DR SAMED ALSALMI

COMMUNICATION

SKILLS SUMMARY

FOR PEDIATRIC

OSCE EXAM.

RESPIRATORY COMMUNICATION OSCE STATION

Breaking bad news - Cystic fibrosis SCENARIO You will be talking to the mother of Hayley, a 3-week-old baby ,who has been found on Guthrie neonatal screening to have raised immune reactive trypsin and to be likely to have CF. She has been asked to come to the hospital for the results and further management to be explained.There is no family history of CF

Explain the results of the Guthrie test to Mrs White and the necessary next steps in management. 1. set consultation in comfortable , quite room where you will not interrupted 2. Greeting the mother 3. Introduce yourself with name, make a good rapport 4. Ask if she want nurse or relative if present to be with her 5. Asking the mother what she knows about her child’s illness. 6. should be very familiar , break bad news sensitively and honestly. Today 'we have received the results of Hayley''s Guthrie heel-prick test. This test screens babies for a variety of illnesses that we can identify early on so that we can begin treatment. The test suggests that Hayley may have cystic fibrosis.[Pause] , Do you know anything about CF? ... 7.Then explain what CF mean CF is an inherited disease which mainly affects the lungs and digestive system.

There is a fault in mucus production and the mucus in CF is thick and prone to infection. Not all children are affected to the same extent. 8.Then explain need to do some further tests to confirm dignisis CF We would like to take some blood for genetic testing and a 'sweat test to see if salty 'If these tests confirm that has CF we will need to start treated her in hospital which manages CF to be able to monitor her growth and to try and prevent infections with antibiotics and physiotherapy.' 9. “Do you understandingme, “Do you have any questions for me ?” 10. Arrange further meeting 11. Offer to meet family members. 12. I will give you information leaflet (if possible) and hospital telephone (Safety net):: 13. thanks

TESTS ON GUTHRIE CARD (POTENTIALLY - NOT ALL CENTRES OFFER ALL TESTS)

Hypothyroidism

PKU

Cystic fibrosis

Sickle cell disease/thalassaemia

Very-long-chain fatty acid (VLCFA) and medium-chain fatty acid (MCFA) defects

SWEAT TESTS CF causes elevated Na and CI in sweat. A level of Na and CL > 60mEq/L is abnormal and 40-60 mEq/L is borderline. Indications Abnormal neonatal screening (should not be performed at < 1 week of age Meconium ileus . Suggestive symptoms, e.g. FTT, repeated chest infections, prolonged diarrhea

Techniques Technique involves quantitative pilocarpine iontophoresis. Two discs are placed on to cleaned skin a few inches apart and an electric current is passed between them. The sweat produced is collected on a paper disc or a macroduct. It takes up to 30 minutes to collect enough sweat (100 mg of sweat is needed). The sodium and chloride are measured in the lab.

Asthmatic pt ,need to discuss with his mother the management pain of Rx including need for a regular inhaled steroid to control of her son 12 yrs old age with persistent night-time cough and daytime wheeze with exercise. Note He lives with his mother (a heavy smoker) and sister, both of whom suffer with eczema. Do not take any further history. 1.Greeting the mother 2.Introduce yourself with name, make a good rapport 3.Asking the mother what she knows about her child’s illness. 4. Asking Is there anything that particularly worried about?” possible side effects

5. reassure her that inhaled steroids at the standard dosing do not have the side effects seen in systemic corticosteroid therapy. 6.Speak about advantages of inhaled steroid. The inhaled corticosteroids reduce symptoms and improve lung function, while uncontrolled asthma has the potential to cause significant growth restriction, impair exercise tolerance and has an associated mortality. The inhaled steroid dosing should be reviewed regularly and the dose gradually reduced to the lowest that provides good symptom control. 7.Speak about disadvantages of inhaled steroid. Inhaled corticosteroids have been shown to cause oral candidiasis; there are case reports of adrenal suppression and short-term linear growth restriction but with attainment of normal adult height. 8.Speak how diffrent side affect of inhaled steroid from systemic steroid .

Skin thinning, purpura, alopecia, striae, 'Cushingoid fades'

Eye : Cataracts, glaucoma

Cardiovascular : Hypertension, hyperlipidaemia

Gastrointestinal: Gastritis and ulceration, pancreatitis ,bowel perforation

Renal : Fluid and electrolyte imbalance

Musculoskeletal : Myopathy, osteoporosis, avascular necrosis

Neurological : Hyperactivity, benign intracranial hypertension, euphoria

Endocrine : Diabetes mellitus ,secondary adrenal insufficiency

Immune system: Increased opportunistic and standard infections 9.confirm the family's understanding of the management plan for an acute exacerbation. A written asthma plan should be provided for every patient and may be divided to: Mild/intermittent symptoms:

Take regular prevention medication as prescribed.

Use reliever inhaler (e.g. two puffs salbutamol every 4 hours) as required. Moderate symptoms:

Take regular prevention medication as prescribed.

Start oral prednisolone if prescribed by your doctor.

Use reliever inhaler (e.g. 2-10 puffs salbutamol every 3-4 hours). Seek medical help within 24-36 hours if no improvement in symptoms.

Severe symptoms (e.g. too breathless to talk):

Use reliever inhaler (e.g.10 puffs salbutamol). If no improvement after 5 minutes call for an ambulance and repeat reliever every 20 minutes.

10. explain what precautions should I take at home to prevent recurrent attacks?

Bed room to be kept clean and dust free

Wet mopping preferable to dry mopping

bed sheets must be easily washable ones in child's bedroom (washed in hot water)

Regular dusting of calendars and paintings and books when child not at home

Keeping animal pets like dogs and cats away from the child's bed room

Smoking to be avoided at home

Strong and pungent odours like wet paint, disinfectants minimized

Windows to be kept open when strong smells of cooking or smoke at home

Windows to be closed when outside air is very much polluted or full of pollen

from flowers and trees

Avoid very cold foods 11.Explain other measurement in management of asthma should include the following:

patient education for maximise concordance with treatment

Patient-oriented goals.

Age-appropriate treatment delivery (e.g. spacer device with mask for infants).

Appropriate medication (as per 'stepwise policy').

Appropriate referral to specialist care.

Aim for minimal symptoms, minimise exacerbations, minimal intervention and normality of life.

12. Establish parental understanding, “Do you have any questions for me?” 13. Provide an information leaflet if possible and Safety net: 14. thanks

Asthma counseling 9 year old Arun has been diagnosed with bronchial asthma. His mother has been explained about the chronic nature of the illness and treatment options. She is anxious about the measures she can take at home to prevent recurrent attacks. talk to mother about "prevention and elimination of triggers at home" 1.introduction to the mother

2.be gentle with the mother

3.explanation to the mother is clear and organised

4.explain precautions should take at home to prevent child from getting recurrent attacks?

a)Bed room to be kept clean and dust free b)Wet mopping preferable to dry mopping c)Light plain curtains,bed sheets washable ones in child's bedroom(washed in hot water) d)Regular dusting of calendars and paintings and books when child not at home e)Keeping animal pets like dogs and cats away from the child's bed room f)Smoking to be avoided at home g)Strong and pungent odours like wet paint, disinfectants minimized h)Windows to be kept open when strong smells of cooking or smoke at home i) Windows to be closed when outside air is very much polluted or full of pollen from trees j) Avoid very cold foods 5. takes feedback from the motehr to be sure if she has understood 6.ask if she has any questin 7. thanks

Peanut allergy management plan consutation David is 19 months old. Developed sever reaction after 10 minutes of ingestion peanut butter treated in ER as anphyaxis, He has a family history of atopy, asthma and hay fever. He had the following investigations:

RAST to peanut 200 IU (negative to other nuts and milk)

Skin test to peanut ++++ (negative to other nuts and milk). You are to give the results of the investigations, formulate a management plan to mum. 1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. Asking the mother what she knows about her child’s illness. 4.Explain Dx The history given suggests that David has had a systemic reaction to the peanut butter with associated wheeze. This would be classed as an anaphylactic reaction in the presence of an atopic family history. 5. Educate patients on the difference between food intolerance and food allergies. When an individual develops symptoms from eating a food that does not normally cause such symptoms in others, then that person is described as having a food sensitivity If Food Sensitivities involving the immune system this immune mediated Food allergies eigther immunoglobulin E, or Non-IgE mediated food allergies immunoglobulin E mediated conditions soon after the food is eaten, known as immediate hypersensitivity reactions. can cause symptoms such as vomiting, diarrhea, eczema and asthma but can cause severe reactions such as swollen lips and throat, hives, and/or a severe drop in blood pressure. non-IgE mediated conditions involve the digestive system (such GERG, food protein-induced enteropathy and food protein-induced enterocolitis) and Some eczema Food Sensitivities not involving the immune system this conditions are often called Food Intolerances or Non-Allergic Food Hypersensitivities. may be due to an individual being very sensitive to some food as IBS or due to an enzyme deficiency, as lactose intolerance 6.Explain Presentation of food allergy variation with the agent and the child's age: in infants the most common causes are milk, egg and peanut in older children peanut, tree nut and fish. Child may has allergy to one type food but mostly more than one 7.Explain in general terms potential problems of food allergy and management options.

– If Manifestations are limited to the skin only (urticaria, erythema, angioedema) this Mild allergy , give oral an antihistamine

– If Symptoms include respiratory symptoms (breathlessness,wheeze , tightness) this Moderate allergy give oral an antihistamine chlorphenamine, salbutamol nebulizer. If not imrove withib 2 hrs take to ER

– If Symptoms of swollen lips and throat, Stridor - Noisy breathing , DOB , hives or shock and unresponsevness severe drop in PB ,or severe GIT upset, this Severe allergy,give auto-injector adrenaline,calling 999 , APLS management in ER

8.Provide clear an information about preventive measurement at home school avoidance of the nuts (Peanut),check food labels often small quantities may present Medic Alert bracelet application form may be offered to the family. Explain use an EpiPen and training for all those involved in the care of the child.

– The EpiPen is administered when a child has signs or symptoms of anaphylaxis. – The dose of adrenaline (epinephrine) is given by the auto-injector through the clothes if

necessary. should follow the 'instructions for use' on the patient information leaflet. – The auto-injector has a grey activation cap and a black tip (the 'needle end').

9.Then arrange follow-up to see dietician the immediately after your consultation to discuss peanut avoidance the allergy specialist nurse to answer any questions that are remaining. You can offer the family a contact number for the allergy nurse and give them a repeat appointment for your allergy clinic. 10.Give written self-management plans and leaflet information 11.address for them some of support groups 12.Establish understanding, check that the mother has understood your instructions?

13.Ask “Do you have any questions for me?” 14.Thanks

Learn how to measuring PEFR consultation 1.Greeting the patient and parent 2.Introduce yourself with name, make a good rapport 3.Asking them what they knows about the illness. 4. Asking if they have idea there about PEFR ?” Its method used to asses ability of your lung to inspire and expire the air to give idea about asthma control and how the drugs are affected 5.Explain the purpose of the procedure . Wash hands Ensure you clearly explain & demonstrate each step of the procedure to patient:

Connect a clean mouthpiece

Ensure the PEFR meter is set to zero

Sit up straight or stand

Take a deep breath (as deep as you can possibly manage)

Place your mouth around the mouthpiece of the PEFR meter, ensuring a tight seal with your lips

Exhale as forcefully as you possibly can manage

Note the PEFR reading

Repeat this process a further 2 times

The highest reading of the 3 should be taken as the overall result

6. Ask – “Do you understand everything I’ve said?” 7. To complete the procedure… Observe patient performing PEFR measurement to ensure good technique 8. Ask if the patient has any questions regarding PEFR 9-Thank patient 10.Wash hands

PEFR- Peak Expiratory Flow Rate (Peak Flow) Peak expiratory flow rate is the measurement of how much the patient can blow out of their lungs in one breath. it can be quite effort-dependent can underestimate significant small airways obstruction . better for large airway disease. its related to height not age . It is a crude measurement and not as accurate as Spirometry. Peak expiratory flow (PEF) measurement is recommended for Asthma as: • home monitoring device especially when they are having a flare up • Assessment of the response to treatment. • Asses severity of asthma : Diurnal variability

There are UK guidelines for the “normal” values which you can use to compare against the values your patient is able to achieve.

