CH OSCE Stems

Children’s Health OSCE Stems
Infectious disease
Newborn sepsis 4
Sepsis 9
Urinary tract infection 14
Neonatology
Neonatal jaundice 1 19
Neonatal jaundice 2 23
Duodenal atresia 26
Prematurity counselling 31
Genitourinary
Nephrotic syndrome 1 35
Nephrotic syndrome 2 41
Respiratory
Croup 44
Asthma 50
Cystic fibrosis 55
Gastroenterology
Acute gastroenteritis 59
GORD + FFT 63
Encopresis 67
Emergency
Diabetic ketoacidosis 73
Accidental poisoning 80
Non accidental injury 84
Child abuse 92
Shaken baby syndrome 97
Haematology
Iron deficiency anemia 100
Immune thrombocytopenic purpura 106
Cardiology
Ventricular septal defect + FFT 112
Kawasaki disease 116
Acute rheumatic disease 122
Neurology
Febrile convulsion 130
Epilepsy 133
Migraine 136
Paediatric surgery
Hirschprung’s disease 143
Intussusception 149
Pyloric stenosis 154
Inguinal hernia 158
Testicular torsion 162
Compiled by Jovy Wong

Musculoskeletal
SUFE 165
Transient synovitis 170
Other
Cerebral palsy 173
Down’s syndrome counselling 177
Compiled by Jovy Wong

Year 4C discipline (CH, WH, GP, and PSYCH) blueprint guide for MONSCEs
The following information is provided to the student body to assist targeted preparation for
their end of year summative practical examination, the Monash Online Simulated Clinical
Examination (MONSCE).
Children's Health - R1 and R2 conditions within these curriculum domains

1. Infectious disease including management of sepsis
2. Neonatology
3. Genitourinary including nephrology
4. Respiratory
5. Gastroenterology
6. Emergency including poisoning and non-accidental injury
7. Haematology
8. Cardiology
9. Neurology
10. Paediatric surgery
General Practice
1. Dermatology
2. Chest pain
3. Dizziness / vertigo
4. Diabetes
5. Hypertension
6. Tiredness / fatigue
7. Obesity
8. Abdominal pain
9. Cough
10. Clinical reasoning
Psychiatry
1. Schizophrenia
2. Substance-Induced Psychosis
3. Bipolar Disorder type 1
4. Major Depressive Disorder
5. Generalised Anxiety Disorder
6. Obsessive Compulsive Disorder
7. Post-Traumatic Stress Disorder
8. Borderline Personality Disorder
9. Anorexia Nervosa
10. Bulimia Nervosa
Women's Health
1. Abnormal uterine bleeding including early pregnancy, post-menopausal, inter-menstrual,
post-coital
2. Pelvic / adnexal mass
3. Disorders of the menopause
4. Acute pelvic pain
5. Contraception
6. Routine antenatal care, screening and monitoring
7. Monitoring of fetal growth and well being
8. Postnatal issues - lactation, infection, venous thromboembolism, psychological
9. Medical disorders in pregnancy - diabetes, hypertension, Rhesus incompatibility
10. Management of normal and abnormal labour
OSCE Station (CH)
You are the MO at the Paediatric Clinic. Madam Rina brings her 14-days old baby boy John
to see you. She is worried because she feels that her baby doesn’t feel right.
Your tasks
1. Take a focused history from Madam Rina (4 minutes)
2. Outline the examination you would like to perform on the patient. The examiner will
verbally provide the examination finding as you ask for them. (2 minute)
3. Interpret the investigation findings. Explain the management to Madam Rina.
(2 minutes)
Show to student in task 3

FBC
- Hb: 19.0
- WBC: 40.0
- Plt: 250
Urine FEME: Normal
RBS: 2.0 mmol/L
Blood cultures: Pending
LP C&S: Pending
CXR: Normal
History
Intro Introduction, consent, confidentiality
Demographics John, 14-days old, boy
Opening I’m worried my baby doesn't seem right

statement
HOPC Feeding reduced for 2 days

- Usually drinks every 2-3 hours, now only once every 5 hours
More irritable
- Has been crying excessively since 2 days ago, but today
appears relatively quieter than usual
- Does not appear very active
Temperature not checked but feel warm
No rash
No seizures
No vomiting
Urine and bowel habits normal
No skin changes
No travel history
No sick contact
Other Normal antenatal, delivery and postpartum

Normal development
Normal vaccinations: taken Hep B, BCG
Diet: Exclusively breast fed
Physical examination
- Vital signs
● RR: 35
● Pulse: 90
● Blood pressure: 90/65 mm Hg
● SpO2: 95%
● Temperature: 39 ℃
- Altered conscious state (lethargy, irritability, floppiness, weak cry)
- Unwell appearance without non-blanching rash
- Features of cardiovascular dysfunction:
- reduced peripheral perfusion, pale, cool or mottled skin, prolonged central
capillary refill time (CRT >2), tachycardia, decreased urine output ( <1
mL/kg/hr) or narrow pulse pressure
- cold shock: narrow pulse pressure, prolonged capillary refill (more common in
neonates/infants)
- warm shock: wide pulse pressure, bounding pulses, flushed skin with rapid
capillary refill (more common in older children/adolescents and often
under-recognised)
- Tachypnoea ± hypoxia ± grunting (not adequately explained by a respiratory illness)
Diagnosis: Late onset neonatal sepsis
Management
- Admit the baby
- Ensure adequate oxygenation, support BP and perfusion
- Monitor for hypoglycemia, electrolyte and acid base imbalances
- Monitor neurological condition (conscious state + BP) & V/S 4hrly
● Seizure chart
- NBM if unconscious
- Fluid management - watch out for SIADH
- Weight and head circumference
● If fontanelle still open - measure head circumference daily (TRO
hydrocephalus)
- Start empirical antibiotics immediately after drawing blood for cultures
● C.Penicilin and Cefotaxime
https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_managemen
t/
Approach to management of sepsis
JANE – 1 month old baby girl presents to ED Sunday night with
a high fever. Please take a hx from her mother Mary (4 mins)
and then consider what you’ll look for in the exam and Ix and
proceed with management plan (4 mins).
Patient Details Jane, 1 month old, Female. Mother = Mary
Presenting Please help me, my child is really sick.
statement
HOPC - Jane was mildly feverish (37.8) on Sunday later
afternoon and a little less playful, but otherwise
appeared ok and mother had booked
appointment with GP for the next morning
- but over the night Jane become increasingly
feverish – she is now really hot, is lethargic,
irritable, inactive, borderline drowsy and appears
ill
- mother rushed in to ED tonight
- has done two half-cup vomits – not much in
content, just watery (no blood/bile)
- Not feeding or drinking anything – Jane wasn’t
hungry/thirsty this morning
- Dry nappies
- Has shakes
- Is sweaty
Pertinent positives
Pertinent - no rash noticed
negatives - no convulsions
- no other neuro sx
- no other gastro symptoms
- no urinary symptoms
- no resp sx
- no ENT sx
- no obvious pain/tenderness around the body…
no limps etc
-
Systems Review SLEEP-nil
EATING
- normal, breast fed
URINE/FAECES
- none today, hasn’t thought that urine has been
foul-smelling etc
BEHAVIOUR
FEVERS/SEIZURES-nil
Birth history Born term with 3.2kg via SVD, no complications

Development Milestone according to age
Medical history GENERAL
IMMUNISATIONS
up to date
Medications Paracetamol – hasn’t worked

Allergies none
FMHx - has a 2 year old brother
- people at home been well
- no recent family overseas travel
- no new pets etc
- goes to mother’s group with many other little
babies that play
SOC HOME – mother and dad @ home
What would you like to do in examination?

1. Components that identify if child is ‘sick’ (colour/activity), including their
vitals and hydration status
Vitals: not in shock, but…
- Tympanic temp = 39
- RR = 50
- HR = 170
- BP = 90/65
Hydration
- dry mucous membranes
- slightly reduced skin turgor
- capillary refill 4s
- sunken eyes
Colour
- pale
Activity/consciouscness:
- decreased activity
- lethargic
- only responding if forceful-ish
2. Examine for localising signs/red flags… (just name some of key systems)
- No rash
- No jaundice
- No respiratory distress
- No GIT sx
- No seizures
- No signs of raised ICP despite drowsiness/vomitting in hx…, no bulging
fontanelle, papilloedema, abnormal motor/posturing, nerve palsies etc
- No other localising signs
Whats your immediate management if you judge Jane’s clinical state as unstable?
- Call for senior help + Admit to ICU
- ABC + O2 administration
- IV access to take blood
o Blood culture, VBG with lactate and glucose
o FBE, CRP, UEC, LFT, coags, +/- group and hold
o Urinalysis and lumbar puncture +/- CXR-considered when patient
is stabilised
- IV empiric a/b
- Fluid resuscitation with NaCl 0.9%

- respiratory support if needed
o conscious-noninvasive High flow nasal cannula, CPAP, BiPAP
o altered conscious level-intubation
- supportive care
o correct glucose or electrolyte derangement
o thermoregulation
- closely monitor-
https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_
management/
Created by: Joshua Wong
Date: 11/10/17
CANDIDATE INSTRUCTIONS
Station title: Liam Neeson
Time allowed: 8 minutes
You are paediatrician working in your own paediatric clinic.
Mrs. Katherine has brought her 3-month old son, Liam Neeson to see you with a complaint of
fever and irritability for the past 1 week. He recently has an episode of vomiting. As he
presented to you in the clinic, you noticed that he was quite lethargic.
Liam was born at 39 weeks through normal vaginal delivery with no antenatal, perinatal and
postnatal complications with a birth weight of 3.2 kg. His immunisation is all up-to-date. He
has been on exclusive breastfeeding. He had a normal developmental growth. He is taken
care of by his mum whom is a full-time housewife.
As a good caring doctor, you are expected to do the following:
TASKS:
1. Take a focused history from Mrs Katherine in regards to Liam’s problems.

[4 minutes]
2. List the appropriate investigations you would like to carry out to the examiner.
[1 minute]
At 5 minutes, some investigation results will be given to you.
3. Please counsel Mrs Katherine on the diagnosis, further management plans for
Liam. [3 minutes]
Date: 11/10/17
EXAMINER MARKING SHEET

Section
1. Introduc on and rapport
● Appropriate introduc on
● Clear simple (non-jargon) language, clear explana ons
● Non-judgemental, pa ent centred, open-ended ques ons
● Empathy, good body language. Address concern of pa ent
● Organised and systema c, Frequent checking on pa ent’s understanding
2. History
PC: Fever, irritable (crying a lot lately) and lethargic for past 1 week
Also vomited once yesterday.
FEVER – 1 week
- mild fever (not measured at home) – feels warmth to touch
- constant throughout the day
- no rigors or night sweats seen
IRRITABLE & LETHARGY – 1 week

- crying a lot lately
- seems restless most of the time
- appears tired throughout the day – used to be an active and cheerful baby
VOMITING – yesterday
- at night – 4 hours after breastfeeding
- milk + fluid content (whitish colour)
- non-projectile
- not posttussive vomiting
- no blood, bilious content
URINARY SYMPTOMS
- noticed that change pampers more frequently (frequency)
- baby seems to cry when urinating.
- no change in colour, no offensive smell, no hematuria.
Relevant Negatives
- No rashes, no jaundice, no swelling, no breathing distress, no grunting sounds, no cold hands

and feet, no seizure episodes, no signs of bleeding/bruising, no bowel symptoms, no LOA, LOW,
no sick contact, no travel history.
PMH:
- first time being sick.
- no previous illness before this.
- no urinary tract anomalies/ hypospadia detected before this.
PFH:
- Only child
- Parents and grandparents well and healthy
- No family hx of vesicoureteric reflux, renal diseases
BIDDS Hx – Stated in stem

3. List appropriate Ix.
Date: 11/10/17
- FBC, PBF, Blood C&S

- U&E
- Renal profile, LFT
- Iron studies ± Electrophoresis
- Urine dips ck
- Ultrasound of Kidneys and Urinary Tract (to check for hydronephrosis, renal obstruc on,
anomalies)
- Urine C&S
- CXR
- Lumbar Puncture
- Monitor Vital Signs
**DMSA (dimercaptosuccinic acid) and MCUG (micturating cystourethrogram)

🡪 Different recommenda ons between Sunflower and RCH guidelines
Sunflower: Both done in <1 year old infant. MCUG – done promptly if urethral obstruc on/
VUR suspected. DMSA – renal morphology, func on)
RCH/ NICE: Not done unless atypical or recurrent UTI.

**IX Results handed to the student.
4. Counsel the mother.

● DIAGNOSIS: Urinary Tract Infec on (UTI)
● Assess pa ent’s knowledge
● WHAT: UTI is one of the commonest infec on in infants and children.
● Infec on of the urinary tract (can be Upper UTI: Kidney and Ureter/ Lower UTI: Bladder,
Urethra)
● Normally bacteria infec on: E.Coli (most common)
● Occurrences of a first- me symptoma c UTI are highest in boys and girls during the first
year of life and markedly decrease a er that.
Generally girls have higher risk of ge ng UTI (3-7%) compared to boys (1-2%)
MANAGEMENT
● IMMEDIATE ADMISSION TO HOSPITAL – under paediatric care
● Monitor vital signs and carry out Ix (as listed above) prior to ini a ng treatment)
● Fluid resuscita on if child appears dehydrated
● Immediate IV An bio c Tx:
Sunflower: Cefotaxime (Infants – <3 months) – un l temperature se led.
RCH: Gentamycin and Benzylpenicillin (<6 months)
Date: 11/10/17
**once Urine C+S results are back, adjust antibiotic treatment according to causative organism
PREVENTION
- encourage IV fluids – for high urine output and regular voiding

- encourage breast feeding if possible
- good perineal hygiene
- prophylactic antibiotic (eg. Trimethoprim/ Nitrofurantoin/ Cephalexin) – controversial – no
evidence-based benefit.
- discharged once temperature stable and symptoms not present.
- FOLLOW UP: Children <6 months whom are responding to treatment within 48 hours should have a
renal ultrasound within 6 weeks of diagnosis. – assess for anomalies of kidney and urinary tract.
- other than that, other follow ups not necessary if everything else is normal. Advise mother to
come back if child shows symptoms of UTI (especially more specific sx: dysuria, loin
tenderness, hematuria – as the child grows up.
5. Reinforce, phamplet, evaluate, follow up.
PHYSICAL EXAMINATION
- Generally appears lethargic
- Warm to touch
VITAL SIGNS
Temp: 38.4°C
BP: 90/70 mmHg
Pulse Rate: 125/min
Respiratory Rate: 35 breaths/min
No other posi ve findings.
Date: 11/10/17
INVESTIGATION RESULTS
FBC: Elevated White Cell Count
Iron Studies: Normal
Lumbar Puncture: Normal (No Growth)
URINE DIPSTICK: Posi ve leukocyte esterase and nitrite
URINE CULTURE: Posi ve for Escherichia coli
RCH (based on NICE GUIDELINES)

Station No: 2
Station title: Michael
STATION STEM: Provided to candidates the day prior
You are asked to see baby Michael Thatcher as the paediatric resident in the post-natal nursery as
Nursing staff have noted that he is clinically jaundiced at 18 hours of age.
Your examination reveals a full term well looking and vigorous baby who except for being obviously
jaundiced is normal to examination.
This patient does not identify as being of indigenous status.
TASKS: Will be provided to candidates in the exam
Candidate task:
1. Take a focused hx (2 minutes )
2. Investigations that u would like to order
3. Explain the condition to mother and management. (total 4 minutes)
4. Answer examiner's question on follow up of patient. (2 minutes)
Information Sheet to be provided to candidate

Results
• Baby appears well, jaundice extending to umbilicus
• FBE – Hb lower limit of normal, otherwise unremarkable
• Unconjugated Bilirubin – elevated
• Conjugated Bilirubin - normal
• Direct Coombs Test Positive
• Blood group – A positive
• CRP normal
• G6PD Normal
Part 1
The candidate will take a history from the patient’s mother. 2 minutes should be allocated,
maximum time allowed is 3 minutes.
Name: Diamond Sparkle, son’s name is Michael Thatcher
HOPC
• Baby was born 18 hours ago
• Normal term vaginal delivery, nil complications
• Has noticed him being yellow since birth
- If asked where, state has been spreading down chest
• Otherwise has been behaving well, nil concerns
• Full breastfeeding at the moment
• First wet nappy and passed meconium, nil concerns
• Birth weight 3.5kg
• Otherwise has been well
Maternal History
• G1P1 – first baby, normal pregnancy
• GBS positive – given 1 dose antibiotics
• Type O+
Baby
• Doesn’t know blood group
• Normal perinatal scans during pregnancy
• Nil family history of relevant genetic conditions
Marks Allocated Criteria
/4 • Addressed Presenting Complaint

• Established baby’s behaviour, feeding and bowels /
urine
• Perinatal/Birth History
• Maternal History – established blood group, GBS status and family
history
Part 2
“State to the examiner what would be your next steps in managing this baby.”
Marks Allocated
/4 1. Check vital signs

2. Perform examination, mentioning
a. Baby’s level of activity
b. Level of jaundice present
3. Blood tests – FBE, SBR, CRP, blood group, Direct Antiglobulin
Test/Coombs test, G6PD
4. Serum bilirubin should then be checked with a graph for the
treatment threshold for phototherapy
Part 3
Provide information sheet to candidate
“Based on these results, explain the likely diagnosis and its implications to mother.”
Results
• Baby appears well, jaundice extending to umbilicus
• FBE – Hb lower limit of normal, otherwise unremarkable
• Indirect Bilirubin – elevated
• Direct Bilirubin - normal
• Direct Coombs Test Positive
• Blood group – A positive
• G6PD Normal
/4 1. Establish diagnosis is ABO incompatibility

2. Explanation of what blood groups are and how this relates to
mother baby interaction
● Explain antigen-antibodies with A and B blood groups
● Explain that present antibodies in mother (as she is O+)
can travel to her son and cause haemolysis
● (note ABO incompatibility can be present in a first
normal pregnancy due to antibody sensitisation from
food)
3. Explanation of why this results in baby’s jaundice
○ Explain bilirubin is the breakdown of red blood cells and
is what is causing him to be yellow
4. Outline perinatal and postnatal prognosis of baby
5. Overall good prognosis
6. Risk is that the haemolysis causes anaemia, as well as bilirubin
building up causing kernicterus (reassure that this risk is rare
and treatable)
7. With phototherapy this condition will subside and have no
long lasting consequences
/2 • Communication Skills to patient
Part 4
“Despite an initial improvement with phototherapy for the past 2 days, today the baby’s bilirubin
remains elevated. He has also been reported as acting lethargic with a concern of low
temperature. Explain to the examiner what you would do next.”
Marks Allocated
/6 • Candidate must exclude sepsis! (this is based on lethargy,

hypothermia, jaundice, GBS positive mother)
• Re-examine baby – including vital signs, conscious state
(lethargy, irritability, seizures), colour, perfusion, potential
focus of infection
• Should be transferred to appropriate treatment ward – special
care nursery at minimum
• Repeat bloods – include FBE, SBR, CRP, 2 sets of blood cultures, blood
gas, glucose and TFTs
• Antibiotics should be commenced – must say that they are started
without being delayed by investigations
• Recommended antibiotics – IV Benzylpenicillin + gentamicin for 48
hours then reviewed
• Consider increasing phototherapy
• LP if suspecting meningitis or initial blood cultures positive
Total Score /20

You are a GP at a local practice. Riley is a 7 day old girl that has presented with jaundice. She is with her
Mum, Jenn, and Mum, Sam.
TASKS:
1. Take a history from Jenn and Sam (4 minutes)
2. Ask for examination and investigation findings (1 minute)
3. Discuss management with Jenn and Sam, and answer questions (3 minutes)
Contributors: Ashleigh Laird

SIMULATED PATIENT INSTRUCTIONS
Name: Riley Manning

Gender: Female
Age: 7 days old
Ethnicity: Australian
Clinical details:
You are playing the role of Riley's parents, Jennifer and Samantha. Riley has been jaundiced for the last 2 days and it
hasn't gone away.
Presenting statement: “We noticed 2 days ago that she was a little bit yellower than normal, but we
didn't think anything of it, but it's just hung around."
History of presenting complaint

