1.

Temper Tantrums
2. Headbanging
3. Breathholding Spell
4. Stuttering
5. Speech Delay
6. Global Developmental Delay
7. Fuzzy Eater
8. SICK BABY QUESTIONS:
9. Immunization Advice
10. Down Syndrome
11. Failure to Thrive (Non-organic Cause)
13. Refugee Assessment

1.
John brought his 4-year-old son Sammy to your GP clinic. He and his
wife think that Sammy has ADHD and want you to check him for that.

o Task:
Further history

(eye contact, seems like happy child; can

communicate with doctor; vital signs, chest
and heart, normal)

Examination Findings

(cannot control him; annoys parents; parents

are frustrated; teachers not having same
problem)

Advise parents about your diagnosis

Features:
Dramatic reaction of kicking, shouting,
screaming, breath-holding, throwing, or banging
of the head
Start 12-28 months and persist until 3-4 years.
Occur if child is tired or bored
Perpetuated if the tantrums are inadvertently
rewarded by the parents to seek peace and avoid
conflict
History:
Detailed history to gain insight into family
stresses
Allows parents to ventilate their feelings
Ask parents exactly what child does during a
tantrum what they do during and after and what
causes the tantrums
School performance
Physical examination
Growth charts
Check hearing and vision
School performance
Management
Reassure that that the tantrums are relatively
commonplace and not harmful

Explain reasons for tantrums and include the

concept that temper tantrums need an audience
Ignore what is ignorable (parents should pretend
to ignore the behavior and leave the child alone
without comment, including moving to a different
area, but not locking the child in his room)
Stay calm and say nothing
Dont give in
Avoid what is avoidable: try to avoid other causes
of tantrums (visiting supermarket)
Distract what is distractable: redirect childs
interest to some other object or activity
Praise appropriate behavior
When ignored, the problem will probably get
worse for a few days before it starts to improve.
Medication has no place in management of
temper tantrums

Ignore what is ignorable

Avoid what is avoidable
Distract what is distractable

2.
A mother of a 2-1/2 boy comes to your GP practice complaining that
child is banging his head several times a day.
Task
Further history
Counsel the mother
Features:
Common
o (5-15%) in infants and toddlers under 4
especially 3
Also occurs in developmental disability and severe
emotional deprivation
Usually prior to going to sleep
Head-banging occurs 60-80x/minute
Lasts several minutes to 60 minutes or more per episode
Associated repetitive movements (body rocking, thumb
sucking)
Child usually not distressed and rarely self-injurious
Consider an autism spectrum disorder
Management:
Reassure that it is self-limiting and usually settles by 3-5
years
Avoid reinforcing behavior by excessive attention or
punishment
Advise distraction or actively ignoring behavior
Place bed or cot in middle of the room away from a wall
Restrict bed time
DDx Headbanging:
Temper tantrum
Pain (ENT infections, teething)
Vision and hearing problems
Autism spectrum disorder
Normal type of headbanging
History:
I understand you have come to see me because youre
concerned about Marthas behavior. When did it start?
How often does this episode occur? For how long? Does

it happen anytime in particular (day or night)? Apart from

headbanging, does he suck his thumb or rocks his body
or hum? Have you noticed any abnormal body
movements? Does he have a bad temper? Does he get
upset when you say no?
How was your pregnancy? Delivery? Any complications
after delivery like infections or jaundice? How is his
general health? Any concerns about his growth and
development? Is he walking upstairs without help? Can
he throw a ball? Can he build a tower of 4 blocks? How is
his speech? Is he trying to combine two words and
making short sentences?
Does he enjoy your company? Does he play with other
children? Any concern about his hearing or vision?
Immunization up to date? Medications? Allergies?
Who do you live with? Any family or financial problems?
Do you have enough support? Any mental or behavioral
problem that run in the family?

Counseling:

According to your childs history, he has a condition which is

called head banging. Have you ever heard about it? It is a
behavioral problem and is very common in this age. In most
cases, head banging bears a self-calming effect on children. It
is similar to other activities like thumb sucking or fondness of a
toy or blanket.
To you, it appears like your son is trying to injure himself when
in fact he is trying to get rid of stress or tension. Children dont
get serious injuries while head banging and grows up normally.
He will grow out of this condition by the age of 4 or earlier.
During head banging, try to ignore him but make sure he gets
plenty of positive attention when he is not banging his head.
Try to move the cot away from the walls or hang a small fabric
or quilt in between the wall and cot. Try to set up a relaxing
routine. A warm bath, quiet story or song may help. Rubbing
his back or stroking his forehead may have a calming down
effect.
I will review your son frequently. Please let me know if you
need any help or support.