CARDIAC COMMUNICATION OSCE STATION

Suggestive communication checklist for mother with cardiac murmur in her son

Introduced your self and greeting the mother

Good eye contact

Good listening

Explain Dx of hole in heart in diagrams

Explain her Dx investigation

Explain her Rx

Advice when she need to contact doctor(difficulty of feeding or breathing,

colour change)

Check understanding

Opportunity to ask questions

Closure/ safety netting/ further information provision

Suggestive communication skill checklist of toddler with breath holding attack

Introduced your self and greeting the mother

Good eye contact

Good listening

Explain Dx of breath holding attack is common and benign

Explain aggravated factors crying ,upset ,pain

Explain her ,your son may change his colour, loss conscious but recover

quickly

Explain her attack may linked to IDA ,so may need to check his Hb

Explain her no need Rx and problem resolve with time

Explain her behavioural modification can help by ovoid confrontation

Check understanding

Opportunity to ask questions

Closure/ safety netting/ further information provision

Consult mother of 6 days old neonate with cyanosis by echo show TGA with PDA/ ASD • inform mother about Dx • What emergency Rx • PGE side effect • Final Rx

• What to do send pt or call surgeon 1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. Asking what they alrady knows about the child condations. 4. Asking Is there anything that particularly worried about?” 5. inform her Dx : today I do have result of your kid, I would like to explain it to you now As you know your baby was cyanosis since birth ,we do echo ,we found he complaing CHD cynotic type named TGA …(pause) Do you know anything about CHD? Do you have any relative has CHD ,or cyanosis since birth?. 6. Explain in general terms what the CHD and TGA. CHD may be simple due to to hole between atrium or ventricle blood go from LT side wich ritch with oxygen to RT side which poor of oxygen so this call non cyanotic CHD When ther shunt from RT to LT we call this cyanotic CHD due to RT to LT shunt Some times as in your baby there cyanotic CHD due to abnormal vessels position or mixtion The artery whose carried oxygenated blood from left heart to body ,wrongly inserted to RT heart and the artery whose carry deoxygenated blood from heart to lung to reoxygenated wrongly inserted to LT heart this mean oxygen gose to lung instead of body this why make him bluish (cyanotic) But good thing there are hole between RT and LT side heart mixing blood and give oxygen to body 6. Explain Rx and risk factor TGA.

no need to give PGE1 infusion to maintane the blood flow PA to aorta ,because alrady

has Patent DA (given as emergency if there is no PDA)

no need to do pallitive operation by open hole between atrium(usualy at time of DX)

because alrady has ASD

your baby need early corrective surgry (ASO) that done at 7days old,this mean call

surgeon now,and prepear to transfer to teritary cardiac surgry cente

7. Do you understanding me, “Do you have any questions for me ?”

8. I will give you information leaflet (if possible) and hospital telephone (Safety net):

9. thanks

You must have idea about PGE infusion CHD. PGE infusion indicated in heart outflow obstruction - duct-dependent lesions

0.025–0.1 mcg/kg/min

critical AS or PS - interruption of the aortic arch - HLHS- obstructed

TAPVR-

duct-dependent lesions suspecte in

Antenatal diagnosis

Sick baby

Shock

Heart failure

Cardiomegaly

Weak or absent femoral and /or brachial pulses

PGE side effect

Apnea, respiratory depression

Hyperthermia

Cutaneous vasodilation (resulting in flushing and edema)

bradycardia and hypotension

seizures

tachycardia ,arrhythmias

congestive heart failure

wheezing

gastric regurgitation, bleeding,

anuria, hematuria, thrombocytopenia, peritonitis, hypokalemia or

hyperkalemia,

GIT AND NUTRION COMMUNICATION OSCE STATION

Counselling mother of NB who confused to breast-Feeding or gives bottle

1.Greeting the mother 2.Introduce yourself with name, make a good rapport 3.Asking the mother what she knows about breast-feeding. 4. Asking Is there anything that particularly worried about?”

Ask if she has any infection disease CMV, hepatitis B and HIV

Ask if she take any regular medication

5. Then mention advantages of breast-feeding for the infant:

provides the ideal nutrition for infants during the first 4-6 months of life

reduces the risk of gastrointestinal and respiratory infection, and preterm NEC

, , , , contain Secretory IgA Bifidus factor Lysozyme Lactoferrin Interferon

immunization response to Hib vaccine is higher in breast-fed than formula fed infants

high oligosaccharides that selectively stimulate infant flora propiotic

improves cognitive and vision development because polyunsaturated fatty acids

Protein qualityMore easily digested curd (60 : 40 whey : casein ratio)

Iron content with high Bioavailable (40-50% absorption)

Ca : ph ratio of 2 : 1 Low renal solute load , improves calcium absorption Prevents

tetany

reduces risk of insulin-dependent diabetes, inflammatory bowel, SIDS (unproven)

The incidence of atopy in infants is reduced

reduces the incidence of infantile colic but no good evidence to show that breast-feeding

6.Mention advantages for the mother:

promotes close attachment enhances mother-child relationship

natural contraceptive

possible reduction in premenopausal breast cancer

7.Mention disadvantages of cow milk

higher risk of gastrointestinal and respiratory infection, and preterm NEC

, , , , not contain Secretory IgA Bifidus factor Lysozyme Lactoferrin Interferon

low amount of iron and copper prone to IDA.

nondigestible short-chain carbohydrates (artificial Prebiotics) stimulate infant flora

propiotic

contains higher protein and minerals than breat milk may make load over kidney

Protein quality less easily digested curd (40: 60 whey : casein ratio)

Risk of cow milk protein intolerance and allergywith High incidence of atopy in infants

Increase the incidence of infantile colic ,regurgitation,GERD

abscent close attachment and not enhances mother-child relationship

8.Mention simple disadvantages of breast-feeding

Nutrient inadequacies beyond 6 months need timely introduction of appropriate solids

food

Transmission of Maternal infection: CMV, hepatitis B and HIV and drugs

:Antimetabolites

Breast milk jaundice, but this benign and self limiting

Volume of milk intake not know

insufficient vitamin K in breast milk to prevent HDON but alrady given prophylaxis vit

K

Less flexible: Other family members cannot help ,may cause emotional upset

9. Establish parental understanding, “Do you have any questions for me?” 10. Provide an information leaflet if possible and Safety net: 11. thanks

Ten Steps to Successful Breast-Feeding for pregnant women in hospital

Every facility providing maternity services and care for newborn infants should

accomplish the following:

1.Have a written breast-feeding policy that is routinely communicated to all health care

staff.

2.Train all health care staff in the skills necessary to implement this policy.

3.Inform all pregnant women about the benefits and management of breast-feeding.

4.Help mothers initiate breast-feeding within a half hour of birth.

5.Show mothers how to breast-feed and how to maintain lactation even if they should be

separated from their infants.

6.Give newborn infants no food or drink other than breast milk unless medically

indicated.

7.Practice rooming-in (allow mothers and infants to remain together) 24 hr a day.

8.Encourage breast-feeding on demand.

9.Give no artificial teats or pacifiers (dummies or soothers) to breast-feeding infants.

10. Foster the establishment of breast-feeding support groups and refer mothers

to them on discharge from the hospital or clinic.

Counselling nursing mother who ask about breast feeding and

drugs 1.Greeting the mother 2.Introduce yourself with name, make a good rapport 3.Asking the mother what she knows about breast-feeding. 4. Asking Is there anything that particularly worried about?”

Ask if she has any chronic illness or infection disease CMV, hepatitis B and HIV

Ask if she take any regular medication

5.then explain need to ovoid unnessesry drugs

No drugs should be taken by a lactating mother unless there are strong clinical

indications.

Avoid antilactation drugs unless clinically indicated

Most drugs that are essential for the mother are secreted in the milk

6. explain drugs can taken , take with causion or ovoid during lactation

Antibiotics are excreted in the milk but there is the possibility of sensitising the infant.

Warfarin, barbiturates, phenytoin, digoxin, steroids, antacids, and occasional doses of

paracetamol pass into the milk in unimportant amounts.

Oestrogens in oral contraceptives may reduce lactation, but the progesterone-only pill is

an effective contraceptive and has no effect on lactation.

A mother receiving carbimazole may continue to breastfeed provided that the infant’s

plasma thyroxine concentration is monitored.

7. explain contraindication drugs during lactation

if receiving radioactive antithyroid treatment or cytotoxic drugs should not breastfeed.

Lithium given to the mother may cause hypotonia, hypothermia, and episodes of cyanosis

in a breastfed infant.

8. Establish parental understanding, “Do you have any questions for

me?”

9. Provide an information leaflet if possible

10.Wishes mother and offers a telephone number where she can have any other queries

answered.

11. thanks

Counselling mother of 3 days -old NB for Successful Breast-

Feeding 1.Greeting the mother 2.Introduce yourself with name, make a good rapport 3.Asking the mother what she knows about breast-feeding. 4. Asking Is there anything that particularly worried about?” 5. then explain how can establishing breast-feeding after birth The first breast-feed should take place as soon as possible after birth.

Feeding Colostrum, that produced for the first few days.

Colostrum differs from mature milk in content of higher protein and immunoglobulin

Volumes are low but no need water or formula supplements ,breast milk will established.

5. then explain techenuq of breast feeding Proper position and latch on (attachment)

Mum must be relax and comfortable

Sitting with support back and baby across chest and abdomen (under arms)

laying down and baby alongside her body,

Placing baby in correct position encourages successful feeding ,avoids damage to nipple.

The baby’s chin must drive into the breast to enable the nipple to reach the palate, so the

baby needs to put his head back and up by supporting the baby’s back at shoulder level,

with the baby facing the mother, chest to chest.

6. then explain physiology of breast feeding Nutritive sucking and swallowing

The sensation of the nipple against the palate stimulates the baby to suck.

If the baby’s head becomes too flexed, the nipple touches the lower jaw and the tongue

and the nose is too close to the breast.

Milk production and release

Baby sucing and good emotion of mum stimulating receptor on nipple that stimulat

hypothalamus then anterior pitutry gland that secret prolactin and posterir pitutry gland

that secret oxytocin that help in secret milk

Avoid time limits on the breasts; offer both breasts at each feeding.

7. then explain Frequency and feeding cues initially encouraged fed on demand to settle down then after a few weeks aregular

schedule.

By the end of the 1st wk, most infants will be taking 60–90 mL/feeding and 6–9

feedings/24 hr.

Some will take enough at 1feeding to be satisfied for 4 hr, but others will want to 2–3 hr.

Most infants wake midnight feeding until 3–6 wk of age; some never,others beyond 3–6

wk

Between 4–8 mo of age, many infants will lose interest in the late evening feeding,

by 9–12 mo of age, most infants will be satisfied with 3 meals/day plus snacks.

8. then explain Mother advice what should not give her baby

sterile water, glucose, or formula unless medically indicated.

artificial teats or pacifiers (dummies or soothers) to breast-feeding infants.

gripe water as,it contains bicarbonate, which produces carbon dioxide in the

stomach

9. then explain how can Assessment of the infant's nutritional status

Test feeding should be avoided whenever possible, as it can create anxiety in some

mothers.

infant weighed, without changing napkin or clothes, before and after each feed during a

24 h.

Feeding can be considered to have progressed satisfactorily if

no losing weight by end of the 1st wk of life

gaining 30 gms/day by end of the 2nd

wk

good urine output

satisfying infant's go quite sleeping and may has bowel motion

If the feed is deficient, putting baby to the breast more frequently and from both breasts

If well nourished full term baby can tolerate a degree of underfeeding for a few days.

If preterm or ill , bottle feed given (complementary feeding) only when absolutely

necessary.

10. then explain common problems with baby

On the 1st day, Intestinal hurry and frequent loose green stools are common at this stage.

some infants pass stools only once a week when reach the age of a few weeks, also no

Rx.

Infants cry for reasons other than hunger; hence, they do not need to be fed every time

cry.

Those who wake and cry consistently at short intervals may

not be receiving enough milk

too much clothing; hot or cold environment ,soiled, wet, diapers; swallowed air [gas];

Some infants cry to gain attention,simply want to be held,stop crying as they are held

if continue cry even if held ,food is offered should be carefully evaluated other

causes

frequent, small feedings or holding and feeding to pacify all crying should be

avoided.

On the other hand, satisfying the infant's true hunger as it is expressed is important.

11. then explain common problems with mother

malplacement infant on the nipple or pulling from breast abruptly cause cracked nipple

breast engorgement prevents by feeding on demand and alleviated expression after

feeding fissure of nipples, can prevent by dry and clean brest after feeding Rx thrush of

baby’s mouth

,need postpartum anxiety and insecurity for the 1st-time mother lactation consultation

In painfull swellin of breast with fever ( mastitis) this need surgical consutation

12. Establish parental understanding, “Do you have any questions for me?”

13. Provide an information leaflet if possible and Safety net

14.Wishes mother and offers a telephone number where she can have any other queries

answered.

15. thanks

Counselling mother of 3-month-old infant for not enough breast milk

1. Introduce your self, make a good rapport

2. Ask about what do they already know

3. Ask about what do they want to know“Is there anything that you are worried

about?”

4. then asked Questions regarding

- Volume and frequency of urine output

- Frequency of feeding

- ask if give artificial feeding/bottle feeding

- Any chronic illness or acute illness in the mother

- Any breast problem

5. Speak to her about advantage of breast feeding

6. Educated her about how to optimize baby’s attachment to breast(correct position)

• Proper position and latch on (attachment)

• Nutritive sucking and swallowing

• Milk production and release

• Frequency and feeding cues

7. Build up confidence in the mother ,in frequent and complete emptying the breast

will help in lactation

8. Encourage mother to take adequate food and rest

9. Speak to her and reassurance about weight gain

- Weight gain 30 grams /day and urine output are the good indicator of adequate feeding

10. Tell about importance of giving breast feed continuously by demand

11. explain the infant coli

12. Tell about dangers of artificial food like allergy,diarrhea,recurrent respiratory infection

13. explain when and how can give complemebtory feeding

14. Ask mother if they have any more question

15. Wishes mother and offers a telephone number where she can have any other queries

answered.

16. thanks mother

Counseling Mother of 2 month old age baby ,that was breast

feeding till 1 mon when she give him cow milk because her work

,talk to mother

1. greeting mother and Introduce your self, make a good rapport,

2. ask what do you know about breast feeding and bottle feeding

3. what are you want to know“Is there anything you are particularly worried

about?”

4. then asked Questions regarding

- whats your job and what time , duration and days of workdays

- who the caregiver for your baby when you are working

- did you have other older kids , how did you feeding them

- Enquires about urination, adequate weight gain. Reassures about adequacy of breastfeeds.

5. said listen I will mention you advantages of breast-feeding for you and infant…

6. Then said now listen to hazards of formula milk….

7. There is solution during 1st 6 mon (explain express , storage of her breast milk)

8 hours in room temperature, 24 hours in refrigerator (non-freezer compartment).

Advises that milk should not be heated but allowed come to room temperature

spontaneously.

Advises to feed the milk with a cup and spoon or paladai.

Advises mother to continue with breastfeeding when she is at home.

8. After 6 mon age you can( explain when and how can give complemebtory feeding )

9. Do you understand me ,if you have any more question iam listening..

10. Provide an information leaflet if possible and Safety net

11.Wishes mother and offers a telephone number where she can have any other queries

answered.