Jaundice: Started 2 days ago on her face. Has now spread to her tummy and arms also.
Nil other symptoms
Feeding: Breastfed every 3 hours. Wakes twice a night for feeding. Often has a little bit of reflux
afterwards. Seems to be full afterwards - won't take anymore.
Breastfeeding has gone well. Had a consultation with the lactation nurse.
Nappies: No changes to wet or dirty nappies.
Growth: Doesn't seem to have lost weight. On the 45th centile.
Sleep: Sleeping really well. Only waking twice in the night for a feed and often goes straight to sleep
afterwards.
During the day she feeds every 3 hours, has a bit of play time after then naps
Probably sleeps for about 18 hours every 24 hours
Negatives
No vomiting or diarrhoea
No rashes or bruising
No fever Development
Normal vaginal delivery at 38 weeks
Differentials No trauma/bruising
Physiological jaundice/Breast feeding jaundice No antenatal complications
Occurs day 3-10 No need for NICU or special care
Sepsis Stayed in for 48 hours after birth because first
No indication of ABO incompatibility baby
Structural Vaccinations - Had hep B and Vit K at birth
Biliary atresia - FTT, Ascites, poor appetite,
jaundice in first few weeks of life Family history
Choledochal cyst - jaundice in first few weeks, Blood type of biological Mum - O+ve
RUQ mass, abdominal pain Nil family history on biological mum's side
Conceived by a sperm donor (apparently nil family
history of any medical conditions)
Social history
Lives at home with Mum and Mum. First child
No smokers in the family

Examination findings:
General inspection - jaundiced baby. head, chest and arms. nil bruising, rashes etc
Head - nil dysmorphic features, no chignon, eyes slightly jaundiced
CVS/Resp - normal, cap refill normal
Abdo exam - Normal, no hernia, no distension/scaphoid
Reflexes - all normal
All else normal
Investigations:
Baby is well and not febrile
Bilirubin (unconjugated and conjugated)
FBE/film/reticulocyte
Group/Coombs
Results: No haemolysis, conjugated bilirubin <15% of total, moderate to high bilirubin level (22mg/dL)
Diagnosis:
Physiological jaundice
Management:
1. Explain diagnosis to the parents
a. Physiological jaundice occurs because the baby's liver now has to process the blood products itself, instead
of relying on the Mum. Usually it should resolve by itself
b. It is more common in breastfed babies
2. Phototherapy
a. Because Riley has a moderate to high bilirubin level, she will be to have phototherapy to help her process
the bilirubin
b. Blue light breaks down the bilirubin to allow it to be excreted in the urine and faeces
c. Can either use the bili blanket for bili light
d. Complications associated - dark urine, diarrhoea, tanning, skin rash, overheating, retinal damage
e. the baby will be undressed and wear an eye mask to protect the eyes
3. Breastfeeding
a. Continue breastfeeding - Riley is a healthy growing baby, no need to stop the breastfeeding.
"What are common causes for jaundice that presents in the first 24 hours after birth?"
Sepsis
Haemolysis
ABO incompatibility
Hereditary spherocytosis, G6PD deficiency

MED4-13 CH Station 5
Station number: 5
Station title: Charlie
You are a paediatric resident. You have been asked to see Charlie with his mother, Danni.
Charlie was born yesterday. The midwives on the post-natal ward have asked you to see
him because he has been vomiting.
 Take a focused history in regard to the presentation (6MARKS)

 Request an investigation and interpret result (2 MARKS)
 Explain to Charlie’s mum the diagnosis (4 MARKS)
 Outline the babies further management / treatment (6 MARKS)

Station number: 5
Station title: Neonatal vomiting (Charlie)
You are Danni, the concerned mother of Charlie. He is your 2nd baby you are an in-patient
on the post-natal ward having delivered him yesterday. Your pregnancy and delivery were
uneventful He was born 2 weeks early and his weight is 3.5kg. His initial baby check done
straight after birth didn’t reveal any issues. He has passed urine normally, but has not
opened his bowels.
However throughout last night he has been vomiting. The midwife has called one of the
paediatric doctors to come and assess him.
In response to the candidate’s questions:
He has vomited 4 or 5 times

You are not sure about the initial vomits but the last one was forceful, large and green in
colour.
You have attempted to breast feed but he doesn’t seem too interested today.
Charlie seems comfortable and not been in any pain.
His tummy looks normal (not blown up / distended)
Your antenatal scans were normal
At 4 minutes
If the candidate hasn’t told you what diagnostic test they will do, ask them what test
Charlie needs to help figure out what is wrong.
The candidate will be given an X-ray
They will explain the diagnosis
Questions you should ask if not already answered
What is the diagnosis?
What treatment does Charlie need?
Does he need any further tests?
If the candidate goes straight to operation ask if other things need to be done before he
has his operation
EXAMINER INSTRUCTIONS
Station number: 5
Any notes made by the candidate to be collected and discarded at the end of the station.
Station construct – tests the candidate’s ability to
 take a succinct history from the mother of a neonate

 make an appropriate diagnosis / differential diagnosis
 counsel mother regarding management
The diagnosis is duodenal atresia. This is suggested by the history of bilious vomiting in a
newborn with no significant pain or distension. The other possibilities are:
Malrotation +/- volvulus

Jejunal atresia
Medical causes of bilious vomiting eg sepsis
The diagnosis is confirmed by the double bubble appearance on the abdominal X-ray.
After the history is taken the role player will ask the candidate if there are any tests that
should be done – you should give them the abdominal X-ray at this point and they will
explain the diagnosis. If they get the diagnosis wrong tell them
“you receive a call from the radiology registrar to tell you that the diagnosis is
duodenal atresia”
No other investigations are required to confirm the diagnosis although a upper GI contrast
is permitted.
The operative approach is a laparotomy (or laparoscopy) and duodeno-duodenostomy.

Other forms of bypass surgery are permitted but outdated (eg gastro-jejunostomy or
duodenojejunostomy)
Outcomes are expected to be good with a 2-3 week hospital stay in most instances. It is
generally an isolated anomaly except when associated with trisomy 21 (30%) making other
major congenital malformations more likely
MARKING SCHEDULE
Station number: 5
History:
1. Are the vomits large / forceful?
2. What colour is the vomit?
3. Is he irritable or in any pain?
4. Has the abdomen been distended?
5. Has he passed meconium?
6. Were the pregnancy / antenatal scans normal?
(6 MARKS)
X-ray:
1. Request abdominal X-ray
2. Double bubble – duodenalatresia
(2 MARKS)
Explanation of diagnosis:
1. Complete obstruction of the intestine
2. Explanation +/- diagram of where the obstruction is
3. Failure of recanalization of duodenum in first trimester
4. No specific cause but associated with trisomy 21
(4 MARKS)
Management:
1. Cannulation / IV fluids for rehydration, replacement and maintenance
2. NG tube insertion on free drainage with regular aspirates
3. Transfer to SCBU / NICU
4. Bloods – FBE / U+E / Cr / group and hold or X-match
5. Chromosomal analysis
6. Referral to a paediatric surgeon for planning surgery
(6 MARKS)
Communication skills
(2 MARKS)
CH OSCE - Prematurity
Objectives:
1. Describe the causes and consequences of prematurity
2. Basic understanding of early, medium and long term management of these babies
Stem
Jerry is a 28 weeks old boy, weighing 1.0kg, born through EMLSCS to Mrs. Smith aged 41 years old. The delivery
was done after Mrs. Smith came to the hospital presenting with PPROM and pathological CTG indicating fetal
distress.
At 5 mins after birth, the baby was noted to have:

• pulse rate of 88 beats/min
• normal respiratory rate of 66 breaths/min with good effort and good cry
• Facial movement with stimulation
• Arms and legs flexed with little movement
• Normal colour with bluish hands and feet
Necessary resuscitation was done and Jerry is currently stable. He is put on an incubator and his vitals signs are
monitored during his transfer to the NICU at a tertiary hospital.
As the attending paediatrician at the hospital, you have taken a history from Mrs. Smith and was told that she had
no antenatal complications and the pregnancy was uneventful. She did not have fever or abnormal PV bleeding
prior to the leaking. However, the previous baby was born preterm as well according to Mrs. Smith.
TASKS:
1. Based on the information given, please calculate the APGAR score of the baby. (1 min)
2. Counsel Mrs. Smith on Jerry’s current condition and explain to her about: (6 mins)
o The risk factors, short and long-term complications of preterm birth.
o The immediate resuscitation done on Jerry and what is monitored at the NICU.
o A brief long-term management needed for preterm babies.
3. Answer some questions from the examiner on prematurity. (1 mins)
Marking sheet
Comments
APGAR score: 6
Prematurity is a condition where the baby/infant is born before 37 weeks of gestation.

- So your baby weighs 1.0kg now, which is extremely low birth weight, so we have to
monitor your baby closely at the NICU.
Risk factors including:

Maternal:
• Previous preterm birth Placenta
• Advanced maternal age
• Low pre-pregnancy weight • Placenta previa
• Acute infection / illness • Placenta abruptio
• Uterine abnormalities (bicornuate) • Placental dysfunction
• Cervical incompetence Others
• Preeclampsia / eclampsia • Smoking
• Previous miscarriages • Alcohol abuse
• History of infertility / IVF • Illicit drug use
Fetal • Heavy physical work
• Multiple gestation • Psychological stress
• Fetal anomalies • PPROM
• Polyhydramnios • Trauma
• Fetal demise/ distress
• Hx of threatened miscarriage
Short term complications:

1. Respi: RDS/hyaline membrane disease, periodic breathing, apnea,
2. Hypothermia, hypoglycaemia
3. GIT: NEC, feeding problems
4. Hepatic: hyperbilirubinemia
5. Cardiac: PDA
6. Neuro: IVH, periventricular leukomalacia
7. Haemato: anemia, sepsis
8. Renal: hyponatremia, hypocalcemia, metabolic acidosis, dehydration
Long term complications:
1. Retinopathy of prematurity
2. Chronic lung disease (bronchopulmonary dysplasia)
3. Osteopenia
4. Neurodevelopmental impairments
Retinopathy of Prematurity - An alteration of the normal retinal vascular development,

mainly affecting premature neonates (<32 weeks gestation or 1250g), which can lead to
visual impairment and blindness. It can occur in neonates treated with any concentration of
oxygen greater than 21%.
Bronchopulmonary Dysplasia - A chronic lung disease, mainly affecting premature neonates,
that develops after oxygen therapy and mechanical ventilation. It is characterised by
decrease in alveolar number and development of cystic changes in the lungs and oxygen
requirement beyond 36 weeks corrected gestation.
Immediate management:
1. ABC
2. Vital signs + SPO2, Blood glucose, ABG, Weight
3. Temperature control (radiant warmer, incubator)
4. Establish IV lines (peripheral IV line, umbilical venous catheter, arterial line, CVP if
indicated)
5. CXR
6. IX: FBC, BUSE creat, Lactate, Septic (blood culture, urine culture), CRP
7. Antibiotics
8. Minimal handling by team
9. Transfer to NICU
In NICU:
1. Monitor baby’s vital signs, cardiorespiratory and oxygen saturation.
2. Monitor baby with continuous amplitude-integrated EEG for cerebral function,
monitor for hypoglycaemia and electrolyte imbalance.
3. Monitor baby in an incubator with environmental humidity and thermoregulation
functions 4 hourly. (gradual weaning from Day 1 - 15)
4. Put baby on respiratory support and maintain SPO2 between 89% - 95%.
• Administer intra-tracheal surfactant if baby has RDS.
• CPAP if baby have apneic episodes (common in babies <32 weeks)
5. Intermittent skin to skin care (benefits: increased physiological stability, longer
periods of quiet sleep, improved self-regulation development, increased breas
feeding incidence and duration, decreased pain perception and reduced stress and
crying).
6. Establish feeding of baby within 90 mins of birth, offer baby feeding every 3 hours.
• If not possible, require parenteral nutrition.
7. Document baby’s urine output, colour, frequency of bowel actions.
8. Discharge when:
a. baby is maintaining temperature
b. feeding well, weight gain of ≥ 3g/day
c. appropriate immmunization and metabolic screening done
d. Fundoscopy and hearing evaluation completed
9. Arrange for home-nursing visits for assessment of mother and baby.
Long term management:
1. Iron supplementation until 6 months corrected age.
2. Multivitamins recommended.
3. Standard immunizations given.
4. Look out for inguinal hernias (in boys).
5. Monitoring of developmental progress.
1. Why do preterm babies have difficulty with thermoregulation?

o Babies have larger surface area to mass ratio, thin skin, lack of keratinized
epidermal barrier, low brown fat store.
2. When should a preterm baby receive their subsequent immunizations?
o Immunizations are given according to chronological age and not adjusted
for prematurity.
MED4200-CH 2014 Main Station 13
Station number: 13
Station title: Sabrina
You have been asked to see Sabrina, a 2 year old, who has presented with her mother
(Naomi) to the emergency department with a three week history of swollen legs and face.
Your tasks for this station are to:
1. Take a history from Sabrina’s mother (4 minutes)
2. Interpret the examination findings at the end of history taking and explain your
provisional diagnosis and management to Sabrina’s mother (4 minutes)
Station number: 13
Station title: Sabrina
Your opening statement is: I am worried about the swellings in Sabrina’s legs and face
You are Naomi Bailey, the mother of Sabrina (age 2). You are concerned about her
presentation but not overly anxious.
The student has been asked to take a history about your daughter Sabrina who presents
to the emergency department with swelling of her legs and face. After receiving
information on the child’s examination findings, the student has also been asked to
explain the likely diagnosis and management plan.
History (4 minutes)
Sabrina (2 years of age) presents to the emergency department with a two-three week
history of swollen legs and facial puffiness. This is gradually getting worse and the degree
of puffiness led you to bring Sabrina in to the emergency department today. Her swelling
was variable in the first week or two and sometimes was not noticeable. Ankle swelling
was particularly bad in the afternoon and face swelling in the morning.
If asked:
• Sabrina has had normal urine output.
• Sabrina has otherwise been in good health attending day-care, playing, in no
apparent pain, and eating/drinking normally.
• Sabrina has had no rashes, no blood noted in her urine, no past history of urinary
tract infections.
• Sabrina is mostly dry during the day (toilet trained) and wears pull-ups to bed.
• Sabrina had a ‘cold’ about a month ago with runny nose and cough but did not
seek medical help at that time. She has otherwise had no infections in recent
months.
• There are no concerns about growth or feeding.
• Developmental profile: at the same level as her brother at that age.
Past History
• Sabrina has no history of allergies, asthma or eczema
• Sabrina’s past medical history: Pregnancy to 38 weeks, Normal vaginal delivery,
well newborn, birth weight was 3.3kg. She has never been to hospital before.
• Antenatal history was unremarkable and ultrasounds were normal.
Immunisation
• Her immunisations are up to date
Medications
• Sabrina has no recent or regular medications
Family History
• The mother has a history of urinary tract infections but there is no family history of
other kidney problems/joint disease/autoimmune disease/ or allergy
• Older brother (5) is well
Social History
• There are no smokers at home
• Naomi and Tom drink alcohol socially (not excessive/not binge)
• You are married to Tom who is a builder. You are a part-time teacher. The children
are in childcare 2 days a week.
• You have good local family support networks.
At 3 minutes – the student will be provided with the clinical examination findings
At 4 minutes – please ask the student “what is wrong with Sabrina?”
• Sabrina’s urine test shows protein (and small amount of blood). This most likely
means that she has Nephrotic syndrome.
• This kidney condition is often preceded by viral illness and will require treatment
with prednisolone (steroids) for a number of months.
• The majority of the time the condition responds to the steroids, however where
this has not occurred, a kidney biopsy may be required.
• A paediatrician or paediatric nephrologist will be asked to advise on further
management.
• Sabrina may require hospitalisation and may require Intravenous protein
(albumin).
• She will need some further blood tests to definitely establish the diagnosis and
may require further treatment.
Possible prompting questions for role player could include: (also use these if the student
states that a specialist is required to determine further management and does not go into
further detail)
• Why has she become swollen?

• What tests will she require?
• What treatment will she require?
• Will she need to be admitted into hospital?
• Can she drink normally?
• Will I have to do anything special when she comes home?
• Will there be further episodes; how can they be prevented/detected?
• Is this condition dangerous/what do I need to look out for?
• What are the side effects of any medications discussed (esp. prednisolone)?
Station construct – this station tests the candidate’s ability to;

1. Take a problem-oriented history.
2. Interpret examination findings and explain to the parent the diagnosis and
management of Nephrotic syndrome.
Examination Findings
Observations: BP 95/55, HR120, Temp 37, Sats 100% RA

Weight: 16 kg (90th percentile) Height 85cm (50th percentile)
Walked with ease into room. Playing with doll on mother’s lap, giggling with simple
games. Well perfused, no rashes. Peri-orbital oedema.
Leg swelling (pitting) bilaterally above knees. Non-tender. Abdomen soft, distended,
ascites present, non-tender.
Chest: good air entry, normal breath sounds, no clear dullness to percussion.
The rest of your examination is unremarkable
Urine dipstick performed whilst in the waiting room: Protein 4+ Blood 1+ Leucocytes nil
Nitrites nil
Management/Explanation
• Sabrina’s urine test shows protein (and small amount of blood). This most likely
means that she has Nephrotic syndrome. ☺
• This condition is often preceded by viral illness and will require treatment with
prednisolone (steroids) for a number of months. ☺
• The condition usually responds to the steroids, however where this has not
occurred, a kidney biopsy may be required. ☺
• A paediatrician or paediatric nephrologist will be asked to advise on further
management. ☺
• Sabrina may require hospitalisation ☺ and Intravenous protein (albumin).
• She may also receive penicillin and aspirin to reduce the risk of infection and
clotting respectively. Ranitidine may also be prescribed.
• In hospital Sabrina will need to be on a fluid balance chart ☺ with no restriction of
fluid intake unless she is drinking excessively ☺. She will have blood pressure and
vital signs checked regularly ☺. She will need to have salt restricted from her diet.
• Sabrina will need to have urine tested daily for protein and recorded. ☺
• After discharge she will need to remain on medication and have her urine checked
at home on a daily basis ☺. She will need regular medical review.
• There is a high probability of further episodes occurring during childhood which
may be diagnosed early with regular urine testing. If relapses occur frequently,
ongoing steroid (or other) therapy may be required. This condition mostly resolves
by adolescence, and overall good long term renal function is expected.
Ix
- Abdo US – Hydronephrosis is not a complication of nephrotic syndrome
Rx
- Steroids – 60mg/kg
MARKING SCHEDULE
This case should easily be recognized as Nephrotic syndrome by the students. The history
taking (and triage observations/urinalysis) should help rule out other potential diagnoses
(e.g. normal blood pressure, only 1+ blood on urinalysis, together with lack of
macrohaematuria, no significant recent infections or no rashes to suggest a “nephritic
state”). Useful information that will help guide management of the Nephrotic syndrome
will also be sought through directed history (e.g. urine output) and routine history (e.g.
immunisation status).
Presenting History: (7 MARKS)

1. Progressive leg and facial swelling ☺
2. No rash
3. No haematuria ☺
4. Normal Urine output ☺
5. Recent viral illness ☺
6. Normal Growth ☺
7. Recent weight gain
Past History: ☺ (1 MARK)
Immunisation: ☺ (1 MARK)
Family History: ☺ (1 MARK)
Examination Findings (no marks)

• This is provided to help the candidate confirm the diagnosis which they should have
made both through reading the triage sheet (information sheet 1) and with the
history.
Explanation of Probable Diagnosis (4 MARKS)

1. Nephrotic syndrome must be mentioned as either the probable diagnosis
or a differential diagnosis ☺
2. Explanation of the Nephrotic syndrome ☺
3. Explanation of the treatment and prognosis of Nephrotic syndrome ☺
Management explanation (6 MARKS)

1. Steroid treatment ☺
2. Urine dipsticking ☺
3. Need for specialised paediatric care ☺
4. Need for admission is not essential but the student should mention that this will
depend on further discussion with paediatrician/nephrologist ☺
5. Fluid balance and salt restriction ☺
6. Renal biopsy if no clinical improvement ☺
Examination Information Sheet
Observations: BP 95/55, HR120, Temp 37, Sats 100% RA
Weight: 16 kg
Walked with ease into room. Playing with doll on mother’s lap,
giggling with simple games.
Well perfused, no rashes.