3.
You are a GP and a 2-year-old boy was brought to you by his father
because an hour ago, the child had a finger jammed by the door then
he stopped breathing and started twitching. Father is concerned about
epilepsy.
Task
Relevant history
Physical examination
o (normal appearance, normal vital signs, finger
has swelling and bluish discoloration, CNS
normal)
Diagnosis and management
Features
Usually 6 months to 6 years
2 types:
occurring with a tantrum - blue attacks: breath-holding
with a closed glottis
And other simply faint in response to pain or fright- white
attacks: reflex anoxic seizures often in response to pain
Become pale, cyanosed jerky movements,
unconsciousness or a fit; lasts for 10-60 seconds
Management: coma position; reassure patients; maintain
discipline and resist spoiling the child; avoid incidents that
frustrate the child or precipitate a tantrum by distraction
methods
Hx:
How is he now? Is it very painful? Offer painkiller. Could
you please describe what exactly happened? Is it the first
time? How long did it last? did he wet himself? Did he
lose consciousness? Or was he drowsy? Did he bite his
tongue?
FHx of epilepsy
Have you noticed that he cries excessively when he
needs something? Does he accept NO easily?
Behavioral problems such as head banging? How is his
health in general? Any fever or head injuries? BINDS?
How is his growth and development? Is he growing well?
His language? Has he started talking? Does he like

playing with other children? Does he emotionally interact

with you? How is the relationship with other siblings?
Are you a happy family? Any kind of stressors in the
family?
Physical examination
General appearance:
Vital signs and growth charts
Examination of injured fingers
Dx and Mx
Your child had a breath-holding attack. It is a common
condition in this age group. It is a behavioral disorder that
is completely harmless. It can be precipitated by pain,
emotion or frustration. Usually, it disappears by 3 years.
Let me reassure you that this is not epilepsy.
Try to avoid the situations which are precipitating it.
Ignore him and keep him safe by putting him in the lateral
position. Distract him. Do not spoil the child by bribing.
This will not lead to any epilepsy or brain damage.
Reading material.
Red flags:
o
o

Review

attacks are more than 1 minute,

loses consciousness or gets drowsy, bite his tongue
or incontinent

4.
You are a GP and a 4-year-old boy was brought because of stuttering
for the last 6 months. He was alright before but the parents think that
the problem developed since he joined Kindergarten. It is more
prominent when the child is excited. His growth and development are
normal
Task
Relevant history
Management
Hx:
Please tell me more about how and when it started. Have
you noticed what type of stuttering it is? Is he able to
initiate his speech? Is he repeating the word often? Are
there breaks within the sentence? Do you notice that his
stuttering increase during a particular
circumstance/situation? Do you think his behavior
remains the same at home or otherwise?
I understand he started Kindergarten 6 months ago, any
problems over there? How is his relationship with his
teachers and the kids? Does he speak the same at
kindergarten? Do you think he is under any kind of
stress? How is the home situation? How is the
relationship between you and your husband and the kids?
Any other family member who stutters? Is this your only
child? What about the other kids?
Do you have any concerns about his growth and
development? Immunization status? Past medical
conditions? How is his appetite, sleep, waterworks and
bowel habits? May I ask, what is your response to the
child when he stutters?
Mx:
Let me reassure you that stuttering is a very common
condition. Around half of all kids who attend kindergarten
stutter in one way or another. It is more commonly seen
with boys between the age of 2 and 5 years. The usual
causes are anxiety, tiredness, unfamiliar or strange
surroundings, reading within groups while using difficult
vocabulary, when the child is forced to speak and when

competing against classmates. Please dont worry.

Stuttering is not related to his intelligence. There is no
organic pathology within his brain or anywhere else. 65%
of kids grow out of this condition by themselves. What is
important at this point is to identify any stress-related
causes to this condition and to rule out any chance of
bullying or teasing. You will need to cooperate with the
child throughout this time.
Allow me to tell you what needs to be done and avoided:
o
o
o
o
o
o
o
o

RCH

Listen to your child. Dont interrupt him in between.