12. thanks her

Counselling mother of 6-month-old infant for complementary feeding

, , 1. Greeting the mother Introduce yourself Asking you want to ask about

2. explain need to Breastfeeding in1st six months,and sustained for up to two years

Continue frequent, on-demand breastfeeding, including night feeding for infants

2. explain need to Introduce complementary foods beginning at 6 months of age

After 6 months of age, breast milk becomes increasingly nutritionally inadequate as a sole

feed, leading to deficiencies in energy, vitamins and iron. babies will exhibit behavioural

changes such as increased crying and poor sleeping, represent and a need for solid food.

complementary foods is important for the nutrition, immunologic, growth, and development

The introduction of solids after 6mo old age with more breast-feeding and the fact that many

weaning foods are gluten-free may be responsible for the reduction in the incidence of coeliac

disease in infancy and lower incidence of gastroenteritis may also be a factor.

iron-fortified cereal or vitamin - minerals supplement as an infant's 1st complementary foods.

3. explain Practice hygiene and proper food handling

Wash caregivers' and children's hands before food preparation and eating.

Store foods safely and serve foods immediately after preparation.

Use clean utensils to prepare and serve food.

Serve children using clean cups and bowls, and never use feeding bottles.

Supporting advice for caregivers and families

4. explain Increase food quantity as child ages and maintaining frequent breastfeeding

Provide 6– 8 month old infants about 200 kcal per day from complementary foods.

Provide 9– 11 month old infants about 300 kcal per day from complementary foods.

Provide 12– 24 month old children about 550 kcal per day from complementary foods.

needed to to give best combinations of foods and practices to achieve energy intake.

5. then explain Increase complementary feeding frequency as the child ages

6–11 month old infants complementary foods 2– 3 times per day with servings of

Mixture of pureed food made of matoko ,potato, cassava, posho or rice mixed with fish

, or bean or groundnuts + green vegetables

thick porrideg of maize ,cassava, millet + milk, soy , groundnuts or suger

Offer 1– 2 times per day nutrition snack, as desired of.

eggs ,banana, bread, papaya, avocado, mango , yogurt, pudding milk

biscuit,crackers ,chaptti with butter , groundnuts past or honey

12– 24 month old infants complementary foods 3– 4 times per day with servings of

mixer of mished of cut family food made out of matoko ,potato, cassava, posho or rice

mixed with fish , bean or bounded groundnuts + green vegetables

thick porrideg of maize ,cassava, millet + milk ,soy , groundnuts or suger

Offer 1– 2 times per day nutrition snack, as desired of.

eggs ,banana, bread, papaya, avocado, mango , yogurt, pudding milk

biscuit,crackers ,chaptti with butter , groundnuts past or honey

6. then explain how gradually increase food consistency and variety as the child ages,

adapting the diet to the infant's requirements and abilities

mashed and semi-solid foods, softened with breas tmilk, if possible, at 6 mo of age.

Feed energy-dense combinations of soft foods to 6– 11 month olds.

Introduce "finger foods" (snacks that can be eaten by children alone) around 8 mo age.

Make the transition to the family diet at about 12 months of age.

7. then explain diversify the diet to improve quality and micronutrient intake

Feed vitamin A-rich fruits and vegetables daily.

Feed meat, poultry, fish daily or as often as possible, if feasible and acceptable.

Use fortified foods, such as iodized salt, vitamin A-enriched sugar, iron-enriched flour

or

Give vitamin-mineral supplements when animal products and/ or fortified foods are

not available.

Avoid giving drinks with low nutrient value, such as tea, coffee and sugary beverages.

8. explain to practice responsive feeding

Feed infants directly and assist older children when they feed themselves.

Offer favorite foods and encourage to eat when they lose interest or loss appetites.

If refuse many foods, try different food combinations, tastes, textures, and methods .

Talk to children during feeding.

Feed slowly and patiently and minimize distractions during meals.

Do not force children to eat.

9. explain to practice frequent and responsive feeding during and after illness

During illness, increase fluid by more frequent breastfeeding, and give favorite foods.

After illness, breastfeed and give foods more often than usual, and to eat more

10. Establish parental understanding, “Do you have any questions for me?”

11. Provide an information leaflet if possible and Safety net:

12.Wishes mother , offers a telephone number where she can have any other queries

answered.

12. thanks

Counseling regarding breast feeding of baby born to HIV

positive mother.

1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.

2. Explains the benefits of breastfeeding for the baby. Also mention that the virus can be

transmitted from the mother to the baby by breast milk.

3. Explains the risks of not giving breastfeeding.

4. Stresses the need for hygiene and exclusive feeding in case mother decides on either.

5. Asks if mother has any doubts and encourages her to ask questions.

6. Wishes mother and offers a telephone number where she can have any other queries

answered.

Cow milk protein intolerance and cow milk protein allergy

Cows’ milk protein intolerance (CMPI) is the clinical syndrome resulting from sensitization and reproducible clinical adverse reaction to one or more proteins in cows’ milk. may be immune or non immune,Immune-mediated -defined as cow milk Allergy CMPA. cow milk Allergy CMPA can manifest via IgE-mediated and non–IgE-mediated Acute type 1-ig E- early hypersensitivity reaction , present with

respiratory symptoms such as wheeze and cough, , rhinitis, asthma .20% to 30%

skin manifestation such as urticaria, rash, and pruritus ,30% to 70%

GIT manifestation rarely present

Rarely IgE-mediated anaphylactic shock

non–IgE-mediated delay -onset type IV hypersensitivity reaction, present with

GIT symptoms (common) .50% to 60%

oesophagitis or colitis (eosinophilic) , enteropathy ,GERD ,failure to thrive –rare

vomiting ,food refusal , Colic .Irritability , Diarrhea ,rectal bleeding malabsorption.

skin manifestation such as atopic dermatitis

chest manifestation such as pumnary hemosidrosis

Cow milk protein allergy the prevalence of confirmed CMA in developed countries during infancy is 2% to 5%. more common in young infants males than females and with a family history of atopy The incidence of CMA is 12% when there is no atopic parent, 20% when there is 1 atopic parent, 32% when there is 1 atopic sibling, 43% when both parents are atopic, and as high as 72% when both parents have the identical type of atopic disease. Approximately 30% to 70% of infants with CMA manifest dermatological symptoms,50% to 60% manifest GIT symptoms, and 20% to 30% manifest respiratory symptoms.

Dx and Rx of cow milk protein allergy Combination skinprick testing (SPT), serum measurement of IgE antibodies to the specific allergen testing, In early hypersensitivity reaction ,results a positive predictive value of 95% for diagnosing IgE-mediated CMPA, but not non–IgE delay hypersensitivity reaction in all condation need for the elimintation cow milk with trial hydrolysed protein for 4 wks then gold standard investigation is the double-blind placebo-controlled food challenge. The child divided to imrove with hydrolysed protein or no , +ve IgE and SPT or negative in oral food challenge test (in clinical setting if +ve IgE and SPT ).involves the child being given increasing amounts of the food or placebo ,then see result if imrove and +ve challenge test:ovoid cow milk, use AA formula for 12 mo ,reasses if imrove and -ve challenge test: use regular cow milk formula if not imrove and +ve challenge test , +ve IgE : ovoid food and cow milk , use AA formula if not imrove and -ve challenge test ,-ve IgE with atopic dermitits then use regular cow milk

if non–IgE mediated MPA suspected with blood , eosinophile in stool (oesophagitis or colitis) ,decreased albumin (enteropathy ) or Increased platelets, ESR rate,CRP (colitis) then obtain Sigmoidoscopic histological confirmation of a superficial colitis. there is a high cross reactivity with soy protein (20-50%) and goat’s milk (90%) also egg, wheat and peanut meaning ,These proteins need to be avoided In breast-fed infants with CMPI, mothers may need to exclude cows’ milk from their diet The natural history of cows’ milk intolerance is one of resolution with 80–90% back on a normal diet by their 4th birthday.It is sensible to challenge regularly

Counselling mother whow search in NET she found relationship between

GERD & cow milk protein allergy (CMPA)

1.Introduce your self, make a good rapport 2.What do they already know 3.What do they want to know“Is there anything that you are particularly worried about?”

4.Explain cow milk protein intolerance and cow milk protein allergy 5.Explain what GERD mean milk regurgitation coming back up from the stomach after they have had a fed, and is something which is quite common in young babies under 1 year and premature infants. discussion about relationship between GERD & cow milk protein allergy, Cow’s milk protein is one of the most common food triggers for adverse reactions in infant. the majority of patients with CMA manifest symptoms involving more than1 system, whereas patients with primary GERD mostly have only 1 system involved. the prevalence of confirmed CMA in developed countries during infancy is 2% to 5%. more common in young infants males than females and with a family history of atopy Recently many research suggests that there is a higher prevalence of cow’s milk protein intolerance in infants with GORD compared to infants without, up to 30% of infants with diagnosed GORD ,diagnosed with cow’s milk protein intolerance based on an elimination diet. Double-blind, placebo-controlled food challenge has long been done (based on an elimination cow milk protein from diet with hydrolyzed or amino acid formula for control group infants whom diagnosed GORD and did not respond to medical intervention (omeprazole)),found , up to 30% of of them,have improved ( cow milk protein intolerance) 6.Speak about advantages of breast-feeding for the infant 7.Establish parental understanding, any questions? 8.Does everything I’ve said so far make sense?” 9.Do you have any questions for me?” 10.Provide an information leaflet if possible and Safety net: 11. Wishes mother , offers a telephone number where she can have any other queries answered. 12.thanks

Counselling, explanation Gastro-oesophageal reflux Introduce your self, make a good rapport Confirm parent & childs details , What do they already know What do they want to know“Is there anything that you are particularly worried about?” Take history if required. Reassurance First of all try not to worry, this is common in infants…the majority of cases will resolve on their own given time, and can be easily helped in the meantime.“ Explain what GERD mean the symptoms that your baby is getting at the moment are due to milk regurgitation coming back up from the stomach after they have had a fed, and is something which is quite common in young babies under 1 year of age ,CP, Downs and premature infants. Oesophageal sphincter not yet fully developed with Short oesophageal length.(allows reflux) Made worse when lying down most of the time When you swallow, food goes down the food pipe (oesophagus) into the stomach. At the bottom of the food pipe there is a ring of muscle opens and closes to let food into The stomach. In young babies this muscle is not fully developed and sometimes may not completely close, which means milk come back up, especially as baby is often lying down. By the age of 1, this usually stops happening – this is for a variety of reasons – because the

muscle has had chance to develop, the baby spends more time sat up/upright, and they are eating rather than just drinking.” Explain managment “As I mentioned at the beginning, this is common and baby is managing to maintain a healthy weight and growing well. If mild (growth ok, no LRTIs/oesophagitis): To reduce their symptoms, there are a few simple changes we can add in. To begin with, we prefer to avoid medication and would suggest that when you feed baby, you do so at a more upright angle, so they are half-sat up; and to keep them resting at this angle for half an hour help encourage the milk to go down. Avoid overfeeding – Feeding them smaller amounts, more regularly may help, too.” Avoid fizzy drinks, caffeine and orange juice. “If you find these methods do not seem to help, and you are still concerned we can using thickeners in baby’s milk (Nestargel or Carobel)–these just help to make the milk a little heavier, and stay in the stomach – or consider some medication such as gaviscon. If baby starts to lose weight-FTT, or gets more distressed- aspiration ,LRTI we can consider medication to speed up passage of food through stomach (Domperidone) medication to reduce stomach acid production (rantidin) doing some investigations, to check everything is okay with their tummy.” Blood tests – Hb/ Urea / WCC / CRP 24 hr oesophageal pH monitoring test – A thin wire is passed down the nose into the lower oesophagus - gives indication of severity of regurgitation Barium studies – looks for structural abnormalities

If continue lose weight, distressed or vomit with blood - oesophagitis we can try Proton pump inhibitor (PPI) – omeprazole Further investigation required - e.g. endoscopy allows direct visualisation of structural abnormalities /oesophagitis (Emergency situations) if necessary or if baby is struggling we can consider surgery – but this is very rarely required.” Establish parental understanding, any questions? “Does everything I’ve said so far make sense?” “Do you have any questions for me?” Provide an information leaflet if possible and Safety net: “This condition is quite common, and as baby is still growing well it is not something to be too concerned about. However if things don’t seem to be settling, or baby starts losing weight, coughing blood or getting chesty, it is important to bring them back in as we will need to do some further tests.” Follow up “I would like to see you again in a few weeks to see how you and baby are doing with some of the changes we have discussed. In the meantime, if you have any concerns or further questions, please feel free to contact me .” Wishes mother and offers a telephone number where she can have any other queries answered.

thanks

Counselling ,Information giving to parents : Infantile Colic 1.Introduce your self, make a good rapport 2.Confirm parent & childs details , What do they already know 3.What do they want to know“Is there anything that you are particularly worried about?” 4.Take history if breast feeding or bottle ,if give any medication for baby. 5.Reassurance colic is common , benign and transite abdominal pain and crying starting in the second week of life and lasting until about few months . 6.education about the condition and explain what colic mean ? colic is inconsolable crying in an infant that lasts many hours a day, starting in the second week of life and lasting until about 3 months of age. Wessell Criteria “Rule of 3’s” definition of a colicky infant was a child who cried for more than 3 hours a day, for more than 3 days a week, for over 3 weeks, which is now used in most current studies of babies with colic. Colic can begin a couple of weeks to four months of age , its peak at 6-8 weeks after birth Crying associated with colic excessive, a high-pitched quality, baby seems as is in pain. associated with flushing of the face, drawing up of the legs, clench their fists, passing gas. Some may have hardened or distended tummies filled with gas. (Gas does not cause colic, but seems to be a symptom of colic from swallowing too much air when they are crying.) The crying is often worse in the evening hours. Colic ends for 50% of cases around 3 months and in 90% by 9 months of age. Babies with colic often need to be held and comforted more 7.Explain What Causes Colic? After all these years, doctors and researchers still have no definite answer to what causes these long crying bouts in some babies. The following is just a short list of things that may increase the chances of cause colic:

A sensitive temperament that needs more attention

Immature nervous system

Unusually sensitive to stimulation

Breastfed babies may be bothered by foods in their mothers’ diets. (Studies have

shown colic and cows milk in mothers diet to be related.)

Bottle-fed babies may be intolerant of certain proteins in their formula.

