is the most likely cause of the irregular, labored breathing

in this patient?
2- What is the most likely cause of the decreased tone in the right
arm?
3- Which study most likely confirms your diagnosis?
QUESTION 57
A 6-week-old child arrives with a complaint of “breathing fast”
and a cough. On examination you note the child to have no
temperature elevation, a respiratory rate of 65 breaths per minute,
and her oxygen saturation to be 94%. Physical examination also is
significant for rales and rhonchi.
124
The past medical history for the child is positive for an eye
discharge at 3 weeks of age, which was treated with a topical
antibiotic drug.

3-What is the best treatment option and its complication at this
age group?
QUESTION 58
A 3-year-old boy’s parents complain that their child has difficulty
walking. The child rolled, sat, and first stood at essentially normal
ages and first walked at 13 months of age. Over the past several
months, however, the family has noticed an increased inward
curvature of the lower spine as he walks and that his gait has
become more “waddling” in nature. On examination, you confirm
these findings and also notice that he has enlargement of his
calves.

2-Which clinical test helps you in the diagnosis?
3-What other features you expect to see?
QUESTION 59
A newborn infant has respiratory distress and trouble feeding in
the nursery. The mother has no significant medical history, but the
pregnancy was complicated by decreased fetal movement. On
physical examination, you note that aside from shallow
respirations and some twitching of the fingers and toes, the infant
is not moving, and is very hypotonic. In the mouth there is pooled
saliva and you note tongue fasciculations. Deep tendon reflexes are
absent. Spinal fluid is normal.
125
2-Where is the defect in this disease?
3-What is the current available treatment?
QUESTION 60
An 18-month-old child presents to the emergency center having
had a brief, generalized tonic-clonic seizure. He is now postictal
and has a temperature of 40°C (104°F). During the lumbar puncture
(which ultimately proves to be normal), he has a large, watery stool
that has both blood and mucus in it.
1-What is the most likely diagnosis in this patient?

2-What is meant by Ekiri syndrome?
3-How you manage such patient?
QUESTION 61
A 16-year-old boy presents to the emergency center with a 2-day
history of an abscess with spreading cellulitis. While in the
emergency center, he develops a high fever, hypotension, and
vomiting with diarrhea. On examination you note a diffuse
erythematous macular rash, injected conjunctiva and oral mucosa,
and a strawberry tongue. He is not as alert as when he first arrived.