Periorbital oedema.
Leg swelling (pitting) bilaterally above knees, non-tender. Abdomen
soft, moderately distended, ascites.
Chest: good air entry, normal breath sounds, no dullness to
percussion.
Rest of the examination is unremarkable.
Urine dipstick performed whilst in the waiting room:

Protein 4+
Blood 1+
Leucocytes nil
Nitrites nil
Candidate OSCE stem: This is an 8-minute OSCE station
You are a medical officer in Hospital Baynes. Janisha, a 3 year old girl was brought in to see you by her
mother, Mrs Kaliamah with a presenting complaint of swelling around both of Janisha’s eyes for 4 days
duration.
(a) Take history

(b) Explain to Mrs Kaliamah about the urinalysis result, provisional diagnosis and
investigations required
(c) Formulate a management plan
It was first noticed when Janisha woke up in the morning 4 days ago, but her mother did not think it was
anything serious. She believed that it might be an allergic reaction to some food as she herself had
allergies to prawns with the same presentation. She started to get slightly worried when not only did the
swellings around the eyes not subside, it started to descend to involve the arms and the abdomen
looked mildly distended.
Other than that Janisha had not been as active, but still have good appetite and had no history of fever,
rash, cough, shortness of breath, vomiting or diarrhea in the past few days or weeks. There is no obvious
abnormality in the urine and none of the family members had such condition.
There is no known medical condition. Janisha was delivered naturally at 39 weeks with no complications.
Birth weight is normal at 2.35kg.
Immunisation is up-to-date. She is having the same diet as other family members since she was 2 years
old. She is currently taken care by her mother who is a housewife. Family relationship has been
harmonious without financial problems.
On examination, Janisha is not anaemic, but looked lethargic. Height, weight and head circumference are
according to age. No jaundice or cyanosis.
Vital signs:
Temperature - 37⁰Celcius
Respiratory rate – 25
Pulse rate – 120/min
Blood pressure – 100/70 mmHg

Urine dipstick results
Leucocytes – Normal
Nitrites – Negative
Protein - +++
pH – Normal
Blood – Negative
Specific Gravity – Normal
Ketones – +
Bilirubin – Negative
Glucose – Negative
Blood Results
Electrolytes - Normal
Serum albumin – 18g/L
Lipid profile – Normal
ASOT – Negative
C3,C4 - Negative
Answers: CH OSCE- NEPHROTIC SYNDROME
Points Inadequate Moderate Well done
Explain diagnosis:
- Nephrotic syndrome
- Common condition affecting particularly children less
than 12 years of age
- Abnormality in kidney filtration system as the filtering
gap widens to allow proteins to be leaked out in the
urine
- Aetiology unknown, but genetic factor plays a role
- Reassure that most likely to respond to tx (steroids),
but high chance of recurrence
Management plan:
- Admit to hospital
- Daily weight measurement, daily urine dipstick
- No extra salt, ensure adequate calories in diet
- Strict fluid balance
- Consider IV 20% albumin and furosemide if
intravascular volume depletion/ symptomatic oedema
eg pulmonary edema
- Prophylaxis antibiotics Penicillin V 12 hourly
125mg/dose. Ranitidine for prednisolone induced
gastritis
- Low dose aspirin if significant oedema
- Prednisolone to induce remission (start 60mg/m2 for
4 weeks, slowly taper)
- Family education. Booklet, remind to test urine for
protein for 1-2 years, note down in diary. Weight
checked daily
- Prevention by immunisation (12 valent conjugate
pneumococcal vaccine)
- Referral to nephro if failure to respond for 2 weeks or
frequent relapses or diagnosis uncertain
Reinforcement, support group and pamphlet, plan for next
follow up
Station title: Stitch

You are the Accident and Emergency medical officer in a metropolitan hospital.
You are requested to see Stitch, a 4-year-old boy who presents to the ED with a
4-day history of flu, cough and fever. According to his mother, Lilo, he has had a
runny nose for 4 days, a cough for 2 days and developed noisy breathing 3 hours
earlier. His mother feels that he is getting progressively more breathless.
His father had a cold the previous week. He is otherwise well but has troublesome
eczema which is treated with emulsifiers and steroid creams. His mother states that
he is allergic to peanuts, as they lead to a deterioration of the eczema within 1– 2
hours. He avoids peanuts and all types of nuts.
A nurse has kindly acquired the following information and hand it to you:
Allergies: Peanuts
Family history: 8-year-old sister has asthma
Past medical/surgical history: Eczema
Medication: Emulsifiers and steroid creams
Developmental milestone: Normal for age
Birth history: 3.4kg, no complications
Tasks:
1. Take a focused history from Stitch’s mother, Lilo, to elicit the cause of his
distress. (5 minutes)
2. Counsel Lilo on Stitch’s management. (3 minutes)
question, you will be handed the examination findings)
(Upon completion of 2nd
1. Introduction and rapport

● Appropriate introduction
● Clear simple (non-jargon) language, clear explanations
● Non-judgemental, patient centred, open-ended questions
● Empathy, good body language
● Address concern of patient
● Organised and systematic
2. Elicit and record of accurate relevant clinical history

a) HOPI
● Previously well child, sudden onset of symptoms
● Noisy breathing / Stridor
o When: Three hours ago
o Characteristic: not sure inhaled or exhaled
o A/W: Cough (sounds like barking), fever, hoarse voice
o Aggravating factor – worse at night, and lying down
o Alleviating factor – tried syrup PCM but didn’t help
● No previous similar episodes
● Activity: during the past 1 day - disinterested in playing & very lethargic
● Feeding: not able to tolerate food now
● No peanuts ingestion
b) Systematic review
● Respiratory – whitish sputum, breathlessness
● Cardio – no chest pain, nothing significant
● GI – no abdominal pain / constipation / diarrhoea / nausea / vomiting / stool changes
/ distension
● No travel history, hx of outside food.
● Other systems review: Nil
c) Other histories
● Birth: term, SVD, BW 3.4 kg, no complications, discharged with me
● Immunization: up to date
● Diet: balanced diet.
● Development: normal
● Social: taken care by me, I’m a housewife
3. Task 1: What are your differential diagnoses? (30 seconds)

● Laryngotracheobronchitis (Croup)
● Inhaled foreign body
● Anaphylaxis
● Epiglottitis
● Severe tonsillitis
● Bacterial tracheitis
4. Task 2: Counsel Stitch’s mother, Lilo, on the management (3 minutes)

a) Explain diagnosis
i. Croup is a common viral infection of the upper airway at the level of the throat,
namely the voice box (larynx) and windpipe (trachea). It is a special problem in
children, who normally have narrow air passages, and usually occurs from 6
months to 3 years of age but can occur up to 6 years or so. The younger the child,
the more susceptible he or she is to croup. It tends to occur in the winter
months.
ii. PROGNOSIS: Croup is usually a mild infection and settles nicely; however, in
younger children it can sometimes cause complete airway obstruction, which is
rapidly fatal. These children need to be in hospital to have specialised treatment
and occasionally an airway tube inserted.
b) Investigations
i. nasopharyngeal airway, CXR, blood tests are NOT usually indicated and may
cause the child distress and worsening of symptoms
c) Treatment
i. Avoid distressing the child further.
ii. Admit if severe
iii. Supplemental oxygen is not usually required. Consider if severe airways
obstruction.
iv. Mild to Moderate Croup
1. Oral Prednisolone 1mg/kg, AND prescribe a second dose for the next evening
OR
A single dose of Oral Dexamethasone 0.15mg/kg.
v. Severe croup
1. Nebulised adrenaline: 5 mL of 1:1000 (5mg) adrenaline, undiluted.
AND
Give 0.6mg/kg (max 12mg) IM/IV dexamethasone
d) Discharge
i. Four hours post-nebulised adrenaline (if given) and/or half an hour post oral
steroid, and stridor free at rest
e) Self-care:
i. Give the child paracetamol for fever.
ii. Offer frequent drinks.
iii. Antibiotics will not help, because croup is caused by a viral infection
EXAMINATION FINDINGS
General Examination:
● General: conscious, irritable and lethargic
● Temperature: 38.0°C
● HR: 116/min
● RR: 52/min
● BP: 110/70
● O2 saturation: 89% in room air
Chest examination:
● Loud noisy breathing on inspiration
● Inspection: Supracostal and intercostal recession.
● Auscultation: no crackles or wheezes
FURTHER INFORMATION
Viral Croup – 6 months to 6 years old, peak 2 years old. (Sunflower)

● mucosal inflammation and increased secretions affecting the airway, with oedema of
the subglottic area.
● accounts for over 95% of laryngotracheal infections.
Aetiology (Paeds Protocols)

● A clinical syndrome characterised by:
• barking cough
• inspiratory stridor
• hoarse voice
• respiratory distress of varying severity.
● A result of viral inflammation of the larynx, trachea and bronchi, hence the term
laryngotracheobronchitis.
● The most common pathogen is parainfluenza virus (74%), (types 1, 2 and 3).
● The others are human metapneumovirus, RSV, Influenza virus types A and B.
Indications for Hospital admission (Sunflower & Paeds Protocols)

● Moderate and severe viral croup.
● Age less than 12 months.
● Poor oral intake.
● Toxic, sick appearance.
● Ease of access to hospital.
● Parental understanding and confidence.
Candidate
You are a member of the paediatrics team. Lisa is a 7 year old girl who has presented to ED with
wheeze on a background of known asthma. The emergency department has provided the following
information:
HOPC: Brought in by her parent Andy/Anna this morning by car. Wheeze started since last night.
Parent tried giving 2 puffs of Ventolin to Lisa every few hours (no spacer) with no noticeable
improvement. Has had symptoms of viral URTI for the past 5 days, nil fever.
Past History
• Asthma – no previous admissions to ED, has missed school days due to asthma. Managed by GP.
• Eczema – known family history
• Immunisations up-to-date
• Normal growth and development
Social History
• Lives with mom, dad and 3 year old brother in Gippsland, 1 hour away from your hospital
• Parent known smoker, tries to smoke outside
• Andy/Anna is concerned about Lisa’s asthma affecting her activity at school – both exercise and
missing school days. Also worried about her not having good sleep.
Within the 8 minutes you are required to do the following:
1. When prompted, explain to the examiner what you would be looking for on clinical
examination, which would determine the severity of her asthma attack.
2. The examiner will then provide you with additional information. Based on this state to the
examiner what would be your next steps in acute management.
3. After prompting by the examiner, explain to Lisa’s parent an appropriate asthma action plan
which addresses the pertinent issues with Lisa’s asthma control.
Patient/Examiner
The candidate has been provided the following information:
You are a member of the paediatrics team. Lisa is a 7 year old girl who has presented to ED with
wheeze on a background of known asthma. The emergency department has provided the following
information:
HOPC: Brought in by her parent Andy/Anna this morning by car. Wheeze started since last night.
Parent tried giving 2 puffs of Ventolin to Lisa every few hours (no spacer) with no noticeable
improvement. Has had symptoms of viral URTI for the past 5 days, nil fever.
Past History
• Asthma – no previous admissions to ED, has missed school days due to asthma. Managed by GP.
• Eczema – known family history
• Immunisations up-to-date
• Normal growth and development
Social History
• Lives with mom, dad and 3 year old brother in Gippsland, 1 hour away from your hospital
• Parent known smoker, tries to smoke outside
• Andy/Anna is concerned about Lisa’s asthma affecting her activity at school – both exercise and
missing school days. Also worried about her not having good sleep.
There are 3 parts to this OSCE. Part 2 has an information sheet to be provided to the candidate
once part 1 has been completed.
Part 1
As examiner: “Can you outline to the examiner what you would be looking for on clinical
examination to determine the severity of Lisa’s asthma attack?”
Marks allocated Criteria

/4 • Mental state – alert/agitated/drowsy
• Tachycardia
• Work of breathing
- Tachypnoea
- Tracheal Tug
- Intercostal recession
- Subcostal recession
- In younger cases than this – nasal flaring, grunting, head bobbing
• Ability to talk – sentences, phrases, single words, none
Note
• O2 saturation while requiring management does not necessarily indicate
severity
• Wheeze is a poor indicator of severity – a silent chest in a severe case can
represent very poor air entry
Part 2
Provide clinical examination information sheet to candidate
State “Based on Lisa’s history and the examination as provided, state to the examiner what would
be your next steps in managing Lisa’s acute asthma attack”
Patient has received 12 puffs of Ventolin 10 minutes ago
HR 130 (Normal 80-130)

BP Normal
O2 95% RA
RR 38 (normal 16-34)
• Patient is alert and orientated

• Marked difficulty in speaking words
• Demonstrates mild tracheal tug and moderate intercostal recession
• Lung Examination shows widespread polyphonic wheeze bilaterally

/6 Candidate should identify this is at least a moderate and likely severe
attack.
• Patient will require admission to paediatrics

• Oxygen therapy is only required below 92%
• Give salbutamol+atrovent burst
- Within 1 hour give 12 puffs salbutamol and 8 puffs atrovent every 20
minutes (as patient is >6 years old)
- Give via MDI/spacer
• Continue after with salbutamol as needed – every 1 hour and stretched
to 3-4 hours before discharge
• Give oral prednisolone
- 2mg/kg for first dose, then 1mg/kg for next 2 days
• If patient is still unresponsive and/or condition deteriorates, consider IV
MgSO4 and calling senior staff and ICU involvement
Note
• Candidate should not recommend CXR or bloods unless there is pertinent
indication to consider alternative diagnosis
• When properly used, spacer is just as effective as nebulised form (use
nebulised if they need O2 hudson mask at same time)
Part 3
State to candidate “Now that Lisa’s asthma attack has settled, explain to Lisa’s parent your asthma
action plan that addresses Lisa’s specific issues with asthma control”
Marks allocated Criteria

/8 Recognition of symptoms
• Wheezing/chest tightness/shortness of
breath
• Should address that sleep disturbance and
night cough also constitutes an asthma
attack
Correct dose of ventolin
• As required by asthma symptoms, not a
daily dose
• Mild 2 puffs Ventolin or more severe 12
puffs Ventolin (for >6 years old), trial every
15-30 minutes
Recommend spacer
• State will be taught with asthma education
When to present to doctor and emergency
• If concerned or worried
• Poor response
• Requiring Ventolin <3 hourly
• Wheeze >24 hours
• Recommend ambulance
Consider giving prednisolone instructions for
home (as family lives 1 hour away from
hospital)
• 1mg/kg 3 days
Exercise
• If Lisa is having known exercise difficulty
due to asthma, consider giving 2
prophylactic puffs of ventolin
Smoking
• Mom should stop smoking
Follow-up
• Arrange to see GP
• Consider referral to paediatrics outpatient
for long-term asthma control
Preventer
• Consider daily preventer if asthma
symptoms continues to not be controlled
/2 Communication – should explain management
in simple terminology to patient
Total Score /20
Pass Borderline Fail

Part 2 – Clinical Examination to be provided to candidate
Patient has received 12 puffs of Ventolin 10 minutes ago
HR 130 (Normal 80-130)

BP Normal
O2 95% RA
RR 38 (normal 16-34)
• Patient is alert and orientated

• Marked difficulty in speaking in words
• Demonstrates mild tracheal tug and moderate intercostal recession
• Lung Examination shows widespread polyphonic wheeze bilaterally
STATION #4: Paediatric station #1
STEM
Jeremy is a 6 week old that has been brought in by his parents who are concerned
that he is not putting on enough weight. Jeremy currently weighs 3.6kg (2nd centile).
Take a history from Jeremy’s mother/father (Jane/John). (4 minutes)

The examiner will then ask you some questions.
Thanks to Julian David Stanley Segan for help with this station
STATION #4: Paediatric station #1
Failure to thrive
STEM
Jeremy is a 6 week old that has been brought in by his parents who are concerned that he is
not putting on enough weight. Jeremy currently weighs 3.6kg (2nd centile).
Take a history from Jeremy’s mother/father. (4 minutes)

The examiner will then ask you some questions.
Marking sheet
Scoring criteria: Candidate should cover at least 10 of the main dot points to receive full
marks (10).
▪ For every question under 10 that is missed, subtract 1 mark.
◊ Feeding history:
● Being breast fed – appears to be attaching well
● Feeds 7-9 times a day, apparently normal volume
◊ No diarrhoea or vomiting
● Stools appear oily and are foul smelling
◊ Normal number of wet nappies (change 4-5 times a day)
◊ No fevers
◊ Past medical history:
● Bronchiolitis at 1 week
● Developed pneumonia subsequently – was treated in hospital for 10 days
◊ No relevant family history
◊ Did not undergo newborn screening
◊ Normal pregnancy and birth (NVB) at 39 weeks
● Did not need any time in special care nursery after birth
● Passed meconium? – yes in first day
● Prolonged neonatal jaundice? - no
◊ Weight of 3.5 kg at birth
◊ No antenatal complications
◊ Social history: Lives at home with mum and dad, no siblings
◊ Development:
● Gross motor – does not raise head to 45 degrees
● Vision and fine motor – does not follow moving objects
● Social – smiles responsively
Further Questions
1. Give some differential diagnoses. What is the most likely? (2 marks)
Candidate should list at least 3 for 1 mark, should identify CF as most likely for 1 mark.
● Cystic fibrosis
● Chronic infection (eg. caused by immune deficiency)
● Malabsorption of other cause (eg. short gut syndrome)
● Insufficient breast milk
● Other cause of inadequate nutrient intake (eg. infant difficult to feed)
● Impaired suck/swallow
● Metabolic disorder (eg. storage disorder, amino/organic acid disorder)
2. Explain the basic pathophysiology of the disease (Cystic Fibrosis) (3 marks)
Candidate should get at least 4 of the following points for full marks. You can prompt
candidate if needed (eg. what is the inheritance?).
● Autosomal recessive disease

● Mutation in a gene (on chromosome 7) that codes for protein CFTR
● CFTR is a chloride channel blocker
● Due to abnormal ion transport in exocrine glands (decreased chloride), there is an
increased viscosity of secretion in these glands
● This results in dysfunction of many systems including respiratory, pancreatic, biliary etc.
3. What investigations could you do to confirm this diagnosis? (1 mark)
Half mark for each point below. Examiner can prompt student on second point if not offered
voluntarily.
● Sweat chloride test (elevated sweat chloride >60mmol/L of two occasions)

● Can confirm with DNA testing if results of sweat test are inconclusive (looking for CFTR
mutation)
4. How would neonates normally be diagnosed? (1 mark)
● Part of neonatal screening – looking for elevated blood trypsin (IRT – immunoreactive
trypsin)
5. List 3 principles of future management for this disease (3 marks)
● Maintaining/optimizing lung function

o Airway clearance
o Chest physiotherapy
o Bronchodilator therapy
o Prophylactic antibiotics (flucloxacillin)
o Rescue antibiotics for any infections
o Mucolytic agents
● Nutritional therapy to maintain adequate growth
o Enzyme supplements/replacement therapy
o Multivitamin/mineral supplements (eg. vitamins A,D,E,K)
o Nutritional support (eg. higher caloric diet)
● Managing complications (eg. pneumothorax, nasal polyps, diabetes, osteoporosis etc)
OVERALL MARK
FAIL BORDERLINE CLEAR PASS
Patient script
Demographics
Baby’s name: Jeremy. Mum = Jane (teacher), Dad = John (teacher).
Jeremy is a 6 week old that has been brought in by his parents who are concerned that he is
not putting on enough weight. Jeremy currently weighs 3.6kg (2nd centile).
◊ Feeding history:
● Being breast fed – appears to be attaching well
● Feeds 7-9 times a day, apparently normal volume
◊ No diarrhoea or vomiting
● Stools appear oily and are foul smelling
◊ Normal number of wet nappies (change 4-5 times a day)
◊ No fevers
◊ Past medical history:
● Bronchiolitis at 1 week
● Developed pneumonia subsequently – was treated in hospital for 10 days
◊ No relevant family history
◊ No known allergies
◊ Parents do not smoke in the house
◊ Did not undergo newborn screening
◊ Normal pregnancy and birth (NVB) at 39 weeks
● Did not need any time in special care nursery after birth
● Passed meconium? – yes in first day
● Prolonged neonatal jaundice? - no
◊ Weight of 3.5 kg at birth
◊ No antenatal complications
◊ Social history: Lives at home with mum and dad, no siblings
◊ Development:
● Gross motor – does not raise head to 45 degrees
● Vision and fine motor – does not follow moving objects
● Social – smiles responsively
CH OSCE
You are the paediatrician on call in the emergency department when suddenly Ms Darwin
brings her 4 month old baby girl in. She complains that her daughter has been having
diarrhoea for the last 2 days.
Candidate instructions:
1. Take a focused history (4 mins)
2. After you finish the history, the examiner will show you the examination and
investigations findings.
3. State your management (Briefly). (2 mins)
4. Counsel the patient’s mother. (2 mins)
Show to students at 4 minutes