Overfeeding the infant or feeding too quickly

infants whose mothers smoked during pregnancy have twice the risk of colic

Intestinal gas ( resulting from too much air swallowed while having crying fits)

Not burping after a feeding or incorrect positioning after a feeding

A low birth weight baby

Hunger

Acid reflux

8.discussion of the 1st management options for Colic should first check to see if the baby needs a change of diaper, has not scratched his or her eyes, if there are any abnormal lumps or swellings in the genital area. Parents should place the crying baby in the crib and let her settle down on her own should never shake baby to stop the crying, most infants do not harm themselves by crying. Breastfeeding mothers making sure one breast is finished before offering the other or only offering one at a feeding and emptying it completelyand Burp your baby. maternal diet modifications consumed a hypoallergenic diet that was free of milk, egg, nuts Formula-fed infants should receive hypoallergenic formulas

9.encouraged parents to try the different behavior modifications Holding or taking the baby on a car or other place is one of the most effective treatments. massage baby tummy with a warm water bottle (make sure it’s not hot). Gently rub your baby’s stomach, in a clock wise direction. (direction the intestines work.) massage baby tummy-down across your knees, while gently moving your legs using a crib vibrator massage shown to reduce colic symptoms by about 65% at3 weeks. baby hammocks made of cloth are used instead of cribs and especially in rural area.

Other treatment options could be considered in non-responders also breastfed babies can give Lactobacillus acidophilus probiotics 1 ml of 30% glucose for four days reduced colic than those receiving sterile water. herbal remedies ,ColiMil® (Matricaria recutita flowers extract, Foeniculum vulgare fruit extract and Melissa officinalis aerial parts extract) and fennel oil emulsions have also been shown to be effective in the treatment of colic in infants. Simethicone is an alternative pharmacologic agent that acts as a detergent to facilitate gas bubbles within the gut to coalesce, decrease distension and discomfort due to excessive gas, simethicone was not superior to placebo in reducing symptoms of colic.

10.Explain need to coping with Colic home-based nursing intervention to decrease parental stress maternal relaxation and reduce anxiety help with baby colic. Try to sleep when your baby sleeps so that you are well rested when they are the fussiest. Seek out support groups in your area for new moms

11.Establish parental understanding, and ask if have any questions? 12.Provide an information leaflet if possible and Safety net: it is not something to be too concerned about. However if there danger signs should be come back again or contact your health care provider this danger signs are :

refusal to feed or Decreased appetite

Fever , blood in stool

repeated vomiting or projectile spit up

greenish vomiting

difficulty breathing

Limp or pale skin

13. Wishes mother , offers a telephone number where she can have any queries answered. 14.thanks

Counselling regarding ORS therapy. 1. Establishes rapport. Introduces himself/herself. Praise the mother for bringing the baby to hospital. 2. Explains that based on the history and examination, the child has lost fluid and salt from the body. 3. Explains that these need to be replaced by providing salt and sugar containing fluids like ORS to the baby. No tea juices etc. ORS is the best medicine for baby. 4. Shows the mother how to take a packet of ORS and dissolve the entire contents in the required amount of water (if the packet is for one liter, the contents have to be put in a one liter bottle of water. If the packet is for 200 ml, the amount will be shown on a glass). 5. Asks the mother to repeat the procedure in front of him. 6. Tells the mother that the ORS can be stored for 8 hours at room temperature and for 24 hours in the refrigerator. 7. Tells the mother that the ORS is to be fed to the child in small sips with a katori spoon or paladai. Shows the approximate level up to which the mother has to give ORS in the next four hours (500 ml). 8. Tells the mother that there may be a transient increase in stools or vomiting when ORS is started. Tells the mother that she should continue giving ORS. Asks mother to monitor the stool, urine and vomit output. 9. Asks the mother if she has any doubts and encourages her to ask questions. 10. Wishes mother and offers a telephone number where she can have her queries answered. 11.thanks

Explain to mother diagnosis of Crohn's disease in her 15 yrs dougher Points to consider: First clarify what she knows or understands about Crohrn's disease. Start with the basics. trying to structure your conversation under sub-headings as follows: What is Crohn's disease? What investigations has she had (blood. radiological. Endoscopic procedures)? She will have had some of these tests performed, so clarify the results as you talk about each test. Management - pharmacological, surgical and nutritional. Remission - she may in particular want to discuss steroids, as this is often an area of concern for patients. Long-term prognosis. it Does she have any other questions or concerns? Is there anything in particular that she wishes to discuss today? Offer written information, and the contact telephone numbers and addresses of support groups. Suggestthat she considers meeting other young people with inflammatory boweldisease. Arrange follow-up. and offer to meet again if she would find this helpful. Wishes mother , offers a telephone number where she can have any other queries answered. Thanks

Explain to mother gastrostomy for her baby with cerebral palsy and epilepsy as he is becoming increasingly distressed each time a nasogastric tube is passed. Points to consider: Ascertain mom understanding of the procedure. What are her main concerns? Ask specifically about the anaesthetic side of the procedure. Reassure her that the anaesthetic would be given by a paediatric anaesthetist in a tertiary centre. Does she know any other children who have a gastrostomy? Does she feel that the procedure will be of benefit to her son? Remember that different centres will perform open surgery vs percutaneous endoscopic gastrostomy (PEG). Most children tolerate the procedure very well with good pain control postoperatively. The procedure will significantly reduce her son levelof distress when he is being fed. Models are available which make explaining the procedure much easier, and you can practise changing the tube. Offer to arrange a time to meet with the gastrostomy liaison nurse. Ensure that written information, with diagrams, is available. Finally- ask Mrs Lancaster whether she has any further questions,and offera repeat appointment if she still has unanswered questions or further concerns. Wishes mother , offers a telephone number where she can have any other queries answered. thanks

Explain to mother rectal biopsy for her son to exclude a diagnosis of Hirschsprung's disease Points to consider: What are the mother thoughts about why her son is having such difficulty opening her bowels? Does anyone else in the family have similar problems? Do the mother understand why you are going to do a rectal biopsy? Explain briefly what the procedure involves. Three small samples of tissue will be taken from the back passage in order to look at the Cells under the microscope. The procedure does not usually require a general anaesthetic. It is possibleto use sucrose (sugar) orally in small babies for pain relief. It is a short procedure, well tolerated by most babies. The mother can feed.bathe and comfort her son as they usually do. What is the intended aim of the biopsy (i.e.to confirm/exclude Hirschsprung's disease)? Do not go into great detail about Hirschsprung's disease. Givea brief explanation, and then mention that if necessary you will spend some time going over the condition in more detail. Do the parents have any particular concerns? Wishes mother , offers a telephone number where she can have any other queries answered. thanks

Explain to parent fundoplication for their girl who has CP ,GERD with recurent chest infection,parents have resisted the idea of fundoplication for a long time Points to consider: Introduce the idea that you would like to talk to parent about the possibilityof S their girl having a fundoplication. Make it clear that you understand that she has not been keen on the idea in the past, but you wondered if it would be all right with her if you could talk to her. Explain why you as a medical team feel that the procedure is in girl's best interests, as there is a constant risk of aspiration, and chest infections are becoming more severe. Also during this admission you needed to use alternative antibiotics due to resistant bacteria, and this is due to the repeated courses of treatment. Listen to mother's concerns, be empathic, and let her explain why she is not keen to go ahead. Offer to briefly describe the procedure, and draw a diagram, as this makes it much easier to visualise. The mother may have specific concerns regarding the general anaesthetic, and the increased risk associated with an anaesthetic in children like. Provide her with some written information, giveher time and space, and do not pressurise her. Offer to meet again once she has had time to think about what has been said. You understand that it is a difficult decision to make, and are happy to try to answer any further questions that she and her husband may have Wishes mother , offers a telephone number where she can have any other queries answered. thanks

Dietary advice for celiac disease. 1. Establishes rapport. Introduces himself/herself. 2. Explains that based on history, clinical examination and investigation results, the child has celiac disease, a condition in which the child is unable to digest wheat and wheat products. 3. Explains that the treatment of this condition is to exclude wheat and wheat products completely from the diet, in addition to items made from oats and barley for the rest of his life. 4. Names a few wheat containing materials not to be taken like atta, maida, sooji, dalia and foods like chapattis, roti, bread, biscuits, upma, noodles, halwa, etc. 5. States that alternative foods in the form of rice, maize (makki),jowar, bajra and sago can be eaten without any restriction and stresses that their nutritional value is as good as wheat products. 6. Suggests to the mother that the best way to control the diet of a child in the family is if all the family members adhere to the same diet so that it does not place a psychological stress on the child 7. Explains to the mother that the diet will have its full effect in about three months. 8. States that the child would have to undergo repeated testing after a period of three months. 9. Asks if mother has any doubts and encourages her to ask questions 10. Wishes mother and offers a telephone number where she can have her queries answered. 11.thanks

Explain mother investigation need for her 8-year-old girl with coeliac disease 1. Explore the mother's ideas and specific concerns. She is clearly worried that Maxine may have coeliac disease. She may not want her to undergo painful procedures such as biopsy. She may want to know whether girl will grow normally, and also whether her 4-year-old brother could develop this condition in the future. 2.Reassure the mother and adopt an empathetic attitude. 3.Explain the steps involved in the diagnosis of coeliac disease. Reassure the mother that endoscopy and biopsy would be performed under general anaesthetic. 4.Explain the inheritance of the condition and the risk of brother developing it. 5.Explain the use of the screening test for her brother if he does not have any symptoms. 6.It is likely that iron-deficiency anaemia is linked to coeliac disease, and this will require iron supplementation. 7.Mention the need for liaison with the school nurse. 8.Offer some literature in the form of information leaflets to the mother

9. Asks if mother has any doubts and encourages her to ask questions 10. Wishes mother and offers a telephone number where she can have her queries answered. 11.thanks

explain-the diagnosis of mother NB boy with congenital pyloric stenosis ,take consent for possible Rx Points to consider: Explain the diagnosis using a diagram, as it is much easier to visualise the food pipe,stomach and pyloric opening this way. Explain 'pyloric stenosis' in non-medical terms. It is a narrowing of the part of the stomach that connects to the small intestine. Due to this narrowing it makes it harder for the milk to pass through, and therefore your son vomits. Be careful when using the term 'pyloric tumour.' Think about the parents' interpretation of the word 'tumour.' Explain that the condition is common, more so in firstborn males, and that there may be a family history. You can briefly explain the operation if you understand it (i.e.Ramstedt's pyloromyotomy). Otherwise say that you are not going into detail as the surgical team will explain this before the consent is taken. Reassure the parents appropriately. Although there are risks with any surgery, the prognosis is excellent. Most babies feed within 24 hours of surgery and tolerate the procedure well, rapidly regaining their lost weight postoperatively. Confirm their understanding. and give them your diagram or written information sheet.

Wishes mother , offers a telephone number where she can have any other queries answered. thanks

Tonsilectomy operation was delayed until late in the afternoon instead of early morning pt was nil by mouth for as short a time as possible,allowing him to continue with his anti-epileptic medication. now returned to the ward and has managed a drink. Your paediatric surgical colleague has asked you to speak to his mother, as she has become angry and upset that her son has suffered due to the delay Points to consider: Explainto mother that you have been asked to speak to her from a paediatric point of view. Tell her that you understand that this situation has been difficult for her and you are sorry she is upset. Let her explain her worries and concerns, responding where appropriate. Highlight the fact that perhaps it was lack of communication that led to her becoming upset. Explain that emergencies cannot be predicted. and sometimes elective surgery does get delayed because of these. Focus on the fact that Jack does not seem to have suffered, the operation went well, without complications, and he is now on the ward and tolerating an oral diet. Offer to speak with the surgical team on her behalf and see where things can be improved so that other children and parents are not put in the same position in future. If she would like to take the matter further. you can arrange for a meeting between herself and the consultant involved. Also offer her details of the Patient Advice and Liaison Service (PALS). You can fill in an incident form which highlights difficulties like these, so that if possible similar situations can be avoided in the future. Finally, you can offer to review Jack. especially if his mother is concerned about seizure control because he missed doses of antiepileptics. Explain that you can be contacted again if she has any other concerns. Wishes mother , offers a telephone number where she can have any other queries answered. thanks

In treated pt with viral induced wheez ,the scales had been set to pounds

instead of kilograms. The dose of paracetamol was then worked out at 15

mg/kg, but on a working weight in pounds instead of kilograms.

