Arab Board OSCE Exam Revision

Pediatric arab board exam revision compilation: emergency, development and examination stations.

1. Arab Board OSCE Exam Revision Fatima Farid Ped Resident Yr 5

2. Emergency Station 10 mins

3. Anaphylaxis Manage airway- may need intubation to secure the airway prior to collapse and worsening edema Breathing- support ventilation and oxygenation via non- rebreather mask 10 L/min 100% FiO2 or bag- mask ventilation if collapsed Connect to vitals monitor; maintain in supine position if possible Urgent IM Epinphrine (1:1,000 concentration) Name: EpiPen Junior Dosage: < 30 kg: 0.15 mg >/= 30 kg: 0.30 mg Repeat every 10 minutes in case of failure to improve

4. Anaphylaxis Remove triggering agent Provide ancillary supportive care: IV 0.9% NaCl fluid bolus 20 ml/kg over 10 mins for hypotension IV/IM/PO Diphenhydramine 1 mg/kg Q6H for pruritus Salbutamol nebulization for wheezing Q20 mins PRN < 20 kg : 2.5 mg > 20 kg: 5 mg Corticosteroids: IV Methylprednisolone 2 mg/kg loading, then 0.5 mg/kg Q6H maintenance Proton- pump inhibitor to prevent steroid- induced gastritis Admit for observation of potential late- phase symptoms Investigations: FBC, CRP in case of suspected underlying infectious cause Blood test to confirm anaphylaxis: serum mast cell tryptase

5. Anaphylaxis Discharge Counseling: Trigger avoidance Anaphylaxis and EpiPen education Family counseling Medi- alert bracelet EpiPen Education: Always carry at least 2 Ensure schoolteachers/ nurses and family members know location of EpiPen around the child in case of emergency Remove safety cap, jab into outer or upper thigh at 90-degree angle – “Blue to sky; orange to thigh” May be given through clothes, including jeans- but avoid seams, zippers and creases Hold in place for 10 seconds, then remove and keep aside Lie down and keep legs upwards, do not sit back up immediately Call ambulance and keep second EpiPen standby in case of second dose requirement

6. Refractory Anaphylaxis Definition: Symptoms unresolving despite 2 doses IM Epinephrine Management: Intensive care admission Optimize fluid resuscitation IV Epinephrine infusion 0.1- 1 mcg/kg/min & may titrate till achieved response IV Methylprednisolone 2 mg/kg loading if not already given IV Methylene Blue single dose May need ECMO if persists

7. Acute Epiglottitis Management: Manage airway with early intensivist consultation for possible intubation – prepare items needed for intubation while they arrive Avoid airway manipulation in the form of throat examination or inducing anxiety/ crying Maintain child in position of comfort, defer blood investigations Support breathing as needed with humidified oxygen via non- rebreather mask Once airway secured: FBC, CRP Blood culture Respiratory viral panel/ throat culture Inpatient admission for observation IV Ceftriaxone + Vancomycin Support nutrition & hydration: PO feeds if stable or maintenance IV fluids Paracetamol for fever and pain control

8. Croup/ Laryngotracheobronchitis Management: Secure airway and support breathing: maintain in position of comfort, humidified oxygen via non- rebreather mask Connect to vitals monitor Keep NPO Racemic epinephrine NEB 2.25%: 0.25- 0.5 ml mixed with 3 ml normal saline Q 20 mins PRN IV/ PO/ IM Dexamethasone 0.6 mg/kg (max dose 16 mg) once Investigations: FBC, CRP Urea electrolytes for dehydration assessment Lateral neck x- ray

9. Croup/ Laryngotracheobronchitis Disposition based upon Westley Score (> 8 is severe): Level of consciousness Cyanosis Stridor Air entry Retractions Score >/ = 8 needs inpatient admission for observation Score >/= 12 needs PICU admission