Be patient if he gets stuck with a word. Please dont
finish his sentences for him.
Repeat what he has said
Reassure him and be supportive.
Dont criticize him for not being fluent.
Dont allow any family member to tease him.
Dont push him to speak
Try to avoid circumstances where he is likely to
stutter.

We will give him a trial of around 6-12 months with these

techniques. You will need to involve his teachers. If at the
end of 1 year, he still doesnt improve, I will refer him to
the speech therapist but usually 80-90% of children
improve if treatment is started before the age of 5 years.
Reading material. Review.
Strong genetic link (50-75%); Developmental anomaly
Period of time that has lapsed since the onset of
stuttering is a strong predictor with little chance of natural
recovery in children >9 year old
Treatment: if >6 mos refer to speech pathologist trained
in Lidcombe programme.

5.
A 9-month-old baby was brought by parents to your GP clinic. They
are concerned that baby could not say any words. The baby was seen
by another GP a few days earlier.

Mx:

Task

Hx:

Relevant history
Management
No physical examination required
Answer parents questions

I know you have come to see me because you are

concerned about your sons speech. Is he babbling?
Does he variable syllables? Does he imitate speech
sounds? Any concern about his hearing or vision? Does
he enjoy musical toys? Does he turn to loud sounds?
How was your pregnancy? BINDS - Is he a term baby?
What type of delivery did you have? Any complication
after delivery such as fever or yellowing of the skin? Did
he have hearing screening after delivery?
How is his general health? Growth Charts ? Any serious
illnesses or recurrent ear infection or head trauma in the
past? Are you still breastfeeding or bottlefeeding? Any
concern about his growth? Immunization up-to-date? Is
he your only child? Regarding his development, can he
sit without support? Can he stand holding on? Can he
pass object from one hand to another (7months)? Can he
try to grasp small objects between his index finger and
thumb (7-11 months)? Does he play peek-a-boo? Does
he enjoy cuddles and eye contact? Has he lost any
developed skills recently (regression)?
What did other doctor say regarding your concerns?
Hows the situation at home? Any recent emotional or
financial stressors? Do you have any FHx of hearing
problem or speech delay?

According to your sons history, he has no problem

regarding his development. As a parent, you are doing a
wonderful job and he reached all his milestones required
at this age group. Usually, we expect baby to say 1-3
clear words between 9 and 15 months. You dont have
any concerns regarding hearing and he is babbling using
variable syllables which are all good sings regarding his
language development.
If you are still very concerned, I can arrange referral to
pediatric audiologist for formal hearing assessment. If
audiogram is normal, I just need to review your son when
he is 12 months old.

6.
A mother presents to your GP practice concerned that her 21-monthold child has not started walking yet.
Task
History
o (spoke 1st word at 14 months, sits with support,
plays with other children; has another daughter)
Physical examination
o (active but with no dysmorphic features; growth
chart height and weight 50 percentile, head
circumference 10th to 25th percentile (Measured
upto 3 years), hypotonia, jerk/reflex brisk)
Advise on further management
Features
Delay in two or more important areas of development
Causes: genetic or hereditary disorders such as Down
syndrome, or other developmental disorders such as
Cerebral Palsy or spina bifida); premature birth, infections
or various metabolic diseases, neurologic (epilepsy)
Investigations: metabolic tests and screening, genetic
testing, hearing and vision test, lead screening, thyroid
screening, EEG, CT scan, psychologic assessment,
Hx:
I understand that you are concerned because your child
is not yet walking, can I ask a few more questions? When
did he lift his head (2-3 months)? When did he start sitting
with support (6months)? Without support (8 months)?
Can he stand while holding on to things? Can he hold
things with his hand and pass it from one to the other?
Pincer grasp? When did he speak his first word? Does he
turn around when you call his name or to loud sounds?
Does he play peek-a-boo? Does he play with other
children? Can he indicate what he wants (15 months)?
Can he drink from a cup (17 months)? Do you have other
kids? How would you compare their development?
Does he get sick often since birth? How was the delivery?
Were there any complications? Have you ever been sick
while pregnant? Did they do the heel-prick test