Speak to mother explain her drug error, what your management will be now

Points to consider: First introduce yourself and make sure that a nurse, preferably one who has been involved in Jessica's care, is present. Ask mother if she would like her partner or a friend or relative to be with her during the discussion. You need to be honest and open and explain exactly what the drug error ,how occurred. Reasure her that Jessica is unlikely to come to any harm because of the increased dose. Explain what the management will involve. In 4 hours' time you will check the paracetamol level in blood. Again emphasise that you expect it to be normal. You can then go on to explain the formal procedure of filling in incident forms, and informing senior nursing staff and theconsultant responsible for Jessica. The aim is to assess the risk and to try to minimise any future risk to other children. This incident is being taken very seriously, and apologise to her that this has happened. She can put her concerns in writing if she feels that this is more appropriate. Reiterate the fact that she does not need to take this any further if she does not wish to, as you can ensure that you will be taking all of the relevant steps to try to prevent this from happening again. Concentrate on Jessica being well. You have realised the mistake and will work with the department to minimise future risk. Offer her the contact details of t ient Advice and Liaison Service (PALS). You can also invite her to meet with the consultant and senior nursing staff if she would like the opportunity to discuss this further. Don’t tell her if you wanna to complain I will guidded you ,but if she want to complain you can guided her Wishes mother , offers a telephone number where she can have any other queries answered. thanks

Boy with Crohn's disease. He is now under the care of the paediatric surgeons, who feelthat he needs a laparotomy with possible bowel resection. The surgical team have asked if you will speak to them about possible blood transfusion before they come and take consent for the procedure. Points to consider: Introduce yourself and explain truthfully why you have been asked to come and talk to them. You may start off by saying something like 'I understand you may have very strong feelings about the use of blood products – how would you feelif it became necessary for their son to receivea blood transfusion?' Reiterate that Joeywould not routinely be given a transfusion. However,as in any operation, there is a risk of bleeding. If your son was to lose a lot of blood during surgery,not giving him a transfusion might put his lifeat serious risk. This may be a very difficultand heated discussion. but regardless of your personal beliefsyou must maintain control of the situation. Gauge the parents' reaction. It may be necessary to seek legal advice,involve the Trust solicitor,or contact the Medical Protection Society or the General MedicalCouncil for further advice. There is the possibility of using a 'cell saver', but there will be a timescale factor to consider here. Allow the parents some time alone to take in what you have said. Involve senior medical staff and arrange a further meeting. Try to empathise and show that you appreciate that this must be a very difficultsituation for them. Wishes mother , offers a telephone number where she can have any other queries answered. thanks

NEPHROLOGY COMMUNICATION OSCE STATION

explain-the diagnosis of nephrotic syndrome to mother of pt who new Dx 1.First ask mother whether she has any ideas about what is causing her son to be unwell. 2. Explains that based on history, examination and doing an initial test on his urine,tell her that he has a condition called nephrotic syndrome. • Has she heard of this or does she know anything about it? • Explain that you appreciate that this has come as rather a shock to her, and you are going to take things slowly and explain what NS is and also the initial management. She can interrupt and ask questions at any time, and if she does not understand something you have said, she should just ask and you will go over it again. 3.In your own words. give a brief explanation of nephrotic syndrome. It is a disorder that affects the kidneys. Normally the kidneys work by tightly controlling what the body absorbs and getting rid of the waste material. excreting it as urine. In nephrotic syndrome the kidneys become 'leaky.' You could describe this as like having a bucket with holes in it. so that water and bigger particles can now pass through. One of the problems that this causes is letting protein through so that it is excreted in urine. We showed that he had protein in his urine by doing the dipstick test. We think of nephrotic syndrome as a disorder which has three main components:

proteinuria = protein in the urine (I.e: 'leaky' kidney)

hypoalbuminaemia = too little protein in the blood, by protein loss in urine

oedema = swelling of the eyes and scrotum, loss of fluid from circulation.

In childhood. if we look at the kidney cells under a microscope we see achange known as minimal change glomerulonephritis. This occurs in about 85% of cases. Nephrotic syndrome occurs in about 2 in 100000 of the population. The mainstay of treatment is oral steroids, and most children will respond within 7 to 10 days. You will also do some further blood and urine tests. Depending on the time available, mention complications ,relapse and prognosis. This is a lot of information to take in at one sitting. 4. States that the treatment for the disease has been started and that in a few days, the swelling over the body will gradually decrease and disappear. Emphasizes the need to continue treatment as per instructions from the doctor and that medications should not be stopped or modified without the doctor’s instructions.

5. Explains that the child’s urinary protein needs to be checked every day and result recorded in a notebook, which needs to shown to the doctor at each visit. Emphasizes on weight and blood pressure monitoring on weekly/biweekly basis from nearby hospital. 6. Explains method of testing urine for protein using dipstick. 7. Says that the child’s treatment will continue for about six months and that regime would be changed depending upon the child’s urine protein response. 8. Explains that the child can eat normal home food and attend school. Emphasizes that the child should not take added salt for his diet. 9. Explains that the child should be brought back immediately if she has abdominal pain, vomiting, fever, recurrence or increase in swelling. 10.Provide mother with written information and then arrange a further meeting either later that day or the following day. 11.Confirm that she has understood the information you have given her 12.Wishes mother and offers a telephone number where she can have her queries answered. 13.thanks

explain-the diagnosis of nephrotic syndrome to mother of 4 yr old boy diagnosed as Nephrotic Syndrome to be started on steroids councle mother 1. Introduces self/ puts the child and attendant at ease. 2. Explains the disease in simple words 3. Explains the medication • Dose • Frequency • Relationship with meals (after meal) • written regimen for tapering the steroids at home 4. Explains side effects • GIT Steroid effect 5. Explains monitoring of response • Urinary output • Body weight • Urine should be dipped daily until remission then twice weekly while still on atapering dose of steroid or if their child is unwell at any time. Results can be recorded in a diary. 6. Asks for queries if any. • Advises to report back if any problems. • Advises about pain abdomen 7.Wishes mother , offers a telephone number where she can have any other queries answered. 8. thanks

NEUROLOGY COMMUNICATION OSCE STATION

Advise the father of 18 months old child with simple febrile seizures

1. Greeting the father 2. Introduce yourself 3. Asking the mother what she knows about her child’s illness. 4.Asking Is there anything that particularly worried about?”

Ask for family history febrile convulsions or eplepsy

Ask for child history of seizures and neurodevelopment 4. reassurance and explain what febrile seizure mean. They are common 3-5% (1 in 20) of all children,M > F ,Often there is a family history 10%. Typically occur 6 months to 6 years old age ,Always in the presence of fever (infection). Due to immaturity of CNS at this age 5. explain what a simple febrile and a complex febrile seizure is. Typical – simple Febrile Seizure • < 15 minutes (95% < 5 minutes)generalized, symmetric ,does not recur in a 24 hour Atypical –complex Febrile Seizure • focal origin or >15 minute duration or multiple (> 1 in 24 hours) 6. explain management plan at home

If they recognise their child has a fever – try to bring the temperature down, strip the temperature down using tepid sponging ,provide a fan and antipyretics(e.g. panadol),

If the child has already started fitting - taught the first aid management of seizures to ensure the environment is safe and to lay the child m the recovery position. Most seizures last less than a couple of minutes but if it lasts longer than this to call for help (ambulance/GP) as need to treat fever and underlying illness.

If there is high risk for recurrent or prolonged seizures (>5 minutes),give rescu of buccal midazolam or rectal diazepam 0.3–0.5 mg/kg

8. explain him about investigation or head a scan ,its no need unless

atypical febrile seizure or abnormal neurologic findings do EEG.

if < 18mon old age ,no classical features of meningitis do an infection screen 7. explain prognosis : Risk for recurrence

There 33% risk for recurrence especially the younger child (50% <1 yr/28% >1 yr).

family history of febrile seizures or epilepsy

low body temperature at time of seizure

shorter duration of fever (<24 hours) before onset of seizure Risk for developing epilepsy in future life

if developmental /or neurological abnormalities of child prior to seizures

if family history of non-febrile seizures

In comolex seizure ,4-12%

In simple Seizure ,1-2% ,similar to the risk for all children 9. Do you understanding me, “Do you have any questions for me ?” 10. I will give you information leaflet (if possible) and hospital telephone (Safety net): 11. thanks

Discussion /Obtain informed consent (lumbar puncture) SCENARIO Your has seen a 6-month-old child whom you suspect may have meningitis. You wish to perform a lumbar puncture before commencing antibiotics.

Please explain this procedure to the child's mother. She is aware of why the lumbar puncture must take place

She has The following questions . · What does it involve? · Would it hurt, and could he have an anaesthetic? · What can be done to reduce the pain? · Is it dangerous, what side effects? · When will I know the result? · What if he doesn’t have it done, can’t you treat him anyway?

1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3.Confirmation of mother's relation to child and understanding of situation. 4. Ask if does she want a relative or friend with her? 5. Reassure 3. Asking the mother what she knows about her child’s illness. 4. Asking Is there anything that particularly worried about?” 5. Explanation why need LP and what septic screen involves. we need LP as part of septic screen to find a catch cause for the illness mostly bacteria by take sample of baby blood , urine and brain fluid that done by LP the sample taken and analysis for infection indicator and part will be culthured 6.give Specific details of a LP - why is it necessary and what is involved. Test involve insertion of small niddle inside lower baby spineunder aseptic condation , when the baby lie down on his lateral side with good flexion for spine ,the prosess is not painfull but can give simple local anesthesia to keep him quite ,and all process just take minutes to half houre When finshed there will be bot any wound just cover clean site and cover by cotton and tap for few days 7. Specifically state the need to hold the child securely stating this is usually the most uncomfortable part for the child. 8. Explain what to expect afterwards Some time we succed to get fluid from 1st try but can try maximum 3 times if not 9. Explain risks of precedure There may be risk as any surgical procedure but here is minimum and we take all causion for this ,there risk for – infection, leak, headache, technically unsuccessful and fears regarding neurological damage and pain 10.Explain benefits of LP– confirm Dx and Rx, selection of treatment, length of Rx and follow-up arrangements 11.explain that we still has Ability to give antibiotics regardless of success of procedure. 12.Ensure the mother understands all you have said. 13.ask “Do you have any questions for me?” 14. thanks

Councle mather regared Dxof A 4 month old baby with SMA 1.Introduce myself to the mother and form a rapport with her 2.explain the diagnosis? Spinal muscular atrophy type - I 3.explain the cause of this condition? Inheritance ,AR 5.mention definitive diagnostic tests for this condition. a) Genetic analysis for SMN gene (surviour motorneurogene) b) Muscle biopsy

5.tell her prgnosis? – appraise her regarding progressive nature of the illness her baby 6. the possibility of recurrences in the next pregnancy 7.explain the various prenatal diagnostic options available 8.Discuss the treatment options for her present child has the disease progresses. 9.Thanks the mother.

2 yr old child weighing 10 Kg is being discharged after admission for febrile seizure. Counsel the mother regarding domiciliary management of seizure with rectal diazepam.

1. Introduces self & puts child and attendant at ease.

2. Explains the problem in brief.

3. Familiarizes the attendant with the drug,the syringe and the catheter.

4. Explains dose(3mg), and loading of the syringe

5. Explains the position of the child (lateral)

6. Explains introduction of the catheter (lubrication, and length of introduction)

7. Explains pushing the drug

• Advises pinching of the buttocks together after Withdrawing the catheter)

• Advises one repetition after 15 mts

8.Explains side effects

Phenobarbitone prescribing error

SCENARIO

David 5 weeks old age is being investigated for prolonged jaundice , given phototherapy for

jaundice in hospital for days 2-5 but has been jaundiced ever. since His current admission

to hospital has been for 2 days ,Because You have noticed that he is very sleepy , has not

feed today. He is jaundiced and has stopped breathing briefly.He is currently receiving

oxygen via a tube under his nose and is on asaturation monitor ,You have noted that David

was meant to have been prescribed Phenobarbital (phenobarbitone) 15 mg once a day,

two days previously but instead has been given 75mg once daily as the writing on the

prescription was misinterpreted..

Mother: show controlled anger ,want to know why this has happened

To talk to Mrs Jones about the prescribing error and its effects on her son

1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. Asking the mother what she knows about her child’s illness. 4. Asking Is there anything that particularly worried about?” The following questions may ask by mother.

· Why is he now on oxygen?

· What are the potential problems / side effects?

· Will it delay the investigations for his jaundice?

· What will be done by the hospital to prevent it happening again?

5.Explain to the parents of how the error occurred

6. Apologize for the reported mistake

7.Recap the situation and to invite parents’ questions about the possible toxic effects to David and how these will be monitored: Phenobarbital Useful in neonatal seizures may be administered for neonatal guandice prenatally in the mother or postnatally in the infant. Usual dose in neonate is 3-5mg /kg/d

therapeutic reference range of: 15-30 µg/mL ,Higher levels tolerated in severe epileptics the toxic side effect over dose > 30 µg/mL,toxic is > 60 µg/mL,so weneed drug monitoring if > 30 µg/mL: Drowsiness , sediation ,lethargy ,mental depression, skin reactions. If > 60 µg/mL: Respiratory depression, apnoea. Phenobarbital’s usual duration of effect exceeds 6-12 hours,half-life in Infants is 40-70 hrs 8. detail the parents about the actions necessary which will include:

notification of an adverse incident to the Hospital Trust

to document fully in medical records of the pt the prescribing error and actions taken

9. Reassure parent.

10. Establish parental understanding, “Do you have any questions for me?

11. thanks

Counselling the parents of a newborn with meningomyelocele regarding the recurrence in the next pregnancy. 1. Establishes rapport. Introduces himself/herself. 2. States that based on history, examination and investigations, a diagnosis of meningomyelocele has been made. 3. Explains about the possibility of recurrence in the next pregnancy. 4. Explains that the recurrence can be prevented by use of folic acid. 5. Advises that folic acid should be started one month preceding conception in the dose of 4 mg OD and continued thereafter. 6. Asks if mother has any doubts and encourages her to ask questions. 7. Wishes mother and offers a telephone number where she can have her queries answered. 8.thanks

ORTHOPAEDICS COMMUNICATION OSCE STATION

Conflict resolution /drug error (methotrexate for arthritis) SCENARIO pharmacist informs you that a drug error has been made. Steven, 13, who is meant to be receiving weekly methotrexate for arthritis, has instead received adaily dose over the holiday weekend. Steven's mother is waiting in the parents' room and is aware a drug error has been made. She is understandably upset over the potential consequences.

You must counsel Steven and his mother about the drug error and discuss what will be done about it. 1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. explain that you have asked the named nurse also to attend and have made efforts not to be disturbed, e.g. cannot be bleeped. 4. apologise for the error. 5. said we understand what you particularly worried about?” 6. Explain what will be done about it . Risk management to deal with error, i.e. notification of the critical incident (and that you will complete the form) and if they wish to take the matter further to involve the patient advisory liaison service. 6. Management regarding effects of medication: blood tests, side effects. Methotrexate's toxic effects are related to its interaction withthe folic acid pathway. Side effects may be dose dependent or independent:

• Mouth sores - dose dependent • Stomach upset (nausea, vomiting, diarrhoea) - dose dependent • Liver toxicity - dose independent • Pneumonitis - dose independent • Bone marrow toxicity • Headache • Drowsiness • Itchiness • Skin rash • Dizziness • Hair loss • Low white cell count.