10. Status Asthmaticus Management: Secure airway, ensure position of comfort Support breathing via non- rebreather mask Insert IV cannulas & collect blood gas C ontinuous monitoring for GCS, signs of respiratory failur e Salbutamol NEB Q20 mins PRN: < 20 kg: 2.5 mg >/= 20 kg: 5 mg Ipratropium bromide NEB 250- 500 mcg Q20 mins PRN (for 3 doses) IV Methylprednisolone 2 mg/kg loading (max dose 60 mg) followed by 0.5 mg/kg Q6H mainten an ce IV Magnesium sulphate 50 mg/kg (max dose 2 grams) slowly over 1 hour under cardiorespiratory monit or ing

11. Status Asthmaticus Consider IM Epinephrine : < 30 kg: 0.15 mg >/ = 30 kg: 0.3 mg In case of persistence, admit to PICU for BiPAP and advanced options: IV Salbutamol IV Aminophylline Terbutaline Investigations: FBC, CRP Blood gas Urea electrolytes Chest x- ray

12. Foreign Body Aspiration/ Choking Management: Maintain airway: If child is alert and able to cough  confirm they’re choking, then encourage coughing If drowsy/ semi- conscious, DO NOT check for pulse  START CPR When delivering breaths, open mouth and trial of object removal under visual guidance Never perform blind finger sweep Insert nasopharyngeal or oropharyngeal airway Support breathing: Non- rebreather mask if awake Breaths via pocket mask or mouth to mouth if unconscious If age: < 1 year: up to 5 back slaps and 5 chest thrusts >/= 1 year: Stand/ kneel behind child  abdominal thrusts

13. Hydrocarbon Inhalation Management: External decontamination Airway: ensure patency, maintain in position of comfort, consider early intubation in cases of oropharyngeal edema/ stridor/ drooling Breathing: Support with oxygen if in distress or SpO2 < 94% Salbutamol NEB if wheezing Chest x- ray if in distress, otherwise 4- 6 hours post- ingestion PICU admission for CPAP/ BiPAP/ mechanical ventilation if severely distressed Circulation: Connect to monitor and perform ECG Insert 2 large bore IV cannulas Keep NPO IV NS 20 ml/kg over 15 mins followed by D5%- 0.45% NaCl with 20 mmol/L KCl over 24 hours Send for blood gas, urea electrolytes, glucose Activated charcoal and gastric lavage contraindicated- emesis will worsen condition Epinephrine should be avoided as it can precipitate ventricular arrhythmias

14. Hydrocarbon Inhalation ARDS: Intubation/ mechanical ventilation Exogenous surfactant therapy HFOV ECMO Ventilation principles in ARDS: Permissive hypercarbia Low tidal volume: 5- 8 ml/kg Gentle PIP < 30- 35 mmHg Use cuffed ETT (to prevent glottic air leak)

15. Retropharyngeal Abscess Management: Airway: ensure patency, early intubation if unable to maintain airway/ very large abscess, maintain in position of comfort, avoid triggering crying/ distress in child Breathing: support with humidified oxygen if SpO2 < 94% or in distress Circulation: Insert 2 large bore IV cannulas Keep NPO Start fluid resuscitation: bolus normal saline 20 ml/kg over 15 minutes Labs: FBC, CRP, PCT, blood culture, urea electrolytes, lateral neck x- ray, CT with contrast of the neck to assess size of abscess (> 2.5 cm2  needs OT) Admit to inpatient Begin IV Clindamycin + IV Vancomycin (MRSA coverage) Paracetamol for fever and pain control ENT & anesthesia consultation for incision and drainage of abscess in OT urgently if progressing to respiratory failure, or to be scheduled if size > 2.5 cm2 in CT

16. Altered Mental Status Management: Appearance- Breathing- Colour  C all for help Connect to monitor Airway: ensure patency, maintainability- insert oropharyngeal airway if unconscious, suction to clear secretions, visualize for foreign bodies Breathing: support ventilation and oxygenation initially via non- rebreather mask 100% O2, then with possible intubation as needed Circulation: Insert 2 large bore IV cannulas IV 0.9% NaCl 20 ml/kg over 10 mins if hypotensive IV D10% 2- 5 ml/kg if hypoglycemic (2 ml/kg in <1 year) Disability: C heck GCS, if < 8 sh o uld be intubated POCT glucose P upils Exposure: Core temperature, initiate passive rewarming if hypothermic S kin rashes, bone fractures, burns