- Infant appears irritable and ill-looking
- Vital signs: T 38.9, HR 170, RR 60, BP 70/50
- Skin appeared ‘doughy’
- Dry lips and dry buccal mucosa
- Soft fontanelle
- Capillary refill time is increased
- Dual heart sounds, no murmur
- Normal breath sounds, no additional sounds
- Distended abdomen
History
- Diarrhoea
● Onset: 2 days ago
● 5-6x/day
● Stools are watery in nature
● Not blood stained
- Vomiting present
● Non-bilious , non-projectile, food particles
● 2x since yesterday
● Not blood stained
- Baby seems irritable, crying a lot (tears decreased)
- Slightly feverish, onset same as diarrhoea
- Feeding is decreased
● Used to take milk (breastfed) 3hrly
● Now refuses to feed
● Mother attempted to feed infant with soup
- No respiratory or other abdominal symptoms
- No rash, fits
- Urine output normal + not reduced (changes diapers 4-5x/day)
- No history of recent travel
- No sick contact or recent travel
- Birth – term, 3.2kg, SVD, uncomplicated

- Immunizations up to date (based on government schedule, did not take
immunisations in the private sector)
- Diet – breastfed 3hrly since birth
- Developmentally not delayed
- Social – attends daycare because mother has to work.
Management
1. Immediate fluid resuscitation – 20mL/kg with normal saline
2. Admit patient for IV rehydration therapy
3. Fluid maintenance therapy
4. Must mention hypernatremia and how fast you want to correct the fluids
5. Monitoring
a. Clinical assessment of dehydration
b. Weight – before therapy and daily afterwards. 6 hourly in children with
ongoing losses
c. Serum electrolytes and glucose – before therapy (draw blood when IV line
inserted) and again after 24 hours. 4-6hrs after onset in more unwell children
d. Input/output chart
At 6 minutes, tell the student

“Baby progresses well in the next 48 hours. She has no vomiting and is tolerating her
feeds. She has passed 2 loose stools, half diapers full. Mother requests for discharge.
Please counsel the mother.”
1. Let mother know if baby is fit for discharge or not – in this case, yes.
2. How to give ORS regimen
a. Give 10mL/kg for mild dehydration, 20mL/kg for moderate dehydration
b. Fluid to be given over 4-6 hours
c. Use syringe to measure amount given, roughly 5mL sips every few minutes.
d. Replace ongoing losses: 10mL/kg for each watery/loose stool and 2mL/kg for
each emesis.
3. Start feeding as usual
a. Continue normal diet including breastfeeding. Bottle-fed babies should be fed
normal full-strength feeds (do not dilute!).
4. Possible complications
Sugar intolerance · Commonest in infants <6 months
· Persistent diarrhoea after feeds are reintroduced
· With carbs intake – stool is watery, frothy and excoriates
buttocks
· Perform reducing sugars test on stools
Lactose intolerance · Clinitest tablet into liquid stool – positive test >0.5%
indicates lactose or glucose malabsorption but not sucrose
(a reducing sugar)
· Should resolve in 4 weeks
· If does not resolve, a carbohydrate free feed + glucose +
fructose should be given temporarily
5. Prevention techniques – hand hygiene, vaccines

a. Yes, vaccination after the first episode is recommended.
b. There are 5 predominant rotavirus strains that has the potential to infect your
child. Recovery from the first rotavirus infection usually does not lead to
permanent immunity. Reinfection can occur at any age. Subsequent
infections confer progressively greater protection and are generally less
severe than the first. First infection after 3 months of age is generally the most
severe.
6. Do not give anti-diarrhoeals
7. When to bring back
a. Not drinking but still has vomiting and diarrhoea
b. If there is a lot of diarrhoea (8-10x/day)
c. Diarrhoea >10 days
d. If there is blood in stools/bilious vomiting
8. Follow-up – the next day if possible.
You are a paediatric registrar seeing a 4 month old baby boy, Jonah, in the Emergency department. His
Mum, Jenny, has brought him in because he doesn't have as much baby fat as his older brother did
when he was his age
TASKS:
1. Take a history from Jenny (4 minutes)
2. Answer some questions from the examiner (4 minutes)

Name: Jonah Baker

Gender: Male
Age: 4 months old
Clinical details:
You are playing the role of Jonah's Mum, Jenny. You are a concerned parent.
Presenting statement: “Jonah just doesn't seem to be as chubby as other babies and I'm worried he will
get cold without his fat."

The MCHN said he isn't putting on much weight
Was 3.1kg at birth, now he weighs 5kg. Has not put on any weight the last 3 weeks
Feeding
Very regularly - he only seems to have small feeds so i just do it more often - like every 1.5-2
hours
He gets quite irritable after feeding
Vomits after feeding - yellow/milky colour, not green, no blood
Hasn't really been wanting to feed the last few weeks, I'm had to keep on putting him on the
breast and he only has little bits
Nappies
Decreased wet and dirty nappies
Associated symptoms
only if asked - Has a cough - he's had it for a while
No fever
No diarrhoea
No apnoeas
Differentials Development
Coeliac/malabsorption Normal vaginal delivery at 38 weeks
No diarrhoea, no smelly stools No trauma/bruising
Heart failure No antenatal complications
Not struggling to breath No need for NICU or special care
No cyanosis noted Vaccinations - Had hep B and Vit K at birth
Gastroenteritis
No sick contacts Family history
No diarrhoea Blood type of Mum - A+ve
Vomiting only after feeding Nil family history
no fever
Decreased intake Social history
only having small feeds - although regular Lives at home with Mum and Dad and older brother,
GORD Joe. Second child
Irritable after feeding, growth reduced Dad smokes - not near kids
Vomiting/reflux

"What are your differential diagnoses?"
GORD
Coeliac
Heart failure
"Conduct an examination"
General inspection: Irritable baby, small for age, normal pallor, normal vitals
Abdomen: soft, non-tender
Cardio: clear, dual heart sounds, no murmur
Respiratory: clear, no wheeze, slight cough
Interpret the Growth chart provided

Born at 3.1kg which is just above the 15th percentile.
At 3 months, drops off the 15th percentile
At 4 months, has crossed the 3rd percentile, indicating failure to thrive.
"What is your diagnosis?"

GORD
"How would you manage this child?"
a. GOR is reflux of the stomach contents into the oesophagus (aka throat), which can cause discomfort
b. GORD is when the above occurs but also results in complications such as poor weight gain
2. Management
a. Sit upright after feeds
b. Smaller more frequent feeds - like you have started doing
c. Can use thickeners in feeds
d. If bottle fed - keep the teet full of milk to avoid them drinking air
e. Eliminate smoking in or around the house
f. PPI (omeprazole) - 5mg once daily

MED4200 Mock OSCE
Station No:
Station title: Mark Campbell
You are a junior doctor in the paediatric outpatient clinic. Mark Campbell, aged 5 years, has been
referred to outpatients by his general practitioner. His mother Jackie is worried that Mark has started
soiling over the past few weeks.
Your task is to:
1. Take a focussed history (4 minutes)

2. Review examination findings provided (1 minute)
3. Explain your diagnosis and management plan to his mother (3 minutes)
Copies of candidate instructions will be given to the student, Sim Patient and the examiner.
3
MED4200 Mock OSCE
Station No:
You will be provided with copies of the candidate and role player instruction sheets.
Gender: female
Age: 30
You are Jackie, mother of 5 year old Mark.
Clinical details:
For the past 6 weeks, Mark has been soiling himself. His stools are semi-liquid, and foul-smelling. He
is soiling up to several times a day and occasionally also at night.
Three months ago he had a problem with his bowel motions. They were hard and difficult to pass, and
caused him bleeding and pain when he went to the toilet; given laxatives at the time and seemed to
improve.
You are unsure how often he is toileting, he is becoming secretive and hiding his soiled underpants.
Mark has a good appetite with well-balanced diet generous in fruits and vegetables
Mark has no stomach pain no pain or bleeding from the bottom currently. He has no fever, doesn’t
feel sick or vomit. He has not travelled or been in contacts with anyone unwell.
Mark is otherwise well and has had no weight loss you are aware of.
Development
• Fully toilet-trained at 3 yo
• Met developmental milestones at appropriate times
He is a good student with no concerns raised at school about his learning ability.
Past history
Mark was born at term by normal delivery with no problems at birth.
His immunisations are up to date and has no allergies.
Medication
None currently; had laxatives 3 months ago for a short time (see above)
Family history nil
Social
Mark lives with both parents and his younger sister, Meggie aged 2 years. You and his father are both
actively involved in child care. You and his father don’t smoke but drink alcohol socially.
Mark enjoyed school prior to recent issue with many friends. He is now teased often and doesn’t want
to go to school.
4
MED4200 Mock OSCE
Mark’’s father is a graphic designer who works at home, you are full-time at home but work as a
teacher’s aide at school ½ day per week. There are several young families in the neighbourhood who
help each other out as needed.
Copies of Simulated Patient instructions will be given to the Sim Patient and the examiner.
How to start the role-play:
I’m getting very concerned about Mark's constant soiling over the past six weeks. It's very
unlike him.
How to play the role:
You are a concerned mother who is understandably concerned about the change in her son
and the impact it is having. You are keen to find a solution to this problem.
5
MED4200 Mock OSCE
Examination findings
• He appears shy and withdrawn
• Height & weight both on the 50th percentile
• Abdomen is soft, non-tender with faecal mass palpated left lower quadrant
• Anus appears normal with no fissures or rash, although some faecal staining
present
• Neurological examination normal
6
MED4200 Mock OSCE
MARKING SCHEDULE
Station No:
Serious
errors and
omissions: All important
No attempt,
Inadequate Adequate, areas covered;
or very
SKILLS skill for year but minimal Excellent
cursory
level or incomplete omissions or
adverse errors
effect on
outcome
Communication Skills 0 1 2
• Empathic approach
• Appropriate use of
language
History 0 2 4 6 8
• Thoroughly explore the
presenting complaint
and associated
symptoms:
• Elicit pattern of stooling
currently as well as
prior bowel habits,
including episode of
constipation 3 months
ago
• Elicit associated
pertinent positives and
negatives
• Enquire about other
relevant review of
systems symptoms (eg.
urinary habits)
• Elicit developmental
history, including social
behaviours and
intellectual
development
• Elicit PMHx, FHx and
SocHx In addition, a
good student may:
• Explore the home and
school situation and
evaluate social
dynamics
• Enquire about carer
concerns
8
MED4200 Mock OSCE
Explanation of Diagnosis 0 1 2 3 4
• Constipation with
overflow (encopresis)
• Likely constipation
started following
episode of painful
defecation
• Due to pressure build
up, liquid stool may
leak around the
obstruction causing the
uncontrollable soiling
• Stretching of the
internal and external
anal sphincter and
chronic distention of the
rectum leads to the
inability to sense the
urge to defecate
Management 0 1 3 4 6
• Investigations rarely
needed
• First, need to relieve
obstruction and empty
colon
• Establish regular bowel
evacuation habits using
stool softeners and
laxatives to achieve 1-2
soft stools per day to
avoid painful defecation
(usually continued for
several months)
• Use of behaviour
modification measures
• Regular clinic follow-up
to check progress
Global Scoring:
  
Clear Fail Borderline Clear Pass
9
MED4200 Mock OSCE
Station No:
Station title: Gayathri
Gayathri, an 8 year-old girl of an indigenous background, has been rushed in to the

emergency department by her mother, Liz. She is drowsy and has just vomited.
The triage nurse has done some observations:
Temperature 38.2°C
HR 165 bpm
BP 90/50 mmHg
RR 45 per minute
TASKS:
1. Take a focussed history. (4 minutes)

2. Interpret investigation findings for the examiner. (1 minute)
3. Explain management to the examiner. (3 minutes)
3
MED4200 Mock OSCE
Station No:
Gender: female
Age: 35
You are Liz, mother of Gayathri, aged 8.
Clinical details:
Gayathri’s teacher asked you to collect her early from school three days ago because Janey wasn't
well.
Over the past two weeks Janey has had a cold, but over the past couple of days she has deteriorated
and today she started vomiting.
Gayathri has been off her food over the past few days and she complains of tummy pain and she has
been drinking a lot of water. She has been drowsy over the past 24 hours.
You have noticed her breathing isn’t normal (too fast) today and you have noticed an strange smell
about Gayathri.
Gayathri has had no cough no rash no fear of bright light or neck pain.
She has had no recent injury, and no bowel or urine problems that you've noticed but Gayathri goes to
the toilet by herself so unless she mentions something you wouldn't know. She seems to have lost
weight recently.
Development
• Fully toilet-trained at 3 yo
• Met developmental milestones at appropriate times
• Average student at school
Past medical problems

• Gayathri has no significant medical problems other than normal childhood illnesses including
colds, bronchitis
• Term delivery with no problems
• No prior hospitalizations, chronic conditions or surgeries
Her Immunizations are up to date.
She is not on any medication.
Gayathri’s grandmother has type 2 diabetes
You separated amicably from the children's father a year ago and your live with your two children.
However their father takes an active role with the children's care. There is no tobacco, alcohol or drug
use in the home.
4
MED4200 Mock OSCE
You work part-time in a shop and have returned to university to study. Your mother helps you take
care of your children.
Copies of Simulated Patient instructions will be given to the Sim Patient and the examiner.
I’m really worried. My other kid has never looked like this.
You are an extremely concerned but sensible mother.
5
MED4200 Mock OSCE
INVESTIGATION RESULTS
Dipstick urine glucose + + +

ketones + + +
leukocytes & nitrates absent
Pulse oximetry 98% (on room air)
Venous blood gas:
pO2 45 mmHg
pCO2 28 mmHg (35 – 45 mmHg)
pH 7.07 (7.35 – 7.45)
HCO3 - 12 mmol/L (22 – 26 mmol/L)
Blood:
Na+ 128 mmol/L (135-145 mmol/L)
K+ 5.1 mmol/L (3.5-5.0 mmol/L)
Cl- 92 mmol/L (95-107 mmol/L)
Urea 10 mmol/L (3-8 mmol/L)
Glucose 70 mmol/L
Osmolality 335 mOsm/kg (275-299 mOsm/kg)
Toxicology Negative
Urine:
Toxicology Negative
6
MED4200 Mock OSCE
Station No:
Station construct – this station tests the candidate’s ability to:
• Take a focused history

• Interpret examination findings
• Discuss a management plan
EXAMINERS’S ROLE:
• The examiner should brief the role player before the exam begins to check his/her
understanding of the case and answer any questions he/she may have.
• Examiners should correct the role player between students if he/she is not
reproducing the role as written. In the event that there is a significant discrepancy
between the written and portrayed roles, details of the student(s) should be
recorded and given to the coordinator for the venue, so that the assessment team
can be advised.
• For consistency and equality across sites the only guidance an examiner may offer a
student who is ‘going off at a tangent’ is to invite them to: “please reread the
instruction sheet”. If they persist in doing the wrong task the examiner may repeat
the advice to “please reread the instruction sheet” they must not tell the student
what they are doing wrong.
• Any notes made by the candidate are to be collected and are to be given to the
staff overseeing the assessment at the end of the session.
7
MED4200 Mock OSCE
MARKING SCHEDULE
Station No:
Serious
errors and
No attempt,
or very
cursory
adverse errors
effect on
outcome
• Demonstrate
empathy
• Use of appropriate
language
History 0 2 4 6 8
• Thoroughly explore the
presenting complaint
and associated
symptoms
• Assess severity of
presentation, including
hydration
• Elicit pertinent positives
and negatives
• Enquire about other
relevant review of
systems symptoms
• Elicit PMHx, FHx and
SocHx
Investigations 0 1 2
• Interpretation: primary
metabolic acidosis
with respiratory
compensation
• Hyperglycaemia and
ketosis
• Apparent
hyponatraemia
Diagnosis 0 1
• Diabetic ketoacidosis
Management – initial 0 2 4 5 7
• Recognise that the patient
is very unwell
• Ensure airway is secure.
8
MED4200 Mock OSCE
• Check breathing and

circulation
• assess conscious level
• commence intravenous
fluids to treat any shock
and then rehydrate
• start insulin infusion
• replace potassium after
commencing insulin
• Monitor glucose,
electrolytes, blood gases
and mental status
frequently (initially hourly)
with strict fluid balance
Global Scoring:
  
9
OSCE Station
Mrs. Lee, mother of Lily, a 3-year-old has come in to your GP

clinic after Lily started vomiting profusely over the last 2
hours. The mother looks anxious. Lily who is sitting on her
mother’s lap is able to hold a block you handed to her but
she is not playing with it and looking tired.
Task 1
Take a focused history from Mrs Lee. (4 mins)
Task 2
Answer the examiner’s question(s). (4 mins)
CH OSCE – Emergency
Inadequate Moderate Well

done
Introduction, confirm identity, consent, confidentiality, no
jargons
History-taking
● Presenting complain: Vomiting for 4 episodes over
the past 2 hours, food content then water, not
projectile, no blood, “I was doing laundry and Lily was
sitting on the kitchen floor playing with some toy
blocks, when I came back I saw her place something
in her mouth but I didn’t give it too much thought at
that time”, vomiting episodes happened about an
hour after that event
● When further questioned, Mrs Lee will say “Her
grandfather has heart problems and is on medication
called ‘Di-something’, and the medicine is kept in the
highest drawer about 4 feet from the ground”
● Other symptoms: Irritable at first hour or so then
quietens, looks very lethargic now, not eating or
drinking
● Relevant negatives: No ingestion of large
food/objects, can’t tell if she’s in pain,
● PMHx: nil, not on any medication
● FHx: mother and father are well, grandfather has
heart problems
● Birth Hx: term, 3.2kg, no perinatal complications,
immunization completed, eating food and drinking
formula milk, no other siblings, developmental well
“normally cheerful and active”
● Social Hx: staying with parents and grandparents,
mother takes care of her, rarely eat out, no travel
history, no sick contact
Supposing Lily doesn’t develop any other serious symptoms,

what medication would you administer to her?
● Activated charcoal
Can you tell me the steps of first aid in Lily’s case of

poisoning?
1. Identify poison.
2. Support vitals– ABCD:
● A – Airway – Relieve any obstruction
● B – Breathing – Ventilate with O2
● C – Circulation - Treat
hypotension/arrhythmia
● D – Dextrose – Avoid severe
hypoglycaemia
● Disability – Dextrose – Avoid severe
hypoglycaemia
- seizures → BZD
- malignant hyperthermia,
serotonin syndrome, NMS
● Decontamination - irrigation of eye
with saline, local anesthetic /
sedation eye drops, skin - remove
clothes, rinse skin with copious water
then soap and water
● E - ECG, enhanced elimination -
urinary alkalization/multidose
activated charcoal / dialysis
2. Dilute the poison.
● Cup of milk or water to drink.
● Gastric lavage and whole bowel irrigation
(limited role)
3. Delay absorption.
● Activated charcoal.
● if patient presents <1hr with normal
conscious state
● 1g/kg orally/NG tube
● Multiple dose: 5-10g every 4
hours, or 0.25g/kg per hour for
12 hours.
● Contraindicated:
● altered conscious state
● ethanol/glycols/alkalis/corrosives
/metal/fluoride/cyanide/hydroca
rbons/mineral acid
● Evaporated milk
2. Administer antidote early (in this case - Digibind)
3. Treat any complications.
● Respiratory failure
● Pulmonary aspiration of gastric contents
● Arrhythmia
● Hypotension
● Seizures
● Delayed effects (e.g. PCM –
hepatotoxicity, tricyclics – arrhythmias)
More information about prevention of accidental poisoning:

https://www.betterhealth.vic.gov.au/health/healthyliving/poisoning-and-child-
safety?viewAsPdf=true
Station number: 1
Station title: Maria
You are a general practitioner serving a rural community. Anna, a 21 years old mother has
brought her 3-month-old daughter, Maria to see you for a runny nose and fever over the
past 2 days. You have assessed Maria and feel that she has a mild upper respiratory tract
infection. You also noticed that Maria has some bruises over both her arms, legs and left
cheek.
Your task is to:
1. Take a focussed history from Anna and explore the various reasons leading to
Maria’s bruises.
2. At 5 minutes, you will be given the examination findings
3. Discuss with Anna the differential diagnosis and suggest appropriate management.
Station number: 1
In this station, the student is required to interview a young mother (Anna) who has
brought her 3-month-old daughter, Maria for an upper respiratory tract infection. Maria
was noted to have some bruises. The student will take a history to explore the cause of
the bruises and recognise that the bruises may have been inflicted by an adult (non-
accidental). You are under stress, and you are responsible for your daughter’s bruises
although the student need not reach this conclusion during the station.
You are Anna, a 21 years old single mother. Your boyfriend left you soon after you fell
pregnant. Since then you have been taking care of Maria on your own.
Maria has been well till two days ago when she started to have a runny nose and sneezing.
She has a low grade fever but is otherwise feeding well and active. She has no
cough/wheeze/vomiting/diarrhoea/fits/change in behaviour/pallor.
Further history about the bruises:

You appear forgetful about most of the details. You claim that the bruises may have
happened a week ago when you were trying to change Maria’s nappy and she rolled off
the bed when you turned around to pick up a clean nappy.
Location of bruise? Face but not sure where else.