3-How you manage such a patient?
126
B- CASE STUDIES WITHOUT IMAGES
ANSWER 1
1- Hemolytic-uremic syndrome (HUS).
2- Peripheral blood smear, which should demonstrate schistocytes
and burr cells and minimal platelets.
3- Severe oligoanuria, hyperkalemia or severe uremia (blood urea
nitrogen >100 mg/dL [35.7 mmol/L]).
4-Platelet transfusions usually are avoided to prevent the
theoretical risk of exacerbating the thrombotic microangiopathic
process and microthrombi deposits.
ANSWER 2
1- Immobilization leads to osteoclast activation and relative bone
resorption.
2- Hyperparathyroidism, hypervitaminosis A, and hypervitaminosis
D.
3- A low-magnesium hyperalimentation formula could lead to
hypocalcemia because magnesium is necessary for the release of
preformed parathyroid hormone from the parathyroid gland.
ANSWER 3
1- Percutaneous liver biopsy.
2- Direct hyperbilirubinemia is a serum direct bilirubin
concentration of more than 1.0 mg/dL (17.1 mcmol/L) with total
bilirubin values of less than 5.0 mg/dL (85.5 mcmol/L) or greater
than 20% of the total bilirubin for values greater than 5.0 mg/dL
(85.5 mcmol/L).
3- Recent studies have shown the best surgical outcomes for
infants who have biliary atresia when the diagnosis is established
by 30 to 45 days of age.
4- Corticosteroids and ursodeoxycholic acid have been suggested
as means to enhance bile flow in the postoperative period.
127
ANSWER 4
1- Gaucher disease.
2- This diagnosis may be confirmed by demonstrating a deficiency
in the activity of blood leukocyte glucocerebrosidase (acid beta-
glucosidase).
ANSWER 5
1- The most likely diagnosis is obstructive uropathy (probably from
posterior urethral valves) with resultant type IV renal tubular
acidosis and hyperkalemia.
2- Intravenous calcium gluconate, which counteracts the effects of
hyperkalemia on the altered membrane excitability. The effect
is short-lived but very effective. It is considered the first-line
approach to severe hyperkalemia.
3- The most common cause for pseudohyperkalemia results from
hemolysis of a difficult sample collection (which is common in
newborns and young children) and marked leukocytosis or
thrombocytosis due to clot retraction.
ANSWER 6
1- Alport syndrome (AS).
2- X-linked recessive disorder.
3- Glomerular basement membrane (GBM) disease and autosomal
dominant polycystic kidney disease (ADPKD).
ANSWER 7
1- Nonsteroidal anti-inflammatory drugs (NSAID)-induced
gastroenteropathy.
2- Misoprostol, a PGE-2 analog, exerts its gastrointestinal
cytoprotective effects by directly countering a primary mechanism
responsible for the damaging effects of naproxen and other COX-1
inhibitors. Among pediatric patients receiving NSAIDs,
coadministation of misoprostol has been shown to be an effective
128
strategy to reduce gastrointestinal symptoms and increase
hemoglobin concentrations.
ANSWER 8
1- The adolescent described in the vignette, who recently
underwent spine surgery, has developed a febrile illness associated
with right upper quadrant fullness and tenderness. Laboratory
studies show elevations in the white blood cell count, gamma-
glutamyl transpeptidase, and aspartate and alanine
aminotransferases but near-normal pancreatic enzyme values.
Acute calculous or acalculous cholecystitis is the most
likely cause of these findings.
2- The diagnostic study of first choice is abdominal
ultrasonography. Typical ultrasonographic findings in acute
cholecystitis include identification of gallstones (in calculous
cholecystitis) or biliary sludge; evidence of bile ductular dilatation;
and a distended, thick-walled gallbladder.
ANSWER 9
1- Sarcoidosis.
2- The diagnosis of sarcoidosis is based on clinical suspicion and
confirmed by biopsy material demonstrating noncaseating
granulomas.
ANSWER 10
1- Nonmonosymptomatic enuresis secondary to urinary tract
infection (UTI).
2- Renal/bladder ultrasonography. This study can help screen for
hydronephrosis and renal stones, which could increase the risk for
a UTI.
3- Treatment of the underlying organic cause often results in
marked improvement. Once a UTI is treated, the urinary symptoms
and enuresis should resolve.
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ANSWER 11
1- Fitz-Hugh-Curtis syndrome or perihepatitis presents as right
upper quadrant pain that result from inflammation of the liver
capsule from ascending pelvic infection.
2- Pyuria raises the possibility of urethritis.
3- Neisseria gonorrhoeae and Chlamydia trachomatis.
ANSWER 12
1- Systemic lupus erythematosus (SLE).
2- Refer the patient for a renal biopsy.
3- The patient can be monitored by periodic assessment of urinary
protein excretion as well as measurement of serologic markers
such as complement components and anti-ds DNA titers.
ANSWER 13
1- Elevated concentration of carboxyhemoglobin. Pulse oximetry
cannot distinguish carboxyhemoglobin from oxyhemoglobin,
resulting in a falsely high reading.
2- Pulse oximetry can yield falsely low saturations in critically ill
patients who have vasoconstriction, poor perfusion, hypothermia,
or arrhythmias.
3- Pulse oximetry uses red and infrared light to measure the level
of oxygenated and deoxygenated hemoglobin. The amplitudes of
the light signals are measured and mathematically calculated to
express the percentage of oxygen saturation.
ANSWER 14
1- Infantile hypertrophic pyloric stenosis (HPS).
2- Other, less common causes of gastric outlet obstruction include
duodenal stenosis, gastric duplication, antral web, and annular
pancreas.
3- Based on the serum electrolyte data, fluid therapy should be
130
initiated with 5% dextrose and 0.45% sodium chloride at
approximately 1.5 times the calculated maintenance rate (~400 mL
per 24 hours, based on the infant’s hydrated weight) or 25 mL/hr.
ANSWER 15
1- Recurrent pancreatitis.
2- Serum lipid measurement.
ANSWER 16
1- Erythropoietin deficiency is expected in the presence of reduced
nephron mass, as is seen in the renal failure exhibited by the child.
His renal failure most likely is chronic because of his poor growth.
2- Reduced substrate for red blood cell synthesis (folate, vitamin
B12, or iron), bone marrow failure, selective red cell aplasia, or
erythropoietin deficiency.
ANSWER 17
1- Hypokalemia, metabolic acidosis, and hypophosphatemia.
2- Fanconi syndrome (nephropathic cystinosis).
3- Ophthalmologic examination reveals cystine accumulation
within the cornea results in intense photophobia.
ANSWER 18
1- Escherichia coli is the causative organism in 80% to 90% of first-
time urinary tract infections (UTIs) in children.
2- Organisms such as E coli, K pneumoniae, and Proteus sp can
reduce dietary nitrate to nitrite, so a positive urine dipstick test for
nitrite, is virtually diagnostic of gram-negative bacteruria. If the test
result is negative in an older child in whom a UTI is suspected, the
infection may be caused by a gram-positive organism such as
Enterococcus sp or S saprophyticus. Of note, the nitrite test is
much less helpful in infants. Conversion of nitrate to nitrite may
take up to 4 hours. Because infants and young children have small
131
bladder volumes and urinate frequently, there may be insufficient
time for nitrites to be formed and, therefore, the nitrite test may
be negative even in the presence of a UTI caused by a gram-
negative organism.
ANSWER 19
1- Acute pyelonephritis.
2- Voiding cystourethrography.
3- Hydronephrosis, renal cysts, nephrolithiasis, urolithiasis, ureteral
dilatation, duplex collecting system, bladder wall thickening, and
ureteroceles.
ANSWER 20
1- Congenital deficiency of thyroxine-binding globulin (TBG).
2- Sex-linked disorder is expressed more completely in males.
Females who are carriers have slightly lower concentrations of
TBG, but they may not be identified as having a low thyroxine value
on newborn thyroid screening.
3- TBG deficiency can be diagnosed by obtaining a normal free
thyroxine value, a low TBG value, or both.
4- It is important to identify individuals who have TBG deficiency
because they require no further evaluation or treatment.
ANSWER 21
1- Hypoxic-ischemic encephalopathy (HIE).
2- Severely acidotic umbilical cord arterial pH (<7.0), with evidence
of metabolic acidemia.
3- Other causes of neonatal seizure include intracranial
hemorrhage, cerebrovascular accidents (stroke), or hemorrhagic
infarction (10% to 15%); intracranial malformation (<10%);
transient hypoglycemia or hypocalcemia (<10%); drug withdrawal
(<5%); and inborn errors of metabolism (<5%).
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ANSWER 22
1- The next best step in the management of the child is the
administration of activated charcoal. Multiple doses of activated
charcoal adsorb salicylates from both the intestinal tract and the
systemic circulation.
2- Toxic effects of salicylates can include gastritis, anticoagulant
effects, increased metabolism, hyperventilation and respiratory
alkalosis, and hepatitis. Reye syndrome, which is characterized by
hepatitis and encephalopathy, may occur if aspirin is given during
certain viral infections. Signs and symptoms include lethargy or
coma, vomiting, tachypnea, and tachycardia.
3- Syrup of ipecac is not indicated because the child described is
fussy and lethargic.
ANSWER 23
1- Membranoproliferative GN (MPGN).
2- Post infectious AGN (PIAGN), immunoglobulin A nephropathy,
viral cystitis, nephrolithiasis, hypercalciuria, and sickle cell disease
or trait.
ANSWER 24
1- Neonatal infections with the herpes simplex virus (HSV).
2- All neonatal HSV infections should be treated with intravenous
acyclovir. The dosage is 60 mg/kg per day in three divided doses
given intravenously for 14 days for disease localized to the skin,
eye, or mouth (SEM) and for at least 21 days for disseminated or
central nervous system disease.
3- Neonates presenting with shock like symptoms during the first 7
to 10 days after birth are a diagnostic challenge. The differential
diagnosis includes five major categories:
1) Bacterial sepsis
2) Inborn errors of metabolism
3) Ductal-dependent complex congenital heart disease
133
4) Nonaccidental trauma
5) Viral sepsis
ANSWER 25
1-Hyperosmolar coma due to type 2 diabetes.
2-Symptomatic cerebral edema.
3-The relatively lower sodium concentration seen in the patient
is a physiologic adaptation to severe hyperglycemia.
Intracellular water is drawn osmotically into the extracellular
space in response to the hyperglycemia. For each 100 mg of
glucose above 100 mg/dL (5.5 mmol/L), the sodium should
be lowered about 1.7 mEq (1.7 mmol) or occasionally, slightly
more.
4-Initial volume expansion with relatively isotonic fluids (0.9%
NaCl) followed by continued slow rehydration over 36 to 48 hours
is the most rational approach to fluid restoration.
ANSWER 26
1- The clinical features of jaundice, hepatomegaly, and invasive
Escherichia coli infection suggests the possible diagnosis of
galactosemia.
2- Soy protein formulas are the first choice of nutrition for
infants who have suspected or proven galactosemia because
the carbohydrate source in these formulas is sucrose or corn
syrup rather than lactose.
3- The reducing substances in the urine represent the accumulation
of galactose.
ANSWER 27
1- Bleeding ulcer or severe gastritis.
2- Best test to identify and treat the suspected lesion is
esophagogastroduodenoscopy with biopsy.
134
ANSWER 28
1- Congenital nephrotic syndrome (NS).
2- Children who have congenital NS lose massive quantities of
essential proteins required for growth and development and are at
risk for malnutrition and failure to thrive during infancy.
ANSWER 29
1- The presence of neurologic disease, liver failure, and hemolysis
strongly suggests fulminant Wilson disease.
2- Serum ceruloplasmin concentrations typically are low in Wilson
disease.
3- The other tests that help establish a diagnosis of Wilson disease
include slit lamp examination of the eyes for Kayser-Fleischer ring.
ANSWER 30
1- The failure to thrive, blond hair, blue eyes, fair skin, markedly
bowed legs, acidosis, and hypophosphatemia reported for the boy
in the vignette represent the classic presentation of nephropathic
cystinosis.
2- The loss of bicarbonate results in acidosis, and the loss of
phosphate results in demineralization of the bones and rickets.
3- The recent use of oral and optic cysteamine, medications
designed to increase the movement of cystine out of the lysosome,
has proven effective in some children who have cystinosis.
ANSWER 31
1- The adolescent girl in the vignette meets the diagnostic criteria
for systemic lupus erythematosus (SLE).
2- Because of the need to classify the form of nephritis prior to the
institution of corticosteroids, the standard of care is to obtain a
renal biopsy prior to treatment. Some forms of lupus nephritis,
including diffuse proliferative nephritis, are treated with
cyclophosphamide as an adjunctive agent, but this medication
135
should not be used for renal indications without a kidney biopsy.
Results of the renal biopsy can provide both prognostic and
treatment information.
3- Once the renal disease is classified histologically and initial
treatment is instituted, the patient can be monitored by periodic
assessment of urinary protein excretion as well as measurement
of serologic markers such as complement components and anti-ds
DNA titers. Patients who exhibit worsening proteinuria, decreasing
concentrations of complement components, or rising anti-ds DNA
titers require assessment for a disease flare, which may necessitate
increasing immunosuppressive therapy (including corticosteroids).
ANSWER 32
1- Hypokalemic, metabolic alkalosis which is explained via an
activated renin-angiotensin-aldosterone system (RAAS).
2- An additional clinical feature of the patient is renal asymmetry.
Taken together with the hypokalemic, metabolic alkalosis, the most
likely explanation is unilateral renal artery stenosis. Activation of
the RAAS results in elevated concentrations of angiotensin II, a
potent vasoconstrictor, which causes high systemic vascular
resistance.
ANSWER 33
1- Laboratory evaluation demonstrates hyponatremia, increased
anion gap metabolic acidosis, and azotemia (elevated blood urea
nitrogen and creatinine values).
2-The patient’s clinical evaluation are consistent with hypovolemia
and prerenal failure.
3- 0.9% sodium chloride at a volume of 300 mL over 1 hour.
ANSWER 34
1- Staphylococcal scalded skin syndrome. Clinically, the lesions
described are characteristic of Staphylococcus infection. Yellow
136
crusting is commonly described. Staphylococcal scalded skin
syndrome is an exfoliative dermatosis that initially presents with
diffuse erythema and skin tenderness. There is usually an isolated
minor local infection, which in this case was the lip.
2- Staphylococcus aureus epidermolytic toxins A and B.
3- Intravenous benzylpenicillin and flucloxacillin.
4- Drying of the erosions followed by desquamation and healing
within 14 days.
ANSWER 35
1- Polycythemia.
2- Manifestations of the “hyperviscosity syndrome” include
tremulousness or jitteriness that can progress to seizure activity
because of sludging of blood in the cerebral microcirculation or
frank thrombus formation.
3- Therapy by partial exchange transfusion with saline or lactated
Ringer solution is preferred, and may be more likely to be useful if
performed prophylactically before significant symptoms have
developed.
ANSWER 36
1- The infant has a ductal-dependant cyanotic congenital
heart lesion. In this example, the child had pulmonary atresia
without a corresponding VSD; another example would have been
transposition of the great vessels without a septal defect to allow
mixing of oxygenated and nonoxygenated blood.
2- The ductus arteriosis typically closes in the first few hours of life;
thus, these children will develop their cyanosis in the same time
frame. Prostaglandin E1 will help keep the ductus patent until a
surgical procedure can be performed.
ANSWER 37
1- Idiopathic pulmonary hemosiderosis (IPH).
137
2- Bronchoalveolar lavage will reveal hemosiderin-laden
macrophages and would be most likely to make the diagnosis.
3- A distinct subset of patients with pulmonary hemosiderosis have
hypersensitivity to cow’s milk (the association is called Heiner
syndrome) and may improve with a diet free of cow’s milk
products.
ANSWER 38
1- Ulcerative colitis.
2- The most serious complication of ulcerative colitis is toxic
megacolon, a medical and surgical emergency in which patients
develop fever, tachycardia, dehydration, leukocytosis, and
electrolyte abnormalities associated with a markedly dilated colon.
ANSWER 39
1- Iron-deficiency anemia.
2- Administration of an oral preparation of ferrous sulfate.
3- Levels of erythrocyte protoporphyrin (EP) are also elevated in
lead poisoning. Iron-deficiency anemia can be differentiated from
lead intoxication by measuring blood lead, which should be less
than 10 μg/dL.
ANSWER 40
1- The patient has classic findings of galactosemia.
2- Cataracts, ascites, and increased risk for E coli sepsis.
3-Benedict test for reducing substances will be positive while
routine urinalysis will be negative, as the urine strips do not react
with galactose.
4- Prompt removal of galactose from the diet usually reverses
the symptoms, including cataracts.
ANSWER 41
1. Beckwith–Wiedemann syndrome.
2. Hemi-hypertrophy.
138
3. Renal ultrasound and serum alpha fetoprotein level.
ANSWER 42
1. Wilms’ tumour.
Wilms’ tumours are the most common genitourinary malignancy of
childhood, affecting 1 in 10 000 children, 75% of children being
under the age of 4 and 90% under the age of 7. Clinical
presentation is generally with a well child and 74% of children
present with the finding of an incidental mass. Fever is unusual,
occurring in 1% of patients, and pain occurs in 44%.
Wilms’ tumours are associated with a number of genetic
syndromes such as WAGR syndrome (Wilms’ tumour, aniridia,
genitourinary malformations and mental retardation), Denys–-
Drash syndrome (pseudohermaphroditism, nephrotic syndrome
and Wilms’ tumour) and Beckwith–Wiedemann syndrome
(exomphalos, macroglossia, neonatal hypoglycaemia,
visceromegaly, hemihypertrophy, characteristic facial features and
linear indentations of the ear lobe). It is therefore important to
look for dysmorphic features. The most common site of metastasis
is to the lungs.
2. Von Willebrand’s disease.
A rare but important complication of Wilms’ tumour is the
development of acquired von Willebrand’s disease, which occurs in
up to 8% of those with Wilms’ tumour.
3. ACE inhibitors.
Hypertension in Wilms’ tumour is caused by a number of
factors, including excess renin production, vascular compression
and pre-existing renal disease. The administration of an ACE
inhibitor in this situation would therefore be an appropriate first
line treatment for Wilms’-induced hypertension.
139
ANSWER 43
1- Down’s syndrome with transient myeloproliferative disorder
(TMD).
2- Blood film will show blast cells. The leucocytosis should have
sufficient blasts to perform IHC on cells. The blasts cells are of
megakaryoblastic lineage. Although they are morphologically
indistinguishable from AML blasts, there are subtle cytochemical
and immunohistochemical differences.
3- Close observation and ensuring the leukaemia resolves is the
management of choice.
ANSWER 44
1- Epstein-Barr virus infection (glandular fever/infectious
mononucleosis) with associated acute haemolysis.
2- Severe haemolysis and splenic haemorrhage.
Neurological complications (e.g. seizures, ataxia, and meningitis),
airway obstruction (from tonsillar hypertrophy) and hepatitis are
among other problems associated with EBV infections but were not
apparent in this case.
3- Monospot and EBV antibodies. An ultrasound scan should be
performed to exclude splenic haemorrhage. Other causes of
haemolysis should be considered especially if this boy is to be
transfused.
ANSWER 45
1- The neurological symptoms and liver dysfunction in this child
can ‘best’ be explained by Wilson’s disease.
2- Evidence of excess copper deposition on liver biopsy is
diagnostic.
3- Treatment entails copper chelation with D-penicillamine or EDTA
and is most effective if commenced early. For this reason, prompt
screening of siblings is essential.
140
ANSWER 46
1- The child described in the vignette presents with confusion,
hyponatremia, and a urinalysis featuring a high specific gravity, all
findings consistent with a diagnosis of the syndrome of
inappropriate antidiuretic hormone secretion (SIADH).
2- His antiepileptic medication, carbamazepine, is associated with
the development of SIADH.
3- The preferred treatment of the child who has SIADH is free
water restriction.
ANSWER 47
1- The patient has meningitis that most likely is due to S
pneumoniae.
2-Appropriate empiric therapy for a person who has suspected
meningitis is a combination of vancomycin and a third-generation
parenteral cephalosporin (cefotaxime or ceftriaxone).
ANSWER 48
1-Nephrogenic diabetes insipidus, central diabetes insipidus.
2- Water deprivation test with desmopressin.
3- Primary nephrogenic diabetes insipidus is usually inherited as an
X-linked recessive disease.
Central diabetes insipidus may be inherited as an autosomal
dominant or autosomal recessive disease.
ANSWER 49
1- Chronic fatigue syndrome (CFS/ME).
2- Other symptoms such as headache, nausea and abdominal pain
are common as are recurrent sore throats, tender lymph nodes,
muscle aches and pains, dizziness and problems with memory and
concentration.
3- Explain to her about what is wrong; give advice about
symptoms, sleep, diet and activity.
141
ANSWER 50
1- Brain tumor.
2- CT scan of the brain.
3- Cyclical vomiting.
4- Migraine with aura
Occipital epilepsy
Poisoning
Benign paroxysmal vertigo
ANSWER 51
1- Hypernatraemia, hyperchloraemic metabolic acidosis
with increased anion gap.
2- Microvillus inclusion disease. It is a severe autosomal recessive
enteropathy that is typically apparent within hours or days after
birth. It is the second most common cause of protracted diarrhoea
in the newborn, after infectious causes. It is characterized by
severe yellow watery diarrhoea and malabsorption due to
hypoplasia and/or atrophy of the villi of the small intestine,
secondary to an inherited defect in the brush border membrane.
This results in severe dehydration, malnutrition and metabolic
acidosis due to bicarbonate loss from the gut.
3- Diagnosis of microvillus inclusion disease is made on small
bowel biopsy.
ANSWER 52
1- Williams syndrome.
2- Fluorescent in-situ hybridization for 7q11.23 deletion.
3- Treatment of Williams syndrome may include rehydration
with normal saline, forced diuresis with saline infusion and
furosemide, a low calcium diet (including low calcium milk)
or, rarely, bisphosphonates.
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1-ANSWER 53
1- Pyloric stenosis.
2- Test feed then ultrasound of abdomen.
3- Intravenous infusion of 0.45% saline and 5% dextrose then
pyloromyotomy.
ANSWER 54
1- Breath-holding spell. Two forms exist.
Cyanotic spells consist of the symptoms outlined and are
predictable upon upsetting or scolding the child.
Pallid breath-holding spells are less common and are usually
caused by a painful experience (such as a fall). With these events,
the child will stop breathing, lose consciousness, become pale and
hypotonic, and may have a brief tonic episode. Although the family
may be concerned that these “tonic episodes” are seizures, the
temporal relationship with an inciting event make this diagnosis
highly unlikely.
2- Avoidance of reinforcing this behavior is the treatment of
choice.
3- They are rare before 6 months of age, peak at about 2 years of
age, and resolve by about 5 years of age.
ANSWER 55
1- Juvenile rheumatoid arthritis (JRA, or Still disease).
2- Arthritis of sternoclavicular joint.
ANSWER 56
1- Phrenic nerve paralysis.
2- Erb-Duchenne paralysis.
3- An ultrasound or fluoroscopy of the chest would reveal
asymmetric diaphragmatic motion in a seesaw manner.
143
ANSWER 57
1- Afebrile pneumonia.
2- Chlamydiae organisms, sexually transmitted among adults, are
spread to infants during birth from genitally infected mothers. The
sites of infection in infants are the conjunctivae and the lungs,
where chlamydiae cause inclusion conjunctivitis and afebrile
pneumonia, respectively, in infants between 2 and 12 weeks of
age.
3- Early treatment with oral macrolides is, however, associated
with an increased incidence in the development of idiopathic
hypertrophic pyloric stenosis; their use in a neonate is with
caution.
ANSWER 58
1- Duchenne muscular dystrophy. It is inherited as an X-linked
recessive trait. Male infants are rarely diagnosed at birth or early
infancy since they often reach gross milestones at the expected
age. Soon after beginning to walk, however, the features of this
disease become more evident.
2- Gower sign (use of the hands to “climb up” the legs in order to
assume the upright position) is seen by 3 to 5 years of age, as is the
hip waddle gait.
3- Associated features include mental impairment and
cardiomyopathy.
ANSWER 59
1- Spinal muscular atrophy (SMA) type I, also referred to as
Werdnig-Hoffman disease, or infantile progressive spinal muscular
atrophy.
2- The defect is found in the survivor motor neuron (SMN) gene
that stops apoptosis of motor neuroblasts.
144
3- The only currently available treatment is supportive care, and
infants with SMA I usually die of respiratory complications by the
second or third year of life.
ANSWER 60
1- Shigellosis.
2- Fatal “toxic encephalopathy” seen with Shigella infection.
3- Supportive care, including adequate fluid and electrolyte
support, is the mainstay of therapy. Antibiotic treatment is
problematic; resistance to trimethoprim-sulfamethoxazole and
ampicillin is common, necessitating therapy with third-generation
cephalosporins in many cases. As always, knowledge of the
susceptibility patterns of the bacteria in your area is the key to
using the right antibiotic.
ANSWER 61
1- Toxic shock syndrome (TSS).
2- Toxic shock syndrome (TSS) is usually caused by S aureus, but a
similar syndrome (sometimes called toxic shock-like syndrome
[TSLS]) may be caused by Streptococcus sp. The strains of S aureus
responsible secrete toxic shock syndrome toxin 1 (TSST-1), and can
cause “menstrual” TSS (associated with intravaginal devices like
tampons, diaphragms, and contraceptive sponges)
or“nonmenstrual” TSS associated with pneumonia, skin infection
(as in this patient), bacteremia, or osteomyelitis.
3- Treatment includes blood cultures followed by aggressive fluid
resuscitation and antibiotics targeting S aureus.
145
PART 2
History taking and
management station
The aim of this station is to assess your ability to take a focused
history and then summaries back to the examiner the main issues
pertinent to the case.
This station closely reflects an outpatient or ward review setting.
Children could have a new diagnosis or complaint, or you may be
asked to address a specific problem in a child with a known
diagnosis. You will never be asked to examine a patient but may be
given additional information, e.g. results of investigations.
You will be given instructions that provide information about your
role and these are often in the form of a referral letter. The parents
and child will also have been briefed; in many cases the clinical
scenario or at least the child ’s background problem is real. In some
cases a role player, health care professional or member of the
public may be used.
In order to pass this station, the following key areas are assessed
1. CONDUCT OF INTERVIEW
 Greet parents and child appropriately and introduce
yourself
 Clarify your role and agree aims and objectives
 Maintain appropriate eye contact/body language
throughout
 Remain attentive throughout; give verbal and non-verbal
signs to the effect
146
 Make sure you are fully understood by patients, parents,
and examiner
 Be confident yet empathetic
 Patient and parent(s) should be at ease with you
2. HISTORY TAKING
Doing this well involves:
 Phrasing questions clearly and making sure they are not all
closed
 Avoiding medical phrases that may not be understood by
patient/parent
 Allowing patient/parent time to speak
 Developing a problem list as you go on
 Exploring the main problems fully, including psychological,
social and family issues as these may be what you are asked
about
 Ensuring your history is focused to getting maximum
information
 Exploring feelings of the patient and parents
ALL THIS NEED PRACTICE
3. INTERPRETATION AND MANAGEMENT PLANNING