(galactosemia, cysticf fibrosis, congenital hypothyroidism,

phenylketonuria)? Is the immunization up-to-date? Is he
eating well? Any problem with urination or bowel? How
are things at home?
Variant 2 (Delayed Walking):
Maybe associated with mild hypotonia; refer to physiotherapist and
review child in one month; reassure; refer if after 1-2 month

Mx:

Physical Examination
o General appearance and scissoring of legs
o Vital signs
o Growth chart
o Neurologic examination: IT PRC (inspection,
tone, power, reflex, coordination)

From the history and examination, your child has a

condition called global developmental delay because it
seems that he has achieved his developmental
milestones at a later time. I am also concerned about his
head circumference which is lower compared to his
height and weight. At this stage I would like to refer him to
a specialist pediatrician who will do a full developmental
assessment. If required, the specialist might do some
investigations.
Referral ASAP.
Review.

7.
Variant 1:
You are a GP and a 2-year-old child was brought by his mother. She
is worried about her childs weight and wants your advice.

Variant 2:
Your next patient in GP practice is a 2-1/2 year old boy brought in by
his father John because he has poor appetite and does not eat
properly. Parents are concerned and feel that he has not been gaining
weight like other children with the same age (Dr. Wenzel)
Variant 3:
Mr. Smith brought his son David who is 2-1/2 years old. Mr Smith is
worried that David is not eating well. The parents are very concerned
about this and think that he is not gaining weight as other children of
his age.

Task
o Focused History
o Physical examination
(weight 15kg, height 95cm)
o Management

Features:
o 8/10 Australian parents are concerned about
their childs eating habits
o 1/3 of parents worry that their child isnt eating
enough
o Management
o Keep calm and dont make a fuss of whether
your child is eating or not
o Be realistic about the amount of your childs
meals
o Dont threaten, nag or yell
o Dont use lollies, chocolates, biscuits, milk or
desserts as bribes

Meal time:
o Be a good role model
o Ask your child to help prepare a meal
o Set up regular habits for eating such as always
putting your child in their high chair or eating at
the same table
o Offer a range of colorful foods
o Encourage self feeding and exploration of food
from early age
o At the end of meal, take your childs plate away.
If they havent eaten much, offer them a healthy
snack later on or wait until next mealtime

History
o What is your concern? Have you brought his growth
charts with you? Do you think he is not eating well? Can
you describe his typical daily diet to me? How much milk
does he take? What type of milk? Do you think he is picky
about his food? Can you describe his behavior at meal
time? Does he eat at the table with his family? Are you
concerned about his general health? Does he have any
problems with his bowel habits (diarrhea, constipation)?
Does he have N/V/tummy pain? Do you think his diapers
are smelly? Any concerns about waterworks? Does he
have fever, cough, SOB? Did he suffer from frequent
respiratory tract infections previously? Do you think he is
pale or turns blue at any time?
o Please tell me more about the pregnancy? Any problems
or complications? Was he delivered full term? NSVD?
What was the BW? Is this a planned pregnancy? Do you
think he has achieved all the developmental milestones
on time? Immunization?
o May I ask, how is the home situation? Any stress/financial
problems? Is he your only child?
o Any family history of anybody on a special diet? Chronic
diarrhea or other genetic conditions? Anyone smoking at

home? Is he able to sleep well? Does he go to childcare?

Did he have the heelprick test ?

Physical examination
o General appearance and dysmorphic features; level of
consciousness
o Bruises over skin
o Growth charts and observe pattern of growth (height,
weight, growth chart)
o Vital signs
o Mouth: evidence of glossitis, cheilitis, or protruding
tongue
o Skin: dry, scaly skin
o Measure bulk of triceps/biceps
o ENT, thyroid, chest, heart, abdomen
o Inspection of genital area: signs of abuse or perianal skin
changes
o Urine dipstick