Bleeding from elsewhere? – Nil
Any other trauma? Nil
Noticeable masses/lumps/pallor/severe infection/bone pain/irritability? – Nil
If the candidate should enquire further in an empathetic manner whether you could have
caused the bruises, you may reply “I am not sure. I could have grabbed her harder than
usual when I changed her nappy. Her crying really gets to me sometimes”
If asked about her nappy rash (seen on examination), mention that you may not have
changed her nappy as often as you should as you were “too busy”
If student enquired about the burn marks on Maria’s leg (found on examination), inform
that you accidentally dropped some cigarette ash on her while smoking 2 days back. You
washed it off “straightaway”
Pregnancy and Delivery
Normal but unwanted pregnancy

Spontaneous delivery, full term, birth weight 3kg
No problems after birth.
Medical /Surgical History

Maria is generally healthy and has no previous hospitalisations.
Diet
Breast-fed since birth. Maria latches on quite well and wants to be fed every 2-3 hours
which is very tiring for you.
Weighs about 5kg now.
Immunisation;
Last given a month ago.
Development:
You think she is “OK”. She can grasp things with her hands, coos and laughs.
Only if candidate ask whether Maria is able to roll over yet, you should mention “Not
really”.
If the student enquires further on how Maria could have fallen off the bed, you look away
and say “I don’t really know”.
Financial
You are unemployed. You receive monthly financial help from the social services which is
just sufficient to cover the basic necessities. You live in a rented one bedroom flat
Family/friends support
Left home a year ago and have had no contact with your parents for past year as they
have felt ashamed by your pregnancy. No close friends as most have moved on to college.
You have no partner at the moment.
Smoking/ Alcohol/Drugs
You smoke one pack of cigarettes a day, more when you feel stressed.
Alcohol or drug intake- Nil.
Contact with Professional help

Saw a social worker a year ago.
Anna’s Feelings
You love Maria but you feel very lonely and unsupported
If student explores further about the possibility of you hurting Maria, you admit that
sometimes you feel so stressed that you want to shake her but you manage to stop
yourself but now you are worried that you may lose control.
Affect
You should appear upset and distressed mainly because you felt you cannot cope with
taking care of Maria anymore.
After 5 minutes, the examiner will hand over the examination findings to the student. You
may then ask
What is wrong with Maria?
Does she need any tests?
Can I take her home?

Station number: 1
Any notes made by the candidate to be collected and discarded at the end of the
station.
Station construct –
This is an integrated station which tests the candidate’s ability to:
Take a focussed history in an infant presenting with multiple bruises, recognise a child at
risk and suggest appropriate management in a General Practitioner setting.
Demonstrate appropriate communication, interpersonal and professional skills
Please ensure that your Simulated Patient understands the scenario completely.
Please refer to the SP instruction sheet for history.
At the fifth minute, you should hand over the examination findings and the SP will ask the
student “What is wrong with Maria? Can I bring her home?”
The students will then proceed to explain their differential diagnosis and appropriate
management to the mother.
Critical Error does not apply to this station.

MARKING SCHEDULE
Station number: 1
History (Medical) (Total 4)

1. Location, duration of bruises
2. Relevant Systems Review (Trauma, fever, recurrent infections, constitutional
symptoms- lethargy, loss of weight/ appetite, joint pain, recent URTI)
3. Family History of bleeding disorders
4. Pregnancy, Birth, Development, Past Medical history
History (Pscho-Social) (Total 4)

1. Identify Maria’s carer
2. Anna’s Family and Financial support, contact with professional Help
3. Alcohol, Tobacco, Drugs
4. Explore Anna’s ability to care for Maria and her feelings
Diagnosis (Total 2)
1. Offer most likely diagnosis with clear explanation-Trauma (Non-accidental)
2. ITP and other bleeding disorders (less likely but still need to be excluded)
Management (Total 6)
1. Recognise that bruises likely caused by trauma
2. Recognise that mother is under a lot of stress
3. Refer to the nearest hospital for baseline investigations and secondary care
4. Explain role of investigations such as full blood count and clotting test
5. Explain need to refer to Child protection services and notification
6. Refer for Support services (eg social services, single parent support group,
government-run child care centre, counselling services and other relevant
agencies)
Communication skills and Clinical Perspective (Total 4)

1. Introduction, establish rapport and consent, lay out purpose of consult
2. Demonstrated empathy
3. Use appropriate lay terms
4. Logical sequence to interview and processing of information derived from questions
No Serious Adequate, All Excellent Total

attempt, errors & but important
or very omissions: incomplete areas
cursory Inadequate covered;
skill for minimal
year level omissions
or adverse or errors
effect on
outcome
History (Medical) 0 1 2 3 4 4
History 0 1 2 3 4 4
(Psychosocial)
At 5 minutes, examination findings are handed to the student. Simulated patient (SP) will ask “what’s
wrong with Maria? Can she go home?”
Diagnosis 0 1 1 1 2 2
Management 0 2 3 5 6 6
Communication
skills and clinical 0 1 2 3 4 4
perspective
Global Score – for standard setting:
  
Active, Afebrile
No pallor.
Symmetrical large bruises on both arms, legs and left cheek.
No lymphadenopathy or hepatosplenomegaly
Severe nappy rash.
Well-defined circular blister with erythematous edge (diameter

0.8 cm) on left leg.
No other abnormalities detected.

Gina is a 5-year-old girl brought in to the A&E department at 8pm by her parents. They state that she
is complaining of a painful arm.
(a) Take a history of the presenting complaint and any other relevant history. (3 min)
(b) State the clinical and behavioural features you would look on examination. Suggest further
investigations. Answer the examiner’s questions. (5 min)
Patient: Gina Fleming, 5 y.o. girl (Parent: Susan / Joe Fleming)
Parent affect: Slightly guarded while answering questions, less eye contact than normal
Presenting Complaint: She fell off her bike a few hours ago and says her arm hurts.
HOPC
● Parent reports Gina was riding her bike in front of the house and fell off (About 4 hours ago)
● Came into the house screaming and holding her arm
● Parent did not witness event
● Gina is quiet and sullen, parent seems relatively unconcerned and makes light of injuries
Pertinent positives
● She’s a tough little thing. Very clumsy. Always falling down and hurting herself.
● Parent thinks she was wearing her helmet
● Pain located on upper right arm, Gina not willing to move arm
● Multiple other recent injuries
Pertinent negatives: Denies numbness or tingling

Review of Systems: Right-handed, eats well, not picky, toilet trained but sometimes wets the bed at
night, occasional nightmares during sleep, no other current complaints
Developmental Hx: Milestones achieved at appropriate ages, attends pre-school, may be slightly
slow in learning letters and reading, recently parent was called by teacher for Gina’s bullying
behaviour
PMH: Asthma as a baby, occasionally wheezes when she has a cold
Birth Hx: SVD, 40 weeks, no complications
Immunisations: Up-to-date
Medications: None
Family Hx
● Father: HTN
● Mother: Hx of depression and asthma
● 2 siblings (3 and 8 y.o.): Healthy
Social Hx
Father currently unemployed, mother working extra hours to compensate (Retail sales and house
cleaning)
8 y.o. sister: Good student, 3 y.o. brother: Favoured child for being a boy
ACTUAL SITUATION: Father drinks heavily, physically abuses mother and daughters when drunk
● Coagulation screen
● notify and involve the Victorian Forensic Paediatric Medical Service (VFPMS)
● provide, when consent is given, a verbal or written report to Child Protection and the
Police.
Station title: Alison Carter

Name: Alison Carter

Age: 4 months old
Presenting history:
Rachel and her daughter Alison present to the emergency.
Alison has been vomiting and Rachel is very distressed.
TASKS FOR THE CANDIDATE:

1. Please take a history from Rachel (4 mins).
2. Please request examination findings for Alison. The examiner will provide
relevant findings (2 mins).
3. Answer the examiner’s questions (2 mins).
Contributors: Maushmi Udaya Kumar

Name: Alison Carter
Gender: Female
Age: 8
Clinical details: You are playing the role of Alison's mum, Rachel
Presenting statement: “She’s been hard to settle recently. But then this afternoon she’s been very
quiet. She’s been vomiting since I got home from work around 1pm”

W: started this morning
W: everything she’s eaten – non-bilious, no blood
Q: 5 times today
Q: like a small cup’s worth
A: nothing makes it better or worse
A: she’s gone floppy. Has spells where I almost feel like she’s stopped breathing!
C: really scared that something’s wrong
Fever:
nil temperature at home. Not hot/clammy.
Respiratory:
Nil cough, sneezing, congested, wheeze.
Meningitis/neuro:
Nil neck stiffness, crying in the light (photophobia) .
GIT:
Nil diarrhoea, hard stools
Feeding:
not feeding today.
Output:
Has a wet nappy this morning – changed at 7am before mum went to work.
Worked a half day and found baby like this.
Growth:
normal till now – good height, weight, HC – around 50th percentile for all
Immunisations:
Just had DTPa,Polio, Hib, Hep B + pneumococcal + rotavirus vaccine given last
week.
Name: Alison Carter
Gender: Female
Age: 8
Clinical details: You are playing the role of Alison's mum, Rachel
Social:
lives at home with mum and dad. Things have been a bit tough recently but
getting though.
Only if candidate asks to expand:
Act very upset – scared something has happened to your daughter. She’s been hard to settle
recently. But then this afternoon she’s been very quiet.
IF candidate specifically asks about dad/where child was when mum was at work:
Alison was with her father this morning. He’s been under a lot of stress. I just don’t
know what to do anymore! :’(
IF candidate specifically asks if Alison’s father may have hurt her:
I thought he’d stop at me! I didn’t think he’d ever touch her but I don’t know what to do
anymore!
Examination
General appearance: Drowsy, lethargic baby, lying on mum.
VITALs: T: 37.2, BP: 68/35, RR: 29, HR: 86, SaO2: 99% RA
Resp: Chest clear, bilateral air entry, no added sounds.
CVS: HSDNM
GIT: soft, non-tender, no masses, bowel sounds normal.
Eye: bilateral retinal haemorrhages.
Neuro: not examined
1. What is your primary diagnosis/cause for Alison’s presenting symptoms?

Shaken baby syndrome
2. What triad of features would you expect from a child with shaken baby syndrome?
Encephalopathy, subdural haemorrhage (N/V, seizures, apnoea, cardiac arrest, altered mental
status), retinal haemorrhages.
3. How would you manage this child?

· Escalate – involve senior paediatrician
· Investigation - coagulation profile, x-ray, bone scan and skeletal survey, MRI
· Treat child for any injuries
· Document everything
· Refer to Victorian Forensic Paediatric Medical Service
MED4200 mock OSCE
Station No:
Station title: Jared White
Jared is a 2 year-old male child who presents to the paediatric clinic with his mother. He was
referred by the Maternal Child Health Nurse who noted that he was quite pale. His mother,
Anne, also thinks he has been quite irritable lately.
Your task is to:

2. Request and interpret laboratory results and explain to the parent your differential
diagnosis and management plan (4 minutes)
IMPORTANT NOTE:
3
MED4200 mock OSCE
Station No:
Gender: female
Age: 20-30
You are Anne, mother of 2 years old Jared and you are concerned that he has been pale and
irritable recently. You are appropriately concerned but not very anxious.
If the candidate asks what the problem is you can say ‘’He’s been really pale and cranky
lately.”
You hadn’t really noticed, but health nurse noted Jared to be very pale at his visit yesterday
Jared has been sleeping a lot lately but also seems very irritable when awake the past couple
of weeks.
Jared has had a recent cold with rash (‘slapped cheek’) 2-3 weeks ago
He has been putting a lot of objects in his mouth and eating dirt and has more bruises past
1-2 weeks.
He has had no fevers and no rash and does not seem to be limping or in pain.
Jared’s diet consists of large amounts of cow’s milk, finnicky eater – refuses vegies often but
lately will eat them, seems to be trying to eat more non-food items lately (eg. dirt, crayons).
He has started toilet training; he is opening is bowels and passing urine as usual
Jared sleeps through the night without difficulty, takes 1-2 naps during day, no night terrors
or unusual sleeping behaviour recently. He has had no diarrhoea and he is otherwise well
Jared is developing normally for his age, has no allergies and immunisations are up to date.
He was born by normal delivery at 39 weeks and was well at birth. He has been well since.
You and your husband are well and Jared has a 6-month old sibling who is well. Both are
non-smokers and drink alcohol socially. Jared’s father is of Greek descent.
Your husband is full-time manager and you work part-time in retail sales (just returned to
work).
4
MED4200 mock OSCE
Investigations
Hgb 86 g/L (110 – 130 g/L)
Hct 0.30 (0.37-0.47),
MCV 65 fL (80 – 100 fL),
MCHC 310 (320-360 g/L),
WCC 8.0 x 109/L ( 4 – 11 x 109/L)

N 5.0 x 109/L
L 2.5 x 109/L
M 0.5 x 109/L
Platelets 250 x 109/L (250 – 500 x 109/L)

Blood film pending
Ferritin 6 (10-250 umol/l)
5
MED4200 mock OSCE
Station No:
• Take a focused history

• Interpret investigation findings
• Explain differential diagnoses
• Explain the management plan
EXAMINERS’S ROLE:
can be advised.
• Unless specified to the contrary, there should be no need for the examiner to
intervene in any way during the running of this station.
6
MED4200 mock OSCE
MARKING SCHEDULE
Station No:
Serious
errors and
No attempt,
or very
cursory
adverse errors
effect on
outcome
• Use of appropriate
language
History 0 3 5 8 10
• explore the presenting
complaint and
associated
symptoms:
• elicit pertinent
associated
positives and
negatives
• screen for pertinent risk
factors – eg. recent
illness, family hx
thalassemia, etc.
• dietary habits, urinary
and fecal output,
sleep habits and
other behaviours
history
• Elicit PMHx including
birth and
immunization hx
• Outline the basics of
the social and
family situation
Investigation interpretation 0 1 2
• Lower haemoglobin
level resulting in
anaemia
• Smaller, paler red
blood cells
7
MED4200 mock OSCE
• Other blood cells

normal
Differential Diagnosis 0 1 2
• Iron deficiency
anaemia due to
excess milk intake
• Thalassaemia
• Reduce milk intake
• Dietary advice
regarding balanced diet
• Oral iron and vitamin C
supplementation
• Follow up FBE
• Reassess possibility of
thalassaemia
Global Scoring:
  
8
OSCE STEM
4-year-old boy Joshua was being brought in by her mother, Janet to
the Pediatrics Clinic for nose bleeding earlier today. His mother is
quite concerned that Joshua had petechial rash on his trunk, arm and
face. She also noticed that Joshua’s nose started to bleed after he
rubbed his nose.
Candidate’s tasks:
1. Take a focused history from Janet.
2. State your diagnosis and how you would manage Joshua.
3. Explain to Janet about Joshua’s condition accordingly.

Script
Joshua, 4 years old, studying in kindergarten
Chief complain:
- Earlier today (morning 8am) : petechial rash over trunk, arms and legs
- Nose bleeding when pt rubbed his nose
History of presenting complains:
▪ 2 weeks ago: URTI (low grade fever, coughs, sneezing – resolved completely after 5
days)
▪ No fever
▪ Normal appetite, energy and activity levels
▪ Not currently on any medication
▪ IS IT LEUKAEMIA? Joshua’s cousin was recently diagnosed with acute leukaemia after
presenting with petechial rash, persistent fever and abdominal pain
About the rash
▪ Flat, pinpoint lesions
▪ Non-blanching
▪ Distribution and progression
▪ No relation to fever
▪ Now there is some bruising as well
Ruling out differentials
▪ No history of trauma
▪ No epistaxis (no other bleeding tendencies apart from when brushing)
▪ No frequent infections
▪ No lymphadenopathy, no abdominal pain/ distension/ masses
▪ No anemia
▪ No bloody diarrhea
▪ No hematuria
▪ No joint pain, joint swelling
▪ No family history of bleeding tendencies
Patient History
Birth history: SVD, 3.2kg, Normal delivery and discharged on the same day, Yellow after few
days(resolve completely without any issues)
Immunization: Up to date
Diet: Exclusive BF until 6/12, on solid food subsequently, taking normal adult diet and cow’s
milk
Development: Goes up and down stairs alone, can walk backwards, can run and pick up toy
without falling, can throw ball
Tower of 6 cubes, imitates straight line drawing
Visual test Snellen’s chart
2-3 word sentences “I want eat”, names 3 objects, obeys 4 simple commands,
points
to 4 body parts
Puts on shoes, socks, pants
Dry by day
Social History: Attends day-care, but no sick contact
Still playing actively
No travel history
Hernia repair at 1 year old
No history of allergy/ asthma
Marking scheme
Domains Not done Partially done Adequately done
Introduction,
Explanation,
Confidentially,
Wash hand
Chief complain:
- Nose bleed [onset, amount,
frequency, clots, colour, any
medications/means to stop]
- Other sources of bleeding
HOPC:
- URTI
- Previous trauma
- Associated symptoms to rule
out [fatigue, weight loss, fever,
joint pain, rash, headache, eye
pain, abdominal pain, bruises,
diarrhea, oliguria]
- Medications
- Liver disease
- Sick contact
- Travel hx
Family Hx
- To rule out familial disease
- Cousin had leukemia
Past Medical Hx/ Surgical Hx
- Hernia repair
Birth history, Immunization,
Diet, Developmental, Social
Diagnosis: ITP
DDx: ALL, HUS, Haemophilia,
vWD, Liver disease, Drug-
induced(warfarin), Dengue,
Meningococcal disease, HSP
Physical Examination
▪ Alert, active, well-nourished and well-looking

▪ Afebrile and haemodynamically stable
▪ Petechial hemorrhages and ecchymosis on his legs, trunk and face and slight bleeding from
his gums
▪ No pallor, lymphadenopathy or hepatosplenomegaly
▪ Neurologically, grossly intact
Vital Signs
BP: 95/70 mmHg
RR: 25
PR: 76 bpm
Temperature: 37C
SPO2: 99%
Blood Investigations
FBC
↓ Platelet
No microcytic, hypochromic cells
Reticulocytes 1%
PBF
Large platelet
Hb/ WC normal
No blast seen
Management Plan
• Usually resolves by 4-6 weeks, triggered by UTRI.
• Monitor Joshua at home, if there is any sign of severe bleeding, bring him in for
treatment.
• For now, no treatment will be given as it is a self limiting condition.
• But if it does not resolve or there’s sign of severe bleeding:-
– oral prednisolone - shown to increase platelets levels more quickly than to
let it recover by itself
– active bleeding - transfuse platelets
– i/v immunoglobulin - rarely given but have a lot of side effects. Can cause
severe reaction to it.
• Care at home
– Should not take aspirin or ibuprofen (another pain killer), because this may
provoke bleeding. Paracetemol is quite safe.
– While the platelet count is very low, advised not to do activities which might
cause bruising or bleeding (eg stay off the climbing equipment, bicycles etc).
– As the platelet count rises, more activity will be allowed, but contact sports,
cycling and other rough physical activity may need to be avoided until your
child's doctor advises.
CH OSCE
Candidate’s instruction
You are a medical officer in Klinik Kesihatan. Jane Smith presents to the KK with her 7
months old son, Jasper who isn’t putting on weight very well.
Tasks:
1. Take a focused history from Jane about her son. [4 mins]
2. Outline the examination you would perform. The examiner will verbally provide
the examination findings as you ask for them. [2 mins]
3. Explain the diagnosis and management to Jane. [2 mins]
Marking Sheet:
History: Pts
Patient’s details Jasper, 7 months old
HOPC When: Was ok, then in the last few months has been
declining
Lethargy: Sometimes very tired

Dietary Hx: Breast fed, just switching to meats & solids.
Seems to be feeding quite fine.
GIT system:
• No V + D
• No signs of pain
Infections:
• “Actually, he has had a number of coughs & colds”
• No photophobia
• No rash
Respiratory:
• URTI symptoms (cough, coryza)
• Slightly WOB + mild dyspnoea
• Wheeze
Haematology:
• Mild pallor
• No jaundice
• No bruising or bleeding
Cardio:
• No cyanosis / hypercyanotic episodes
Past medical Born at term (NVD), no complications

history Went to ED once 2 months ago for ‘mild pneumonia’ – given
antibiotics and managed with GP
Immunization Up to date
Medications Nil
Allergies Eczema
Family history Atopy
Developmental Normal
Social history In day care 4/7
Physical General Appearance:
examination • Well or unwell: Ok looking, slightly pale
• Conscious state: Slightly lethargic
• Interactive: Yes
Vital signs
• RR = 54
• HR = 145
• T = 37.7°C
• BP = 120/80
Peripheries: No peripheral cyanosis or other features

Face: Nil
Mouth: No central cyanosis
No Rash / neck stiffness / bulging fontanelle
Respiratory symptoms:
• Use of accessory muscle
• Mild intercostal & subcostal retractions
• No nasal flaring or grunting
• Auscultation: Basal crepitations
Cardiology: A murmur is present, what would you like to

know about it?
• Timing: Pansystolic murmur
• Added features: no added sounds
• Localisation: loudest at Apex
• Grading: 2-3/6 (no thrill)
• Variation: Louder during expiration
• Radiation: No obvious radiation
Abdomen
• Hepatosplenomegaly
ENT: Mild redness of the TM

No palpable lymph nodes
Differential Heart failure due to VSD
diagnosis
Ddx of wheezing (HEART, LUNG, GI)
• Heart failure 2o congenital heart disease (for severe
one 90% present at 1st week),
• Infection
o Acute bronchiolitis (MOST COMMON) - but no
fever, no runny nose, and the
o Pneumonia (fever, probably won't tolerate 2
weeks)
o Cystic fibrosis (usually lung complaints
• GIT
o GERD - recurrent + poor → can lead to
aspiration pneumonia
o Laryngomalacia - but stridor
o Tracheoesophageal fistula (usually present at
week 1)
o Oesophageal atresia (usually present at wk1)
Investigation - FBE – anaemia, consider Fe-studies
- U&E
- LFT – albumin (nutritious status)
- Sterile urine sample for MCS (SPA or CSU)
- Heart failure investigation: CXR + ECG + ECHO
Management of 1. Admit to hospital
heart failure 2. O2 - nasal prongs
3. No IV fluid → fluid restriction (50%
4. Prop the patient up
5. Furosemide +/- spironolactone, ACEi (reduce
afterload)
Nutrition: NG feeding / rice tube feeding.