17. Altered Mental Status Investigations: POCT glucose Blood gas Urea electrolytes FBC, CRP, PCT Blood and urine cultures Urine analysis Urine drug screening Creatinine Liver function test CT brain if neurologic deficits; followed by LP if safe ECG/ EEG Metabolic screening

18. Altered Mental Status Empiric Management: Suspected infection: IV Ceftriaxone IV Acyclovir Suspected hypoglycemia: Dextrose 10% bolus 2- 5 ml/kg Suspected opioid overdose: IV Naloxone 0.1 mg/kg (max dose 2 mg) S uspected raised ICP: H ead elevated in midline position, 30 degrees Mannitol 0.5 g/kg H ypertonic saline 3% 5 ml/kg Suspected non- convulsive status epilepticus: IV Lorazepam 0.1 mg/ kg

19. Status Epilepticus Management: Connect to monitor, obtain vitals, call for help Maintain in recovery position, left lateral side Secure surroundings, keep pillow under head Start timer and record progression Airway: secure, ensure patency, suction secretions, insert nasopharyngeal airway if conscious/ oropharyngeal airway if unconscious Breathing: support with non- rebreather mask 100% 10 L/min Circulation: insert 2 large bore IV cannulas or IO if unsuccessful Disability: check POCT glucose, electrolytes (including Ca, Mg), pupils Exposure: temperature, skin rash, bone fractures

20. Status Epilepticus At 0 minutes: Rectal Diazepam 0.5 mg/kg (max dose 20 mg) IV Diazepam 0.2 mg/kg (max 10 mg) IV Lorazepam 0.1 mg/kg (max dose 4 mg) After 10 minutes : Repeat Benzodiazepine After 15 minutes: IV Phenytoin 20 mg/kg over 20 minutes (to not exceed 1 mg/kg/min rate) O ther option: IV Levetiracetam 60 mg/kg After 20 minutes: IV Phenobarbitone 20 mg/kg over 20 minutes (to not exceed 2 mg/kg/min rate) Call PICU, if still after 20 minutes: Expected sedation and respiratory depression  intubatio n , ventilatio n Continuous EEG monitoring IV Midazolam or Pentobarbital infusions

21. Status Epilepticus Investigations: POCT glucose Blood gas Urea electrolytes including Ca, PO4 , Mg CT brain EEG A nti - seizure medicine blood level Febrile: FBC, CRP, PCT, blood/ CSF/ urine cultures Drug OD: Serum & urine toxicology screen ( i.e TCA/ anti- psychotic), aspirin level

22. Status Epilepticus Extra investigations if < 6 months: Blood gas Ammonia Pan- cultures Metabolic screening: Plasma amino acids Urine reducing substances Serum lactate, pyruvate Neonatal screening report check Coagulation profile LFT

23. Supraventricular Tachycardia Management: Connect to monitor, apply AED pads Airway: patency, maintainability, insert oropharyngeal airway if unable Breathing: support with NRM 10 L/min 100% FiO2, bag- valve- mask ventilation if apneic Circulation: Apply cold compress to upper half of face if easily available Insert 2 large bore IV cannulas in the nearest vein to the heart in UL If unstable: start CPR  synchronized cardioversion 0.5 J/kg  rhythm check  still persists, repeat 1 J/kg  may give up to 2 J/kg If stable: give Adenosine 0.1 mg/kg rapid push (max 6 mg) followed by rapid saline flush  second dose 0.2 mg/kg (max dose 12 mg)  Cardiologist consultation for Amiodarone 5 mg/kg or Procainamide

24. Supraventricular Tachycardia Investigations: Repeat vital signs 12- lead ECG Urea electrolytes Glucose

25. Upper GI Bleeding Management: Connect to monitor Airway: ensure patency, maintainability, check for bleeding source/ broken teeth/ abrasions Breathing: support oxygenation (if SpO2 < 94%), ventilation via non- rebreather mask Circulation: 2 large bore IV cannulas IV NS 0.9% 20 ml/kg over 10 mins Maintenance IV fluids 100 mg/kg/day Nasogastric lavage to assess gastric contents (fresh vs old blood) IV Esomeprazole 1 mg/kg/ dose OD IV Octreotide Fresh frozen plasma 15 ml/kg Upper GI endoscopy within 24- 48 hours of onset