 Demonstrate a good understanding of different problems
raised in the history
 Discuss the differential diagnosis listing the most likely first
 Outline the essential points in the management: be sensible
and pragmatic, i.e. do not suggest any experimental or
controversial treatments unless asked about them directly
 Discuss referral to other agencies and be aware of providing
further contact information
147
HISTORY TAKING OSCE STATIONS
QUESTION 1
Take a detailed history from this 4- year- old child?
QUESTION 2
A 14-month-old boy has started vomiting and has loose watery
stools up to eight times a day. He has a low grad fever and is rather
quiet. Other mothers at the nursery report similar findings in their
children.
Task
Take a focused history and suggest 2 diagnoses.
QUESTION 3
Thuha is a one year old child who present to your clinic because of
chronic cough (more than one month). On examination temp: 37.50
C, respiratory rate: 34 breaths/min with no signs of respiratory
distress.
Task
Take a focused history and suggest to the examiner three helpful
investigations.
QUESTION 4
Noor is a 7-year-old child who has been brought in by her father to
your same-day/urgent session with an exacerbation of her asthma.
Task
Which aspects of history do you need to get from Noor’s father?
QUESTION 5
Zainab is a 7-year-old child who has been brought in by her mother
to your same-day/urgent session with an exacerbation of her
asthma.
148
Task
What red flags for asthma you would look for?
QUESTION 6
Layla brought her two and a half year old son, Ali, to the
emergency because he just had fever and fit. The ER team
managed Ali is in the next room and he is stable now. Mrs. Layla is
waiting in this room. You are the physician on duty now. In the next
minutes enter the room and talk to her.
Task
Take a focused history and suggest 3 helpful investigations.
QUESTION 7
A young primi mother said, my 3-day-old baby has had a fit. She
was a healthy term infant who is breast-fed. She has a nasty
infected umbilical cord stump.
Task
Take a focused history and suggest 3 differential diagnoses.
QUESTION 8
A young pregnant mother brought her 18-month-old child with a
fever and rash.
Task
Take a focused history and mention your next step for this worried
mother.
QUESTION 9
A 6-year-old boy was seen in the pediatric outpatient department.
His parents complained that he was the shortest boy in his class.
On examination, the child’s height was 106 cm (3rd centile).
Task
Take a focused history and suggest a single valuable available
investigation.
149
QUESTION 10
A 7- year- old child presented with purpura and easy bruising for
the last few days.
Task
QUESTION 11
A 2-year-old girl who is otherwise developing normally does not
say any words which are recognizable. She is a third child, and her
siblings’ speech development was normal.
Task
Take a focused history and give 3 differential diagnoses.
QUESTION 12
After a normal birth and delivery, the mother said, my baby is now
12 hours old and has blue lips and tongue.
Task
QUESTION 13
An 8-year-old girl has started to get recurrent symmetrical
headaches. They are of gradual onset and are described thus‘… like
a band around my head’. She is having problems coping with the
demands made by her school and has missed a third of her
schooling this term.
Task
Take a focused history and what are the indications of C/T scan in
this patient.
QUESTION 14
A 6-month-old child has developed sudden onset episodes of
screaming and drawing up his legs; he has not opened his bowels
recently, and looks very pale.
150
Task
Take a focused history and give 3 differential diagnoses.
QUESTION 15
An 8-year-old boy presents to his GP with acute abdominal pain.
The pain is lower abdominal and constant. He has been off his food
for about 10 days, and has lost some weight. There has been no
vomiting. In addition, he recently had fever with a sore throat. His
urine looks ‘smoky’ and red, as if there is blood in it.
Task
Take a focused history and what clinical examination would you
like to perform?
QUESTION 16
A 3-week-old girl was noted by his mother to have persisting
jaundice. She is still breast-fed, but has not yet regained her birth
weight.
Task
QUESTION 17
An 18-month-old boy, who is otherwise well, has just started
climbing upstairs. He is very adventurous, and recently his mother
has noticed more bruises on his legs.
Task
QUESTION 18
A 4-year-old and her friends have mistaken iron tablets for sweets,
and eaten a number of them. The mother is uncertain how many
were in the bottle, but there are quite a few left.
Task
151
QUESTION 19
An anxious mother telling you, my 6-year-old boy is disruptive in
class, has no friends, and is aggressive.
Task
Take a focused history from the mother and suggest 3 differential
diagnoses to the examiner.
QUESTION 20
My 3-year-old boy doesn’t play with other children, isn’t speaking,
and seems to be in a world of his own. This is the complaint of a
young mother.
Task
Take a focused history and suggest 3 differential diagnoses to the
examiner.
152
HISTORY TAKING OSCE STATIONS
ANSWER 1
Suggested checklist of detailed history
1 Introduce yourself and greet the parent and child

2 Explain that you are going to ask some questions and
obtain consent to do this
The history
3 Ask the age, sex, and preferred name of the child
4 Confirm the relationship of the accompanying adult
5 Chief complaint & duration
6 History of present illness
Systems review
7 General questions :Activity, tiredness, mood, sleep,
school absences
8 Gastro-intestinal system: Appetite , feeding habits ,
composition of foods , any weight loss , stools , abdominal
pain , how many teeth?
9 Respiratory system: Cough, pain, shortness of breath,
sputum
10 Cardiovascular system: Palpitation, cyanosis at rest or
exertion, sweating day or night
11 Nervous system: Headache , head injury, convulsion ,loss
of consciousness at any time, eye problems, hearing,
speech, any weakness of limbs, abnormal movements
12 Genito- urinary system: Pain ( site ) , frequency of
micturation, enuresis ( day or night ) , color of urine ,
dysuria , menses in girls above 10 years
13 Locomotor system: pain or stiffness of joints, weakness or
unsteadiness
153
14 Blood: Shortness of breath, tiredness, bruising, bleeding,
change in skin color
15 Skin: Rashes, jaundice, dryness, scaling, eczema, impetigo,
bruising, birthmarks, pigment change, hemangiomas,
warts
Prenatal history (pregnancy)
16 Mother age, previous pregnancies, miscarriages, and
abortions
17 Pregnancy duration
18 Maternal health before and during pregnancy
19 Specific illnesses related to or complicated by pregnancy
like diabetes , hypertension and infectious diseases
20 Drugs taken
21 X-ray exposure
22 Antenatal care
23 Smoking and drinking alcohol
Birth history (Natal history)
24 Nature of labor and delivery
25 Degree of difficulty and length of labor
26 Whether the baby breathed & cried spontaneously or
required resuscitation
27 Analgesia given
28 Complications encountered
29 Birth order and birth weight
30 Gestational age
31 Apgar score
Neonatal history
32 Onset of respiration
33 Resuscitation efforts
34 Cyanosis
35 Jaundice
36 Convulsions
154
37 Congenital anomalies
38 Infections
Previous history
39 Specific illnesses experienced such as childhood
communicable diseases or recent contact with them
(chicken pox, measles, mumps, rubella, whooping cough)
40 Operations , injuries or hospitalization
41 Allergies
42 Current medications
Vaccination
43 Exact date of each immunization.
The following table shows the Iraqi protocol of vaccination
Age Type of vaccination
First week O P V + Hepatitis B vaccine + B C G
2 months O P V + (Hepatitis B vaccine + D T

P+Hib)+RV
4 months O P V +( D T P +Hib) + RV
6 months O P V +( Hepatitis B vaccine + D T

P+Hib) + RV
9 months Measles vaccine
15 months MMR
18 months OPV+DTP
155
4 – 6 years OPV+DTP
Feeding
44 Infant feeding method: breast or formula, if breast-fed;
duration & any associated problem. For formula – fed
infant; formula type, its dilution, any formula changes,
feeding frequency, the amount taken at each feed.
45  for older infant ; age at introduction of solid foods
, the current diet composition , problems like
difficulty feeding , regurgitation or vomiting
46  Vitamin supplements are taken or not? Record the
dose.
47 Development
 Smiling (4 – 6weeks)
 First vocalization ( 12 weeks )
 Head control ( 16 weeks )
 Reach out & get objects (28 weeks)
 Baby turn over ( 28 weeks )
 Sit with support on the flour (28 weeks)
 Sit up unsupported ( 40 weeks )
 Single word with meaning (12 months)
 Walk without help ( 15 months )
 Feed self using cup with no help (15 months)
 Sentences not in imitation (21 – 24 months)
 Sphincter control by day (2 years)
 Sphincter control by night ( 3 years )
 Dress self apart from rear buttons & shoe laces
(3 – 4 years)
Family history
48 Father & mother age, consanguinity & condition of health
156
49 Sibling’s ages & condition of health
50 Asthma, eczema, hay fever, tuberculosis, cardiovascular
disease & others
Social history
51 Parents: - Father & mother occupation
-Type of housing (overcrowded or not)
- Extended family or single parent
- Family – urban or rural
52 Child: - Nursery
- Preschool
- School & progress
After taking the history

53 Ask the parent if there is anything that he might add that
you have forgotten to ask about
54 Thank the parent and child
The above checklist can be used when you are asked to

take a detailed history from any patient in OSCE or long
case examination.
157
ANSWER 2
Suggested checklist of a 14-month-old child with vomiting and

diarrhea
1 Greet the mother and Introduce himself

2 Ask about age and residence?
3 Ask about frequency of bowel motion per day, amount, and
character?
4 Ask if there is any blood in the stools?
5 Ask about associated fever, vomiting, or abdominal pain?
6 If the vomiting is bile-stained, consider obstruction?
7 Ask about similar condition in the family?
8 Ask about recent travel and drug history?
9 Ask about type of feeding?
10 Ask about previous attack and past medical history?
11 Ask about vaccination?
12 Thank the mother and tell her if she has any question
D.D.
13 Food poisoning
14 Gastro-enteritis
158
ANSWER 3
Suggested checklist of a 1-year-old child with chronic cough
1 Greet the parents , child ,and Introduce himself

2 Check for vaccination (BCG, DTP, and Measles)?
3 Check for consanguinity?
4 Check for history of contact with T.B. or pertussis?
5 Check for history of foreign body inhalation?
6 Check for congenital heart disease?
7 Check for family history of asthma or atopy?
8 Check for past history of meconium ileus and chronic
diarrhea?
9 Type of cough (nocturnal ,productive ,exercise induced ,
followed by a whoop)?
10 Ask about history of previous similar attacks?
11 Ask if the mother wants to add anything or has any question?
12 Thanks the mother
INVESTIGATIONS
13 CXR
14 CBP
15 Sweat test
159
ANSWER 4
Suggested checklist of a 7-year-old child asthma exacerbation
1 Greet the father , child ,and Introduce himself

2 Ask about time of onset of attack?
3 Was it gradual or acute onset?
4 How has she been treated so far?
5 Has there been any relief?
6 Has she a history of severe asthma attacks/ hospital
admissions?
7 How her asthma is normally managed?
8 Has there been any change in Noor’s asthma medication
or delivery device?
9 Does Noor have any other medical problems, such as a
recent respiratory tract infection?
10 Does she have a cough?
11 If so, when does it occur? Nocturnal? Productive?
12 Is she short of breath on exertion?
13 Is she taking any new or other medications – including
over-the-counter medication?
14 Has she been in contact with any triggers, e.g. pets,
smoke or other known allergens?
15 Have there been any recent events in Noor’s life that
might have upset her?
16 Thanks the father
160
ANSWER 5
Suggested checklist of red flags of asthma in a 7-year-old girl
1 Cyanosis
2 Too breathless to talk or feed
3 Silent chest
4 Pulse rate above 120
5 Respiratory rate above 30
6 Oxygen saturation < 92%
7 Use of accessory muscles of respiration
8 Poor response to relief medication
9 Weak respiratory effort
10 Exhaustion
11 Confusion
12 Coma
13 Previous recent hospital admissions
161
ANSWER 6
Suggested checklist of a 2.5-year-old child with febrile seizure

2 Ask the attendant to recreate the seizure?
3 Did the attendant noticed the fever and for how long before
the attack?
4 Ask about previous seizure?
5 Ask about family history of febrile seizure?
6 Ask about family history of epilepsy?
7 Ask about headache and photophobia?
8 Ask about diarrhea?
9 Ask about skin rash?
10 Ask if the seizure was focal or generalized?
11 Ask about duration of seizure?
12 Ask about developmental history?
INVESTIGATIONS
14 Lumbar puncture
15 CBC
16 Blood sugar
17 Serum calcium
162
ANSWER 7
Suggested checklist of a 3-day-old neonate with seizure

2 Ask about history of difficult labor, i.e. prolonged, forceps
(perinatal hypoxia, intracranial trauma)?
3 Ask about history of prolonged rupture of the membranes
(sepsis)?
4 Ask about maternal history of drug abuse (drug
withdrawal)?
5 Is there a family history of stillbirths or neonatal deaths
(some inborn errors)?
6 Ask about poor feeding?
7 Is the baby irritable or drowsy?
8 Ask the mother to describe the fit?
9 Ask about a flare around the umbilicus with bad smell?
10 Ask about consanguinity?
11 Ask about family history of neonatal seizures?
D.D.
13 Meningitis
14 Low serum levels of glucose, calcium, magnesium or
sodium
15 Inborn errors of metabolism
16 Perinatal hypoxia/ischaemia, intracranial trauma or
haemorrhage
163
ANSWER 8
Suggested checklist of an18-month-old child with a fever and rash

2 Ask about vaccination?
3 Ask about contact with childhood exanthems?
4 Does the child have a sore throat (pharyngitis), or red
eyes (conjunctivitis)?
5 Is there any evidence of arthralgia?
6 Is there any evidence of swollen glands in the neck?
7 Ask about fever, high or low?
8 Does the child look mildly unwell, or miserable, toxic, and
unwell-looking child?
9 Ask about cough?
10 Ask about desquamation of the skin round the nails, and
peeling of the skin?
11 Ask about way of rash progress?
12 Ask about missed periods?
13 Is the rash itchy?
15 Next step for this worried mother is rubella serology?
164
ANSWER 9
Suggested checklist of a 6-year-old child with short stature

2 Has he always been short or small?
3 Is there any history of chronic illness? (e.g. celiac disease,
heart or kidney disease)
4 Was he a product of normal birth and delivery? (ask about
birth weight)
5 Was he born premature or growth restricted?
(constitutional short stature)
6 What ethnic group is the family from? (ethnic differences
in height)
7 How tall are his parents? (familial short stature)
8 What is the social background and family relationships?
(emotional neglect or other forms of child abuse are causes
of psychosocial short stature)
9 Is he falling behind his peers? (height falling off centiles as
in growth hormone deficiency)
11 Single valuable available investigation
is bone age
165
ANSWER 10
Suggested checklist of a7- year- old child with purpura and easy
bruising