Management of Refer to paediatric cardiologist
VSD Management is surgical closure of the defect
25% of children require Mx (rest close spontaneously)
Mild / moderate → can observe for 1 year → see whether

close on their own
Extra: 1. Still’s murmur (vibratory): systolic murmur, decreases on
Name 2 innocent standing and increases on lying or squatting.
murmurs Hyperdynamic (anaemia / Infection)
2. Venous hum: heard at the neck, continuous murmur,
decreases on lying flat, disappear when neck pressure/
lying supine / press hard on jugular vein
3. Pulmonary flow murmur: systolic, soft-blowing murmur at
pulmonary area [in early infancy as pulmonary vascular
resistance decreases, more blood flow to the lung]
4. Carotid bruit: systolic murmur at neck, NOT heard at
heart
Station title: Melody

Name: Melody
Age: 5 months old
You are the medical officer in a metropolitan hospital. Melody, a 5 months old girl
who is brought to the paediatric clinic by her mother, Ariel has come to see you.
Melody has fever, sore throat and rash which made Ariel really worried since she is
her first child. Her medical records include the following information:
Allergies: Nil
Family history: Only child, nothing significant
Past medical/surgical history: Nil
Medication: Nil
Developmental milestone: Normal for age
Immunisation: Up-to-date
Mother’s antenatal history: Nothing significant
Tasks
1. Take a further history from Melody’s mother, Ariel, to elicit the cause of her
symptoms. (4 minutes)
2. List out 3 differential diagnoses. (1 minute)
3. Counsel Ariel on Melody’s condition and the appropriate management. (3
minutes)
task, you will be handed the examination and

(Upon completion of 2nd
investigation findings)
● General: irritability, lethargy, pallor

● Temperature: 39.8°C
● HR: 120
● RR: 35
● BP: 85/60
● CRT: 2 secs
Appearance:
● bilateral conjunctivitis
● erythematous, cracked lips
● erythematous pharynx
Other examinations:
● non-specific maculopapular rash over the trunk
● cervical lymphadenopathy with the largest node being 2 cm in diameter
● chest is clear and no other abnormalities
INVESTIGATION FINDINGS
Investigation Values Normal

Haemoglobin 10.7 g/dL 10.5–13.5
White cell count (WCC) 26.3 x 109/L 4.0–11.0
Neutrophils 18.2 x 109/L 1.7–7.5
Platelets 430 x 109/L 150 - 400
Sodium 137 mmol/L 135-145
Potassium 3.7 mmol/L 3.5-5.0
Urea 4.2 mmol/L 1.8-6.4
Creatinine 58 mol/L 27-62
C-reactive protein (CRP) 63 mg/L <6
Erythrocyte sedimentation rate (ESR) 107 mm/hour 0-15
FURTHER INFORMATION
Figure 1 RCH Guidelines

1. Introduction and rapport

● Appropriate introduction
● Clear simple (non-jargon) language, clear explanations
● Non-judgemental, patient centred, open-ended questions
● Empathy, good body language
● Address concern and reassure patient’s guardian
● Organised and systematic
2. Elicit and record of accurate relevant clinical history

a) HOPI
● Fever: 10 days, 38OC, no change for the past 10 days even after seeing a GP
● Associated symptoms:
o Blood shot eyes: 10 days
o Dry lips – 10 days
o Occasional cough – 2 days ago
o Rash – 2 days ago, generalized at abdomen
o Sore throat: 10 days
b) Systematic review
• No nausea or vomiting
• Bowel movement not affected
• No previous similar episodes
• Feeding: less than usual
• No history of travel or contact with infections
Other diseases Clinical features

Kawasaki Disease (other ● Conjunctival infection
symptoms) ● Cervical lymphadenopathy
● Mucous membrane changes (strawberry tongue, red, dry, cracked lips)
● Red and oedematous of palms and soles
● Peeling of fingers and toes
● Inflammation of BCG vaccination site
Group A Streptococcal Scarlet fever:

infections – tonsillitis, ● acute febrile illness
Scarlet fever, acute ● URTI: mostly pharyngitis
rheumatic fever ● diffuse, fine papular erythematous rash that appears on the trunk,
extremities, and face, but with circumoral pallor
Acute rheumatic fever:

● 3 to 4 weeks following the onset of group A streptococcal pharyngitis
EBV, Adenovirus Infectious Mononucleosis (EBV):

● cervical or generalised lymphadenopathy
● pharyngitis
● malaise
● fever
Systemic juvenile ● fever, rash, lymphadenopathy, and arthritis

idiopathic arthritis (JIA) ● usually fever of unknown origin (FUO)
● The rash is a fine, evanescent salmon pink, usually appears on the
trunk, proximal extremities
● The rash accompanies the spikes of fever and tends to disappear when
the fever is down.
● Anaemic
Sepsis or Toxic Shock Toxic shock syndrome:

syndrome ● An acute febrile illness
● associated with vomiting, diarrhoea, myalgia, strawberry tongue, and
erythematous rash with subsequent desquamation.
● Many develop acute respiratory distress, hypotension, and shock.
● common in 15 to 25 years of age.
Sepsis (children)
● fever or low body temperature
● tachypnoea
● tachycardia
● bradycardia (neonates and infants)
● altered mental state or behaviour
● decreased peripheral perfusion (cold shock)
● change in usual pattern of activity or feeding in a neonate
● dry nappies/decreased urine output
● mottling of the skin, ashen appearance, cyanosis
Stevens-Johnson ● High fever

Syndrome ● severe explosive mucosal erosions
● widespread bullous skin lesion
Drug reaction ● History of exposure to the drug

● Oral lesions or ulcers
● periorbital oedema
c) Other histories
● Birth: term, SVD, BW 3.2 kg, no complications, discharged with me
● Immunization: up to date
● Diet: breast milk
● Development: normal
● Social: taken care by me, I’m a housewife
3. What are your differential diagnoses?

● Kawasaki Disease (for this case)
● Group A Streptococcal infections – tonsillitis, Scarlet fever, acute rheumatic fever
● EBV, Adenovirus
● Systemic juvenile idiopathic arthritis (JIA)
● Sepsis or Toxic Shock syndrome
● Stevens-Johnson Syndrome
● Drug reaction
4. Counselling and management.

● KD is the most common vasculitis of medium sized vessels in childhood
● the most common cause of acquired heart disease in children in developed countries
causing coronary artery aneurysms (CAA)
● more common in Asian children under 5-year-old
● Approximately 85% of cases occur under 5 years of age, peak age 18-24 months
● Investigation:
o In all patients consider: (since already done so just move on to echo)
▪ FBE, CRP, ESR, UEC, LFT (NB ESR is unreliable after IVIg
administration)
▪ Blood culture
▪ Serum to store
▪ Urinalysis (sterile pyuria)
▪ ECG
o Echocardiogram – at baseline (this should not delay initiation of treatment)
and at 6 weeks. Abnormalities should be managed in consultation with
paediatric cardiology and haematology services.
● Primary treatment
o IV Immunoglobulins 2 Gm/kg infusion over 10 - 12 hours.
▪ Therapy < 10 days of onset effective in preventing coronary
vascular damage.
o Oral Aspirin 30 mg/kg/day for 2 wks or until patient is afebrile for 2-3 days
● Maintenance:
o Oral Aspirin 3-5 mg/kg daily (anti-platelet dose) for 6 - 8 weeks or until ESR
and platelet count normalise.
o Follow up 6 weeks later and do echo
o If coronary aneurysm present, then continue aspirin until resolves.
o Alternative: Oral Dipyridamole 3 - 5 mg/kg daily.
You are the intern in the ED of Green Woods hospital and have been
asked to talk to Mrs Jamilah who brought in her 8 year old son, Rafiq
complaining of fever and severe joint pain by his mother
Task :
1. Take a full history (4 mins)
2. List your differentials and state the clinical features you would
look for on examination - (2 mins)
3. State the investigations you would like to perform - 1 min
4. Management plan- 1min
Patient Hx :
• Patient : andy
• Age: 8 years
• Presenting statement: He’s been having really high fever and severe
pain in his knees recently
• HOPC
– Fever- on and off, 39 degrees, 1 week ago, A/S myalgia lethargy
– Pain
• Site- both knees
• Onset- 2-3D
• Character- ache
• Radiation- none
• A/S- red and tendre
• Timeline- started with the shoulder(2-3D) than moved to
knees
• Exacerbating- moving
• Relieved by NSAIDS
• Severity- 9/10
• Pertinent positives
– Recent URTI 2 weeks ago
• Three weeks ago, he had flu like symptoms (fever, runny nose, sore
throat, and cough) and shortness of breath.
– Shortness of Breath started 3 weeks ago. This is his 1st
episode of breathlessness. Constant breathlessness with
hyperventilation. Not aggravated by exertion. Not alleviated
by rest.
– Fever for 3 days. Low grade fever with no night sweats and
no chills and rigors. Continuous fever. No rash seen.
– Cough for 3 days. Productive cough. Off and on. No
hemoptysis.
• Yesterday, he was severely short of breath and went back to the GP.
A chest X-ray was done and his heart looked ‘big’ and was referred
to this hospital.
– SOB on exertion
• Pertinent negatives
– No rash
– No chest pain
– No abnormal movements- chorea
– No trauma / abuse
– No red eye, red tongue,
– No PND, orthopnea,….
– No sick contact
– No travel hx
• SR
– No neuro st’s
– RESPI- SOB
– Cardiac- none
– GIT- Nil
– Renal*** - nil
• Birth history- normal
• Immunisation- up to date
• Development- good
• Diet -
• Social – lives with 12 other people in a small house
• PMH
– 6 months ago had a similar complaint
• FH
– Nil
• Medication- nil
• Allergies- nil
• Social circumstances
– Poor
– Lives in a small house with 10 people
Risk factors of Rheumatic Heart Disease

• Poverty
• SEC- low
• Living in crowded areas
• Ethnicity- aboriginal,
• Family history
2. Differentials :
• Septic arthritis/gonococcal -
monoarthritis + severe
• JIA - Recurrent, fever, >6 wks
• Reactive arthritis - not so
severe
• Leukemia
• Lyme disease - travel, rash
fever
• Kawasaki
• HSP
• Rheumatic fever
• Dengue - retro orbital pain,
fever myalgia , rash
3. Physical Examination
Rheumatic Heart Disease Features

1. General 1. Migratory polyarthritis†
2. Skin (extremely painful, affecting
large joints)
3. Vitals :
– Pulse rate: 134 2. Sydenham chorea‡ (in 25% of
– Respiration rate: 44 Indigenous Australians with ARF,
especially adolescent females)
– B/P: 98/69
– SPO2: 99 3. Jerky movements of hands, feet,
tongue and face
4. Cardio & respi 4. Carditis (apical pansystolic
– Raised JVP murmur or early diastolic
murmur at base of heart)
pericardial friction rub
– Apex beat is displaced 1cm
lateral to the mid clavicular 5. Subcutaneous nodules (strong
line. Palpable thrills and association with carditis)
parasternal hives. 6. Erythema marginatum§ (bright
pink macules or papules on
– Pansystolic murmur heard at extremities or trunk)
the mitral valve and radiate to
7. Fever ≥38.0°C
the axilla.
– There is bibasal dullness at
the both lungs. Reduced
breath sound in both lung. No
crepitation
5. Abdo- nil
6. MSK
– Red tender left knee
Dx Criteria
4. Investigations :
a. Throat swab and culture for GAS- +
b. ASOT-400 IU/mL (normal <320 IU/mL)
c. Blood culture
d. Blood
i. Fbc -Mild microcytic, hypochromic anaemia
ii. WBC
iii. U&E
iv. ESR & CRP
v. Renal Func Test - aware of Post Strep GN
e. CXR- Cardiomegaly
f. ECG
g. ECHO- Moderate mitral stenosis
h. OTHER
i. rheumatoid factor, antinuclear antibody (ANA), Lyme
serology, blood cultures, and evaluation for gonorrhea.
ii. Arthrocentesis
5. Mx :
You are an intern in the emergency department. Erica brings her 4 year old daughter Mahlie in after
she fell over and started shaking.
TASKS:
1. Take a history from Erica (4 minutes)
2. Please list your differentials, and examine as necessary (1 minute)
3. Please explain the management of your most likely differential to Erica (3 minutes)

Name: Mahlie Tale

Gender: Female
Age: 4 years old
Clinical details:
You are playing Erica, Mahlie's Mum. You are a very concerned parent.
Presenting statement: " Mahlie just fell to the ground and started shaking all over. I'm really worried.
Does she have epilepsy??"

About 2 hours ago, she just fell to the ground and started shaking all over
Did not start in one particular part of her body that I noticed
Lasted about 2 minutes, then just stopped all of a sudden
She was back to her normal self pretty much right away
Has never happened before
Other symptoms
Did not experience anything before (Aura)
No nausea, no vomiting, no pain
No weight loss, no diarrhoea
Hasn't noticed a fever, but hasn't measured her temperature
No recent trauma or headaches
Did not lose control of her bowel or bladder
Did not bite her tongue
Her older sister had a cold a couple of days ago
Differentials
Development
Febrile convulsion
Normal development - reaching all milestones
Generalised seizure
NVD at 39+6, no complications
Complete recovery within 1 hour
No antenatal complications
Sister had URTI - risk factor
Vaccinations up to date
Breath holding
Not upset prior to happening
Family history
did not seem to hold breath
No history of epilepsy or neurodevelopmental
Afebrile seizure
conditions.
No known pathology or trauma
Nil other history
No developmental delay
No aura
Social history
Vasovagal syncope
Lives at home with Mum, Dad and older sister (7)
No dizziness or nausea

Possible differentials
Febrile convulsion
Breath holding
Vasovagal syncope
Afebrile seiure
General inspection: 4 year old girl sitting comfortably on the bed
Vitals: Temp 38.5, HR 70, RR 24, BP 100/70
Respiratory: clear, no wheeze, slight cough and runny nose
Diagnosis
Febrile convulsion
Management
a. Febrile convulsion is a seizure that occurs in the setting of a fever. They usually last less than 10 minutes
and children are back to their normal selves within an hour after it happening.
b. Febrile convulsions are due to the rapid change in the temperature rather than the fever itself
c. Febrile convulsions are common in children aged between 6 months and 6 years and they do grow out of
them. However, it may occur again in Mahlie before she grows out of it.
d. The risk of developing epilepsy in children with febrile convulsion is about 1% which is similar to the risk in
the general population.
e. It is most likely due to the URTI that she has caught from her sister
2. Management now
a. No investigations because foci can be identified
b. She is clinically well so can be discharged, and there appears to be no risk of a serious bacterial infection
c. Mahlie may be a bit cranky for a couple of days - this will pass
d. Resume normal routines and put them to sleep in their own bed
e. Fever control - risk of a convulsion has passed by the time you notice a fever, so putting the child in a cool
bath or giving panadol will not reduce the risk
3. Provide information on acute seizure management (RCH parent information sheet)
a. stay calm
b. Ensure the child is on a soft surface and nothing that can cause harm is close by (limit touching the child,
focus on moving objects of her way)
c. Watch closely or film for the doctor
d. Time how long the seizure lasts
e. Do not put anything in her mouth
f. Call the ambulance if:
i. It is your first seizure - not relevant for Mahlie
ii. The seizure lasts >5 minutes
iii. Mahlie does not wake when the seizure ends
iv. Mahlie looks very sick when the seizure ends

Station title: Lily's shakes

Name: Lily Lee

Age: 6 years old
Presenting history:
You are an intern in the ED reviewing 6 year old Lily, with her mother Mrs Lee. Lily
was brought into the ED by ambulance following an episode of "shakes".
TASKS FOR THE CANDIDATE:

1. Please take a history from Lily's mother, Mrs Lee (4 mins).
2. Please request examination and relevant investigations for Lily. The examiner
will provide relevant findings (2 mins).
3. Discuss your diagnosis and management with Mrs Lee (2 mins).
Contributors: Alissa Heng

Name: Lily Lee

Gender: Female
Age: 6 years old
Ethnicity: Australian born Chinese
Clinical details: You are playing the role of Lily's mother, Mrs Lee.
Presenting statement: "Doctor, I'm really worried. Lily had an episode of shakes this morning."

When/What? She was playing on the floor when she suddenly fell to the ground, froze up,
then started having jerking movements of her limbs.
How long did it last? A few minutes.
Where did it start? Nowhere in particular, she was shaking everywhere.
How many episodes? She has had 1 similar episode a month ago. Doctor said to monitor her
progress.
How long to revert to normal self? Half an hour. Was initially confused.
Fever? No fever.
Associated symptoms? She was blinking rapidly and had shallow breathing during the seizure.
LoC for a few minutes. Moved toys out of the way, did not hit her head on anything. No recent
trauma or headaches, no tongue biting, did not lose control of bowel or bladder.
Birth Differentials
Born 37/40 weeks, spontaneous vaginal Febrile convulsion (most common
delivery differential for seizure in an OSCE): rule
Normal newborn screening out due to fever
Feeding/Hydration Epilepsy: idiopathic, structural, metabolic,
Normal Down Syndrome, CP
Vaccinations CNS infection
Up to date Secondary seizure: hypoglycemia, breath-
Growth + Development holding spell, cardiac
Normal
Note: while febrile convulsions is the most common
SHx/FHx
differential for a seizure in the OSCE, it is
Lives with mum and dad
important to rule out other causes of a seizure!
Cousin has Dravet Syndrome

Examination findings: Investigations:
(Do not just give these to the candidate, they Metabolic screen (UEC, CMP, VBG, BSL,
have to ask for each one) TFT): normal
Vitals: BP 110/70, RR 22, HR 70, Temp 37.0 EEG: some epileptiform activity (indicated
General inspection: tired-looking child performed if second unprovoked seizure,
Neuro/cardio: normal generally awake and sleep EEGs should
both be obtained)
MRI brain: normal
Septic screen not necessary, no fever
Diagnosis:
Epilepsy - 2 or more unprovoked seizures occurring >24 hours apart or diagnosis
of epilepsy syndrome
Primary: idiopathic (GTC)
(Secondary: structural, metabolic, Down Syndrome/CP)
Management:
What is epilepsy?
Epilepsy is a brain disorder that leads to a person having repeated seizures, in many cases the
cause is unknown
Occurs in 1 in 200 children
During seizures, there is abnormal excessive electrical activity in the brain, and this causes the
person to convulse (their muscles jerk), fall, or behave strangely (e.g. stare into space, not
respond when spoken to)
Prognosis depends on several factors, including age, other brain disorders, response to
medication. Some resolve by adulthood. Others may continue into adulthood, but can lead a
normal and active life with lifestyle changes and medication (if needed).
General management
Refer to neurology for ongoing review
They may prescribe a medication called carbamazepine or valproate
Avoid triggers: poor sleep, stress, acute illness, flashing lights, medication noncompliance
First-aid (same principles as febrile convulsion!): during active seizure, ensure that surroundings
are clear (no sharp objects etc), do not restrain them or put anything in mouth, call ambulance if
>5 minutes; all other times take precaution e.g. showers instead of baths, buddy system in pools
Consider seizure diary or recording next seizure on video
Epileptic seizures are not usually dangerous. However, a person is at risk of being harmed if they
are in a dangerous environment when a seizure occurs, for instance if they are in a swimming
pool, driving a car or climbing a ladder. Children with epilepsy can usually lead a normal and
active life, but they need to take care with certain activities, such as swimming.