26. Upper GI Bleeding Labs: Blood gas POCT glucose Blood group and save Cross match FBC PT, PTT Liver function test Urea electrolytes Creatinine Amylase, lipase Abdomen x- ray (foreign body) and USS (portal HTN) Urgent endoscopy to identify bleeding source MRA/ CTA in cases of vessel anomalies- diagnostic and therapeutic

27. Cardiac Arrest Management: Appearance- Breathing- Colour  Unresponsive, gasping/ apneic , pale/ cyanosed  Check pulse and breathing  If absent, call for help & start chest compressions Single resuscitator: 30:2 chest compressions to breath ratio. 2 hands technique over sternum, push hard and fast- at least 4- 5 cm deep with adequate recoil, minimal interruptions Once help arrives- connect to monitor & AED. Switch to 2 resuscitator technique- ratio 15: 2. Pause briefly to allow rhythm analysis. If unshockable rhythm: asystole, pulseless electrical activity  continue CPR for 2 minutes (5 cycles), administer Epinephrine every 3 minutes 0.1 ml/kg of 0.1 mg/ mL. If shockable rhythm: V fib, pulseless VT  defibrillation 2 J/kg, continue CPR  defibrillation 4 J/kg + start IV Epinephrine every 3 minutes 0.1 ml/kg of 0.1 mg/ mL formulation  defibrillation 6 J/kg + Amiodarone 5 mg/kg bolus + Epinephrine Q3 minutes

28. Cardiac Arrest Assess for H & T: Hypovolemia Hypothermia Hypoxia Hydrogen ions (acidosis) Hypoglycemia Hypo/ hyperkalemia Tension pneumothorax Tamponade around heart Toxins Thrombosis: lung or heart

29. Paracetamol Toxicity Toxic dose: 150 mg/kg Management: ABC Labs: FBC, CRP, LFT, glucose, bilirubin, PT/ PTT, urea electrolytes, creatinine Activated charcoal 1 gram/kg within 4 hours ingestion N- acetylcysteine indications: Serum acetaminophen level at 4 hours post- ingestion high level on Rumack - Matthew nomogram Deranged liver function NAC dose: PO 140 mg/kg loading followed by 70 mg/kg every 4 hours for 17 doses; IV 3 bag method over 21 hours (1 hr  4 hrs  16 hrs )

30. All Doses EpiPen (1:1,000): < 30 kg  0.15 mg >/= 30 kg  0.3 mg IV Epinephrine for anaphylaxis: 0.1- 1 mcg/kg/min IV/ IM/ PO Diphenhydramine 1 mg/kg Q6H IV Methylprednisolone 2 mg/kg loading (max dose 60 mg)  0.5 mg/kg Q6H maintenance Salbutamol NEB: < 20 kg: 2.5 mg >/= 20 kg: 5 mg IV Dexamethasone 0.6 mg/kg (max dose 16 mg) Racemic epinephrine NEB 2.25% 0.25- 0.5 ml mixed with 3 ml normal saline Q 20 mins PRN IV MgSO4 50 mg/kg slow infusion over 30 minutes under monitor IV D10% bolus 2- 5 ml/kg STAT for hypoglycemia

31. All Doses IV Naloxone 0.1 mg/kg (max dose 2 mg) IV Mannitol 0.5 g/kg IV Hypertonic saline 3% 5 ml/kg (for raised ICP) PR Diazepam 0.5 mg/kg (max dose 20 mg) IV Diazepam 0.2 mg/kg (max dose 10 mg) IV Lorazepam 0.1 mg/kg (max dose 4 mg) IV Phenytoin 20 mg/kg over 20 mins (max rate 1 mg/kg/min) IV Levetiracetam 60 mg/kg IV Phenobarbital 20 mg/kg over 20 mins (max rate 2 mg/kg/min) IV Esomeprazole 1 mg/kg/dose OD IV/ IO Epinephrine 0.1 ml/kg of 0.1 mg/mL concentration Q3-5 mins IV Amiodarone 5 mg/kg bolus, may be given 3 times (15 mg/kg) PO Activated charcoal: 1 gram/kg PO NAC: 140 mg/kg load, 70 mg/kg Q4H for 17 doses IV NAC: 3 bag method over 21 hours (1 hr  4 hrs  16 hrs )