Management
o I do not see any real cause for concern. Please dont
worry, your child looks physically fine to me. The only
problem might be that he is a bit lower than the weight
percentile. This could be completely normal for him, but
what is important is to acknowledge that his behavior
regarding food needs to be reviewed.
o It looks like he is fuzzy about his eating. A fuzzy eater is
one who refuses to try a new food at least half of the time
when it is offered. It is very common with this age group.
Almost half of all toddlers fit this description. Please
understand that this is not a disease, but a variant of
normal behavior.
o It is important to establish healthy eating habits to avoid
problems like obesity and eating disorders later in life. I
will refer you to the dietitian to help you, but I do have
some suggestions. Generally, show the child a healthy
eating pattern by adopting it yourself. Try to offer a variety
of food at different times throughout the day. Please dont

force him and dont threaten him, but also dont bribe him
into eating. Dont be discouraged if they reject a new food
initially. You will need to offer it at least 3-4 times in the
beginning. Have a regular routine to eat meals together
with the family at the table. Encourage the child to feed
himself and to help you prepare his food. Please
understand that a child has appetite equivalent to his fist.
You can offer 3 small meals and 2 snacks in between.
Please make sure that he is not tired, ill, or emotionally
upset when offering food. Lastly, as long as your child is
putting on weight please do not stress yourself about his
health and weight.
o Reading material.
o Referral to dietitian.

8.

Ask what is wrong? Can you tell more about it?

Fever? Did you give any medications for the fever? Did it
help?
Does he have cough? Noisy breathing? Difficulty
breathing? Runny nose?

ENT: Have you noticed the baby pulling at the ear?

Is she able to feed? Is she able to keep the feeds down?
Any vomiting?

UTI/dehydration: How wet are the nappies? Any change

on the color or smell of nappies?

Joint: does she cry when you touch her anywhere?

Any rash or abnormal posturing?

Contacts: Do you have any other children? Are they sick?

Does your child go to childcare?

BINDS.
o
o
o
o
o
o

Physical examination:
o
o
o

How has your baby been since birth?

Immunizations up to date?
Nutrition
Development
Allergies
Rashes

General appearance,
vitals,
Length, Height, Weight and anthropometric
measurements

Do not forget ENT, abdomen and genitals!!

Urine examination

9.
You are a GP and a 6-weeks-old baby boy was brought in by mom.
He is the first child of the family. The child has been breastfed and is
gaining weight. All examination up to now is normal. The mother
wants to know how and when the child is going to be immunized.
Task

Outline the current immunization protocol

Explain what diseases are covered by it

As you know, immunization is a very important aspect of preventive

medicine.It works in two ways:
Firstly, it stimulates the immune system of the child to
produce cells that defend the body.
Secondly, we inject the child with the same bugs as that of
the disease, but these bugs have been weakened by certain
techniques so they cant produce the disease.
Immunization is offered at certain times starting at birth and then at 2,
4, 6, 12 and 18 months. Later doses are usually at preschool age.
Usually, more than one dose is required for complete protection.
With the development of immunization program in majority of the
countries of the world, a number of serious and lethal disease have
been eradicated. That is why, immunization is recommended for all
children all over Australia.
Within the governments program, the diseases that are covered are

chickenpox,
rotavirus that produces diarrhea,
polio,
infections like measles, mumps, and rubella,
hepatitis B,
pneumococcal vaccine that prevents respiratory and brain
infections, and
DTPa vaccine that prevents against whooping cough,
tetanus, and diphtheria or gray membrane infection of the
throat.

As you know, all medications have side effects. Majority of vaccines

have a few insignificant side effects like local skin reaction (pain,
redness, and swelling of the skin), sometimes especially with DTPa
the child can develop high-grade fever, but we usually give
antipyretics half an hour before the vaccine to prevent that. This side
effect is sometimes accompanied by excessive, inconsolable high
pitched crying (because of pertussis component). With the arrival of
acellular pertussis vaccine, these side effects have been minimized.
There are some contraindications for these vaccines
especially the live vaccines such as MMR, chickenpox,
OPV oral polio vaccine:
Absolute Contraindications:
o History of Anaphylaxis
o Encephalopathy within 1 week following injection
of DTPa (at 2nd, 4th or 6th month of injection
with DTPa)
o immunodeficiency states (child with HIV, on
chemotherapy, on treatment with high-dose
steroids >2mg/kg for more than 2 weeks)
Relative Contraindications where we will delay the
vaccination:
o Fever >38.5
o If child has been on chemotherapy previously
delay for 6 months after stopping

My friends child had an egg allergy and it was not given

to her child. Is this true?
Previously, kids who had history of egg allergy were not
given MMR but now it is recommended to give the
vaccine in a controlled manner where all equipment for
resuscitation is available.
I have heard a lot about homeopathic vaccination?
o Up till now, there is no evidence in medical
literature that supports efficacy of homeopathic
vaccination. However, the decision is still yours.