2 Ask about bleeding from other sites (mucus membrane)?
3 Ask about preceding ARI?
4 Ask about previous similar attack?
5 Ask about fever and mouth ulcers?
6 Ask about family history of same presentation?
7 Ask about consanguinity of parents?
8 Ask about associated café eu lait spots?
9 Ask about stature and skin color?
10 Ask about any bleeding after circumcision or tooth
extraction?
11 Ask about associated eczema?
INVESTIGATIONS
13 CBP
14 Factor Assay
15 Bone marrow study
166
ANSWER 11
Suggested checklist of a 2-year-old child with delayed speech

2 Ask about pregnancy?(congenital infections)
3 Ask about birth history? (birth asphyxia, sepsis)
4 Ask about early development including responses to sounds
and voices?
5 Ask about infant illnesses, especially meningitis and
recurrent ear infections? (e.g. otitis media)
6 Ask about exposure to ototoxic drugs? (e.g. gentamicin)
7 Is she socially responsive and does she attempt to copy
sounds?
8 Ask about family history of deafness and/or language delay?
9 Enquire about potential psychosocial stresses within the
family?
10 Is there a failure of comprehension; e.g. can she follow a
command?
11 Is there a problem with the production of sounds?
12 Can her parents understand her?
13 Does she use non-verbal communication to demonstrate her
needs?
D.D.
15 Maturational language delay
16 Hearing impairment
17 Mental retardation
18 Psychosocial deprivation
19 Autism
167
ANSWER 12
Suggested checklist of newborn with cyanosis

2 Is the cyanosis central (of the lips and tongue) or peripheral
(hands and feet)?
3 Does the infant get breathless on feeding?
4 Any respiratory distress?
5 Ask about hypothermia?
6 Ask if the infant ever looked pink?
7 Is there a family history of congenital heart disease?
8 Are there any other signs of systemic illness, e.g. poor
feeding or rashes?
9 Are there any dysmorphic features, e.g. Down’s syndrome?
(associated with increased incidence of congenital heart
lesions)
D.D.
11 Cyanotic congenital heart disease
12 Respiratory causes
13 Metabolic causes
14 Hypothermia
168
ANSWER 13
Suggested checklist of an 8-year-old child with headache

2 Ask about aura of migraine like nausea, vomiting, pallor?
3 Ask about family history of migraine?
4 Ask about symptoms of raised intracranial pressure:
worsening school progress, behavioral change, and early
morning headaches?
5 Ask whether the headache is recurrent or progressive in
nature?
6 Ask about hypertension?
7 Ask about signs and symptoms of sinusitis?
8 Ask about visual acuity and problems of vision?
9 Ask about history of school problems?
Indications for C/T scan
11 Altered consciousnessoptions
12 Focal neurological signs
13 Papilloedema
14 Headaches worsening (e.g. waking at night)
15 Change in behavior or personality
16 Worsening school performance
169
ANSWER 14
Suggested checklist of a 6- month- old child with intestinal

obstruction

2 Is it first attack and the baby was previously well?
3 What relieves the pain?
4 Ask about any vomiting and diarrhea?
5 What color are the stools? (i.e. is there blood present)
6 Ask about pallor or any recent viral infection?
7 Ask about testicular torsion (in boys)?
8 Ask about inguinal hernia?
9 Ask about dysurea and frequency?
10 Ask about trauma?
D.D.
12 Acute intussusception
13 Acute infantile colic
14 Acute gastroenteritis
15 Testicular torsion (in boys)
16 Strangulated inguinal hernia
17 Other cause of intestinal obstruction
18 Urinary tract infection
170
ANSWER 15
Suggested checklist of an 8-year-old child with red urine

2 Ask about unexplained low-grade fever or dysurea? (Urinary
tract infection)
3 Ask about history of sore throat in the previous 3 weeks?
4 Ask about reduced urine output, and peri-orbital oedema in
the days preceding presentation?
5 Ask about history of trauma?
6 Ask about skin rash ?(Henoch–Schonlein purpura)
7 Ask about colicky loin pain ?(Renal calculi)
8 Ask about history of bloody diarrhea .pallor, and ecchymosis
?(Haemolytic uraemic syndrome)
9 Ask about history of sickle cell disease?
10 Ask about history of bleeding disorder?
Clinical examination to be performed
12 Blood pressure
13 Examine the abdomen for tenderness and masses
171
ANSWER 16
Suggested checklist of a 3-week-old neonate with prolonged

jaundice

2 Ask about feeding activity?
3 Ask about abdominal distension and umbilical hernia?
4 Ask about weight gain in more detail?
5 Ask about baby pyrexia?
6 Ask about excessively sleepy or lethargic neonate?
7 Ask about constipation?
8 Enquire about the color of urine and stool?
9 Is the urine smelly? (a fishy smell may occur with UTI)
10 Enquire about previous babies?
11 Enquire about family history of jaundice?
INVESTIGATIONS
13 Liver function tests
14 TORCH screen
15 α-1- antitrypsin
16 Urine for Benedict and glucose
17 Radionucleotide excretion scan to assess biliary excretion
172
ANSWER 17
Suggested checklist of an 18-month-old child with bruising

2 Enquire about walking activity and frequency of falls?
3 Ask about painful swollen joints (haemarthroses)? which
occur in coagulation disorders (e.g. haemophilia)
4 Ask about abdominal pain, painful joints, and preceding
coryzal illness? (e.g. as in HSP)
5 Ask about lethargy, pallor, mucosal bleeding or other
features of ill health? (e.g. as in leukaemia)
6 Take a social history and enquire about carers and family
dynamics?
7 Does the history fit the pattern of bruising observed, and
was appropriate medical attention sought?
8 Are the histories of different care-givers consistent?(if
suspicious of NAI)
9 Are there any suspicious lesions which might suggest NAI?
(e.g. slap or grip marks, burns or wheals, suspected
fractures)
10 Is the bruising localized to the lower limbs (accidental
bruising or HSP) or generalized (coagulopathy or leukaemia)?
DIFFERENTIAL DIAGNOSES
12 Normal toddler bruising
13 Non-accidental injury (NAI)
14 Henoch–Schonlein purpura (HSP)
15 Clotting disorder (e.g. idiopathic thrombocytopaenic
purpura, haemophilia)
16 Leukaemia (or other conditions causing thrombocytopaenia
173
ANSWER 18
Suggested checklist of an 8-year-old girl with iron poisoning

2 Ask about specific iron compound and the iron content of
each tablet?
3 Ask about the maximum number of tablets in a full bottle,
and how many are left?
4 Ask about number of tablets found on the floor, or in the
children’s clothing?
5 Have any of the children vomited since the ingestion?
6 Have any of the children had any other symptoms which may
suggest iron toxicity, e.g. diarrhoea, abdominal pain or
haematemesis?
7 Ask about drowsiness, convulsions?
8 Check the body weight of each child ?(so maximum dose per
kilogram can be established)
The minimum toxic dose of iron in children is estimated to be
anywhere from 20 to 60 mg/kg
9 Thanks the mother
INVESTIGATIONS
10 Plain abdominal X-ray
11 Serum iron level
12 Blood glucose
13 Plasma electrolytes, including chloride and bicarbonate (for
anion gap)
14 Full blood count
174
ANSWER 19
Suggested checklist of a 6-year-old child with ADHD

2 Can he maintain attention or easily distracted?
3 Can he follow instructions?
4 Does he complete a task or easily moves from one incomplete
task to the next?
5 Is his physical activity appropriate to the situation?
6 Can he sit quiet easily?
7 Ask about excessive fidgeting and talking?
8 Ask about social skills, e.g. turn-taking?
9 Ask about family history of hyperactivity?
10 Ask about early childhood stresses such as abuse or
hospitalization?
11 Ask about ear nose and throat problems?
13 Attention deficit hyperactivity disorder (ADHD)
14 Normal, but very active child
15 Specific learning disability
16 Hearing or visual problem
17 Autistic spectrum disorder
175
ANSWER 20
Suggested checklist of a 3-year-old child with ASD

2 Can he make eye contact?
3 Does he come for comfort when hurt or upset?
4 Does he have marked routines or rituals, which produce
violent temper tantrums if disrupted?
5 Does he have unusual motor features (e.g. flapping hands,
walking on tiptoe)
6 Does he have fears or phobias?
7 Does he have sleeping and eating disturbances?
8 Does he have self-injury and abnormal sensory responses
(e.g. highly sensitive to noise)?
9 Ask about history of hearing or visual impairment?
11 Pervasive developmental disorder (autism)
12 Hearing or visual impairment
13 Learning disability
14 Physical or sexual abuse
176
PART 3
The communication
skills station
This section of the exam is intended to look at how you
communicate in your everyday clinical practice and has been
designed to mimic that closely. Remember it is not enough just to
be a good listener, your job is to address patient’s and their
family’s concerns appropriately and to provide them with reliable
information about the child’s condition and the management plan.
This requires a broad knowledge of common pediatric conditions.
You are being marked in three areas:
1. Conduct of interview
2. Appropriate explanation and negotiation
3. Accuracy of information given
The patterns of communication scenario described could be

1. Information giving
2. Breaking bad news
3. Consent
4. Critical incident
5. Ethics
6. Education
The scenarios are realistic and commonly seen in everyday clinical

practice.
Make a shortlist of conditions that you plan to know in details.
No conditions should be considered too serious or too trivial to
come up in the exam.
177
COMMUNICATION SKILLS OSCE STATIONS
QUESTION 1
Ali has been presented with limping and pallor for the last 2 weeks.
His CBC had shown marked thrombocytopenia 22000/cmm,
marked elevation of WBC 47000/cmm, and low Hb 7g/dl,
blood film had shown many blast cells.
Yesterday, after consent, bone marrow aspiration was done. This
morning, the result came with the diagnosis of leukemia.
Ali,s father is upset because no one talks to him until now about
the diagnosis.
The doctors are planning to transfer Ali to the tertiary center of
pediatric oncology.
Task
Identify Ali's father current concerns about Ali's clinical condition
and your future plan of management and prognosis?
QUESTION 2
Zahraa, a young mother tells you, my child has a rash and I am
pregnant. What if it is German measles?
Task
Convince the mother and alleviate her worry.
Discuss the problem with mother and tell her your suggestions.
QUESTION 3
Karar was born at term after an uncomplicated pregnancy to a
prime mother .Routine newborn examination revealed a cardiac
murmur. Echo scan confirmed small muscular VSD .The mother is
upset about the diagnosis, and also about the fact that this was not
picked up on the antenatal scans. Karar,s mother is asking to speak
to someone. You are the resident on call.
178
Task
Explain to the mother the diagnosis and the planned management.
QUESTION 4
A young mother tells you. My infant child has had his first febrile
convulsion, what does it mean?
Task
Counsel the mother about the disease and its management.
QUESTION 5
A young mother tells you .My toddler keeps having frightening
breathholding attacks.
Task
Counsel the mother about the disease and its management.
QUESTION 6
A young mother consults you saying, my baby vomits after feeds, I
am changing clothes all the time, what should I do?
Task
Counsel the mother about the problem and its management.
QUESTION 7
My child cries all the time with colic, she is 45 days old, her birth
weight was 3 Kg and now she is 4.3 Kg, what shall I do?
Task
Convince the mother and alleviate her worry.
Answer the mother questions.
QUESTION 8
My baby is always wheezy with a cough and cold. Does this mean
she has asthma?
Task
Alleviate the mother’s worry.
Answer her questions
179
QUESTION 9
Ali brought his 7-year-old child saying, why is my child overweight?
Ali is asking to speak to someone. You are the resident on call.
Task
Explain to the father the size of the problem and the planned
management.
QUESTION 10
A young, anxious, and worried mother telling you, my newborn
baby has been diagnosed with Down’s syndrome.
Task
Alleviate the mother worry and explain to her what does Down’s
syndrome mean for her?
QUESTION 11
Hawraa, an 8 months old female with history of frequent bowel
motion for 2 days associated with 1 attack of vomiting; on
examination the patient has some dehydration.
Task
Explain to the mother, her child’s condition and its management.
QUESTION 12
A young mother telling you, all my friends are advising me not to
give my child MMR vaccine.
Task
Convince the mother, alleviate her worry, and answer her
questions.
QUESTION 13
A teacher consult you seeing, my son has been diagnosed with
cystic fibrosis, what does this mean for him?
180
Task
Explain to him everything you know about cystic fibrosis and
answer his questions.
QUESTION 14
An 11-year-old boy has recurrent headaches which are throbbing,
over his left eye, and are associated with a visual aura. They are
worsening in severity and frequency, but his school progress is
good. His mother gets migraines that respond to treatment. Clinical
assessment suggests that the boy also has migraine.
The mother and the child require verbal and written information
about migraine.
Task
Arrange and introduce these informations for them.
QUESTION 15
A pharmacist tells you, my 7-year-old son keeps getting tummy
ache on the way to school.
Task
Discuss the problem of recurrent abdominal pain and answer her
questions.
QUESTION 16
An anxious mother telling you, my 10-year-old daughter is
constipated, and this is very distressing. Can you give her
something?
Task
Discuss the problem of constipation and its remedy.
QUESTION 17
A young mother brought her 3-week-old baby, who is still
jaundiced? The baby is well, afebrile and breast feeding well with
181
good weight gain. Examination is normal and the stool and urine
are normal colour. The serum bilirubin is all unconjugated.
Task
Discuss the problem with the mother and alleviate her worry.
QUESTION 18
A young mother telling you. I am worried that there has been a
case of meningococcal disease at my child’s school. Please could
you tell me about meningococcal disease and the symptoms,
including looking for skin rashes?
Task
Discuss the problem with her and answer all her questions.
QUESTION 19
An old mother brought her young daughter saying. My 14-year-old
daughter has deliberately taken a paracetamol overdose. What
treatment does she need?
Task
Discuss with mother the problem of deliberate paracetamol
overdose ingestion and what is your advice to prevent this in the
future?
QUESTION 20
A father consults you about his 9-year-old boy who wets his bed. It
seems that this boy has always wet his bed at night. His bowel
habit is normal, and he is otherwise in good health. His father wet
the bed until he was quite old. The physical examination, including
abdominal, spine, lower limb neurology and urinalysis, is normal.
Task
Discuss the problem with them and suggest your options of
management.
182
COMMUNICATION SKILLS OSCE STATIONS
ANSWER 1
Suggested communication skill checklist of an 8-year-old child with
leukemia
1 Introduced himself friendly and greet the father and child