32. Examination Stations 10 mins

33. CNS Plan HAND WASH Introduction, permission Request to expose- ideally remain in underwear only Show examiner that you are looking at him from all directions General Exam: Aids: this will tell me the extend of his mobility (?tone/ power issues) Dysmorphisms: complex genetic diseases, macro- vs microcephaly, abnormal eye movements, tongue fasciculations Feel the head for fontanelles, VP shunt presence Look into their eyes to see any rings, spots Skin for neurocutaneous markers Check if they are wearing pampers

34. CNS Plan By this point I will be able to tell if I am in one of 3 scenarios: A- Normal looking, well- grown child, think of: CNS disease: Hidden spots/ rough patches/ nerve area lumps  NF/ TS Acquired LMNL disease: GBS/ CIDP/ TM/ cord compression (trauma/ tumour ) Acquired UMNL disease: brain tumour / stroke Muscle disease  DMD/ BMD/ congenital muscle dystrophies Nerve disease  Charcot- Marie Tooth Disease Issues from his past: Prematurity causing Spastic Diplegia (LL affected, so he looks good otherwise) or Hereditary Spastic Diplegia Back area scars  Repaired MMC in childhood with cord compression/ spinal dysraphism

35. CNS Plan B- Globally delayed, malnourished, unaware child: Cerebral palsy See next slide for causes of CP Brain atrophy secondary to severe hydrocephalus, +/- VP shunt Congenital hydrocephalus: Walker- Warburg syndrome Aqueductal stenosis Dandy walker cyst Arnold- Chiari malformation Acquired hydrocephalus: Intraventricular hemorrhage Meningitis/ empyema Choroid plexus tumour C- Innocent- looking, bright eyed but very weak- bodied child  most likely SMA

36. CNS Plan Causes of CP: Antenatal: Prematurity Antepartum hemorrhage: placental abruption, vasa previa Congenital infections (TORCH) Maternal drug abuse Fetal genetic disorders Structural brain malformations Natal: Birth asphyxia Brain hemorrhage Post- natal: Sepsis/ infections Brain hemorrhage Kernicterus Non- accidental injury

37. CNS Plan Gait: Forwards walk: Hemiplegic circumduction + arm flexed gait  Spastic Hemiplegia Diplegic scissoring gait  Spastic diplegia High steppage + slightly unbalanced gait  CMT Ataxic, broad- based, unsteady gait  Cerebellar ataxia Weak legs gait: Waddling gait + PROXIMAL muscle weakness (+ Gower) + lumbar lordosis + calf muscle hypertrophy  DMD/ BMD Waddling gait + PROXIMAL muscle weakness (+ Gower) + tongue fasciculations  SMA- 3 Waddling/ weak gait + DISTAL muscle weakness (- Gower)  GBS/ CIDP Tip toe Heel walk  unable in DMD, CP Tandem walk  unable in cerebellar disorder Test for Romberg sign : + in sensory ataxia (  CMT) Bend back for scoliosis Gower sign  + in DMD & SMA 3

38. CNS Plan Once patient lying back on bed: Inspect: leg length discrepancy, muscle bulk, scars, visible fasciculations Tone: log roll + passive movement If high tone, check for ankle clonus Power: ask to lift arm/ leg off bed  grade 3/6, then can go up or down Reflexes: brachioradialis, biceps, triceps, knee, ankle Babinski reflex: Normal: down- going plantars Abnormal (UMNL): up- going plantars Cerebellar: Hold a toy (intention tremor) Oculomotor apraxia Dysdiadokokinesia Finger to nose test Heel to shin test Tandem walk Sensation: Deep: joint position, vibration on bony prominence Superficial: light touch, temperature, pain Cortical: 2 point discrimination,

39. Specific: Cerebellar Examination HAND WASH General examination Gait: tandem walk Romberg Sign Ocular nystagmus Scanning speech: “hippopotamus” Intention tremor: Button his shirt Hold a far away object (“take my pen”) Finger to nose test Dysdiadokokinesia Heel to shin test Knee DTR: pendular I would like to complete my clinical exam with vitals, growth chart, full neurological examination, developmental assessment, higher mental status and cranial nerves.