Important blood tests include full blood count, liver function tests, urea and creatinine

7. Establish parental understanding, “Do you have any questions for me? 8. thanks

ENDOCRINE COMMUNICATION OSCE STATION

Congenital hypothyroidism consutation SCENARIO 2-week-old infant Dx as congenital hypothyroidism by the normal screening process Guthrie test. child looked clinically hypothyroid ,mother ask if this final Dx ,and if possible to repeate blood tests You must inform mother and explain, diagnosis , discuss the potential problems and treatment options. 1. Greeting the mother 2. Introduce yourself with name, make a good rapport

Ensure you in comfortable and quite room Ensure you ask if there is anyone else she would like to be present.

3. Asking the mother what she knows about her child’s illness. 4. Asking Is there anything that particularly worried about?” 5. inform her Dx : today I do have result of your kid, would i like to explain it to you now As you know we take blood sample as routine screen doing for all neoborn for early Dx of many diseases and result of your baby was +ve for cogenital hypothyroidism …(pause) Also should know that diagnosis is not in doubt and no further blood tests needed. Do you know anything about hypothyroidism? Do you have any elderly relative might well be on thyroxine. 6. Explain in general terms what the thyroid gland does. 7. Explain the need for lifelong thyroxine and the reasons for this.

Although your child may look perfectly well without treatment, we can predict that in

weeks or months his skin may become dry, feeding more difficult and his muscles

more floppy. We know that without regular thyroxine his growth will be poor and his

intellectual development slower than normal

8. “Do you understandingme, “Do you have any questions for me ?” 9. I will give you information leaflet (if possible) and hospital telephon (Safety net) 10. thanks

The key features of congenital hypothyroidism are worth knowing:

– Growth failure and intellectual impairment – Poor tone and Decreased physical activity for the child's age – Thick tongue – Hoarse cry – Coarse facies. – Anaemia – Umbilical hernia – Constipation – Jaundice

Treatment is with levothyroxine. Initially the child may be very responsive to thyroxine, so

advise the mother that it may take some time to settle on aregular dose. It is important to

emphasise the need to take regular thyroxine.You can imagine it is difficult to understand

why you have to keep giving regular medication to a completely well child! Emphasising

the risks of intellectual impairment (avoid the term retardation) is useful in this regard

Consult mother of DKA child refused to admission

1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. Asking what they alrady knows about the child condations. 4. Asking Is there anything that particularly make you refused admision?” 6. said , he complainin DKA ,do you knw whats this mean 7.then explain DKA ,its one of most critical situation result from acomplication of DM when there there very high suger in blood ,high acidity of blood and sever dehydration 4. then explain why need to admited Said your son in critical situation regardless your causes , take him ahome at this point is not in best interests and it is need his condition 1st to stabilised as a priority. He need to admitted to ICU in 1st few day ,as he need th stabilized his suger and prevent its complication which ketoacidosis is one of them ,its associated with high acidity of his blood ,loss of fluid -sever dehydration when loss more than 10% of his body fluid and loss salt and K . So your kid need to give insulin by continue iv infusion,not SC as usual,with water and salt replacement and treated acidosis and K if low, all this need to done very slowly may take 48 hrs with regular check his blood , urinre suger and ketons,measured gases from artery because rapid increase of iv fluid or rapid decrease of his suger can be also serious . Also we need prevent aspirate his vomits by stop oral feeding , wash stomach with NGT 5.Explain prognosis With early and good replacement of fluid and insulin pt can completely recovering, but In some pt brain may swelling and gose in seizur attack and coma state need drugs to shift fluid from brain and may need ventilator support with mortality rate may reach to 25%. 6. explain when can send home Said after start treatment we see respond and assessment his clinical and lab result If clinically stabe start regain consciose and RBS <250 ,acidosis and ketosis decrease ,no any more dehydration then can transfer to word for another few days whre pt can regain fully his consciose tolerated oral feedin ,no more vomting ,normal gases then can switch to SC insulin for 24 hrs assed again if Ok sen home 7. Do you understanding me, “Do you have any questions for me ?” 8.thank

boy diagnosed as DM Type I requires combining short 6 units

Actrapid and intermediate acting insulins 4 units Insulatard.

Counsel regarding administration.

1. Introduces self & puts child and attendant at ease.

2. Explains the problem in brief.

3. Explain procedure (painless , need to take daily)

4. Tells about the two insulin (Milky and Plain) and insulin syringe

5. Remove half an hour before from fridge and shake lightly

6. To give 15-30 minutes before food

7. Select areas –mark them for every day => thigh and site rotation

8. Swab the top of the vial with spirit swab provided

9. Explains the calculation of dose in ml , Draw an amount of air equal to the

dose of insulin required ,Takes 4U air in a syringe puts it in insulatard vial

(keeping the vial upright) and then takes 6 U air in a syringe puts it in

actrapid vial(vial upright)

10. Inverts the bottle withdraws 6u actrapid then withdraws syringe inserts

in insulatard and withdraws up to 10u i.e. 4u

11. Cleans area with spirit

12. Allows it to dry

13. Pinches the subcutaneous area –inserts the needle at 45 degree angle

and injects then withdraws needle with syringe and slowly releases pinch,

no rubbing massaging

14. Syringe reusable/disposal in sharp

14. Can use same needle for 2-3 times

15. Keep insulin in fridge

16. Explain Briefs about the symptoms of Hypoglycemia

17.Inquires about any doubts and advises to report ,back in case of any problems.

18. Thank you

GENETIC COMMUNICATION OSCE STATION

Counseling regarding possible premature baby<23 weeks. 1. Greeting and Introduce your self, make a good rapport Congratulat them about new baby and should ask if they know if the baby is a boy or girl or if they have decided upon a name (so you don t have to refer to the baby as 'it'!). 2.Ask what do they already know about premature baby Check if parents have had previous experiences with premature ,might be to ask the couple what they thought would happen if their baby were to be born prematurely. or know relatives with same condition “Do you know anyone else with premature baby?” You may find they know far more than you expected or much less than you'd hoped! 3.Ask What do they want to know“ 4.Then talk in general about what prematurity mean and what conditions associated Normaly the full term pregnant duration is more than 37 wks and more at this time the lung ,heart ,eyes and brain is mature ,fit for extrautrine live . If deliver before 37 wk from the 1st day of the last menstrual period are termed premature and has immature lung , heart,eyes and brain 5.Explain them brifly some Identifiable Causes of Preterm Birth

Fetal : Fetal distress ,Multiple gestation ,Erythroblastosis

Placental :Placenta previa ,Abruptio placentae

Uterine :Incompetent cervix (premature dilatation)

Maternal :Preeclampsia Chronic illness ,Infection UTI, bacterial vaginosis, Drug (cocaine)

Other : Premature rupture of membranes ,Polyhydramnios Iatrogenic 6.Then explain them neonatal problems associated with premature infants

Respiratory: RDS (HMD) ,Apnea , BPD ,Pulmonary haemorrhage

Cardiovascular : Patent ductus arteriosus

Hematologic : Anemia (early or late onset) ,Vitamin K deficiency

Gastrointestinal:Poor GIT function—poor motility, NEC, juandice ,Kernicterus

Metabolic-Endocrine: Hypothermia ,Hypocalcemia ,Hypoglycemia, Hyperglycemia

Central Nervous System : Intraventricular hemorrhage,HIE, Seizures, ROP ,Deafness

Renal : Hyponatremia ,Hypernatremia ,Hyperkalemia

Infections: congenital, perinatal, nosocomial: bacterial, viral, fungal 7.Then explain them resuscitation and stabilisation of preterm.

babies born preterm need immediate resuscitation because risk for RD < 32 weeks

Importance of early CPAP, and surfactant replacement therapy, need for MV in NICU

'If we are able to stabilise your baby we will take him/her to the neonatal unit where we will keep the baby warm, give fluids by drip and necessary medications.'

Frequent blood gases ,xrays and relevant blood testing and cultures,cranial sonar

Monitor for expected complications-air leaks pulmonary ,haemorrhage, apnea, sepsis

Pt may develope PDA, on days 2–5, mainly in the extremely low birth weight infant (<1000g) ,< 28 weeks' gestation and in those who have received surfactant Rx so a prophylactic strategy starting indomethacin on the first day of life. If the ductus reopens or fails to close completely, 2nd course may be used, give ibuprofen. If fails surgical ligation is appropriate.

Survival rate

for infants born at > 28 weeks gestation now better than 90%.

80% survive at 26–27 weeks' gestation

in gestational age 25 weeks is 50–70% You must know the dose and major side effect of and CI of indomethacin :

indomethacin give at dose 0.1 mg/kg q24h for 3–5 days

transient oliguria, managed by fluid restriction until urine output improves.

NEC can be ameliorated by giving the drug as a slow infusion 1–2 hours.

The drug should not be used if the infant is hyperkalemic, the creatinine is > 2 mg/dL, or the platelet count is < 50,000/mL.

8. Then explain them duration need for hospitalization (may be long time)and medical criteria for discharge of the premature infant include

the ability to maintain temperature in an open crib

nippling all feeds and gaining weight at least 1.5kg

the absence of apneic and bradycardiac spells requiring intervention.

Infants going home on supplemental oxygen should not desaturate too badly (< 80%)

in room air or should demonstrate the ability to arouse in response to hypoxia.

befor discharge check with screen for cong anomalies, vision, hearing 4–6 wks of age

Factors situation play a role in the timing of discharge.

support for the mother at home and the stability of the family

Home nursing visits and early physician follow-up can be used to hasten discharge.

9.Then explain long term complication

higher incidence of neurodevelopmental delay and severe neurologic sequelae, cerebral palsy, cognitive delay, and hydrocephalus, is reported in 10–25% of survivors with birth weights < 1500 g.

increased rate of disabilities, including learning, behavioral and psychiatric problems. , imainly nfants with birth weights < 1000 g

Risk factors for neurologic sequelae include

Seizures

grade III or IV intracranial haemorrhage

periventricular leukomalacia

ventricular dilatation

severe IUGR

poor early head growth

need for mechanical ventilation

chronic lung disease

NEC

low socioeconomic class. Other morbidities in these infants include

chronic lung disease prolonged oxygen requirement and still need O2 >36wk post LMA

reactive airway disease, resulting in an increased risk from respiratory infections and

hospital readmissions in the first 2 years;

retinopathy of prematurity with associated loss of visual acuity and strabismus

hearing loss

growth failure (child going to be small for 1st 2 yrs if only premature without sequla).

10.Then explain follow-up.

multidisciplinary outpatient follow-up for ND delay and severe neurologic sequelae.

monthly palivizumab (Synagis) injections during their first winter Infants with residual lung after hospital discharge to prevent severe infection with respiratory syncytial virus.

receive the normal immunisation schedule at chronological rather than corrected age • For children who are on the neonatal intensive care unit, oral polio vaccine should be deferred, with the first dose being given on discharge from hospital, and the second and third doses being given at monthly intervals thereafter.

All PT < 1500 g birth weight or younger than 32 weeks' has risk for ROP Initial eye examination should be performed at 4–6 weeks of age in infants with a birth weight < 1500 g or in those born at < 28 weeks' gestation, as well as in infants weighing > 1500 g with an unstable clinical course. Then Follow-up is done at 1 to 2 week intervals until the retina is fully vascularized.

Anemia in the Premature if < 28 weeks ,symptomatic or hematocrit drops below 20%. transfusion, or alternatively Epoetin alfa, 250 U/kg, given subcutaneously three times per week or added daily with iron dextran to parenteral nutrition, For optimal effect, supplemental iron at a dosage of 4–8 mg/kg/d should be given.

11. Do you understanding me, “Do you have any questions for me ?” 12. I will give you information leaflet (if possible) and hospital telephone (Safety net): 13. thanks

Counsel the mother of a down’s syndrome 1.Introduce your self, make a good rapport it is important to congratulate the parents for having a new baby and assure them that the doctor/genetic counselor are there to support them. 2.Asking for what she knows about the child’s condition. 3.What do they want to know“Is there anything that particularly worried about?” 4.Speak what Down syndrome mean As we know normal human body has 46 chromosomes, half 32, come from father and half 23 from mother, 2 of these chromosomes make sex of baby male or femal and 44 for make physical shape and other organs, when there abnormal in number eigher increase, decrease or if 2 chromosome fuse togather or change position this result in abnormal baby ,if this abnormality in chromosomes no 21 baby will has down syndrome 5.Speak about the causes of Down syndrome Mostly result from an error at maternal oocytes during pregnancy ,mother gives 24 crromosoms not 23 and father give 23 this rise to a down baby with 47 instead of 46 chromosomes, regardless the mother healthy with normal chromosomes,this related to maternal age at 20 the risk is 1:2000 , at age 30 1:700, at age 40 1:100 and at age 45 1:50 Or may be due abnormal of parent 25% (mother or father) chromosom before pregnecy, one of them carrier, has chromosomal 21 fused to other (14, 15, 22 or 21) with abnormal total 45 chromosomes but balance translocation so look healthy ,they will have baby with unbalanced translocation down syndrome with 46 chromosomes. but in 75% of translocation cases neither parent carries a translocation this de novo 6.Telling common early problems of downs we watch for congenital heart defects (40%) AVSD (ECCD) needs Echo

Digitalis and diuretics usually required for CHD ,correction at 3 mon age in AVSD (ECCD)

Subacute B endocarditis prophylaxis

Adenotonsillectomies may be required for obstructive sleep apnea GIT anomalies: (6%) Duodenal atresia (30%) ,Hirschsprung (3 %) ,TEF needs Abdominal US

early surgical repair of GIT anomalies(Duodenal atresia - urgent) hypothyroidism (15% ) Check TSH, thyroid hormone Hearing impairment ,congenital cataracts 59% needs Hearing snd vision evaluation

early cataract extraxtion in neonatal period ,subsequent coreection with glasses or CL 7.Telling common latter problems of downs to watch for (Education and vaccination) Moderate to severe learning difficulties ,Small stature and delayed motor milestones need

early intervention programs a) Physical b) Occupational c) Speech therapy

Provide behavioral Rx and psychotherapy for behavioural Disorders

Schooling , Not all children will have mental retardation, but most will Increased susceptibility to infections (recurrent chest infection with CHD ,SOM (75%))

influenza vaccines for children with chronic cardiac and respiratory disease

Prompt treatment of respiratory tract infections and otitis media Skin infection and dental caries need dental hygiene ,Fluoride,Good dietary habit Atlantoaxial sublaxation need cervical spine radiography (flexion extension views)