2 Explained the purpose of the clinical setting
3 Maintained good eye contact
4 Showed sympathy &empathy to the situation
5 Listened attentively
6 Asked for background information (Address and education
level of the father)
7 Revised with the father the results of the investigations &
bone marrow aspiration
8 Tried to explain the diagnosis to the father & simplify it in an
easy understandable way
9 Asked the father if he had any background information
about the disease
10 Explained to the father that the disease is not untreatable
depending on its type, compliance & attachment to doctor
advice, and patience
11 Tried to explain the plane of treatment in simplified brief
way (type of treatment, duration, prognosis…)
12 There is a need for the use of blood and blood products at
different time of treatment
13 Explained the complications of the disease if not treated
14 Explained the complications of the treatment
15 Asked the father if there is any question or any subject to be
discussed
16 Ability to convince the father and ends the consultation
nicely
183
ANSWER 2
Suggested communication skill checklist of pregnant mother in

contact with suspected German measles
1 Introduced himself friendly and greet the mother

5 Asked for background information (education level of the
mother and immunization status of the child and mother)
6 Rubella is a rare childhood exanthema in Iraq due to uptake
of the MMR vaccine
7 The child is likely to have a rash from some other infection if
he has been immunized
8 Take blood from mother and child for rubella serology if the
vaccination status is unknown
9 Asked about gestational age of fetus
10 If the child has rubella infection and the mother is non-
immune, the highest risk to the fetus is in the first trimester
11 Asked the mother if there is any question or any subject to
be discussed
12 Ability to convinces the mother and ends the consultation
nicely
184
ANSWER 3
Suggested communication skill checklist of mother with cardiac

murmur in her son

4 Explain the diagnosis of hole in heart with diagrams
5 Hole in heart is the commonest heart problem in newborn
6 Karar remains well, no treatment is required now, and it may close
spontaneously
7 Antenatal scan can’t detect a small hole in the heart
8 She can take Karar home and care for him like any other baby
9 Advise them to contact a doctor if he has any difficulty at home
with feeding ,breathing, color change etc
10 Ascertain the parent’s understanding
11 Asked the mother if there is any question or any subject to be
discussed
12 Ability to convinces the mother and ends the consultation nicely
185
ANSWER 4
Suggested communication skill checklist of first simple febrile

seizure
4 Explain that febrile convulsions are common, and affect
about 3 per cent of all children
5 The commonest ages to be affected are between 6 months
and 6 years
6 The convulsions are usually brief, lasting under 15 minutes,
and generalized tonic–clonic
7 The precipitant is commonly a viral upper respiratory tract
infection
8 Febrile convulsions often run in families
9 In about 15 per cent of cases, another febrile convulsion will
occur during the same episode of illness
10 The risk of a further febrile convulsion with another illness is
about 30 per cent
11 The risk for epilepsy after febrile convulsion is only about 2–
4 percent.
12 The immediate management is to reduce the temperature,
e.g. anti-pyretic medication (paracetamol) and tepid
sponging
13 Do not place anything in your child’s mouth
14 Call an ambulance if; the convulsion is atypical (i.e.prolonged
more than 15 minutes), one-sided, your child has a rash
15 Asked the mother if there is any question or any subject to
be discussed
nicely
186
ANSWER 5
Suggested communication skill checklist of a toddler with

frightening breathholding attacks

4 Explain that blue breath-holding attacks are common and
benign
5 They can be set off by crying, upset, pain
6 Your child may go blue and lose consciousness, but will
rapidly recover
7 No drug treatment is necessary, although these episodes
have been linked to iron deficiency and it would be worth
checking your child Hb
8 Attacks will resolve by themselves
9 Behaviour modification therapy with avoidance of
confrontation may help
discussed
nicely
187
ANSWER 6
Suggested communication skill checklist of a baby with

gastresophageal reflux

4 Explain that Gastro-oesophageal reflux is common, and usually
harmless
5 It involves lots of washing and makes the house smell
6 It happens when food in the stomach gets pushed back up the
gullet, due to immaturity of the muscle at the base of
the gullet that should stop this reflux
7 The acid that comes up with the food may irritate the baby
and cause discomfort
8 Simple measures may help: nurse the baby upright or at 30
degrees after feeds
9 Try adding a proprietary thickener to bottle feeds
10 If necessary, there are drugs that will help
11 Please let me know if there is blood in the refluxed milk
12 If it persists, further investigation and treatment may be
necessary
discussed
nicely
188
ANSWER 7
Suggested communication skill checklist of an infant with colic
1 Greeting the mother and introducing him/her self

2 Gives the mother a chance to explain her point of view and
concerns and justify them
3 Colic is very common in infancy, and consists of paroxysmal,
inconsolable crying or screaming together with drawing up
of the knees
4 This can occur several times a day, but it is more common in
the evening
5 Colic affects almost all babies at some point
6 The cause is unknown, but is benign, and it is not associated
with other disease
7 Colic is completely harmless and goes away by itself, usually
by the age of 3 months
8 Proprietary remedies may help some, but not all babies
9 Management is by swaddling the child up for comfort, and
cuddling
10 If you just can’t cope any longer, please seek help from family
and friends, or your health visitor or GP
11 Uses listening techniques and verbal & non verbal technique
to express concern & understanding
nicely
189
ANSWER 8
Suggested communication skill checklist of a child with cough and

wheezy chest
1 Greeting the mother and introducing him/her self
2 Gives the mother a chance to explain her point of view and

concerns and justify them
3 Shows understanding of the patients point of view and extent
of her suffering
4 Wheezing during the first few years of life is very common
5 As long as the baby remains centrally pink and continues to feed

well, this will be a self-limiting problem and no specific treatment is
necessary
6 Some babies with more severe wheeze may benefit from treatment
with inhaled bronchodilator therapy
7 Wheezing in infancy is very common, and about 50 per cent will

experience some wheezing, particularly after viral respiratory
infections
8 Not all of these wheezy infants will develop asthma, and two-thirds
of children who have wheeze less than 3 years of age will be
wheeze-free at 9 years

nicely
10 Ready to explain and answer any question
190
ANSWER 9
Suggested communication skill checklist of a 7-year overweight

child
1 Greeting the father and introducing him/her self

3 Gives the father a chance to explain his point of view and
concerns
4 Take short history to see if there is any indication of
pathology such as,
tiredness and lethargy in hypothyroidism,
growth failure in Cushing’s syndrome
5 Look at the phenotype of the parents (are the parents
overweight )
6 Enquire about diet and exercise
7 Ask about fat distribution (uniform in exogenous obesity)
8 Ask about abdominal striae and acanthosis nigricans
9 Tell the father that the most likely diagnosis is exogenous
obesity
10 Exogenous obesity frequently induces more rapid growth
11 The father needs to be reassured that there is no underlying
pathology
12 Explain that weight is determined by the balance of calorie
intake and energy expenditure
13 Give dietary advice to reduce the fat content in the diet,
reduce salt and increase fibre
14 Give exercise advice and suggest 30 minutes of exercise that
makes the child breathless, every day
15 Set realistic targets for weight, and give positive
encouragement
16 Ready to explain and answer any question
191
ANSWER 10
Suggested communication skill checklist of a mother who gave

birth to a newborn with Down syndrome
1 Introduced himself friendly and greeting the mother

5 Down’s syndrome (DS, Trisomy 21) is the commonest
chromosomal abnormality
6 Individuals with DS have an extra chromosome 21. This
happened at some stage prior to fertilization. Although it is
more common in older mothers, the precise cause is not
known
7 Sometimes not all of the cells have an extra chromosome;
this is called mosaicism
8 DS is not preventable, but there are tests that can be done
during pregnancy
9 Individuals with DS have certain physical characteristics which
are usually recognizable at birth. These include:
characteristic facies (upslanting eyes, wide palpebral fissure,
prominent tongue); hypotonia; flattened occiput; single
palmar creases, curved fifth finger, wide space between first
and second toes (sandal gap); white spots on the iris
(Brushfield spots)
10 Associated with a degree of developmental delay (although
most milestones are reached eventually)
11 Mild to moderate learning difficulties (IQ variable, but usually
> 80)
12 Early feeding difficulties may be encountered
13 There is an increased incidence of congenital anomalies
192
(particularly cardiac lesions and duodenal atresia)
14 Life expectancy is reduced (particularly if there are associated
congenital anomalies), but people with DS can now live into
their fifties
discussed
nicely
193
ANSWER 11
Suggested communication skill checklist of an infant with diarrhea

and some dehydration
1 Introduce himself and greet the mother

2 Eye contact with the mother
3 Explain that based on history and examination the child has
lost fluid and salt from body and she have some
dehydration
4 Explain that the condition is not dangerous if treated
correctly and your cooperation is very important
5 The main line of treatment is ORS
6 Explain to the mother how ORS prepared and should given
by spoon not by bottle
7 Not used after 24 hour , and should prepare other packet
8 Ask the mother to repeat information and if she have any
question
9 Should avoid tea and cola
10 No need for antibiotics
11 Indication of antibiotics
12 Mention to the mother the danger sign and symptom
13 Ask if there is any question
14 Give her telephone number if she need any help
15 Thank her
194
ANSWER 12
Suggested communication skill checklist of a mother refuses giving

MMR vaccine to her baby

3 Measles infection is a childhood killer and a cause of
considerable mortality (1 in 1000 under 1 year of age)
4 It is also responsible for a rare fatal, degenerative disease,
subacute sclerosing panencephalitis (SSPE)
5 MMR is part of the IRAQ immunization schedule
6 Measles vaccination rarely causes complications, including
death in about 1 per million cases
7 Recently, concern has been expressed regarding a possible
association between MMR vaccination and autism in children.
Several large-scale epidemiological studies have found no
evidence for such an association
8 There is no documented risk of developing autism due to
MMR vaccination
8 Some parts of the world where the vaccination rate has fallen
below 70 per cent are facing a measles epidemic
11 Give telephone number for any consultation or help
12 Thank the mother
195
ANSWER 13
Suggested communication skill checklist of a child with cystic

fibrosis
1 Introduced himself friendly and greet the father

3 Cystic fibrosis (CF) primarily affects the lungs and the
digestive system
4 When a person has CF there is a problem with the movement
of salt across the lining of certain important cells in the lungs,
pancreas and reproductive system. This causes a build up of
thick, sticky mucus which can block the tubes in these parts of
the body
5 The consequence of this build up of mucus is that the small
airways of the lungs can become blocked; this makes
breathing difficult and the lungs more susceptible to
infection. The blockage in the pancreas means that important
enzymes, which are necessary to digest fats, cannot get into
the intestines and so fats in the diet are poorly absorbed
6 Common symptoms include poor growth ; fatty stools; cough,
wheeze ; chronic chest infections ; difficulty passing stool
from birth; and sterility
7 There is no cure for this condition
8 The mainstay of treatment is chest physiotherapy ,regular
antibiotics, and enzyme supplements
9 CF is an inherited condition. Both parents are ‘carriers’ for the
disease. There is a one in four risk of this occurring with each
pregnancy
12 Thank the father
196
ANSWER 14
Suggested communication skill checklist of a young boy with

migraine
1 Introduced himself friendly and greet the mother and the boy
3 Discuss how their symptoms fit the diagnosis of migraine
4 Alleviate their fear of brain tumor, your careful and thorough

assessment has excluded this, and provided the reasons why
5 The cause of migraine is not known
6 Consider triggers as important factors
 diet (e.g. chocolate, cheese)
 environment (e.g. smoke, bright lights)
 medication (e.g. the pill)
 hormones (e.g. menstruation, anxiety)
7 Prompt treatment of early symptoms with an analgesic such
as paracetamol, which may be combined with an antiemetic
8 Discuss prophylaxis (reduced frequency of headaches)

9 Discuss biobehavioral evaluation and therapy as essential
effective migraine management
10 Indication of preventive therapy and the duration of
treatment
13 Thank them
197
ANSWER 15
Suggested communication skill checklist of a 7-year- old child with

recurrent abdominal pain

3 Recurrent abdominal pain occurs in at least 10 per cent of
school-age children
4 Less than 10 per cent of affected children will have a
definable organic cause. In 90 per cent the cause is functional
abdominal pain
5 Functional abdominal pain is characteristically peri-umbilical,
worse on waking, associated with a family history of
abdominal pain or migraine, and not accompanied by any
other features of ill health
6 It is important that a full history and examination are
performed to exclude other causes, such as threadworms or
constipation
7 It may be helpful to explain the pain to the child and parent
as ‘the intestine becoming so sensitive that it is as if the child
can feel the food going round the bends’
8 About half of affected children have a rapid resolution of their
symptoms, following referral
9 About one-quarter resolve gradually
10 About one-quarter go on to develop irritable bowel syndrome
as adults
11 No medical treatment is required
14 Thank the mother
198
ANSWER 16
Suggested communication skill checklist of a 10-year-old girl with

constipation

3 Constipation is the infrequent painful passage of hard stools
4 It is common in children, and is sometimes precipitated by a
superficial perianal tear
5 Sometimes it is exacerbated by stress, and children may
withhold stool for fear of the associated pain. The rectum
then becomes full and distended and the sensation of
needing to defecate is lost. Involuntary soiling usually follows
as the full rectum overflows
6 Examination may reveal an abdominal mass which is
indentable
7 It is important to explain to the child and parents that
constipation is common, soiling is involuntary, and recovery
of normal bowel habit takes as long as the constipation took
to develop
8 Mild cases of constipation may respond to mild laxatives (e.g.
lactulose) and extra fluids
9 In more severe cases, treatment begins with stool softeners
for 2–3 weeks (e.g. docusate), followed by large doses of
powerful oral laxatives (picosulphate or senna) until the
stools are liquid
10 Relapse is common, and positive encouragement by the
child’s family and doctor are essential
13 Thank the mother
199
ANSWER 17
Suggested communication skill checklist of a 3-week-old newborn

with prolonged neonatal jaundice

3 The commonest cause for prolonged jaundice is breast milk
jaundice
4 There is no specific test that we can do to confirm this, so we
need to consider other important causes
5 Bilirubin forms bile which is normally broken down in the
intestines, and it is this that make stools a yellow color
6 The combination of pale stools (like putty) and dark urine
should alert us that there is a problem(biliary atresia)
7 It is important that this condition is treated as soon as
possible before irreversible damage occurs in the liver
8 That your baby’s stools and urine are normal color and the
bilirubin (unconjugated) is very reassuring
9 Sometimes an infection (particularly of the urine) can cause
jaundice. The fact that your baby is well, does not have a
fever, is feeding well and thriving makes this unlikely
10 By far the most likely cause is jaundice from breast milk. This
is common, harmless and needs no treatment. It usually
resolves in 2–3 weeks
11 There is no need to stop breast feeding to confirm the
diagnosis. This will only deprive your baby of the important
nutrients and substances which improve immunity that
breast milk contains
14 Thank the mother
200
ANSWER 18
Suggested communication skill checklist of a child was in contact

with meningococcemia

3 Meningococcal disease is a serious infection caused by certain
bacteria which may cause (septicaemia) or inflammation of
the lining of the brain and spinal cord (meningitis)
4 Neisseria meningitidis (meningococci) is the bacterium
responsible. It is found in the noses and throats of 5–10
percent of the population, but rarely causes serious disease
unless it enters the bloodstream or spinal fluid
5 Meningococci can spread among people through the
exchange of saliva and other respiratory secretions during
activities such as coughing and kissing
6 Common symptoms of meningococcal disease include high
temperature, headache, drowsiness and vomiting. A stiff neck
can occur with the meningitis
7 Unusual rash occurs with the septicaemia. Typically, this rash
is dark red and does not blanch when pressure is applied
8 If these symptoms occur – or if you are in any doubt at all – it
is very important that medical advice is sought urgently,
because if the disease has developed it is very important to
administer antibiotics directly into a vein or a muscle
9 Close contacts and people in the same house should be given
antibiotics to prevent this occurring (antibiotic prophylaxis).
These antibiotics can be taken by mouth
12 Thank the mother
201
ANSWER 19
Suggested communication skill checklist of a14-year-old girl with

paracetamol overdose intake
1 Introduced himself friendly and greet the mother and patient