40. Specific: Cerebellar Examination Cerebellar Ataxia: Acute: Viral cerebellitis : VZV, EBV, CMV ADEM Trauma Stroke or space- occupying lesion Cerebellar hemorrhage: vascular malformations, bleeding disorders Poisoning- phenytoin and antihistamines Vestibular dysfunction Chronic: Genetic: Ataxia telangiectasia, Friedreich ataxia Nutritional: Vitamin B12 and E deficiencies Metabolic: Abetalipoproteinemia Congenital: agenesis/ aplasia/ hypoplasia cerebellum, dandy- walker malformation, Chiari malformation

41. Specific: High- Steppage Gait HAND WASH Charcot- Marie- Tooth Dse : Distal muscle wasting- “Champagne bottle legs” Bilateral pes cavus High steppage gait, slightly unsteady Romberg + Hypotonia Hyporeflexia Distal sensory loss DDx: Peroneal nerve damage with foot drop Multiple sclerosis Guillain- Barre Syndrome SCFE P oliomyelitis

42. Specific: Hemiplegia Fixed flexion deformity with pronated arm, hypertonia, reduced power, hyperreflexia DDx ( U n ilateral focal brain lesion): CVA/ stroke: I schemic infarction H emorrhagic infarction I ntracranial mass N euronal migration disorder N eonatal meningitis/ encephalitis

43. Specific: Hypotonia DDx: SMA DMD/ BMD/ congenital myopathies Hypothyroidism Syndromes: Down syndrome Prader- Willi disease Pompe disease (Glycogen storage disease- 2) Zellweger disease

44. CVS Plan HAND WASH Possibilities: Scars present: With cyanosis: Full corrected c o ngenital cyanotic heart disease with repair < 6 months ago P artially corrected congenital cyanotic heart disease Wi th out cyanosis: F ully corrected congenital cyanotic heart disease > 6 months ago C orrected acyanotic heart disease: older child, healthy- looking Scars absent: With cyanosis: U ncorrected congenital cyanotic heart disease (unlikely): ToF P ulmonary hypertension: isolated or secondary to left to right shunting heart disease ( Eisenminger Syndrome) Without cyanosis: Innocent murmur Septal heart lesions: VSD, ASD, AVSD Valvular heart lesion: AS, PS, PDA

45. CVS Plan Cyanotic heart diseases & their corrections: TGA  PGE1, balloon atrial septostomy via cath , midline sternotomy for arterial switch procedure TAPVR  PGE1, balloon atrial septostomy via cath , midline sternotomy for correction of aberrant pulmonary vein connections Truncus Arteriosus  midline sternotomy for vessel separation ToF : If severe RVOT obstruction in neonatal period  BT shunt (subclavian artery to pulmonary artery) Otherwise corrected at 6 months age with VSD closure + RVOT enlargement Hypoplastic left heart syndrome: Norwood procedure: first few weeks of life Bidirectional Glenn procedure: 3- 6 months old Fontan procedure: 18 m- 4 years Heart transplant

46. CVS Plan Syndromic Child: Down syndrome: ASD, VSD, AVSD, pulmonary hypertension Noonan syndrome: peripheral pulmonary stenosis Turner syndrome: bicuspid aortic valve/ aortic stenosis/ coarctation of aorta Marfan syndrome: aortic root dilation/ aortic regurge Cornelia de Lange syndrome: VSD, ToF William syndrome: supra- valvular aortic stenosis, peripheral pulmonary stenosis Alagille syndrome: peripheral pulmonary stenosis Possible Case: Rheumatic heart disease: mitral regurgitation

47. CVS Plan Systolic murmurs: Apex area (left fifth intercostal space MCL): Mitral regurgitation  radiates to left axilla Mitral valve prolapse  radiates to left axilla Tricuspid area (lower left sternal border 4-5 ICS): VSD Tricuspid regurge Still’s murmur Aortic area (right 2 nd ICS mid- clavicular area): Aortic stenosis: supra- valvular, valvular, sub- valvular  radiates to carotid Venous hum/ innocent flow murmur Pulmonary area (left 2 nd ICS mid- clavicular area): Pulmonary stenosis, pulmonary valve stenosis ASD Coarctation of aortic  radiates to inter- scapular area PDA  radiates to left infra- scapular area Venous hum/ innocent flow murmur