MED4200 Mock OSCE
Station No:
Station title: Jenny Li Lin Jiang
Jenny is a 14 year-old female referred to paediatric outpatients for assessment of

headaches. She attends with her mother.
Your task is to:

2. Review examination findings provided (1 minute)
3. Explain your diagnosis and management plan to the patient
(3 minutes)
3
MED4200 Mock OSCE
Station No:
Gender: female
Age: 14 years
You are Jenny, 14 years old, and are attending the outpatient clinic with your mother.
Clinical details:
You have been getting severe headaches over the last few months. Your headaches are typically
right-sided with a sensation of throbbing/ pressure. You have had a headache for 2 days which is
resolving – now ~3/10, peak of headache ~9/10. You lie down in a dark room most of the day and
sleep when you have a headache.
The headache is associated with ‘seeing sparkly lights’ beforehand, nausea, occasional vomiting,
dizziness and dislike of bright lights. You feel irritable and don’t communicate much during attacks.
You have tried taking other the counter painkillers for the headache, with little effect.
You now have regular periods, which started age 13. Periods are heavy with cramping and headaches
typically occur at the onset of the period. Your most recent period started yesterday.
You have no numbness, tingling, or weakness and you have not experienced fever/ chills or changes
in weight. You mostly eat a balanced diet; but drink a lot of cola. Your favourite snack is chocolate.
You have been previously fit and well. You are an average student and are enjoying school in year 8,
and you have not experienced bullying.
Your mother has a history of ‘migraines’, otherwise no family history of note.
You Live with your parents and younger brother. You have several close friends.
You don’t smoke, and haven’t tried drugs. Your interests include netball, music, jazz dance
‘’I’ve been getting these headaches.’’
4
MED4200 Mock OSCE
You are sensible, usually outgoing teenager distressed by regular headaches. You and your
mother are keen to understand what is causing these headaches, whether there is a serious
underlying problem, and how to manage them.
5
MED4200 Mock OSCE
Station No:
Well looking teenager
Height on 50th centile, weight on 75th centile
Blood pressure 110/70, heart rate 70bpm
Normal neurological examination
Pupils equal and reactive
Fundoscopy normal
6
MED4200 Mock OSCE
Station No:
• Take a history of a child with headache

• Review examination findings and formulate a differential diagnosis
• Explain a management plan to the patient
EXAMINERS’S ROLE:
can be advised.
• Unless specified to the contrary, there should be no need for the examiner to
intervene in any way during the running of this station.
7
MED4200 Mock OSCE
MARKING SCHEDULE
Station No:
Serious
errors and
No attempt,
or very
cursory
adverse errors
effect on
outcome
• Appropriate use of
language
History 0 2 4 6 8
• Elicit pattern of
headaches (duration,
frequency, timing with
menses)
• Establish severity of
headaches and their
impact on functioning
history, including social
behaviours and
intellectual
development
• Relevant past medical
history and family
history
• Explore the home and
school situation and
evaluate social
dynamics
Diagnosis/ Problem List 0 2
• Most likely migraine 1
• Possible tension
headache (space
occupying lesion
unlikely)
8
MED4200 Mock OSCE
• Reassurance – benign,
treatable condition
• Review triggers
• Non pharmacological
management
(darkened, quiet room,
regular exercise,
relaxation, healthy
diet)
• Pharmacological
Treatment – simple
pain relief, treat
nausea; triptans;
preventative therapy if
frequent, severe
attacks
Global Scoring:
  
9
Station number: 9
Station title: Henry
You are a paediatric resident who has been called to the emergency department in a large
regional hospital, where you have been asked to see Henry, who is an 8 week old baby.
His mother Miranda is becoming increasing concerned about her son’s infrequent bowel
actions.
1. Take a focused history from the baby’s mother to determine the possible causes for
this baby’s difficulties (4 minutes).
2. Interpret Henry’s examination findings (2 minutes)
3. Explain to her in straight forward language how you will manage her baby and what
you consider to be likely causes for his problems (2 minutes).
Station number: 9
Opening statement: I am worried about Henry’s poos.
You are Miranda a 33-year old married mother. You are concerned about Henry’s
infrequent bowel actions.
Henry was delivered by elective Caesarean Section at 38 weeks. He was well and did not
require any Special Care. He had good “APGARs”. You were discharged at 72 hours after
his delivery. He weighed 3.5kg and continues to be ‘around the 50 th centile’.
You are breast-feeding him and he feeds every 3-4 hours in the day and once overnight.
You are happy he is breast feeding well. He doesn’t vomit. Apart from when he is trying to
open his bowels, he is very happy. He has no rashes and when he had his routine
examination before he left hospital, the doctors told you he was normal. He is smiling and
appears to be interested in his environment. You think his development is fine, ‘just like
his brother’. He is passing urine normally. He has no rashes or eczema.
You are very concerned about his bowel pattern though. His first poo (meconium) was
after he left hospital on his 4th day of life. Since then he is straining a lot and only goes
once every 7 days; what does come out is small and hard. There is no blood or mucous in
his poo. He moves all his limbs normally. He is now 8 weeks of age, a friend who is a GP
recommended giving him some medicine called ‘Lactulose’. You have been giving him a
teaspoon for the last week with no improvement.
He is well, but you don’t understand why this is happening
You were well throughout pregnancy, have never smoked, and have no history of alcohol
or drug ingestion. All your scans were normal.
There is no history of diabetes, hypertension or any other known medical conditions.
You have not returned to work since the birth of your older son Edward who is now 2
years old. Previously you had worked as a speech therapist. Your husband who is a banker
is very supportive and there are no social issues. He took 3 weeks paternity leave and
helps out around the house and with the children a great deal.
You older son, Edward has some mild eczema, but there is no other relevant family
history. Specifically, there is no family history of bowel problems.
Station number: 9
Any notes made by the candidate to be collected and discarded at the end of the station.
1. Take a focused history from the baby’s mother to determine the possible causes for
this baby’s difficulties (4 minutes).
2. Interpret Henry’s examination findings (2 minutes)
3. Explain to the baby’s mother in straight forward language how he/she will manage her
baby and what the candidate considers to be likely causes for his problems (2
minutes).
The candidate arrives in the examination room (Emergency Department Cubicle). Initially,
the candidate should take a focused history from the child’s mother. He/she should be
expected to recognize that the child’s pattern of bowel opening would not be normal in
infancy. Furthermore either the history or the history plus examination findings should
lead him/her towards a possible diagnosis of Hirschsprung’s disease with recognition of
the need for further tests and gastroenterology/surgical review. A request for review by a
senior Paediatrician in the first instance would be reasonable.
At 4 minutes, if the candidate has not requested it, then they should be handed the sheet
of examination findings.
The student is required to explain in simple terms that:
a) The baby has a pattern of stooling which is not typical in infancy with regards to
the frequency, associated effort and initial delay in passage of meconium.
b) The baby will need further tests and more specialized review.
c) The better candidate may specifically mention Hirschsprung’s disease as the most
likely diagnosis.
The candidate should assimilate the examination findings, which are highly supportive of
Hirschsprung’s disease into his/her explanation.
INFORMATION FOR EXAMINER
1. History [8 marks]
 Antenatal history including scans 
 Lack of family history of gastrointestinal symptoms
 No obvious neurological/developmental issues 
 Feeding history/lack of vomiting 
 Absence of atopy/eczema
 Infrequent stooling pattern 
 Delayed passage of meconium 
 No response to treatment
2. Interpretation of examination findings [4 marks]

 Not acutely unwell or vomiting - unlikely to be upper gastrointestinal
 Normal spinal development/lower limb neurology - unlikely to be hypothyroid or
spina bifida, but see below, would be lesser differential diagnoses
 Distended abdomen/normal external anal appearance – not likely to be anal
atresia/stenosis
 Gush of stool – very suggestive of Hirschsprung’s disease
3. Recognition of differential diagnoses and suggested management [6 marks]

 Needs to recognize not normal and needs senior review, a request for either senior
paediatrician or paediatric surgeon would be appropriate
 Recognition of possible large bowel obstruction would be expected 
 Requesting an abdominal x-ray before review would be expected 
 Transfer to a centre with specialized paediatric service should be mentioned
 Child should be placed nil by mouth with intravenous fluids
 The candidate may consider neurological or spinal problem or more complex
surgical/dysmotility issue, but very unlikely
4. Communication skills [2 marks]

MARKING SHEET
Serious
errors and All
omissions: important
No
Inadequate Adequate, areas
attempt,
SKILLS skill for but covered; Excellent
or very
year level incomplete. minimal
cursory
or adverse omissions
effect on or errors
outcome
History 0 2 4 6 8
Interpretation of 0 1 2 3 4
examination findings
Recognition of 0 1 3 4 6
differential diagnoses
and suggested
management
- Hirschprungs
- Ix: suction rectal
biopsy, abdo
Xray
- Rx: surgical
resection, NBM,
NGT
- Complication:
hirschprung
associated
enterocolitis
Communication skills 0 1 1 2 2
  
Examination Findings
General examination:
Henry looks clinically well.

He is afebrile. He has a heart rate of 120 (normal), with normal
capillary refill and warm peripheries. He is not irritable and is alert
and active. Moving legs normally, spine appears normal.
Abdominal examination:
His abdomen is soft and non-tender with normal bowel sounds, it

appears distended.
Normal external genitalia; normal perianal inspection with a

normally placed anus of normal calibre.
Following rectal examination, there is a gush of liquid stool.

Station number: X
Station title: Noah
You are an intern who has been called to the emergency department in a large regional hospital, where
you have been asked to see Noah, who is an 18 month old child. His mother Allie has brought him into
hospital with increasing concern about her son’s stomach pain.
1. Take a focused history from the child’s mother to determine the possible causes for this child’s
presenting complaint (4 minutes).
2. Interpret Noah’s examination findings (2 minutes)
3. Explain to Allie what you think the likely causes for his problem is, and how you will manage her child (2
minutes).
(examiner to give to candidate at 4 mins)
• VITALS: Temp 37.6*C, HR 118, RR 24, BP 85/55, weight 11kg.

• GENERAL APPEARANCE: He is alert, but distressed, teary and in obvious
pain, holding onto mum. His skin is pink with good perfusion and brisk
capillary refill.
• HEENT: His oral mucosa is pink and moist. There are no ulcers in the
posterior pharynx. His tympanic membranes are normal.
• CHEST: Heart regular rhythm and normal rate. Lungs are clear with good
aeration.
• ABDO: His abdomen is slightly distended and a mass is felt on palpation.
You hear normoactive bowel sounds.
• GENITOURINARY: Normal external genitalia; normal perianal inspection
with a normally placed anus of normal calibre.
• RECTAL EXAM: Normal rectal examination, some liquid stool of normal
colour on glove.
SIMULATED PATIENT + EXAMINER INSTRUCTIONS (3 pages)
Station number: X
Station title: Noah
Opening statement: Noah’s been very unsettled with some tummy pain.
You’re Allie, a 28-year old married mother. You’ve brought your son Noah to the emergency department
because he has been very unsettled and crying a lot with tummy pain.
• Only volunteer information when asked directly (aka. candidate needs to ask to obtain further
details)
• You’re also the examiner: please circle marks obtained for candidate feedback after the mock OSCE.
HISTORY [8 marks total, 4 minutes)

HOPC:
• Where: upper abdominal “stomach pain”, points to his stomach when asked where his “ouchie” is.
• When (1 mark): began approximately 6 hours ago, awoke at 06:00 crying. Carried and settled him
after a few minutes when he fell back asleep. However, over the next few hours he has had several
episodes where he has intermittently woken up crying and doubling over (drawing up her legs),
requiring to be cradled to settle. Usually sleeps through the night.
o If asked, has also vomited once tonight – greenish brown colour [biliary vomiting] (0.5
marks)
o If asked, episodes last 2-3 minutes, occurred every hour but increasing now, every 30 mins.
• Quality: seems to come and go.
• Quantity: has been crying, sometimes bending down to cry, and less playful than usual. Also has
preferred to not walk and be carried by mum.
• Input/feeding history (0.5 marks): poor appetite and refused food for past 6hr
• Output: has urinated but not passed bowel motions for past 6hr* (0.5 marks). Last stool yesterday
was normal, no blood (0.5 marks).
• Negatives: no fever, cough, rhinorrhoea, diarrhoea, rashes. No history of abdominal trauma.
o If asked, brother was sick last week with a cold, Noah was coughing and sniffling the last
two days but it was mild and you didn’t think much of it.
*N.B. Red currant jelly stools is usually a late sign
ANTENATAL HISTORY: (1 mark)

• Delivery: normal vaginal delivery
• Gestational age: 37.5 weeks
• Maternal comorbidities: gestational diabetes, ex-smoker (didn’t smoke during pregnancy
• Antenatal scans were normal
• Birth weight: 3550 grams
• Did not require NICU or special care nursery, good APGARs, discharged 72 hours after delivery.
• Mother: G2P2
MEDICAL + DRUG HISTORY: (2 marks)

• No medical illnesses, surgeries or hospitalisations
• Development: meeting milestones normally, no obvious neurological or developmental issues
• Normal growth – 25th-50th centiles, trajectory has been normal
• Breast and bottle fed until 12/12, introduced solids at 6/12, no problems.
• Immunisations up to date
• No medications
• No known allergies or intolerances
FAMILY HISTORY:
• Family history of heart disease
• No family history of bowel disease (1 mark)
SOCIAL HISTORY: (1 mark)

• Home:
o Father (Arthur) – plumber, very supportive, mother (Allie), 4yo older brother (Finn)who was
sick with viral URTI last week from kindergarten
o Husband/father
• Attends day care but did not attend today
AT 4 MINUTES
Either at 4 minutes, or when the candidate has completed taking a history from you, please hand them a
sheet of examination findings, which they should be expected to interpret. For your reference, the
examination findings are listed here:
Exam:
• Vitals: Temp 37.6*C, HR 118, RR 24, BP 85/55, weight 11kg.
• General appearance: He is awake, alert, and being carried by mom. He is not crying currently. His
skin is pink with good perfusion and brisk capillary refill.
• HEENT: His oral mucosa is pink and moist. There are no ulcers in the posterior pharynx. His tympanic
membranes are normal.
• CHEST: Heart regular rhythm and normal rate. Lungs are clear with good aeration.
• ABDO: His abdomen is distended and tender, and a mass can be felt in his right upper quadrant.
There are few bowel sounds.
• GENITAL: His genitalia are normal (no scrotal/testicular swelling or tenderness).
Interpretation of examination findings [4 marks total, 2 minutes]

• Not acutely unwell or in shock (1 mark)
• Distended abdomen – suggestive of obstructed bowel (1 mark)
• Mass in RUQ combined with history – typical of intussusception (1 mark)
• Abdomen is not peritonitic – does not suggest transmural ischaemia or perforation at this stage (1
mark)
Recognition of differentials and suggested management [6 marks total, 2 minutes]

The candidate should then start explaining their management to you. If they don’t, you may prompt them
with the following:
a) “What do you think is wrong with Noah?”
b) “What can you do for him?”
c) “What tests might he need?”
The student is required to explain in simple terms that:

a) Possible differentials:
a. Intussusception (1 mark)
b. At least 2 others (1 mark): malrotation volvulus, strangulated inguinal hernia,
gastroenteritis, Meckel diverticulum
b) The baby will need investigations:
a. Abdominal Ultrasound (1 mark): might see “target sign” if transverse, “tram track sign” if
longitudinal, or “pseudokidney sign”
b. Others (0.5 marks): abdominal XR, FBE and film (anaemia, WCC), UECs (for fluid therapy)
c) MANAGEMENT: Noah will need more specialised review (0.5 marks), with a paediatrician,
paediatric emergency physician or paediatric surgeon. Needs referral and admission under
paediatric surgical team.
d) May need transfer to a centre with specialised paediatric service (0.5 marks)
e) Will need to be placed nil by mouth with intravenous normal saline/fluids (0.5 marks) and will likely
need air barium enema insufflation (diagnostic and therapeutic (0.5 marks). Air enema is >75%
successful in reducing intussusception. If fails twice, can try open or laparoscoic operative
reduction.
f) Other (0.5 marks): analgesia, broad-spectrum IV antibiotics, NGT suction.
MARKING SHEET
Serious
errors and All
omissions: important
No
Inadequate Adequate, areas
attempt,
SKILLS skill for year but covered; Excellent
or very
level or incomplete. minimal
cursory
adverse omissions
effect on or errors
outcome
History 0 2 4 6 8
Interpretation of 0 1 2 3 4
examination findings
Recognition of differential 0 1 3 4 6
diagnoses and suggested
management
Communication skills 0 1 1 2 2
¨ ¨ ¨
Samuel, a 4-week old boy has been brought in to the emergency department by his parents. He
presents with vomiting.
TASKS:
1. Take a history from Samuel's Dad, Jarrod (3 minutes)
2. Interpret the investigation findings (1 minute)
3. Please explain the diagnosis to dad (1 minutes)
4. Explain the management plan to the examiner (3 minutes)
You will not be prompted to move on.

Name: Samuel Tran

Gender: Male
Age: 2-weeks old
Ethnicity: Australian/Vietnamese
Clinical details:
You are playing Samuel's Dad, Mark.
Presenting statement: "He started vomiting 3 days ago, but it seems to be getting worse! We're really
starting to get worried!"
History of presenting complaint : Vomiting

When - started 3 days ago
Initially started off as a small amount - now forceful
Progressively getting worse
Has not happened before
If prompted - "still happy to feed afterwards"
Quality - yellow / milk coloured vomit
If prompted - "never green in colour"
No Blood / mucus within vomit
Quantity - First day was 1-2x per day, now it's as soon as after he's fed
Alleviating - nothing noticed
Aggravating - Being fed makes the vomiting worse
Recent illness - no
Associated symptoms
Yes - mum has noticed a mass in the upper part of abdomen
No fever, weight loss or chills
No diarrhoea
No rash
No urinary changes
Birth history Growth & Development

Normal vaginal delivery at 39+4, no complications Normal development - reaching all milestones
Sleep
Feeding Sleeping well - no changes
Still happy to feed - just not getting any food down
Social history
Hydration Lives at home with Mum, Dad and sister.
50% less wet nappies than before Sister is 3yo and did not have this presentation
Nobody smokes in the house
Vaccinations
Up to date with vaccinations (Vitamin K + HepB) Family history
Mum had a brother with similar presentation
Otherwise no relevant history
Contributors: Ashleigh Laird & Mirsada Prasko

Investigation findings
Examination findings not required here but if a candidate requests - give the following information: stable,
afebrile . Vitals all within normal limits. Abdomen SNT with a noticeable mass in the right upper quadrant.
Investigations - a VBG, UEC and ultrasound have been ordered - results below. Urinalysis is negative, if requested.
Please reveal these to the candidate for interpretation - they do not have to ask for the specific tests:
Urea/Electrolytes/Creatinine
Sodium: 135 (Normal: 135 - 145 mmol/L)
Potassium: 2.1 (Normal: 3.5-5 mmol/L)
Chloride: 40 (Normal: 98-106 mmol/L)
Bicarbonate: 5 (22-28 mmol/L)
Blood urea nitrogen: 4 (Normal: 2.9-7.1 mmol/L)
Creatinine:
Venous Blood Gas

Blood gas values Electrolyte Values
pH: 7.46 (Normal: 7.30 - 7.40) cNa+ 135 mmol/L (135 - 145)
PCO2: 45% (Normal: 40-50) cK+ 2.1 mmol/L (3.5 - 5.2)
PO2: 50% (Normal: 30-50) cCa2+ 12.0 mmol/L (115 - 1.33)
HCO3: 5 (Normal: 22-28) cCLl- 40 mmol/L (95 - 110)
Oximetry values Anion Gap 66 mmol/L
ctHB 121g/L Metabolite values
O2 saturation: 99.2% cGLu 4.2 mmol/L (3.0 - 7.7)
FO2Hb 97.5% cLac 0.9 mmol/L (0.5 - 2.0)
FCOHb 0.6%
FHHb 0.6%
FMetHb 1.3%
Ultrasound
Ultrasonography report:
The top image shows the distal stomach with a dilated
stomach and thickened pyloric walls. The image below
shows the thickness measuring to 5mm, and a pylorus
length of 18mm.