What if I travel in between and my son misses a dose?

o There is a special catch-up schedule for children
who have missed their doses or who come to
Australia from overseas.
I am going to give you a Schedule that will tell you exactly
when to bring the child for each vaccination.
It is important to maintain a record for your child
(blue/yellow book).
MMR and autism?
o There is no literature up to now that supports it.

10.
You are an HMO in a hospital and a mother of two just delivered a
baby. The pediatrician suspects that the baby has Down syndrome.
The first child is normal. The pregnancy and delivery of this child is
normal.

Task

Counsel

Ask examiner for typical physical features of down

syndrome
Counsel

I know from the notes that your child has been suspected
of having a condition called Down syndrome? Do you
have a special concern at this moment? I would like to
ask the examiner about certain features specific to Down
Syndrome.

Physical features of Down Syndrome:

Floppiness at birth (reduced muscle tone) - most
important sign 90%
Microcephaly
Additional features that may or may not be present: flat
occiput, moon-shaped face, short neck, flat nose, wide
nasal bridge, epicanthal fold medially and upward slanted
eyes, small low-set ears, small mandible, prominent
tongue, brush field spots on iris (depigmented, whitish
spots), cleft lip or palate, single palmar crease
associated diseases: duodenal atresias,
hirschsprung disease
cardiac problems are difficult to diagnose at birth
Counseling:
From the examination findings, I highly suspect that your
baby does have Down syndrome. I understand that this
will be a big shock for you. Are you alright to continue?
Do you know anything about Down syndrome?

Basically, it is a genetic abnormality that can happen in

about 1 in 800 pregnancies. It is associated with a degree
of learning impairment as well as developmental delay. It
has been associated with advancing maternal age and
certain genetic defects within mom or dad. It is the
leading cause of cognitive impairment all over the world.
We still need to confirm the diagnosis through gene study
(Karyotyping). We will take some blood from baby and
send it to the genetic clinic. I would suggest that you bring
your partner when the results are being discussed.
At the moment, we need to do some tests to find out if
your son has some of the associated defects i.e.
o
o
o
o
o
o
o
o
o

Heart disease (VSD),

hypothyroidism,
cataracts,
hearing problems,
spinal or backbone defects (atlanto-axial instability),
and
abdominal ultrasound (duodenal atresia)
We will do TFTs, echo, USG of abdomen, and spinal
xray. Later on, we will continue to monitor him for the
development of any intellectual disability.
Usually, these kids have limited intellectual ability but
they are usually very compliant, cheerful and happy
kids.
With the latest advancements, the average life span
for a down syndrome baby is >55 years.

You will have a lot of support from centerlink, social

worker, respite care, child psychologist, Down Syndrome
Association of Australia.
Causes: non-disjunction or translocation

12.
You are a GP and an 18-month-old boy is brought to your clinic
because his mother says he is not eating well. His growth charts show
that his weight dropped from 50th to 3rd percentile. His mom is worried.
History

Task

History (preterm at 35 weeks; not feeding x 6mos; 19

years old single mom with no job)
Physical examination (pale)
Investigation
Diagnosis and management

Failure to thrive drop of more than 2 percentile of weight on a

growth chart; majority between 25-75 percentile
Causes of Failure to Thrive
Reduced calorie intake
Cleft palate
Persistent vomiting
Anorexia of chronic diseases
Improper breastfeeding technique
Inadequate provision of food
Malabsorption:
o
o
o

Reduced absorption of Food

Cystic Fibrosis
Coeliac disease

Chronic diarrhea - IBD

Chronic liver disease
Increased number of calories used
Congenital heart disease
Diabetes
Hyperthyroidism
Recurrent UTIs
Cystic fibrosis
Inborn errors of metabolism
Psychosocial issues
Neglect

Poverty
Parental depression
Behavioral disorder in the child (ADHD, autism)
Coercive/Forceful feeding

Can you describe your childs typical daily diet to me?