Surgical reduce and stabilize the atlantoaxial subluxation if significant neurologic deficits Increased risk of seizures ,leukaemia , solid tumours and Alzheimer's disease

8.Speak about inheritance & Possibility in next child For baby with clinical feature of down can confirm with karyotype and cytogenetic test The risk to have othe baby with down syndrome this depend on baby and yours genes if your baby hase 47 chromosomes, the risk recurrence rate is 1%.As you as other women , this means that if we had one hundred women exactly like you, one would have a baby with DS ,The other ninety nine would not If your baby hase 46 chromosomes , must check your chromosomes if the mother is carrier with abnormal 45 chromosomes risk to have baby with down is 10 % if the father is carrier with abnormal 45 chromosomes risk to have baby with down is 2 % if a parent carries the rare 21:21 translocation, all the offspring will have Down's syndrome if mother and father has normal 46 chromosomes , the risk of recurrence is < 1% 9.Speak about Antenatal screening for Trisomy 21 in next pregnancy first trimester (at 12-14 weeks):using maternal age plus 1. Ultrasound scan for nuchal translucency measurement /cong.malformation 2. Maternal blood levels of: (detection rate 87-92%) • high (PAPP- A) high (B-hCG) low (MSAFP)

if low MSAFP, high B-hCG ,PAPP-A ,+ve sonography and maternal age >35 yrs

need confirmation of a chromosomal abnormality by an invasive genetic test ( CVS). 2nd -trimester screening (16 and 20 weeks) tests are Additional to ultrasound measurement to these serum markers are ;

the triple-screen test.

high free or total B-human chorionic gonadotrophin (B-hCG)

low maternal serum AFP (MSAFP)

low unconjugated oestriol (uE )

or qudriple tests by additional test name inhibin-A (inhibin) If Low MSAFP , low oestriol , high B-HCG and +ve sonography , risk of trisomy Mainly with maternal age older than 35 yrs,prompt further discussion, including; require amniocentesis for fetal AFP and chromosomal study

if low fetal AFP , trisomy 18 and 21 related to decreased hepatic production. if fetal chromosomes show 47 this non-disjunction down or 47, 46 moasicm if fetal chromosomes show 46 chromosomes need cytogenetic and FISH may be translocation with 3 copies chr 21 if parents are balanced tranlocation45 chr Although in most instances a normal chromosome pattern will be identified, the

possibility of an abnormal result and the option of termination should be discussed 10.Establish parental understanding, “Do you have any questions for me?” 11.Provide an information leaflet if possible and Safety net: 12.Speak about Follow up Growth and development– need Specific growth charts Genetics – counselling for parents (new pregnebcy) Cardiac – SBE prophylaxis may be necessary for certain cardiac diseases Ophthalmologic – q6mo, then q2yr ENT– Annual audiologic evaluation in first 3 years, then q yearly screening atlantoaxial instability with cervical spine radiography (flexion extension views) in preschool years, then qdecade, especially before sporting events Endocrine , 6 mo, 12 mo, then qyearly 13.thanks

Counselling mother ask about Antenatal screening for down 1.Explain what Down syndrome is. 2.Speak what screening is Using maternal blood screen some hormons related to pregnancy + Ultrasound scan

MSAFP ,PAPP- A and B-hCG in first trimester (at 12-14 weeks)

MSAFP , , B-hCG , uE ,and inhibin-A 2nd -trimester screening (16 and 20 weeks)

Ultrasound scan for screen congenital anomalies of fetus in first and 2nd trimester if low MSAFP, low oestriol ,high B-hCG ,PAPP-A ,+ve sonography and maternal age >35 yrs

We said screen test +ve and there risk for trisomy

that it gives the risk of the problem existence; that it is not diagnostic and does not guarantee that the baby does not have Down's syndrome.

3.Explain what a risk is this is particularly important . Explain the test says the risk is 1:100. This means that if we had one hundred women exactly like you, one would have a baby with DS. The other ninety nine would not. that a screen positive result does not mean that the diagnosis has been made, merely that the patient falls into the risk category, and amniocentesis is offered in 2nd trimester 4.Explain how can confirm Down syndrome is. amniocentesis is the diagnostic test and would be offered if she wished to proceed with it and not screening.what is involved a needle inserted, fluid aspirated, a 0.5 - 1% risk of procedure induced miscarriage, etc. you have choice to continue with amniocentesis regardless risk unless she would wish to have termination. But not wait chance for your baby to be down or no fluid used to measure fetal hormons (AFP) , see if identically drops with maternal result,as this hormone pass placenta and secret to amniotic fluid by fetus also fluid used for chromosomal study of fetus

5.Explain what your option regardless the result is. If down confirm would wish to have termination or contine pregnency If down not confirm as in most instances a normal chromosome pattern will be seen

would wish to have termination or contine pregnency 6.Establish parental understanding, any questions?

“Does everything I’ve said so far make sense?”

“Do you have any questions for me?” 7.Provide an information leaflet if possible and Safety net:

Said parents take your time for decision and come back ,but call me for any question 8.Thanks

Counselling mother ask about Antenatal screening Familial inheritance (genetic condation) such Hemophelia,CF ,DMD,SCD,thalassemia Chromosoml abnormalities (non usulay inheritance)such down with increase mother age Developmental abnormalities (non inheritance) such NTD

Antenatal screening for Trisomy and NTD

first trimester (at 12-14 weeks):using maternal age plus 1. Ultrasound scan for nuchal translucency measurement /cong.malformation 2. Maternal blood levels of: (detection rate 87-92%) • high pregnancy-associated plasma protein (PAPP- A) • high free B-human chorionic gonadotrophin (B-hCG) • low maternal serum AFP (MSAFP)

if low MSAFP, high B-hCG ,PAPP-A ,+ve sonography and maternal age >35 yrs

need confirmation of a chromosomal abnormality by an invasive genetic test ( CVS). 2nd -trimester screening (16 and 20 weeks) tests are Additional to ultrasound measurement to these serum markers are ;

high free or total B-human chorionic gonadotrophin (B-hCG)

high inhibin-A (inhibin)

low maternal serum AFP (MSAFP)

low unconjugated oestriol (uE ) If Low MSAFP and oestriol , high B-HCG and inhibin-A and +ve sonography ,risk of trisomy with maternal age > 35 yrs,require amniocentesis for fetal AFP and chromosomal study if low fetal AFP , risk for trisomy 18 and 21 related to decreased hepatic production. if fetal chromosomes show 47 this non-disjunction down or 47, 46 moasicm if fetal chromosomes show 46 chromosomes need cytogenetic and FISH may be translocation with 3 copies chr 21 if parents are balanced tranlocation45 chr Although in most instances a normal chromosome pattern will be identified, the

possibility of an abnormal result and the option of termination of pregnancy should be discussed beforehand

if normal fetal amniotic fluid AFP this bad techniques or wrong date If Low MSAFP , With normal B-hCG and oestriol ,risk of IUGR confirm the diagnosis with f.up sonography

if high MSAFP do additional testing with sonography and Amniocentesis with high fetal amniotic fluid AFP neural tube defect (eg, anencephaly, spina bifida,meningiomylocel) ventral abdominal wall (eg, gastroschisis, omphalocele,TEF) defects threatened abortion , IUD and twin hepatoplastoma, teratoma and hemingioma, nephrotic syndrome, PUV ataxia telengactasia turner and patue syndrome

with normal fetal amniotic fluid AFP bad techniques or wrong date

Counselling mother ask about inheritance risk

Familial genetic condation such Hemophelia,CF ,DMD,SCD,thalassemia • AR if both parents are carrier then 2 of 4 will be carriers, 1 of 4 will be affected • AR if one parent carrier other affected then 1 of 2 will affected ,1 of 2 will be carriers • AR if one parent carrier (only) then 1 of 4 will be carriers • AR if one parent affected (only) then all child will be carriers • AD if one parent affected (only) then 1 of 2 will affected • XLR if mother carrier then 1 of 2 of male affected , 1 of 2 of femal will be carriers • XLR if father affected then all femal will be carriers • XLD if mother affected then 1 of 2 of male affected , 1 of 2 of femal will be affected • XLD if father affected then all femal will be affected

Chromosoml abnormalities (non usulay inheritance)such down inheritance & Possibility in next child if family has down with karyotype 47 chromosomes, the risk recurrence rate is 1%. increase with increase mother age as other women if family has down with karyotype 46 chrom, the risk depend on parents chromosomes

if the mother is carrier abnormal 45 chromosomes risk to have baby with down is 10 %

if the father is carrier abnormal 45 chromosomes risk to have baby with down is 2 %

if a parent carries the rare 21:21 translocation, all the offspring will have Down's

if mother and father has normal 46 chromosomes , the risk of recurrence is < 1%

HEMATOLOGICAL COMMUNICATION OSCE STATION

Counselling the parents about the further management of baby with

thalassemia.

1. Establishes rapport. Introduces himself/herself.

2. States that based on history, examination and investigations, a diagnosis of

thalassemia has been made.

3. Explains the need for blood transfusions and hepatitis vaccinations for the

infant and need to maintain the Hb above 9 gm/dL.

4. Explains that cure can be achieved by bone marrow transplantation from a

sibling.

5. Explains to them that prenatal testing is available in the next pregnancy.

6. Suggests the role for cord blood collection from the next child, which can be

used for stem cell transplantation to this infant.

7. Asks if mother has any doubts and encourages her to ask questions.

8. Wishes mother and offers a telephone number where she can have any other

queries answered.

9.thanks

3 days old male pre-term at 26 weeks' ,with Hb 10 g/dl ,has been transfused

with the wrong blood (rhesus positive instead of rhesus negative), due to an

error. You have since assessed baby. who remains well and stable.

You have also discussed this matter with the consultant haematologist and the

neonatal consultant.

Speak to mother explain her this error,and what your management will be

now

Points to consider: First introduce yourself and make sure that a nurse is present, preferably one who has been involved in baby care. Ask mother if she would likeher partner or a friend or relative to be with her during the discussion. You need to be honest and open and explain exactly what the error is and how it occurred. It The incident is being taken very seriously, and apologise to her that this has happened. Reassure her that you have assessed Thomas and he remains stable. Preterm infants do not mount 'transfusion reaction.' There is no immediate intervention indicated according to expert advice from the haematology consultant. This incident may have implications for the future. as Thomas's immune system is sensitised and may produce antibodies. This situation will be monitored. You can then go on to explain the formal procedure of filling in critical incident forms. and informing senior nursing staff and the consultant responsible for her baby. The aim is to assess the risk and to try to minimise any future risk to other children. She can put her concerns in writing if she feels that this is more appropriate. Offer her the contact details of the Patient Advice and Liaison Service (PALS). Reiterate the fact that she does not need to take this any further if she does not wish to, as you can ensure that you will be taking all of the relevant steps to try to prevent this from happening again. Concentrate on her baby being well. A mistake has occurred and this will be dealt with in order to minimise future risk. Invite her to meet with the consultant and the unit manager if she would like the op

Boy with Crohn's disease. He is now under the care of the paediatric surgeons, who feelthat he needs a laparotomy with possible bowel resection. The surgical team have asked if you will speak to them about possible blood transfusion before they come and take consent for the procedure. Points to consider: Introduce yourself and explain truthfully why you have been asked to come and talk to them. You may start off by saying something like 'I understand you may have very strong feelings about the use of blood products – how would you feelif it became necessary for their son to receivea blood transfusion?' Reiterate that Joeywould not routinely be given a transfusion. However,as in any operation, there is a risk of bleeding. If your son was to lose a lot of blood during surgery,not giving him a transfusion might put his lifeat serious risk. This may be a very difficultand heated discussion. but regardless of your personal beliefsyou must maintain control of the situation. Gauge the parents' reaction. It may be necessary to seek legal advice,involve the Trust solicitor,or contact the Medical Protection Society or the General MedicalCouncil for further advice. There is the possibility of using a 'cell saver', but there will be a timescale factor to consider here. Allow the parents some time alone to take in what you have said. Involve senior medical staff and arrange a further meeting. Try to empathise and show that you appreciate that this must be a very difficultsituation for them.

14-year-old Dx with leukemia and refused Rx Speak with his parent Points to consider Ask Jason's parents if they are aware of any particular issues which are worrying Jason and therefore leading to his refusal of treatment. possible areas of concern include fear related to the death of his grandla her. anxiety, pain, and the side-effects of treatment. do they believe that he is aware of the serious consequences of if he remaining untreated (i.e. death)? Who has talked to your son so far? Has anyone talked with him on ame-to one basis? has he built a rapport with any of the doctors or nurses on the unit? At this point you can bring up the concept of 'Gillick competence' now known as 'Fraser competence') . would oe likely that if your son continued to refuse treatment,premission to go ahead would be sought from court. this would be a last resort. The biggest risk is of alienating the boy completely from his parents and the medical staff. It would be preferal to resolve this issue without resorting to legal measures. involve her agents in speaking to Jason (e.g. counsellor ,psychologist). who are specially trained in talking with young people. aknowledge his parents' anxiety, and the fact that this is a very difflcult situation. You also need to understand how difficult this is For pt and continue to offer support. Perhaps allowing boy to meet with other young people on the unit may offer him some support and reassurance. clarify away forward (i.e. arrange a further meeting, possibly with psychologist). reassure parents that they are not alone. and that they are not the only parents who are faced with this situation. The multidisciplinary team will support them as a family.