3 The risk from paracetamol overdose occurs as a result of
hepatotoxicity
4 If a significant quantity has been ingested, then treatment
with intravenous N-acetylcysteine is warranted
5 Deliberate poison ingestion is a common presentation in
older children, and can often be in response to precipitating
factor
6 Individuals who attempt to self harm have a much greater
risk of psychiatric illness, and are therefore at risk of
repeating the attempt
7 In view of this, all patients taking a deliberate overdose
should undergo social, psychological and/or psychiatric
assessment prior to discharge
8 This assessment can offer an opportunity for difficulties
between adolescents and parents to be discussed
11 Thank the mother
202
ANSWER 20
Suggested communication skill checklist of a 9-year–old boy with

nocturnal enuresis
1 Introduced himself friendly and greet the father and patient

3 Bedwetting is common at this age; 3 per cent of normal 10-
year-olds wet the bed once a week, or more
4 There is often a family history of bedwetting
5 Usually, children who wet the bed do not have physical or
emotional problems
6 Bedwetting can become a problem for many children and
their families, particularly once children go to junior school
7 Bedwetting happens during a type of sleep in which sleep-
walking and sleep-talking occur in younger children
8 Because it happens during sleep, the child has no conscious
control over it
9 Reassure your child, especially if they are upset
10 Try absorbent pads. The pads go under the bottom sheet to
keep the bed drier and more comfortable
11 Encourage your son to shower before he goes to school. The
smell of urine is very strong and can hang around
12 Establish a suitable reward systems (e.g. star charts) and a
reward after a preset number of stars have been earned
13 Certain medications may help, but the problem often occurs
again when the medications finish
14 Most children grow out of the problem, even without
treatment
17 Thank the father and the patient
203
PART 4
Clinical stations
Preparation and technique are intertwined. The well-prepared
candidate will give themselves many opportunities to pick up
marks, just as the poorly prepared candidate will inevitably drop
marks. In particular if your examination technique is poor you will
fail.
Three key areas are usually assessed:
 Conduct of examination - Introduce oneself, puts parent
and child at ease. Displays an appropriate level of
confidence. Appropriate pace without rushing.
Acknowledge child fully and explain intended examination if
deemed appropriate. Adjusts language and behavior to suit
age of child.
 Clinical examination - Systemic and uncluttered technique.
Able to identify clinical signs and interpret their meaning.
 Discussion with examiners – Sensible differential diagnosis.
Able to suggest a sensible management plan, including
investigations. Demonstrate an understanding of impact of
findings on patient and family unit.
It is essential to be completely clear about how to examine any

system. Decide on your own method, learn it and practice it. Use
this method throughout the preparation period when seeing short
cases. Try not to change your approach in the run up to the exam.
Remember there is no definitive way to examine any system; you
need to find your own scheme. Whichever scheme you use,
remember that the examiner is unlikely to tolerate imprecise or
204
clumsy clinical examination and this should be avoidable with
proper preparation.
Remember that confidence in the exam comes from knowing that
your examination technique is not only correct but it is also
reproducible in a highly stressful environment. This comes from
relentless practice of examination and presentation in the
company of several different examiners. It is important to be mock-
examined by a range of colleagues, some whom you know and
some of whom you don’t. This reflects the different examiners who
will soon be assessing you in the clinical stations with no prior
knowledge of your performance in a previous station, or indeed
your performance in the work place.
During the examination itself there are many pitfalls:
 Poor engagement with the child. Including failure to look at

a child to judge whether you may be eliciting pain.
 Failure to talk your way through an examination when it has
been requested/is appropriate
 Lack of conviction in your findings, enabling an examiner to
place doubt in your mind throw you off balance. For
example, a candidate was asked to examine an abdomen
with bilateral masses and then asked to present her
findings. She presented the patient as having an enlarged
spleen and liver. The examiner was able to change the
candidate’s mind twice as to whether the masses were
kidneys or liver and spleen in the subsequent discussion.
 Stopping the examination when you have identified the
organ in question. For example, there is a set routine for
examining an enlarged liver you must continue with your
examination until you are stopped.
 Excluding a clear physical sign if you feel it does not fit in
with other signs.
205
BASIC FORMAT FOR CLINICAL EXAMINATION
 Introduce yourself to the child and parent

 Be prepared to talk about your findings as you proceed
 Observe and be prepared to comment on:
 General appearance and health – well or unwell? Ward
patients are occasionally used
 Dysmorphic features – syndromic or otherwise
 Growth and nutrition – note obvious abnormalities. You
may be asked to assess pubertal status
 Development – neurodevelopment abnormalities may be
noted during examination of other systems
 Hands – color, clubbing, nail abnormalities, poor perfusion
 Face – cyanosis, anemia, jaundice
 General observations such as presence of a nasogastric
tube
 Palpate
 Auscultate
 Ask for permission to examine any other relevant part of
the body
 Describe your findings
 Answer questions about your findings until the bell rings for
the end of the station
206
CARDIOVASCULAR SYSTEM STATION
Suggested Check list for cardiovascular system examination
Before starting
1 Introduce yourself AND greet the child and parent
2 Explain the examination and ask for consent to carry it out
3 Wash hands thoroughly and dry them
4 Stand by the right side of the patient
General inspection
5 inspect the child carefully, looking for any obvious abnormalities
in his general appearance
6 Is he breathless or cyanosed
7 Inspect the precordium and the chest for any scars and
pulsations
Inspection and examination of the hands
Take both hands and assess them for:
8 Color and temperature
9 Clubbing
10 Nail signs
11 Determine the rate, rhythm, and character of both radial pulses
and femoral pulses
12 Record the blood pressure in both arms
Inspection and examination of the head and neck
13 Inspect the conjunctiva for signs of anemia
14 Inspect the mouth and tongue for signs of central cyanosis
15 Assess the jugular venous pressure (difficult in very young
infants)
16 Locate the carotid pulse and assess its character
Palpation of the heart
17 Determine the location and character of the apex beat
18 Palpate the precordium for thrills and heaves
207
Auscultation of the heart
19 listen for heart sounds, additional sounds, and murmurs in
The aortic area
The pulmonary area
The tricuspid area
The mitral area
20 Any murmur heard must be classified according to:
Timing
Grading
Site
Radiation
21 Ask the patient to sit
Expose the back
Auscultate between the scapula
Auscultate the bases of the lungs and check for sacral edema
22 Palpate the abdomen to exclude ascitis and/or an enlarged liver
23 Cover the child and thank the child and parent
Don’t suggest the pulse character is abnormal unless it is very

obviously abnormal. If you are unsure, it is less likely to be
significant and you should move on
As a rough guide a systolic blood pressure should be no more

than 90 plus double the child’s age
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RESPIRATORY SYSTEM STATION
Suggested Check list for respiratory system examination
Before starting

General examination
5 Conscious state
6 Dyspneic or not
7 Cyanosed or not
8 Examine for clubbing and capillary refill
Expose the chest well.
9 Examine the chest wall from front, sides and from foot end
Comment on:
10 Symmetry of the chest wall
11 Respiratory rate
12 Contraction of accessory muscles of respiration
13 Palpate the trachea if central or not
14 Localize the apex beat
15 Assess for chest expansion
16 Assess for vocal fremitus (always compare both sides and
axilla)
17 Percussion (always compare both sides and axilla)
18 Auscultation (always compare both sides and axilla)
19 Assess for vocal resonance (always compare both sides and
axilla)
20 Examine for liver span
Ask the patient to sit
209
21 Expose the back
Always compare both sides
Comment on :
22 Symmetry of the chest wall
23 Deformity of the spine (kyphosis, lordosis or scoliosis)
24 Assess for chest expansion
25 Assess for vocal fremitus (always compare both sides and
axilla)
26 Percussion (always compare both sides and axilla)
27 Auscultation (always compare both sides and axilla)
28 Assess for vocal resonance (always compare both sides and
axilla)
29 Examine ear and throat
30 Cover the back and thanks the patient
Signs of respiratory distress

Severe signs in bold are very unlikely to be seen in the exam
situation but you may be asked about them:
Audible wheeze
Tachypnoea
Tachycardia
Nasal flaring
Intercostal/subcostal/sterna recession
Tracheal tug
Abdominal respiration/see-sawing of abdomen
Drowsiness and confusion
Cyanosis
Hyperexpanded chest plus clubbing implies cystic fibrosis or other

chronic suppurative lung disease
Hyperexpanded chest without clubbing implies asthma or
bronchopulmonary dysplasia
210
GASTROINTESTINAL SYSTEM STATION
Suggested Check list for gastointestinal system examination
1 Before starting
Introduce yourself AND greet the child and parent
4 Position the child so that he is lying flat and expose his
abdomen as much as possible
5 Stand by the right side of the patient (unless you are left
handed)
6 General inspection
Inspect the abdomen noting any:
• Distension ,umbilicus, and pulsations
•Localized masses
•Scars and distended veins
•Any bulge elicited by flexion of the trunk
7 Inspection and examination of the hands for
Clubbing
Koilonychia
Palmar erythema
Pulse (at least 15 seconds)
8 Inspection and examination of the head, neck, and upper
body
Inspect the sclera and conjunctivae for signs of jaundice or
anemia
Inspect the mouth, looking for ulcers ((Crohn's disease),
angular stomatitis (nutritional deficiency), atrophic glossitis
(iron deficiency, vitamin B12 deficiency, folate deficiency),
furring of the tongue (loss of appetite), and the state of the
dentition
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Examine the neck for lymphadenopathy.
9 Palpation of the abdomen
Ask the child if he has any tummy pain and keep your eyes on
his face as you begin palpating his abdomen.
Light palpation - begin by palpating furthest from the area of
pain or discomfort and systematically palpate in the four
quadrants and the umbilical area. Look for tenderness,
guarding, and any masses
Deep palpation - for greater precision. Describe and localize
any masses.
10 Palpation of the organs
Liver- starting in the right lower quadrant, feel for the liver
edge( regular or irregular )using the flat of your hand, surface
(smooth or nodular ) , texture ( firm or hand ) , and tenderness
11 Spleen - palpate for the spleen as for the liver, starting in the
right lower quadrant
12 Kidneys - position the child close to the edge of the bed and
ballot each kidney using the technique of deep bimanual
palpation
13 Percussion
Percuss the liver area. also remembering to detect its upper
border
Percuss the suprapubic area for dullness (bladder distension)
If the abdomen is distended, test for shifting dullness (ascites)
14 Auscultation
Auscultate in the mid-abdomen for abdominal sounds. listen
for 30 seconds at least before concluding that they are
hyperactive, hypoactive or absent
15 Examination of the groins and genitalia
Inspect the groins for hernias and, in boys, examine the testes
(this is particularly important in younger infants)
16 Cover the abdomen and thank the patient
212
COMMON EXAM QUESTIONS
 How you differentiate between a liver, spleen, and kidney?

 Why is it a liver?
 Why is it a spleen?
Liver
 Right hypochondrium
 Cannot get above it
 Moves with respiration
 Dull to percussion
Spleen
 Left hypochondrium
 Cannot get above it
 Moves with respiration
 Dull to percussion
 Has a notch
Kidney
 Can get above it
 Doesn’t move with respiration
 Resonant
 Ballotable
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The classic triad of colicky abdominal pain, vomiting, and bloody
stools only occurs in 10% of children with intussusceptions
Imaging studies in patients with suspected appendicitis are most

helpful when the diagnosis is unclear, especially in female
adolescent patients in whom it is often difficult to clinically
differentiate RLQ pain from appendicitis versus ovarian pathology
If an inflamed appendix presses on the bladder, the bladder can

become inflamed and urinalysis may demonstrate WBCs and
RBCs—don't let a “positive” urinalysis fool you if everything else
points to appendicitis
 Murphy's sign: pain with inspiration when pressure is

placed on RUQ
 Charcot's triad: fever, jaundice, and right upper quadrant
pain
 Reynold's pentad: fever, jaundice, right upper quadrant
pain, hypotension, and altered mental state
 Gallstones are much rarer in children than in adults and
are usually associated with an identifiable risk factor such
as hemolytic disease, hypercholesterolemia, obesity, CF,
and biliary tract malformations
 42% of patients with sickle cell disease will have gallstones
by the age of 18
 Patients with distal obstructions from gallstones can have
concomitant pancreatitis
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Suggested Check list for examination of the back
Before starting
5 Ask the patient to sit
6 Inspect for any swellings, deformities or scars
7 Palpate for edema over the sacrum
8 Palpate for the tenderness in the renal angles
9 Palpate for tenderness over vertebrae
10 Auscultate the renal angles for bruit
11 Percuss the renal angle (posteriorly)
12 Cover the back and thank the patient
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NEUROLOGY STATIONS
Suggested check list for examination of cranial nerve (I-VI)
1 Before starting
Introduce yourself AND greet the child and parent
The olfactory nerve (CN I)
4 Ask the patient to smell different scents, e.g. orange ,soap,
coffee
The optic nerve (CN II)
5 Test visual acuity on a Snellen chart
6 Test near vision by asking the patient to read a page in a book
7 Test color vision
8 Test the visual fields by confrontation
9 Examine the eyes by direct fundoscopy
The oculomotor, trochlear, and abducens nerves (CN III, IV,
and VI)
10 Inspect the eyes, paying particular attention to the size and
symmetry of the pupils
11 Look for visible ptosis (Horner's syndrome) or squint
12 Test the direct and consensual pupillary light reflexes
Explain that you are going to shine a bright light into the
patient's eye and that this may feel uncomfortable
13 Perform the cover test. Ask the patient to fixate on a point and
cover one eye
14 Observe the movement of the uncovered eye
Repeat the test for the other eye
15 Examine eye movements. Ask the patient to keep his head still
and to follow your finger with his eyes and to tell you if he
sees double at any point
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Look out for nystagmus at the extremes of gaze
16 Test the accommodation reflex. Ask the patient to follow your
finger in to his nose
The trigeminal nerve (CN V)
SENSORY PART
17 Test light touch in the three branches of the trigeminal nerve
18 Compare both sides
19 Indicate that you could test the corneal reflex
MOTOR PART
Test the muscles of mastication (the temporalis, masseter, and
pterygoid muscles) by asking the patient to:
20 •Clench his teeth (palpate his temporalis and masseter
muscles bilaterally)
21 •Open and close his mouth against resistance (place your fist
under his chin)
22 Test the jaw jerk
Ask the patient to let his mouth fall open slightly. Place your
fingers on his chin and tap them lightly with a tendon hammer
After the examination
23 Thank the patient
217
Suggested check list for examination of cranial nerve (VII-XII)

