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

1. Arab Board
OSCE Exam
Revision
Fatima Farid
Ped ResidentYr 5

2. Emergency
Station
10 mins

3. Anaphylaxis
1. Manage airway- may need intubation to secure the airway prior to
collapse and worsening edema
2. Breathing- support ventilation and oxygenation via non- rebreather
mask 10 L/min 100% FiO2 or bag- mask ventilation if collapsed
3. Connect to vitals monitor; maintain in supine position if possible
4. Urgent IM Epinphrine (1:1,000 concentration)
1. Name: EpiPen Junior
2. Dosage:
1. < 30 kg: 0.15 mg
2. >/= 30 kg: 0.30 mg
3. Repeat every 10 minutes in case of failure to improve

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

5. Anaphylaxis
1. Discharge Counseling:
1. Trigger avoidance
2. Anaphylaxis and EpiPen education
3. Family counseling
4. Medi- alert bracelet
2. EpiPen Education:
1. Always carry at least 2
2. Ensure schoolteachers/ nurses and family members know location of EpiPen around the
child in case of emergency
3. Remove safety cap, jab into outer or upper thigh at 90-degree angle – “Blue to sky; orange
to thigh”
4. May be given through clothes, including jeans- but avoid seams, zippers and creases
5. Hold in place for 10 seconds, then remove and keep aside
6. Lie down and keep legs upwards, do not sit back up immediately
7. 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
1. Management:
1. Manage airway with early intensivist consultation for possible intubation –
prepare items needed for intubation while they arrive
2. Avoid airway manipulation in the form of throat examination or inducing anxiety/
crying
3. Maintain child in position of comfort, defer blood investigations
4. Support breathing as needed with humidified oxygen via non- rebreather mask
5. Once airway secured:
1. FBC, CRP
2. Blood culture
3. Respiratory viral panel/ throat culture
4. Inpatient admission for observation
5. IV Ceftriaxone + Vancomycin
6. Support nutrition & hydration: PO feeds if stable or maintenance IV fluids
7. Paracetamol for fever and pain control

8. Croup/ Laryngotracheobronchitis
• Management:
1. Secure airway and support breathing: maintain in position of comfort,
humidified oxygen via non- rebreather mask
2. Connect to vitals monitor
3. Keep NPO
4. Racemic epinephrine NEB 2.25%:
• 0.25- 0.5 ml mixed with 3 ml normal saline Q 20 mins PRN
5. IV/ PO/ IM Dexamethasone 0.6 mg/kg (max dose 16 mg) once
6. 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:
1. Secure airway, ensure position of comfort
2. Support breathing via non- rebreather mask
3. Insert IV cannulas & collect blood gas
4. Continuous monitoring for GCS, signs of respiratory failure
5. Salbutamol NEB Q20 mins PRN:
1. < 20 kg: 2.5 mg
2. >/= 20 kg: 5 mg
6. Ipratropium bromide NEB 250- 500 mcg Q20 mins PRN (for 3 doses)
7. IV Methylprednisolone 2 mg/kg loading (max dose 60 mg) followed by 0.5 mg/kg
Q6H maintenance
8. IV Magnesium sulphate 50 mg/kg (max dose 2 grams) slowly over 1 hour under
cardiorespiratory monitoring

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:
1. IV Salbutamol
2. IV Aminophylline
3. Terbutaline
• Investigations:
• FBC, CRP
• Blood gas
• Urea electrolytes
• Chest x- ray

12. Foreign Body Aspiration/ Choking
• Management:
1. Maintain airway:
1. If child is alert and able to cough  confirm they’re choking, then encourage coughing
2. If drowsy/ semi- conscious, DO NOT check for pulse  START CPR
1. When delivering breaths, open mouth and trial of object removal under visual guidance
2. Never perform blind finger sweep
3. Insert nasopharyngeal or oropharyngeal airway
2. Support breathing:
1. Non- rebreather mask if awake
2. Breaths via pocket mask or mouth to mouth if unconscious
3. If age:
1. < 1 year: up to 5 back slaps and 5 chest thrusts
2. >/= 1 year: Stand/ kneel behind child  abdominal thrusts