What type of milk does he take (breast milk, cows milk,
formula milk)? How much milk does he take?
Have you introduced solids? Does he eat meat? Does he
eat with the family at the table? Do you think his appetite
is okay?
Does he have any other problems, like diarrhea,
constipation, vomiting?
Any change in the number of wet nappies? Did he suffer
from frequent infections since birth?
How was your pregnancy with this child? Was it a
planned pregnancy? Any problems at delivery? Did he
have the regular screening tests that are done at birth
Heel prick test:

o
o
o
o

cystic fibrosis,
galactosemia,
hypothyroidism,
phenylketonuria

How has his health been since birth? Any problems

regarding growth and development? Vaccination?
May I ask what the home situation is? Are you supported
by your partner, family and friends?
What do you do for a living? Any financial problems? Any
help from centerlink?
Do you own a house or are you renting?
Do you smoke or drink? Have you ever tried recreational
drugs (relevant because it might interfere with your childs
growth)?
Any family history of anybody on a special diet? Cystic
fibrosis?

Physical Exam:
General appearance
Vital signs and growth chart for height, weight and head
circumference; immunization status
Chest and Lungs/Cardiac
Abdomen: distention, organomegaly, bowel sounds
Muscle wasting especially over the buttocks, lack of fat in
the cheeks and temporal area
Investigations:
FBE, Urine MSC, LFTs, UEC, TFTs, Iron studies, fecal
microscopy and culture, stool for fat and fatty acid
crystals, celiac microscopy, chloride sweat test
Management
Your child has failure to thrive because of malnutrition. It
means that there is no serious medical condition that can
be diagnosed. The actual problem is the quantity and
quality of food that is provided to your child. You will need
to improve his feeding habits. I will give you some written
material about proper dietary habits. It is important to give
him a balanced diet containing fruits, vegetables, meat
and milk to prevent any nutritional deficiencies.
I have also identified that you need some help in the form
of social and financial support. I will contact a social
worker who will help you find support from centerlink and
also to look for a job.
I will give you some contact address of support groups for
single moms where you can talk about your problems.
For the anemia, you can try some iron-fortified cereals to
improve his hemoglobin level. Please remember a
healthy balanced diet is the most important factor for your
childs growth and development.
Referral to dietitian and review.

13.
You are a GP and your next patient is Majuk who is 18-months old
attending your practice with his Dad John as they have a letter from
the community nurse who requested check for Majuk. They are
refugees from Sudan and their family had a very stressful time as they
spent the last 5 years in a refugee camp.

History
Examination findings
Address the problem
Investigation and management

Sensitivity for the hardship and trauma they endure

Need a lot of reassurance from GP to help them and not
from the authority.
I am not from the government or immigration. I am here
to help you and your son and if you are happy for me to
do that, I will let your family doctor know everything we
have done and any treatment we need to start but I will
not report this to anyone else without discussing with you
first.
Communication problem language problem
interpreter service (1300 655 820) or have appointment
with interpreter;
History:

Any problems? How is he? Any concern about his hearing?

Vision? Sleep? Behavior?
BINDARS:
o How was his delivery?
o Any problems with your wifes pregnancy?
o Was he delivered term or preterm?
o Any immunization?
o Is he breastfed? Until now? When was solid
introduced? Any plans to stop breastfeeding? Any
problem with his development? Social history?
Serious illnesses in the family?

Growth assessment
Nutritional assessment (vitamin D)
Developmental assessment
Vaccination status (do you have any written
record) BCG scar in deltoid region or lateral
aspect of elbow joint in African patient!!!
o Dental assessment
o Mental health assessment of the family
o Financial and housing assessment
o English classes
Tuberculosis:
o
o
o
o

Task

How is everything with you dad? How is your mood? Do you

feel low? Hows your sleep and appetite?
Assessment:

Investigations:

CXR and PPD Mantoux test; Quantiferon gold test

(tuberculosis interferon assay) helps differentiate
between positive mantoux due to BCG vaccine and
latent TB

o Routine: FBE,TFTs, LFTs, RFTs, BSL

o Infections: Hepatitis B serology, CXR,
schistosomiasis (urine/serology),
o Nutritional test: iron studies, vitamin D levels,
calcium,

Management:
Refer to dietitian
Monitor growth and development
Time table to re-immunize. Contact camp to track
Dental issues
Mental health assessment refer to
psychologist
o Paperwork for centerlink
o Advise for English class
o
o
o
o
o