48. CVS Plan Innocent murmurs: Asymptomatic, incidental findings Isolated to systole Musical nature Short in duration Soft, no associated thrills or heaves Change with position (louder in supine) Types: Flow murmurs: pulmonary or aortic areas Still’s murmur: tricuspid area  loudest on lying down Venous hum: bilateral sub-clavicular area  disappears on lying down

49. CVS Plan Crucial Points: Pulse: Rate Rhythm Volume Character Radio- radial delay Radio- femoral delay Respiratory rate, signs of distress Hepatomegaly Lower limb & sacral edema

50. CVS Plan Chest wall scars: Left thoracotomy: PA banding PDA repair Coarctation of aorta repair BT shunt Lobectomy Left diaphragmatic hernia repair Right thoracotomy: BT shunt G lenn procedure L obectomy Righ t diaphragmatic hernia repair T racheo - esophageal fistula repair Midline sternotomy: any valve or septal defect repair Left upper region: cardiac pacemaker

51. CVS Plan Clubbing DDx: Cardiac: Cyanotic congenital heart disease Pulmonary: Bronchiectasis Lung abscess Empyema Cystic fibrosis Fibrosing alveolitis GIT: Inflammatory bowel disease Biliary cirrhosis Biliary atresia Others: Severe hyperthyroidism Familial Traumatic Idiopathic

52. Abdomen Plan Isolated hepatomegaly: Structural liver disease: Biliary atresia Choledochal cyst Polycystic liver disease Fatty liver Sickle cell disease Tumours : Hepatoblastoma Hepatocellular carcinoma Glycogen hepatopathy (2ry to uncontrolled DM) Heart failure

53. Abdomen Plan Isolated splenomegaly: Gaucher disease Neiman Pick disease Thalassemia Sickle cell anemia Chronic myeloid leukemia Kala azar disease

54. Abdomen Plan Hepatosplenomegaly: Infection: EBV, CMV Infiltrates: leukemia, lymphoma, LCH, HLH Metabolic disease: MPS, lysosomal disorders, peroxisomal disorders Blood disease: thalassemia Hepatosplenomegaly + portal HTN: Alpha- 1 antitrypsin deficiency CF- associated liver disease Wilson disease Autoimmune liver disease Chronic viral hepatitis Congenital hepatic fibrosis

55. Kasai Procedure Indications: biliary atresia & type 4b choledochal cyst Ideal timing: before 45 days of life Procedure: Hepato- porto - enterostomy Bypass the fibrosed extra- hepatic bile ducts and connect directly to the jejunum to allow drainage Complications: Failure of procedure (especially if beyond 45 days) Surgical wound site infection Ascending cholangitis Hepatic fibrosis (late stage)

56. Liver Transplant Indications Acute liver failure: Viral/ infectious Drug- induced Autoimmune hepatitis Chronic liver failure: Extra- hepatic biliary atresia (most common) Alagille syndrome Alpha- 1 antitrypsin deficiency Wilson disease Tyrosinemia Liver tumours - hepatoblastoma

57. Renal Transplant Indications Child with chronic kidney disease (GFR < 20) & any of below: Symptoms of uremia Failure to thrive Delayed psychomotor development Metabolic bone disease Causes of pediatric CKD: Obstructive uropathy Hypoplastic/ dysplastic kidneys Reflux nephropathy FSGS PCKD

58. Musculoskeletal Plan P- GALS assessment: Hand wash Screening questions: Do you have any pain or stiffness in your bones, muscles or joints? Do you have any trouble getting dressed alone? Do you have any trouble going up or down stairs? Remove clothes, inspect front- side- back Gait: forwards, tip toe, heel Back: bend to check for scoliosis Hands behind head elbows out  arms outstretched palm down  fist  MCP squeeze  palms up  finger opposition  prayer sign  reverse prayer  arms up to roof  look at sky  ears to shoulders  3 fingers in mouth Legs: active then passive movements Once target joint seen: Look  feel  move  function