The facial nerve (CN VII)
4 Look for facial asymmetry
SENSORY PART
5 Indicate that you would test the anterior two-thirds of the
tongue for sensation
MOTOR PART
Test the muscles of facial expression by asking the patient to:
6 Lift his eyebrows as far as they will go
7 Close his eyes as tightly as possible. (Try to open them)
8 Blow out his cheeks
9 Purse his lips or whistle
10 Show his teeth
The acoustic nerve (CN VIII)
11 Test hearing by confrontation test
12 Carry out the Rinne and Weber tests
13 Examine the ears by auroscope
The glossopharyngeal nerve (CN IX)
14 Test the gag reflex by touching the tonsillar fossae on both
sides
The vagus nerve (CN X)
15 Ask the patient to phonate (say "aaah~) and, aided by torch,
look for deviation of the uvula
The accessory nerve (CN XI)
16 Look for wasting of the sternocleidomastoid and trapezius
muscles
Ask the patient to:
17 Shrug his shoulders against resistance
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18 Turn his head to either side against resistance
The hypoglossal nerve (CN XII)
19 Aided by a pen torch, inspect the tongue for wasting and
fasciculation
20 Ask the patient to stick out his tongue and to wiggle it from
side to side
Asymmetric crying facies, a relatively common finding in the

newborn nursery, is caused by hypoplasia of the depressor anguli
oris. It is considered a minor congenital anomaly and has only
cosmetic consequences. This is in contrast to a congenital facial
nerve paralysis, which can be associated with trauma or
developmental causes (and potentially associated with a number
of syndromes), which can lead to difficulty with eyelid closure
(leaving the cornea susceptible to damage) and to feeding
difficulties.
219
Suggested check list for examination of motor system of the
lower limbs
4 Position him and ask him to expose his legs
Inspection
5 Look for deformities of the foot
6 Look for abnormal posturing
7 Look for fasciculation
8 Assess the muscles of the legs for size, shape, and symmetry
Tone
9 Ensure that the patient is not in any pain
10 Test the tone in the legs by rolling the leg on the bed, by
flexing and extending the knee
Power
11 Test muscle strength for hip flexion, extension, abduction and
adduction
12 Knee flexion and extension
13 Plantar flexion and dorsiflexion of the foot and big toe
14 Compare muscles strength on both sides, and grade it
Reflexes
15 Test the knee jerk with a tendon hammer
16 Test the ankle jerk with a tendon hammer
17 Test for clonus of knee and ankle
Test for the Babinski sign
Cerebellar signs
18 Carry out the heel·to-shin test.
Gait
19 If he can. ask the patient to walk to the end of the room and
to turn around and walk back
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Suggested check list for examination of sensory system of the
lower limbs
Before starting
4 Position him on a couch and ask him to expose his legs
Examination
5 inspect the legs before you start
light touch
6 Ask the patient to close his eyes and apply a wisp of cotton wool
to the sternum and then to each of the dermatomes of the leg
Pain
8 Ask the patient to close his eyes and apply a sharp object
to the sternum and then to each of the dermatomes of the leg
Vibration
10 Ask the patient to close his eyes and apply a vibrating tuning fork
on the sternum and then over the bony prominences of the leg
Proprioception
12 Ask the patient to close his eyes. Hold one of his toes by its sides
and move it at the interphalangeal joint. asking him to identify the
13 direction of each movement
Compare both sides
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Suggested check list for examination of motor system of the
upper limbs
Before starting
4 Position him and ask him to expose his arms
Inspection
5 Look for abnormal movements such as tremor, fasciculation,
dystonia, and athetosis
6 Assess the muscles of the hands, arms, and shoulder girdle
for size, shape. and symmetry
Tone
7 Test the tone in the upper limbs by holding the patient'S
hand and simultaneously pronating and supinating and
flexing and extending the forearm
Power
8 Shoulder abduction
9 Elbow flexion and extension
10 Wrist flexion and extension
11 Finger flexion, extension, abduction and adduction
12 Thumb abduction and opposition
13 Compare muscle strength on both sides, and grade it
Reflexes
14 Test biceps, supinator, and triceps reflexes with a tendon
hammer
16 If a reflex cannot be elicited, ask the patient to clench his
teeth and re-test (reinforcement)
Cerebellar signs
17 Test for intention tremor, dysynergia, and dysmetria by
222
asking the patient to carry out the finger-to-nose test
18 Test for dysdiadochokinesis
223
Suggested check list for examination of sensory system of the
upper limbs
Before starting
4 Position him so that he is comfortably seated and ask him to
expose his arms
The examination
5 Light touch. Ask the patient to close his eyes and apply a wisp
of cotton wool to the sternum and then to each of the
dermatomes of the arm
6 Compare both sides as you go along
7 Pain. Ask the patient to close his eyes and apply a sharp
object - ideally a neurological pin - to the sternum and then
to each of the dermatomes of the arm
9 Vibration. Ask the patient to close his eyes and apply a
vibrating tuning fork to the sternum and then over the bony
prominences of the upper arm
11 Proprioception. Ask the patient to close his eyes. Hold one of
his fingers by its sides and move it at the distal
interphalangeal joint, asking him to identify the direction of
each movement
224
Suggested check list for cerebellar examination

3 Wash your hands
4 Ask the patient to stand up. Ensure that he is steady on his
feet and inspect his posture from both front and side
5 Ask him to walk to the end of the room and to turn around
and walk back
6 Walk heel-to-toe in a straight line
7 Ask him to do Romberg's test
8 Sit the patient and check finger – nose test
9 Intention tremor. Ask the patient to do something, e.g.
remove his watch or write a sentence
10 Examine muscle tone in the elbow (flexion and extension)
and wrist (flexion and extension, abduction and adduction)
joints.
Compare both sides
11 Dysdiadochokinesis
12 Heel-to-shin test
13 Test the knee jerk and ankle jerk
225
NEONATAL EXAMINATION STATION
Suggested check list for neonatal examination
Before starting
1 Introduce yourself to the mother, explain the examination,
and ask her for her consent to carry it out
2 Wash your hands
General inspection
3 Note color, position, tone, movements, skin abnormalities,
and any other obvious abnormalities
Head
4 Palpate the anterior and posterior fontanelles
5 Measure the head circumference
Face
6 Inspect the face for dysmorphological features
7 Check the patency of the ears and nostrils
8 Using an ophthalmoscope, test the red reflex and pupillary
reflexes
9 Test eye movements (squint)
10 Elicit the rooting reflex by lightly touching a corner of the
baby's mouth
11 Introduce a finger into the baby's mouth and feel the palate
(cleft palate)
Examine the palate using a torch and spatula
Chest
12 Take the radial and femoral pulses, one after the other and
then both at the same time (radio femoral delay)
13 Listen to the heart using the bell of your stethoscope
14 Listen to the lungs using the diaphragm of your stethoscope
15 Turn the infant over and listen over the back
16 Count the respiratory rate
226
17 Count the heart rate
Back
18 Examine the spine, focusing on the sacral pit (neural tube
defects)
19 Check the position and patency of the anus
Abdomen
20 Inspect the abdomen and the umbilical cord
Palpate the abdomen
21 Palpate specifically for the spleen, liver, and kidneys (thumb
in front, finger in the loin)
22 Examine the genitalia, in male infants note the position of the
urethral meatus (hvpospadias), ask about the urine stream,
and feel for the testicles (undescended testes)
Hips
23 Abduct the hips (Ortolani test, detects relocation of a
dislocated hip)
24 Next, adduct them whilst applying pressure with your thumbs
(Barlow test, detects a dislocated hip)
Arms and hands

25 Inspect the arms and hands, paying particular attention to
the palmer creases (trisomy)
26 Count the number of fingers on each hand
Feet
27 Inspect the feet and test their range of movement
28 Count the number of toes on each foot
Posture and reflexes
29 Test head lag by lying the baby supine and pulling up his
upper body by the arms
30 Test the Moro reflex by lifting the head and shoulders and
then suddenly dropping them back - the arms and legs should
227
abduct and extend symmetrically, and then adduct and flex
31 Test the grasp reflex by placing a finger in the baby's hand
32 Measure the length and weigh the baby
33 Thank the mother
228
PART 5
Development stations
The development station can be a very challenging section of the
exam and each candidate should have a well-practiced approach to
avoid nerves and fear affecting their performance. We advise that
you team up with a colleague and start with as many normal
healthy children as you can. Be observed and timed.
The following are some practical points about how your style and
approach can reassure the examiner and the parents that you
know what you are doing.
 Structured systemic approach (start at just below estimated

age and work up until just above expectation)
 Keep to the examiner’s instruction
 Ask questions but keep to the bare minimum to accomplish the
task. As a general rule you will be able to ask questions but not
where clinical exam will suffice. The examiner will want to
know that you have chosen your questions carefully and in a
structured way
 Start by getting down to the child’s height and begin playing
with child and observing/commenting. Opportunistic
observations and comments are the key to a well rounded
performance
 When directing them to an activity, start with easy tasks and
progress to more difficult ones
 Find something the child can do and something they can’t do,
so that you have a minimum and maximum age. Aim to assess
229
developmental age to within 2-3 months up to 2 years, and
within 4-6 months for 2- to 5- year-olds
CONDITIONS COMMONLY SEEN IN THE EXAM
 Down syndrome
 Non-mobile toddler
 Global delay
 Hypotonia
 Hemiplegia/diplegia
 Normal children
 Autism/autistic spectrum
230
SUGGESTED SCHEME FOR DEVELOPMENTAL EXAMINATION
IN INFANTS
Gross motor examination (posture and movement)
Remember muscle control progresses from the head down.

Suggested system for a baby could be:
 Lie the child supine and assess their general tone/limb positions
and movements( you could comment on vision at this stage)
 Pull on the hands or arms until the baby is in sitting position
(for 3- to 6-month-old children): look for head lag, assess
straightness of spine, upper limb and truncal tone, grasp reflex
 Hold the child in ventral suspension: comment on truncal tone,
head lifting, position of limbs
 Place the child prone and observe their ability to lift their
head/torso/roll over or crawl away
 Finish by assessing the presence of primitive reflexes
PRIMITIVE REFLEXES
o Asymmetric tonic reflex: disappear around 4 months

o Grasp: disappear around 4-6 months
o Moro: becomes less dramatic then disappear by 3-6 months
o Stepping: disappear by 2-3 months, reappear as child start
walking at 10-15 months voluntarily
o Downward parachute: protective responsive, develops around
4-6 months
o Forward parachute response(7-10 months)
231
Fine motor (vision and manipulation)
 In a baby, try to ascertain whether the baby can fix and follow.
Remember you must be silent when you are doing this as
babies will turn their heads to sound and this can be misleading
 Use a toy or interesting object and watch how the baby grasps
and explores the object
 Look for passing from one hand to another and mouthing.
Ensure that both hands can grasp equally well. In older infants
could comment on their ability to let go of a toy, and object
permanence
 Use something small (e.g. tiny piece of paper) to assess pincer
grasp
 Comment on pointing
Speech
 Comment on any vocalization you hear
Hearing
 Normal practice would be to ask the parents whether they have

any concerns about a baby’s hearing; the examiner may be
happy for you to do this.
 There are other key questions that provide evidence of hearing
development, for example, recognizing their own name/Mama
and dada sounds, etc. Be familiar with these so you can ask
them if you are given the opportunity
Social
 Watch the interactions with you and with its parents
232
 Comment on smiling; comment on what games the parents
plays with their child and how the child responds
 Look for the presence or absence of stranger awareness
 Make sure the child and parent are comfortable with you
before you try waving/clapping/playing peek-a-boo, etc
And finally
 Have some questions prepared in case the examiner lets you

ask them. If allowed then concentrate on social and hearing
questions as these are difficult to assess fully in an exam
environment
 Be prepared to order your findings in a logical sequence; this
will put the examiner at ease
 Think about the next investigation or referral if any abnormality
is found
233
Suggested check list for development of 3-month-old infant
1 Introduced yourself friendly and greet the mother

2 Ask the name of the child
3 Prone: Lifts head and chest with arms extended; head above
plane of body on ventral suspension ( do it )
4 Supine: Tonic neck posture predominates; reaches toward
and misses objects; waves at toy ( do it )
5 Sitting: Head lag partially compensated when pulled to
sitting position; early head control with bobbing motion;
back rounded ( do it )
6 Reflex: Typical Moro response has not persisted; makes
defensive movements or selective withdrawal reactions
( do it )
7 Social: Sustained social contact; listens to music; says “aah,
ngah” ( ask the mother )
8 Thanks the mother
234
1 Introduced yourself friendly and greet the mother

3 Make relationship with the child
4 Prone: Rolls over; pivots; crawls or creep-crawls (Knobloch)
(do it )
5 Supine: Lifts head; rolls over; squirms (do it )
6 Sitting: Sits briefly, with support of pelvis; leans forward on
hands; back rounded (do it )
7 Standing: May support most of weight; bounces actively
(do it )
8 Adaptive: Reaches out for and grasps large object; transfers
objects from hand to hand; grasp uses radial palm; rakes at
pellet (do it )
9 Language: Forms polysyllabic vowel sounds
( ask the mother )
10 Social: Prefers mother; babbles; enjoys mirror; responds to
changes in emotional content of social contact
( ask the mother )
235
1 Introduce yourself friendly and greet the mother

4 Sitting: Sits up alone and indefinitely without support, with
back straight ( do it )
5 Standing: Pulls to standing position; “cruises” or walks
holding on to furniture ( do it )
6 Motor: Creeps or crawls ( do it )
7 Adaptive: Grasps objects with thumb and forefinger; pokes
at things with forefinger; picks up pellet with assisted pincer
movement; uncovers hidden toy; attempts to retrieve
dropped object; releases object grasped by other person
( do it )
8 Language: Repetitive consonant sounds (“mama,” “dada
( ask the mother )
9 Social: Responds to sound of name; plays peek-a-boo or pat-
a-cake; waves bye-bye ( do it )
236

2 Ask about the name of the child
4 Sits up alone and indefinitely without support, with back
straight (do it)
5 Make a sound by a rattle near each ear and then above his
head (do it)
6 Rises independently (ask the mother or observe it)
7 Walks with one hand held (do it)
8 Picks up pellet (do it)
9 Releases object to other person on request or gesture
(do it)
10 Uncovers hidden toy (do it)
11 Says a few words besides “mama,” “dada” (ask the mother)
12 Plays simple ball game (do it)
13 Drink from cup (ask the mother)
14 Makes postural adjustment to dressing (ask the mother)
15 Responds to sound of name (do it)
237
SUGGESTED SCHEME FOR DEVELOPMENTAL EXAMINATION
IN OLDER CHILDREN
Gross motor examination (posture and movement)
What is the child doing now?