Counsel a mother of child has been diagnosed ALL

1. ensure you in comfortable and quite room where you will not interrupted 2.Greeting the and Introduce yourself with name, make a good rapport 3. Asking what they alrady knows . 4. Asking Is there anything that particularly worried about?” 5.would like any one to be present with you 6.today I do have result of your kid, would you like me to explain it to you now 7.give diagnosis : Build up event to the result and DX As you know we take biopsy and result are not as we hop,I am sorry to tell you its leukemia ,,, take pause ,,,,,,,,,,,,,,,,,, see respond , can ask about how they are felling Then said leukemia is a blood cancer of WBC’s I know this news was huge shock ,can ask what going though in your mind explain and answer their question

8. Shows sympathy and reassures that the overall prognosis is excellent. 9. Says that the etiology is not known. 10.Says that treatment involves drugs (chemo) and occasionally radiotherapy. 11.Says that the duration of treatment will be 2 ½ to 3yrs. 12.there will be side effects of chemo like hairfall, infections, bleeding tendencies etc. 13. Also there may be long term complications like decreased growth, repeat cancer. 14.Stresses the need for neutropenic care – avoid giving outside food, avoid overcrowded places, avoid frequent visitors. 15. there risk of relapse – CNS, testicular, blood and hence the need for regular followup after completion of treatment. 16.you need to consult doctor before giving regular vaccines , some vaccine will not given. 17. Establish parental understanding, “Do you have any questions for me?” 18. Provide an information leaflet if possible and Safety net: 19. thanks

Councle parent of child had purpura

This is the peripheral smear of a 4 year old child who presented with a Hb of 10gm/dL, TLC 9000, Platelet 30,000 and no organomegaly or lymphadenopathy. The child had purpura but no significant bleed ,was stable. Parents are well educated and live in city. Kindly counsel the parents of this child

1. Introduces himself and tries to make the parents comfortable.

2. Talks about the disease ITP

3. Talks about the possibility of any other disease

4. Talks about the need for injury prevention

5. Tells about the warning signs when they have to report to the hospital

6. Talks about the self limiting nature of the disease

7. Establish parental understanding, “Do you have any questions for me?”

8. Provide an information leaflet if possible and Safety net:

9. thanks

Counsel the mother, whose child has been diagnosed with

Haemophilia A 1. Introduction

2. Explain the disease

3. Removal of guilt

4. Problem addressed – current problems (Jt. Bleed ))

5. Associated problems.. deep bleeds

6. Treatment drug / dosage / side effect to watch Factor VIII / Cryo / FFP

7. On discharge : precautions at home

8. Precautions at school / play . Helmet / knee / elbow

9. To inform about condition in case of any future medical intervention

10. Counsel for future preg/ of prenatal diagnosis for her and others in Family

11. Investigate other relevent members

12. School / play

13. Future cure / vaccination MAY come up …

14. When to follow up

15. When to come in emergency?

16. Ask if they have any more questions?

17. Thank the Mother

Counsel the father whose child has Difficult to gain access

to his vein. SCENARIO Oliver, a 2-year-old child ,cerebral palsy with severe developmental delay , he has been admitted with gastroenteritis and is mildly-moderately dehydrated. He is not shocked but will require fluid therapy, which he has not tolerated by bolus nasogastric feed. Oliver needs a cannula but is extremely difficult to gain access to. Stuff has had repeated attempts and despite parents' suggestions to ask for help to continued regardless. Parents eventually became extremely angry and are demanding to take their child to another hospital. You have been asked to speak to the parents of Oliver 1. Greeting the mother 2. Introduce yourself with name, make a good rapport 3. Need to apologise to parents. 4. Need to explain that this is a situation which should not have occurred that the situation will be discussed at a clinical governance meeting to ensure it does not happen again.It is important that a solution is found for Oliver in the meantime, as Oliver 's health is the most crucial at this point. 5. explain how wrong to transfer to another hospital Transfer at this point is not in Oliver's best interests and it is imperative his condition is stabilised as a priority. Show parents that Oliver is your most important priority in this matter and that by stabilising his condition and so calming his parents it may be that a transfer is no longer requested. 6. You may therefore say: 'It is important that Oliver is stabilised before we would consider sending him to another hospital. That decision must be made by the consultant,who unfortunately due to his acute clinical workload cannot be here at this time. It is my intention to provide Oliver with a means of receiving fluid and ensuring his adequate hydration. At that stage it will be possible to speak to Dr Smith about his subsequent care. 'Obviously the parents are going to be very upset and empathising with their frustration is paramount. 7.You should not have to make clinical decisions to reheadrate via NGT not suggesting that a continuous infusion via a nasogastric tube be commenced to ensure Oliver's hydration. It may be that there was little clinical need for the cannula in the first place and you must indicate to the parents that you will examine Oliver to assess hydration. This must be done sensitively as, although the SHO has overstepped the mark, you do not want to imply that he is clinically incompetent. 8. Do you understanding me, “Do you have any questions for me ?” 9. thanks

INFECTION COMMUNICATION OSCE STATION

Childhood immunisation consultation Possible station

Parent wants to know more about vaccination

Parent refused to give vaccination

Parent hearing some thing about vaccination like (MMR scandle) 1.Greeting them 2.Introduce yourself – explain your role 3.Confirm parent & childs details 4.check what they understanding about vaccine & ask what they want to find out What would you like to know about the vaccination programme? What do you already know?” Is there anything particular that concerns you regarding the vaccination programme?” 5.Explain them the ideal vaccine An ideal vaccine should confer long-lasting, or even lifelong protection against the disease with a single or a small number of doses. And this taken by give vaccine that consist of different types, dependent upon the organism and the immunogenicity and route.

live viral vaccines (give in a small dose/MMR , OPV )

live bacteria vaccines (BCG )

Inactivated viral vaccine (IPV)

Inactivated bacterial (Hib, typhoid and Cholera)

Inactivated bacterial toxin(DPT)

Recombinant viral vaccines (HBV,HPV)

Recombinant bacterial vaccines(protein -MenC /polysaccharide - Quadrivalent Men,HiB) 6.Explain them the importance of vaccination Giving a child a vaccination against a disease dramatically lowers the risk of them catching the illness which could be extremely harmful to them both in the short and long-term. Vaccines prevent uncommon diseases,smallpox has been eradicated thanks to a worldwide vaccination program. Similarly, Polio has been eradicated in the Western countries. Several other vaccinated conditions have become very uncommon since vaccinations were started. Vaccinations help protect children from serious disease & also provide protection for society as a whole (herd immunity) The reason for vaccination is to protect your child and the community as a whole.” By stopping the disease developing in your child, we also stop your child being able to spread the disease, so it can be considered a public health benefit too. The aim is to immunize enough people that we can stop the disease completely – this happened with smallpox in some countries” Vaccines prevent serious diseases with devastating consequences you can see dramatic change in disease and its complication after vaccination befor vaccine deaths : 0.1- 0.5% of MM, 10% of Diphteria, 50% of Tetanus, 1% of polio after vaccine 0 death and polio last epidemic in 1969 then erudacated Pertussis befor vaccine 1 in 400 infants death , after vaccine 5 deaths Hib befor vaccine 5 % meningitis, 15% deafness ,after vaccine 50 cases Rubella befor vaccine 200 cases after vaccine 3 cases

7.Explain them what vaccines should children receive? Immunizations are recommended by the major governing bodies including the Canadian Paediatric Society (CPS),the American Academy of Pediatrics (AAP) and World Health Orginization (WHO), and vaccines should children receive are:

At birth BCG vaccine /Hep B vaccine Engerix®

2 months DTaP /OPV / Hib /Rotavirus Rotarix® /PCV 13-valent ,Prevenar13 /Hep B

4 months DTaP /OPV/ Hib/ Rotavirus Rotarix®/Men C vaccine

6 months DTaP OPV /IPV/ Hib /PCV 13-valent Prevenar13®/ Hep B

12 months Hib /PCV Prevenar13®/ Men C / MMR MMR II®plus

4 - 5 years (pre-school) DTaP /OPV/ MMR MMR II®plus

12 to 13 years (girls only) HPV 6,11,16,18-Gardasil® at,6-24 months apart (2-3 doses)

13-18 yrs DT/ OPV

8. Mention diseases that prevent by vaccine BCG vaccine against pulmonary TB ,pneumonia.skine and lymph nodes infection) dipheteria(sore throat,UAO,CMP ) tetanus(seizure,muscle spasm,respiratory muscle weakness and R.failure) Pertusis (pneumonia, seizure) OPV vaccine against muscle weakness and paralysis Hib vaccine Against epiglottitis, meningitis, pneumonia PCV vaccine against meningitis, pneumonia Men C vaccine against meningitis,deafness Rotavirus vaccine against diarrhea,vomting,dehydration Measles vaccine against fever,cough, pneumonia,encehalitsis,corneal ulcer Mumps vaccine against orchitis,deafness Rubella vaccine againstflu ,skine rash ,congenital rubella syndrome 9.Explain them the Side effect is not thing in compare to disease complication Following vaccination, there may be swelling and discomfort at the injection site and a mild fever and malaise such DTaP . local reaction such IPV , Hib, measles and rubella, may be followed by fever,rash,arthritis.serious reactions, including anaphylaxis, occur but very rare. 10. Explain him contraindications The only remaining absolute contraindications for pertussis-containing vaccines are: Confirmed severe local or anaphylactic reaction to a previous dose vaccine

Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B

contra-indication to MMR vaccination: non-HIV-related immunodeficiency a

children with allergy to gelatine

children with a history of anaphylaxis to egg immunised under medical supervision

Contraindications OPV: Postpone if acute illness with pyrexia, diarrhoea/vomiting

Immunodeficiency/Treatment with steroids/immunosuppresants

First four months of pregnancy

contra-indication to influnza vaccination: anaphylaxis to egg immunised under medical supervision

11.Do you understanding me, “Do you have any questions for me ?” 12. I will give you information leaflet (if possible) and hospital telephone (Safety net): 13.thanks

You must have idea about Other extra vaccine for high-risk populations

PCV vaccine 23 - valent available for high risk groups

Men quadrivalent vaccine available for high risk groups

Influenza vaccine – inactivated IIV at 6 - 18 months (routine USA) (2 doses).

Influenza vaccine – live attenuated LAIV available for high risk groups

HAV vaccine at 12 and 18 months(routine USA ) (2 doses)

Varicella -Varivax® at 1 and 3-4 yrs (routine USA ,canada) (2 doses)

Recommendations vaccines for traveler to endemic area Typhoid , give at 2 years one dose, and boster every 3 yrs- capsule

Cholera ,give at 2 years 3 doses 6wks apart and boster every 2 yrs inject

Dengue , give at 9 yrs old age, 3 doses ,6 mon apart inject

You must have idea about myths about vaccines 1) Vaccines are not safe : vaccines are generally safe. The most common reaction is a local reaction at site of injection involving tenderness, bleeding, hematoma or local infection. Systemic reactions may include fever, rash, joint and muscle pain, fainting or seizures however is very uncommon. Anaphylaxis to the vaccine is seen in 1 to 3 out of a million. 2) Too many vaccines at once overwhelms the child’s immune system ,no evidence 3) Vaccines weaken the child’s innate immune system ,its activates the child’s immune 4) MMR causes inflammatory bowel disease ,There is no conclusive evidence 5) MMR causes Autism There is no causal association found. This debate began in 1998 when an article was

published in the Lancet by Dr. Wakefield and 12 co-authors who claimed to have found a link between the MMR vaccine and autism in a small study of 12 children. The co-authors withdrew their names from the study and it was retracted, when it was found that Dr. Wakefield had a fatal conflict of interest. He was doing paid research for a group of parents of autistic children who were trying to mount a suit against the makers of the MMR vaccine.

6) Vaccines are not necessary-the diseases are gone. From the above incidence data it is clear that although fewer cases are found, only

small pox have been completely eradicated. To prevent outbreaks, authorities say that at least 95% of the population need to be vaccinated (See: Herd immunity above)

7) Vaccines contain poisonous substances This debate has its origins in the debate about the MMR vaccine causing Autism. It was

thought that Thimerosal (a preservative used in multi-dose vials) might be the agent explaining the association demonstrated by Dr. Wakefield. Since then Thimerosal have been removed from all vaccines in Canada due to the concern of a higher than acceptable Mercury content found in Thimerosal.

8) Natural medicines provide safer protection ,No evidence

24 yr old lady diagnosed as HIV + at 36 weeks of gestation.

Counsel regarding perinatal transmission and follow up. 1. Ensures the presence of husband 2. Introduces self/ puts the couple at ease. 3. Explains the disease in simple words 4. Explains the incidence and modes of perinatal transmission 20-30% • Prenatal • Intranatal • Breast feeding 5. Explains modalities of reducing rate of transmission • ART to mother and child • LSCS Vs Vaginal delivery • Breast feeding Vs top feeding 6. Explains effect of measures – reduction by 50% 7. Explains screening of the infant 8. Explains safety of cuddling, petting and kissing 9. Asks for queries if any. 10.Advises to report back if any problems.

Information giving to parents/ management issues 28 year old Meera who has delivered 1 hour ago in your hospital. Baby weighs 2.8 kg and has no apparent problem. She was tested HIV positive during early preganency. Her CD4 count was 500. She has been on Anti retroviral drugs (tripple drug regimen) since 14 weeks of gestation. a. What is advice regarding breast feeding and weaning? b. What is the advice regarding ART for the baby? C.What is the advice regarding breast feeding?

d.What is the advice regarding ART for the baby? Answer a. advice regarding breast feeding and weaning Exclusive breast feeding upto six months Start complementary feeds at six months Continue breast feeds with complementary feeds upto one year of age b. advice regarding ART for the baby Syrup nevirapine 15 mg OD for 6 weeks only 2. 25 years old, Mrs Nazeema has delivered a female baby weighing 3 kgs one hour back. She was unbooked and was detected to be HIV positive during delivery. She was given nevirapine during delivery. C. advice regarding breast feeding Exclusive breast feeding upto six months Start complementary feeds at six months Continue breast feeds with complementary feeds upto one year of age

d. advice regarding ART for the baby Syrup nevirapine 15 mg OD for 6 weeks Syrup nevirapine 20 mg OD for 6 weeks -6 months Syrup nevirapine 15 mg OD for 6 -9 months Syrup nevirapine 15 mg OD for 9 months to 1 year Syrup nevirapine to be continued for one week after all the breast feeding is stopped.