59. Musculoskeletal Plan Marfan Syndrome: (>/= 7 systematic score) Facial features Myopia Reduced upper to lower segment ratio Increased arm span (more than height) Scoliosis/ thoracolumbar kyphosis Skin striae Wrist sign  pinky to thumb around wrist Thumb sign Pectus excavatum or carinatum Hind foot deformity Pes planus

60. Development Station 10 mins

61. Enter The Room Introduce yourself Ask for permission Wash your hands Ask mother: “Does the child have any hearing or seeing problems?” Decide if you think the child is dysmorphic Turn to the child, be very enthusiastic: What is your name?  1 yr How old are you?  2 yrs Are you a boy or a girl?  3 yrs Where do you live?  4 yrs When is your birthday?  5 yrs

62. Fine Motor Cubes: tower, bridge + train, stairs 6 & 10 Drawing shapes Draw a man Picture puzzle Beads and string Scissors

63. Fine Motor Cubes: Just bangs cubes  10 months 3 cubes  18 months Age x 3  number of cubes If he reaches 9 cubes = 3 years  go for: Bridge and train  confirms 3 years Stairs of 6  4 years Stairs of 10  5 years Simultaneously check if child can identify: 2 colours  2 yrs 3 colours  3 yrs 4 colours  4 yrs

64. Fine Motor Drawing: Vertical scribble/ line  18 months Horizontal scribble/ line  2 yrs Circle  3 yrs Cross  4 yrs Square  4.5 yrs Triangle  5 yrs Diamond  6 yrs LOX STD

65. Fine Motor Draw a Man: 3 parts  3 yrs 4 parts  4 yrs 5 parts  5 yrs 5 parts

66. Fine Motor Picture Puzzle: 2 shapes  2 yrs 3 shapes  3 yrs 6 shapes  4 yrs

67. Fine Motor Scissors: Random cuts  3 yrs Straight line  4 yrs Shape cuts  5 yrs Beads & String: Big beads  3 yrs Small beads  4 yrs

68. Gross Motor Walk: Forwards  1 yr B ackwards  2 yrs S ideways  3 yrs T andem : F orwards  4 yrs B ackwards  5 yrs Tip toe: Stand  2 yrs Walk  3 yrs Hop  4 yrs Skip  5 yrs Ball: Throw/ kick to me  2 yrs Catch hand outstretched  3 yrs Catch hands up  4 yrs Catch well  5 yrs Ask mom about stairs: Needs help  1.5 yr Up child, down help  2 yrs Up down child  2.5 yrs Up adult, down child  3 yrs Up down adult  3.5- 4 yrs

69. Social Feeding Cup  1 yr Spoon  18 m Spoon + fork  2 yrs Spoon + fork + knife  3 yrs Dressing: Removes shoes and socks  18 m Helps with dressing  2 yrs Undresses  3 yrs Dresses under supervision  4 yrs Dresses alone  5 yrs Caring: Indicates needs  1 yr Indicates toilet  1.5 yrs Dry by day  2- 3 yrs Toilet alone, face wash, brush teeth, comb hair  4 yrs Dry by night  5 yrs Playing: Bye bye , peek a boo  1 yr Milk to baby doll  2 yrs Parallel play  3 yrs Takes turns  4 yrs I am mom, you are dad  5 yrs

70. Speech 1 yr : Says mama and baba Responds to name 18 months: Knows mama, baba and 1 more word Obeys 1 word command Points to 3 face parts 2 yrs : 2 things about self: name, age 2- word sentences Follows 2- step commands  “get ball and give to mommy” 2 colours 2 common objects

71. Speech 3 yrs : 3 things about self: name, age, gender 3 colours 3- word sentences Follows 3- step commands  “come here, take pencil and give to mommy” 3 common objects Nursery rhymes 4 yrs : 4 things about self: name, age, gender, address 4 colours Counts to 10 using 1 hand 5 yrs : 5 things about self: name, age, gender, address, birthday 5 colours Counts to 10 using 2 hands

72. Good Luck!