Explain diagnosis to dad
Diagnosis: Hypertrophic pyloric stenosis
Assesses attitudes + knowledge
Gives a RCH info pack - https://www.rch.org.au/kidsinfo/fact_sheets/Pyloric_stenosis_an_overview/
Explains the diagnosis:

Pyloric stenosis is a condition that affects the digestive system and causes your baby to vomit forcefully.
It affects an estimated 1/500 babies.
Food normally moves down from the stomach to the small bowel via an opening called the pylorus -
pyloric stenosis occurs when the muscles around the pylorus become bigger and squeeze the opening -
causing it to become narrow (or stenosed).
Food cannot empty out of the stomach because there isn't enough room for the food to pass through, as
such it is often vomited out. Often babies tend to be hungry afterwards and the pylorus can sometimes
be felt under the skin - it typically looks like an olive.
It usually occurs in babies from 2-6 weeks of age and an operation is required to fix the problem.
Typically, this condition occurs in Caucasian families, particularly if theres a maternal family history and
tends to occur in males 4x more than females, and pre-term babies over term babies.
Explain management to the examiner

1. Admit Samuel into hospital
2. Consult the paediatric surgeons - in the meantime:
3. Stop the oral feeds
a. Insert an NGT if profuse vomiting despite stopping feeds
4. Gain IV access for fluid resuscitation
a. Fluid bolus: 0.9% sodium chloride (10-20ml/kg)
b. Replace any deficits with 0.9% sodium chloride + 5% dextrose
c. Maintenance: 0.9% sodium chloride + 5% dextrose
i. Daily rule: 100/50/20
ii. Hourly rule: 4/2/1
d. When urine output is adequate - include potassium IV in the fluids (1-2ml/kg/hour)
5. Surgical work-up:
a. 2 talking things - refer to paeds surg (already done) + explain to parents
b. 2 oral things - NBM + NGT
c. 2 IV things - Cannulate, IV access with baseline bloods + IV rehydration
d. 2 medical things - Analgesia + anti-emetic (ondansetron)
6. Definitive surgical management: Ramstedt's pyloromyotomy
a. Conducted only once fluid imbalances corrected
b. Laparoscopic > open procedure
c. Muscle hypertrophy is cut down sparing the mucosa
d. Post-op: can be fed orally within 6 hours

Brad is 5 months old and has developed a lump in his groin on the left side when he cries
over the last 2 days. Otherwise he is well and is feeding well off the breast and gaining
weight normally.
Examination is normal and no abnormalities in the groin were detected.
1. Complete a history. Explain what you would like to look for on examination. Counsel
parent on the likely causes for the presentation. (6mins)
2. Discuss suggested management. (2mins)
History
Inguinal hernia
• WHERE? Left groin swelling
• WHEN notice? the child cries
• Noticed only lately, but thinks that it has been there quite some time
• Surprisingly, the next day when I looked, it disappeared! (intermittent)
• Feels hard but PAINLESS

Any other problems?
Yes, umbilical swelling (Umbilical hernia): increased in size for the first 2 months but is now
stable.
• Birth hx: Preterm baby- 34 weeks via C Section due to poor intrauterine growth, 1.6kg,
hospitalized 1 week.
• Neonatal: Uneventful. Catch up growth after 2 months
• Developmental: Normal, immunization: up to date
• Weight -5.5kg, height-60cm –ALL normal
• Feeding: Normal
Physical examination
• Healthy, active boy
• Both testes palpable within the scrotum
• No asymmetry
• When begins to struggle, a smooth firm swelling appears in the left inguinal region
• Distension of the left hemiscrotum.
• With gentle pressure, it disappears
• Umbilical hernia present – no other findings.
• Remainder of the examination is unremarkable.

Ddx
• Hernia
• Hydrocele
• Hydrocele of the cord
• Lymph node
• Undescended testes
Patient’s prompts
1. What is the swelling at the groin? Why does this happen to my child?
2. Is surgery necessary? (groin swelling)
3. Is there a need to worry- the swelling on his umbilicus? Does he need to go through
another surgery ??
Counselling
What it was and why it occurred?
- Inguinal hernia occurs when the bowel slides through an open canal into a pouch in
the groin/scrotum. This appears as a lump in the child’s groin, often intermittent
(that’s why you only notice it when your baby cries)
- More likely to occur in boys and PRE-TERM babies.
- Sometimes the lump goes down into the scrotum where the testis sits in a boy. Or
into a labium (girl)
- WHY? Testis descends into the scrotum at 28th week in utero through a diverticulum
of the peritoneum (processus vaginalis)
- Failure of obliteration of processus vaginalis leads to inguinal hernia/hydroceles.
Management of inguinal hernia

- Refer surgical
● Try to reduce the hernia with opioid analgesia + sustained gentle
compression (TAXIS)
● Do not continue if signs of bowel ischemia (discolouration, baby toxic looking)
❖ Surgery delayed 24-48 hours to allow for resolution of oedema
❖ Prompt repair is necessary d/t risk of strangulation or incarceration
❖ Small bowel easily become trapped in the hernia, blood supply to
bowel compromise bowel obstruction/ strangulation
❖ [Sx of strangulation: inability to push hernia back (irreducible),
excessive crying, later vomiting, abd distension and constipation ]
- Surgery: herniotomy
● Involves ligation and division of the hernia sac (processus vaginalis)
● Under appropriate anaesthetic
Management of umbilical hernia

- Results from failure of umbilical cicatrix to contract following separation of umbilical
cord.
- Incarceration is very rare in childhood.
- Common condition and > 95% will resolve spontaneously by 2-3 years.
- In infants, hernia may become large and increase in size in the first 6 months.
- No treatment needed - although parents will often require reassurance.
- Refer to the OPD of General Surgery if still present after 2 years or if there is parental
anxiety due to large size in infancy.
- Surgery should be considered if the hernia is still present after the age of 3 years.
(risk of incarceration increases in adulthood. )
Prepared by: Joshua Wong
Date: 29/8/2017
OSCE STEM [8 MINUTES]
You are paediatrician working in your own paediatric clinic.
Mrs. Sandy has brought her 11 year-old son, Sponge Bob to see you with a complaint of
intermittent pain in his hip. As he walks to your clinic, he appears to be limping. Otherwise,
he is a big-sized child whom is looking rather well.
Sponge Bob was born at 39 weeks through normal vaginal delivery with no antenatal,
perinatal and postnatal complications with a birth weight of 3.2 kg. His immunisation is all
up-to-date. Sponge Bob assumes a picky diet avoiding vegetables and fruits. Mrs Sandy is
seldom at home because of work, thus Sponge Bob often resorts to fast foods and take aways.
He had a normal developmental growth. He has no significant past medical history, past
surgical history and family history. He has no known allergies.
As a good caring doctor, you are expected to do the following:
TASKS:
1. Take further history from Sponge Bob to identify a possible diagnosis [5

minutes]
You have conducted a physical examination. Findings will be given to you.
2. List your differential diagnosis. [1 minutes]
3. A hip x-ray will be provided. Tell the examiner your provisional diagnosis and
further management plans for this patient. [2 minutes]
Date: 29/8/2017
Marking Sheet
No Marking Points Comments

1 Appropriate introduction, consent + confidentiality
Clear simple (non-jargon) language, clear explanations
Non-judgmental, patient centered
Listens and allows opportunity for patient questions
Empathy, good body language
Addresses frustrations and irritations of patient
Organized and systematic
2 History
PC: Pain in the right hip.
“ I am a bit worried about Ali’s speech. It seems to be a
bit delayed.” Started noticing 2 months ago.
S- right hip
O- since a few months ago ( pain started after started to
put on weight)
C- dull pain which worsens with activity
R- occasionally felt in the knee
A- when lie down/ stationary
T- day and night
E- after walking/ school- pain is most severe
S- worst pain is 7/10
No fever, no swelling/lump, no bleeding, no stiffness, no
fall/trauma, no previous injuries, no travel history.
Home-Stay with mother (mum and dad divorce few

months ago)
Education- Like to study and doing quite well in school
Eating-Is a fussy eater, opt for sweet drinks and fast
food
Activities- like to watch the Ellen show and play
computer games
Drugs- n/a
Sexuality- n/a
Suicide- no thoughts/ guilt about parents divorce –
comfort eating
Safety- often being tease at school for being fat.
PMH (including birth, immunization and diet), PFH and

Social Hx has been stated in the stem. No marks allocated for
these questions
3 Differential Diagnosis
● Refer image below (according to age)
4 State Likely Diagnosis and Further Management

● Provisional Dx: Slipped Upper Femoral Epiphysis
Further Investigations
● Investigations: Ruling out infections- FBC, ESR, CRP,
Blood culture, C3,C4, septic workout
● Imaging: Ultrasound
Date: 29/8/2017
● X-ray :anteroposterior and frog-leg lateral views of both
hips to diagnose SUFE
● Invasive: Joint aspiration
Mainstay Tx – prevent progression/ complication- chondrolysis /
avascular necrosis
● Referral to orthopedics
● Non weight bear- crutches
● SURGERY: In situ screw fixation
● Prophylactic pinning- unaffected hip rarely needed
unless risk of subsequent slip ( obesity/ endocrine
disorders)
● Refer dietitian
● Counsel on exercise – if diet and activity fail only
prescribe orlistat
● Counsel mother on healthy eating habits
● Prescribe with analgesics
● Bed Rest
● Sexual health and safety
● Screen for depression - CES-DC
EXAMINATION FINDINGS:
General: A young Chinese boy with big body build. Appears to be well-oriented and pink at
room air
BMI: 27.5 kg/m2 (>95th percen le)
Vital signs:
Pulse Rate: 78 beats/min, good volume, normal rhythm
Respiratory Rate: 70 breath/min
BP: 120/80 mmHg
Temp: 36.8°C
Date: 29/8/2017
Pulse Oxymetry: 99%
MSK:
● Right hip is not red/inflamed.
● Unable to bear weight on the right foot.
● Restricted abduc on and internal rota on of right hip
● Right limb appears to be externally rotated (out-toeing)
● Range of mo on of the right hip is smaller compared to the uninvolved le hip.
● Tenderness upon movement of right hip.
PNS: No abnormali es
X-ray of the Right Hip

Date: 29/8/2017
(RCH Guidelines)
Please refer Sunflower Book for a more complete list of differen als.
You are a GP, Josie, a 12 year old girl has presented with hip pain and a limp. It has been present for the
last couple of days.
TASKS:
1. Take a history from Josie and her Mum, Iris (4 minutes)
2. Please list your differentials, and examine as necessary (1 minute)
3. Please explain the management of your most likely differential to Josie (3 minutes)

Name: Josie Davis

Gender: Female
Age: 8 years old
Clinical details:
You are playing Josie's Mum, Iris.
Presenting statement: "She's just had a really sore hip for the last couple of days, I tried panadol and it
helped a little bit but not a lot."

Started 2 days ago
Came on gradually
No trauma that she can remember
Dull ache in hip, does not radiate
At its worst it is probably a 7/10. Panadol got it down to about a 4/10
Gets worse when she is walking around
No swelling, erythema, bruising or bleeding
Associated symptoms
No nausea, vomiting
No diarrhea
No fever, no weight loss, no chills
No abnormal bleeding
Sick: had a cold last week. Just a head cold, nothing too bad, she's better now
Differentials
Development
Transient synovitis
Normal development - reaching all milestones
Dull pain in hip
Has not yet had menarche
Recent URTI
NVD at 40+2, no complications
Septic arthritis
Not in excruciating pain when moving the limb
Vaccinations up to date
No oedema or erythema
No recent trauma
Family history
Perthes
Nil family history
Hasn't noticed any restriction on movement
SUFE
Social history
BMI 21
Lives at home with Mum, Dad and younger sister (7)
No change to appearance/rotation of limb

Possible differentials
Transient synovitis
Perthes
SUFE
Septic arthritis
General inspection: 8 year old girl laying on the bed, doesn't appear to be in any obvious pain
Vitals: Temp 37, HR 70, RR 24, BP 100/70
MSK: Decreased ROM in hip, particularly internal rotation
Respiratory: clear, no wheeze, slight cough and runny nose
Diagnosis
Transient synovitis
Management
a. Transient synovitis is commonly called an "irritable hip," and is the most common cause for limping in a
child. It is due to the inflammation of the lining of the hip joint.
b. It most commonly occurs after a viral illness.
c. Symptoms, which Josie has been experiencing, include a limp, difficulty standing, or groin, hip, thigh or
knee pain
2. Management
a. An irritable hip will get better on its on with rest
b. it should start to improve over a couple of days and should be better in 2 weeks
c. Ibuprofen is helpful as it can relieve pain and reduce inflammation.
3. When to see a doctor:
a. if she develops a fever
b. Develops an obvious swelling or redness
c. Has increased or persistent pain despite ibuprofen
d. Is in pain at rest
e. Is not improving over the next couple of days

Sally, a 40 year old lady has come in with her 5-day old daughter. She has been told that her baby was
diagnosed with Down syndrome. She had come in to receive more information about this. Please
counsel Sally about down syndrome including medical issues for her baby due to this condition.
TASKS:
1. Take a relevant antenatal history from the mother (3 minutes)
2. Explain Down Syndrome diagnosis to the mother (2 minute)
3. Please explain the medical issues due to down syndrome (3 minutes)
You will not be prompted to move on.

Mother's name: Sally Gisbe

Gender: Female
Age: 40 years old
Baby's name: Ashley Gisbe
Clinical details:
You are playing Ashley's mum, Sally.
Presenting statement: "When my baby was born the doctors mentioned about some down syndrome
characteristics, and they did a test to confirm it ... I needed some time but i'm finally here to learn more about it"
Relevant antenatal history

G1P1 - this is Sally's first child, never been pregnant before
Antenatal screening - she knew the risks because of her age but decided that her decision wouldn't change
the outcome so never went through with them.
Had all the other regular check-ups like the 20-week scans and blood tests - all normal
Ashley born via normal vaginal delivery at 38+6/40 weeks gestation - no complications
No time spent within the hospital - discharged later that day
Other relevant history:

Ashley currently formula fed - difficulty latching on
Up to date with vaccinations
Feeding appropriately - no issues with growth
Hydration - producing 4-7 wet nappies per day
Family history - nil positives
Social history - Lives with husband, feels well socially supported.
No smoking, alcohol or illicit drugs
Gynaecological history - not relevant, if candidate asks:
LMP was 10 months ago
Usually periods regular with 28 day cycle, bleeding for 4-5 days
No mennorhagia, dysmennorhea, fullness or post-coital bleeding

Explain diagnosis to mum
Diagnosis: Down syndrome - also known as, Trisomy 21
Assesses attitudes + knowledge
Give a RCH info pack:
https://www.rch.org.au/genmed/clinical_resources/Screening_for_children_with_Down_Syndrome/
Explains the diagnosis:

Down syndrome is a genetic condition where an individual has inherited extra genetic information
Our body is made up of cells - in each cell we have genetic material in the form of chromosomes. We
have 26 pairs of chromosomes, one from each parent giving rise to a total of 46 chromosomes
In Down Syndrome, individuals have inherited an extra chromosome so instead of having 46
chromosomes, they have 47 within their cells - specifically, it is an extra chromosome 21 and this is why
it is sometimes called 'Trisomy 21'.
We don't know why it happens - it is nobody's fault as to why it occurs
There is no cure and it's a life long condition - affecting approximately 1/1000 individuals in Australia
Explain the medical issues associated

There is no cure - we can however, closely monitor and explain what to look out for
Growth + development Respiratory system
Growth delay - we have specific growth charts OSA
Delayed motor milestones Tonsillitis
Moderate to severe intellectual disability Severe croup
Short stature Recurrent URTIs ( narrow upper airway)
Obesity GIT
Failure to thrive Coeliac disease
Neurological Hirschsprung's disease
Epilepsy Duodenal / anal atresia
Alzheimer's (early onset) Constipation (low muscle tone)
Senses
Recurring otitis media + hearing deficits
Congenital lens abnormalities (3%) - strabismus, cataracts, squint, myopia
Endocrine
Reproductive
Congenital hypothyroidism
Infertility & cryptorchidism in males
Type 1 diabetes mellitus
No specific things in females
Immunological
MSK
Immune deficiency
Joint hyper-flexibility
Increased risk of ALL & solid tumours
Atlanto-occipital subluxation
Cardiovascular system
Hip dysplasia
Septal defects - most commonly AVSD
Vertebral abnormalities
Heart block, bradycardia

Not required as part of the station - extra information about medical conditions
Routine screening for down syndrome:

At birth
TSH as part of Guthrie heel prick test
Refer to geneticist
Counselling on prenatal diagnosis
Birth - 1 month
Physical examination for evidence of Trisomy 21 with particular attention to cardiac, GIT, opthal
Offer genetic counselling - discuss recurrence
Echocardiogram by paediatric cardiologist incase any cardiac disease missed on exam
Newborn hearing screen + follow up
Check for duodenal atresia
If constipated - consider dietary intake
1 month - 1 year
Audiology + ENT assessment at 6 and 12 months of age (annually thereafter)
TSH at 6 + 12 months
Annually
TSH after 12 months of age
Audiology + ENT after 12 months of age
FBE
Ophthalmic assessment from ages 1-5 years old
Screen for symptoms of coeliac disease
Every 2 years:
Ophthalmology assessment between 5-13 years old, then every 3 years thereafter
All visits:
Assess developmental progress
If constipated - assess dietary intake
Discuss atlanto-axial instability and monitor for myelopathy
Assess OSA and consider polysomnography

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Children’s Health OSCE Stems

Compiled by Jovy Wong

Compiled by Jovy Wong

Children's Health - R1 and R2 conditions within these curriculum domains

Show to student in task 3

Urine FEME: Normal

RBS: 2.0 mmol/L

Blood cultures: Pending

Intro Introduction, consent, confidentiality

Demographics John, 14-days old, boy

Opening I’m worried my baby doesn't seem right

HOPC Feeding reduced for 2 days

Other Normal antenatal, delivery and postpartum

Birth history Born term with 3.2kg via SVD, no complications

Medications Paracetamol – hasn’t worked

What would you like to do in examination?

- Fluid resuscitation with NaCl 0.9%

You are paediatrician working in your own paediatric clinic.

As a good caring doctor, you are expected to do the following:

1. Take a focused history from Mrs Katherine in regards to Liam’s problems.

At 5 minutes, some investigation results will be given to you.

EXAMINER MARKING SHEET

IRRITABLE & LETHARGY – 1 week

- No rashes, no jaundice, no swelling, no breathing distress, no grunting sounds, no cold hands

BIDDS Hx – Stated in stem

- FBC, PBF, Blood C&S

**DMSA (dimercaptosuccinic acid) and MCUG (micturating cystourethrogram)

RCH/ NICE: Not done unless atypical or recurrent UTI.

4. Counsel the mother.

- encourage IV fluids – for high urine output and regular voiding

- discharged once temperature stable and symptoms not present.

RCH (based on NICE GUIDELINES)

STATION STEM: Provided to candidates the day prior

TASKS: Will be provided to candidates in the exam

Information Sheet to be provided to candidate

Name: Diamond Sparkle, son’s name is Michael Thatcher

Marks Allocated Criteria

/4 • Addressed Presenting Complaint

/4 1. Check vital signs

Provide information sheet to candidate

Marks Allocated Criteria

/4 1. Establish diagnosis is ABO incompatibility

/2 • Communication Skills to patient

/6 • Candidate must exclude sepsis! (this is based on lethargy,

Total Score /20

Contributors: Ashleigh Laird

Name: Riley Manning

History of presenting complaint

Contributors: Ashleigh Laird

Contributors: Ashleigh Laird

 Take a focused history in regard to the presentation (6MARKS)

SIMULATED PATIENT INSTRUCTIONS

In response to the candidate’s questions:

He has vomited 4 or 5 times

Your antenatal scans were normal

The candidate will be given an X-ray

They will explain the diagnosis

Questions you should ask if not already answered

What is the diagnosis?

Birth history: 3.4kg, no complications

Viral Croup – 6 months to 6 years old, peak 2 years old. (Sunflower)

Aetiology (Paeds Protocols)

Indications for Hospital admission (Sunflower & Paeds Protocols)