Observe and comment in less cooperative or less directable
children. Think about:
 Gait
 Running
 Climbing
For older children think about asking them to:

 Jump up high
 Stand on one foot
 Kick a ball
 Bounce and catch a ball
 Ride a tricycle
 Climb stairs if stairs available
There will be equipment provided to assess gross motor function in

older children, so look for tricycles and balls when you get into the
room and don’t forget to use them if they are appropriate.
Remember to join in and look like you are having fun no matter
how stresses you are. Be enthusiastic and congratulate them
loudly, often this best left towards the end of the examination as
once you have encouraged them to run about and kick a ball they
may not want to stop and do something that requires more focus.
If you get a chance to ask the parents a question then, (how does
the child go up and down stairs) is an excellent way to be very
specific about which milestones have been reached
238
Fine motor and vision
This is an excellent place to start your examination, particularly if

the child is focused on a (sitting down) activity when you arrive in
the room.
Always start by watching and commenting before directing the
child towards more specific activities. A suggested sequence is as
follows:
1. Picture book
 This is better suited for young toddlers
 Look out for pointing, recognizing pictures and turning
pages
 Remember to comment on vocabulary and speech as this
can often be assessed using the pictures in the book
2. Drawing (if pen and paper handy) - Are you good at drawing?
Can you draw?
 Be careful to note whether the child can imitate (child
watches as you draw a shape) or (paper covered and the
child cannot see what you are drawing until you are
finished). As a general rule, imitating comes approximately
2 months before copying. Make sure you use the right
terminology when reporting findings
 If you are in the middle of a full developmental assessment
you may well be able to get all the information you need to
comment on developmental stage with this activity alone.
You could then quickly move on to other areas. If you have
been only asked to assess fine motor and vision then spend
more time on this activity and definitely include drawing a
person if you are assessing an older child
3. Building blocks – Let’s do some building – can you do this?
 Remember the difference between copying and imitating as
described before
4. Other activities – you may be supplied with equipment to assess
239
 Threading beads
 Using scissors
 Matching colors
Hearing and speech
 Pointing to body parts

 Ask about name, age, boy or girl, counting, birth day
 Comment on vocabulary and how easy the child is to
understand
Social
For toddlers (you may need to ask the parents for most of these)
the questions are all to do with self-care/independence.
 Dressing
 Toileting
 Eating and drinking
For older children, ask about activities and friends at school or
preschool.
Finally
Keep the presentation of development stage confined to

categories. Be systematic.
First comment on developmental age for each area of
development you have assessed.
Next comment on whether you feel this appropriate to the child’s
chronological age, or whether you feel it is delayed. Also comment
on whether the delay is isolated to one area of development or
concerns several areas. Be aware of the limitations, as well as the
significance of your findings.
240
Suggested check list for development of 18-month-old child

4 Runs stiffly; sits on small chair ( do it )
5 Walks up stairs with one hand held ( do it )
6 Explores drawers and wastebaskets ( ask the mother )
7 Makes tower of 4 cubes ( do it )
8 Imitates scribbling ( do it )
9 Dumps raisin from bottle ( do it )
10 Speak 10 words (average) ( ask the mother )
11 Names pictures ( do it or ask the mother)
12 Identifies one or more parts of body ( do it )
13 Feeds self ( ask the mother )
14 Seeks help when in trouble ( ask the mother )
15 May complain when wet or soiled ( ask the mother )
16 Kisses parent with pucker (do it or ask the mother )
241
1 Introduce himself friendly and greet the mother

4 Runs well ( do it )
5 Walks up and down stairs, one step at a time ( do it )
6 Opens doors ( do it )
7 Climbs on furniture ( do it )
8 Jumps ( do it )
9 Makes tower of 7 cubes (6 at 21 mo) ( do it )
10 Scribbles in circular pattern ( do it )
11 Imitates horizontal stroke ( do it )
12 Folds paper once imitatively ( do it )
13 Puts 3 words together (subject, verb, object)
( ask the mother )
14 Handles spoon well ( do it and ask the mother)
15 Often tells about immediate experiences ( ask the mother )
16 Helps to undress ( ask the mother )
18 Listens to stories when shown pictures ( ask the mother )
242

4 Goes up stairs alternating feet ( do it or ask the mother)
5 Makes tower of 9 cubes (do it)
6 Makes vertical and horizontal strokes, but generally will not
join them to make cross (do it)
7 Imitates circular stroke (do it)
8 Refers to self by pronoun “I” (ask the mother)
9 Knows full name (do it)
10 Helps put things away (do it or ask the mother)
11 Pretends in play (do it or ask the mother)
12 Thanks the child and his parents
243

4 Rides tricycle ( ask the mother )
5 Stands momentarily on one foot ( do it )
6 Makes tower of 10 cubes ( do it )
7 Imitates construction of “bridge” of 3 cubes ( do it )
8 Copies circle ( do it )
9 Imitates cross ( do it )
10 Knows age and sex ( do it )
11 Counts 3 objects correctly ( do it )
12 Repeats 3 numbers or a sentence of 6 syllables ( do it )
13 Most of speech intelligible to strangers ( ask the mother )
14 Plays simple games (in “parallel” with other children)
( ask the mother )
15 Helps in dressing (unbuttons clothing and puts on shoes)
( ask the mother)
16 Washes hands ( ask the mother )
244

4 Hops on one foot ( do it )
5 Throws ball overhand ( do it )
6 Uses scissors to cut out pictures ( do it )
7 Climbs well ( do it )
8 Copies bridge from model ( do it )
9 Imitates construction of “gate” of 5 cubes ( do it )
10 Copies cross and square ( do it )
11 Draws man with 2 to 4 parts besides head ( do it )
12 Identifies longer of 2 lines ( do it )
13 Counts 4 pennies accurately ( do it )
14 Tells story ( ask the mother )
15 Plays with several children , with beginning of social
interaction and role-playing ( ask the mother )
16 Goes to toilet alone ( ask the mother )
245

4 Skips ( do it )
5 Draws triangle from copy ( do it )
6 Names heavier of 2 weights ( do it )
7 Names 4 colors ( do it )
8 Repeats sentence of 10 syllables ( do it )
9 Counts 10 pennies correctly ( do it )
10 Dresses and undresses ( ask the mother )
11 Asks questions about meaning of words ( ask the mother )
12 Engages in domestic role-playing ( ask the mother )
246
CLASSIC WARNING SIGNS OF DEVELOPMENTAL DELAY
Fine motor/vision
 Fixed squint at any age

 Hand preference before 18 months (usually not established
until third year)
 Not staring/no visual fixation or following at 6 weeks
 Immature grip at 18 months
 Still casting at 18 months
Speech/hearing
 Failure to respond to sound at any age

 Inability to understand simple commands at 18 months
 Not babbling at 12 months
 No spontaneous vocalization at 18 months
 Unable to speak in short sentences at 2i/2 years
 Unable to understand speech at 21/2 years
 Poor articulation making speech difficult to understand at 4
years
247
Gross motor
 Asymmetrical neonatal reflexes – up to 6 weeks

 Excessive head lag past 6 weeks
 Persistence of primitive reflexes (e.g. Moro/asymmetric tonic
reflex at 6 months)
 Unable to sit or weight bear, absence of saving reactions at 12
months
 Not standing at 18 months
 In boys: think about Duchenne muscular dystrophy
 If upper body gross motor motor development is normal
(sitting with straight back, reaching for toys, normal head
control): think about problems with hips or spine
Social/behavioural
 Failure to smile: average age is 5 weeks, should be concerned if

not smiling at 6 weeks
SOME KEY INVESTIGATIONS FOR UNEXPLAINED

DEVELOPMENTAL DELAY
 Chromosomes
 Fragile X
 Thyroid function tests
 Creatine phosphokinase
 Metabolic screen
 X-rays (hip/spine)
 Neuroimaging
248
OSCE TIPS
Don't panic. Be philosophical about your exams. Put them into

perspective. And remember that as long as you do your bit, you are
statistically very unlikely to fail.
Read the instructions carefully and stick to them. Sometimes it's
just possible to have revised so much that you no longer "see" the
instructions and just fire out the bullet points like an automatic
gun. If you forget the instructions and/or the actor looks at you like
Caliban in the mirror, ask to read the instructions again.
Quickly survey the cubicle for the equipment and materials
provided. You can be sure that items such as hand disinfectant, a
tendon hammer, a sharps bin, or a box of tissues are not just
random objects that the examiner later plans to take home.
First impressions count. You never get a second chance to make a
good first impression. As much of your future career depends on it,
make sure that you get off to an early start. And who knows? You
might even fool yourself.
Don't let the examiners put you off or hold you back. If they are
being difficult, that's their problem, not yours. Or at least, it's
everyone's problem, not yours. And remember that all that is gold
does not glitter; a difficult examiner may be a hidden gem.
Be genuine. This is easier said than done, but then even actors are
people. By convincing yourself that the OSCE stations are real
situations, you are much more likely to score highly with the
actors, if only by "remembering" to treat them like real patients.
This may hand you a merit over a pass and, in borderline situations,
a pass over a fail. Although they never seem to think so, students
usually fail OSCEs through poor communications skills and lack of
empathy, not through lack of studying and poor memory.
Enjoy yourself. After all, you did choose to be there, and you
probably chose wisely. If you do badly in one station, try to put it
249
behind you. It's not for nothing that psychiatrists refer to
"repression" as a "defense mechanism", and a selectively bad
memory will put you in good stead for later life.
Keep to time but do not appear rushed. If you don't finish by the
first bell, simply tell the examiner what else needs to be said or
done, or tell him indirectly by telling the patient, e.g. "Can we make
another appointment to give us more time to go through your
treatment options. Then summarize and conclude. Students often
think that tight protocols impress examiners, but looking slick and
natural and handing over some control to the patient is often far
more impressive, and probably easier.
Be nice to the patient. Have I already said this? Introduce yourself,
shake hands, smile, even joke if it seems appropriate - it makes life
easier for everyone, including yourself. Remember to explain
everything to the patient as you go along, to ask him about pain
before you touch him, and to thank him on the second bell. The
patient holds the key to the station, and he may hand it to you on a
silver platter if you seem deserving enough.
Take a step back to jump further. Last minute cramming is not
going to magically turn you into a good doctor, so spend the day
before the exam relaxing and sharpening your mind. Play some
sports, rent out a DVD, and make sure that you are tired enough to
fall asleep by a reasonable hour.
Finally, remember to practise, practise, and practise. Look at the
bright side of things: at least you're not going to be alone, and
there are going to be plenty of opportunities for good
conversations, good laughs, and good meals. You might even make
lifelong friends in the process.
250
REFERENCES
1. PREP 2011, American Academy of Pediatrics

2. PREP 2010, American Academy of Pediatrics
3. PREP 2004-2008, American Academy of Pediatrics
4. Self-assessment, Current Paediatrics (2001-2006),
www.elsevier.com/locate/cupe
5. Neel L Burton, Clinical Skills for OSCEs, 2006 Informa UK ltd
6. Andrew Ewer, Timothy G. Barrett & Vin Diwakar, Core
Clinical Cases in Paediatrics 2005, Hodder Arnold
7. Carmen M. Coombs, Arethusa Stevens Kirk, Julia A.
McMillan, oske's pediatric certification and recertification
board review 2011, LIPPINCOTT WILLIAMS & WILKINS, a
WOLTERS KLUWER business
8. Simon Bedwani, Christopher Anderson, Mark Beattie, Short
Cases, History Taking, and Communication Skills for the
Paediatric Membership, 2nd Edition, PasTest
9. David Newble, Malcolm Reed, Developing and running
OSCE, Academic Unit of MedicalEducation,The University of
Sheffield,January 2007
THANKS FOR GOD
251
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PEDIATRIC OSCE STATIONS 1 st Edition 2013

Book · April 2013

The user has requested enhancement of the downloaded file.

COLLEGE OF MEDICINE/UNIVERSITY OF KARBALA

KARBALA TEACHING HOSPITAL FOR CHILDREN

CHILDREN WELFARE HOSPITAL

1st Edition 2013

This book is dedicated to

A very special thanks is extended to my son Ali Zuhair

Number of Deposition of This Book at Iraqi House of Books and

Part 1 Static stations 1

Part 2 History taking and management stations 146

Part 3 Communication skills stations 177

Part 4 Clinical stations 204

Part 5 Development stations 229

Contrary to popular belief, an OSCE is not a method of assessment

The length of time spent at each station is usually short (5-10

The OSCE format is very flexible allowing a wide selection of tasks

A- CASE STUDIES WITH IMAGES

1-What is your diagnosis?

1- What is the most important reason for urgent pediatric

1-Which condition is most consistent with this boy’s features?

1-What is the most likely diagnosis?

1-Is renal biopsy indicated for this

1- What is the most likely cause for this clinical presentation?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely explanation for this patient’s syncopal

1- What is the most likely explanation for these findings in this

1-What is your diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely organism?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely cause of her laboratory results?

1-Where is the site of the foreign body?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1- What is the most likely cause for this boy’s recurrent

1-What is the most likely diagnosis?

1-Mention the bacteria Implicated in this case?

1-What is the most likely diagnosis?

1-What are the most important laboratory studies to obtain at

1-What is the most likely diagnosis?

1-What is the most likely causative agent?

1-What is the most likely diagnosis?

1-What is the most likely cause for the patient condition?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What are these oval structures?

1-What you expect to find in his urine examination?

1- What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1-What is the most likely diagnosis?

1- What is the most likely cause of this patient's gynecomastia?