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

14. Hydrocarbon Inhalation
• ARDS:
1. Intubation/ mechanical ventilation
2. Exogenous surfactant therapy
3. HFOV
4. 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:
1. Airway: ensure patency, early intubation if unable to maintain airway/ very large
abscess, maintain in position of comfort, avoid triggering crying/ distress in child
2. Breathing: support with humidified oxygen if SpO2 < 94% or in distress
3. Circulation:
1. Insert 2 large bore IV cannulas
2. Keep NPO
3. Start fluid resuscitation: bolus normal saline 20 ml/kg over 15 minutes
4. 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)
5. Admit to inpatient
6. Begin IV Clindamycin + IV Vancomycin (MRSA coverage)
7. Paracetamol for fever and pain control
8. 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:
1. Appearance- Breathing- Colour  Call for help
2. Connect to monitor
3. Airway: ensure patency, maintainability- insert oropharyngeal airway if unconscious,
suction to clear secretions, visualize for foreign bodies
4. Breathing: support ventilation and oxygenation initially via non- rebreather mask 100% O2,
then with possible intubation as needed
5. Circulation:
1. Insert 2 large bore IV cannulas
2. IV 0.9% NaCl 20 ml/kg over 10 mins if hypotensive
3. IV D10% 2- 5 ml/kg if hypoglycemic (2 ml/kg in <1 year)
6. Disability:
1. Check GCS, if < 8 should be intubated
2. POCT glucose
3. Pupils
7. Exposure:
1. Core temperature, initiate passive rewarming if hypothermic
2. Skin 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)
• Suspected raised ICP:
• Head elevated in midline position, 30 degrees
• Mannitol 0.5 g/kg
• Hypertonic 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)
• Other 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  intubation, ventilation
• 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
• Anti- 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:
1. Connect to monitor, apply AED pads
2. Airway: patency, maintainability, insert oropharyngeal airway if unable
3. Breathing: support with NRM 10 L/min 100% FiO2, bag- valve- mask ventilation if
apneic
4. Circulation:
1. Apply cold compress to upper half of face if easily available
2. Insert 2 large bore IV cannulas in the nearest vein to the heart in UL
5. 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
6. 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:
1. Repeat vital signs
2. 12- lead ECG
3. Urea electrolytes
4. 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:
1. CNS disease: Hidden spots/ rough patches/ nerve area lumps  NF/ TS
2. Acquired LMNL disease: GBS/ CIDP/ TM/ cord compression (trauma/ tumour)
3. Acquired UMNL disease: brain tumour/ stroke
4. Muscle disease  DMD/ BMD/ congenital muscle dystrophies
5. Nerve disease  Charcot- Marie Tooth Disease
6. Issues from his past:
1. Prematurity causing Spastic Diplegia (LL affected, so he looks good otherwise) or Hereditary
Spastic Diplegia
2. 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
• Poliomyelitis

42. Specific: Hemiplegia
• Fixed flexion deformity with pronated arm, hypertonia, reduced
power, hyperreflexia
• DDx (Unilateral focal brain lesion):
• CVA/ stroke:
• Ischemic infarction
• Hemorrhagic infarction
• Intracranial mass
• Neuronal migration disorder
• Neonatal 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 congenital cyanotic heart disease with repair < 6 months ago
• Partially corrected congenital cyanotic heart disease
• Without cyanosis:
• Fully corrected congenital cyanotic heart disease > 6 months ago
• Corrected acyanotic heart disease: older child, healthy- looking
• Scars absent:
• With cyanosis:
• Uncorrected congenital cyanotic heart disease (unlikely): ToF
• Pulmonary 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 2nd ICS mid- clavicular area):
• Aortic stenosis: supra- valvular, valvular, sub- valvular  radiates to carotid
• Venous hum/ innocent flow murmur
• Pulmonary area (left 2nd 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
• Glenn procedure
• Lobectomy
• Right diaphragmatic hernia repair
• Tracheo- 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:
1. Do you have any pain or stiffness in your bones, muscles or joints?
2. Do you have any trouble getting dressed alone?
3. 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:
1. What is your name?  1 yr
2. How old are you?  2 yrs
3. Are you a boy or a girl?  3 yrs
4. Where do you live?  4 yrs
5. When is your birthday?  5 yrs

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

64. 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

65. 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

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

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

68. 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

69. Gross Motor
• Walk:
• Forwards  1 yr
• Backwards  2 yrs
• Sideways  3 yrs
• Tandem:
• Forwards  4 yrs
• Backwards  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

70. 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

71. 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

72. 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

73. Good Luck!