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Paediatric Fatigue History ♯1

You are a GP in a metropolitan clinic. Simpson has been brought in today because his mum, Sarah, explains that he has become increasingly fatigued and lethargic over the last couple of months. You bring up Simpson’s medical record and read the following:

Patient information

Name and age: Simpson Davis, 4 years-old

Medical Hx and Developmental Hx:

  • Bronchiolitis at age 6
  • Vaccinations are up-to-date
  • Nil medications
  • Nil allergies

Family Hx:

  • Younger brother (20 months) – nil medical or developmental conditions
  • Mother: Nil medical Hx, Father: Asthma

Social Hx:

  • Lives with parents and brother, Jed
  • Goes to day care 4 days/week

Candidate instructions:

You will have 8 minutes to perform the following:

  1. Take a focused history from Sarah. Examination findings will be given after you have completed your history. (3 minutes).
  2. Ask the examiner for key investigations and interpret them. (1 minute).
  3. Explain the diagnosis and management to Sarah (4 minutes).

TASK 1 – HISTORY (3 MINUTES)

MARKS

History of presenting complaint

  • Opening Statement: “Simpson has just been really tired lately!”
  • When: last 3 to 4 months, been getting gradually worse over time
  • Quality and Severity: Simpson is tired when he comes home from day-care and just wants to watch TV or have a nap. He used to come home and play in the garden or with his trains. He gets very tired quickly when the family goes for walks or to the park. He has also been playing up a lot more than he used to
  • Associated symptoms: (see below)
  • Exacerbating/relieving factors: does not seem to improve with a good night’s sleep.
  • Beliefs: “I’m not sure, I thought it might have been day-care but he’s tired even on weekends”
  • Impact on patient: “It’s really hard to manage him and keep the rest of the family entertained and organised”.
  • Concerns: “It’s not some horrible blood disease is it?”

Systems review/ associated symptoms/risk factors

Symptoms in BOLD indicate positive answers, other answers are suggestions of what is required in terms of questioning.

Haematological

  • Iron deficiency anaemia: pallor, fatigue, SOB (when walking to park/playing), restricted/unvaried diet, high consumption of cow’s milk (see Diet below)
  • Leukaemia/Lymphoma: bruising, bleeding, recurrent sickness/colds, fevers, weight loss, bone pain, chest pain, SOB
  • Sickle cell anaemia: family history, pain crises, haematuria
  • Thalassaemia: jaundice and anaemia at birth, unknown Hb-opathy screening antenatally, poor growth

Gastrointestinal

  • Coeliac disease: fatigue, weight loss, bloating, abdominal pain, diarrhoea/constipation, irritability, family history of coeliac/autoimmune disease
  • IBD: fatigue, diarrhoea, abdominal pain, weight loss, fevers, blood/mucous in stools, rashes, history of IBD/autoimmune disease
  • Protein/Nutrient Deficiency: weight loss, fatigue, muscle wasting, dietary imbalance

Cardiovascular:

  • Heart failure: fatigue, SOB, swelling/oedema, history/family history of cardiac conditions, recurrent chest infections.

Endocrine

  • Diabetes Type 1: fatigue, irritable, lethargy, weight loss, polydipsia, polyuria, polyphagia
  • Hypothyroidism: fatigue, lethargy, iodine deficiency, history/family history of hypothyroidism, weight gain, oedema

Infectious:

  • fever, night sweats, chills, rigours, infective foci (chest pain, cough, chronic sore throat, enlarged lymph nodes, abdominal pain etc.)

Sleep:

  • gets 12 hours usually, occasionally wakes through the night

Marking criteria

Full marks for asking at least 4 different systems adequately (either >1 cluster or 3 to 4 systems review questions)

3 marks for asking at least 3 different systems adequately or 4 inadequately.

2 marks for asking at least 2 different systems adequately or 3 inadequately.

1 mark for asking at least 1 system adequately or 2 inadequately

Paediatric/ Developmental History

  • Birth: normal vaginal delivery at 39 weeks, no complications
  • Feeding/Diet: fussy eater, very difficult to get a range of foods into him. Favourite treat (especially when tired) is a bottle of warm chocolate milk. Having 2 to 3 per day to settle him when he’s being difficult.
  • Hydration: well hydrated
  • Growth: on the 40th percentile for both height and weight and is tracking normally along growth lines

TASK 2 – ORDERING AND INTERPRETING INVESTIGATION FINDINGS (1 MINUTE)

Investigations Required

  • Full blood count
  • Blood film
  • Iron studies (ferritin)

Investigation Findings

(See image

section below)

  • Microcytic hypochromic anaemia
  • Low ferritin
  • Film: target cells, anisocytosis, poikilocytosis

Conclusion: Suggestive of IDA

TASK 3 – EXPLANATION AND MANAGEMENT OF IRON DEFICIENCY ANAEMIA (4 MINUTES)

Explaining IDA

  • Simpson has iron deficiency anaemia.
  • Iron deficiency is very common in children and usually nothing to worry about
  • When kids are growing they need a lot of iron as it is important for the development of lots of areas including the brain, immune system, blood, muscles and energy production. It helps carry oxygen around the body.
  • Symptoms of iron deficiency anaemia include lethargy, irritability, fatigue, and paleness. Sometimes children find it more difficult to concentrate or might misbehave. They can get short of breath with exercise as there is not enough oxygen getting around the body. They can sometimes get a harmless murmur. Sometimes they can eat non-food items as a product of being deplete of iron.
  • If iron deficiency continues, children may have developmental delay, decreased memory, poor immune function, and poor cognitive development. So it is really important to avoid iron deficiency anaemia where possible.
  • Often iron in the diet may be inadequate, especially in fussy children. Cow’s milk also disrupts the absorption of dietary iron into the body.
  • When children get iron deficiency anaemia, it usually means their stores if iron are depleted, and they need to restore them

Candidate must explain in non-technical terms. They must chunk their information and check understanding along the way. If the candidate does not include these skills in their explanation, they can only be awarded a maximum of 3 marks.

Management of IDA

Dietary Advice

  • Increase iron rich foods and reduce cow's milk consumption.
    • Red meat three to four times per week
    • Alternatives: beans, lentils, chickpeas, poultry, fish, eggs, nuts and nut pastes, green leafy vegetables
  • Limit to <500mL per day of cow’s milk
  • Vitamin C: oranges, lemons, mandarins, berries, kiwi, tomatoes, cabbage, capsicum, broccoli
  • Encourage solid foods at mealtimes to keep children full so they don’t need to fill up on milk.
  • Consider referral to dietician
  • Iron Supplementation
    • Oral supplements
      • 1 to 2mg/kg/day is preventative.
      • 3 to 6mg/kg/day is therapeutic.
      • Continue for 3 months after anaemia has been corrected to replenish stores then check Hb and ferritin.
  • Considerations
    • Fe can make a child's stool black and cause constipation.
    • Oral Fe may also stain teeth.
    • Better absorbed with vitamin C (orange juice)
    • Fe can be toxic in high doses so don't self diagnose and treat without consulting a doctor

Follow-up: 3 months to assess Hb and ferritin

Underlined items are the key point in the management of IDA. The additional information is not required for full marks in this section but may improve the global performance of the candidate.

TOTAL MARKS
Total:

EXAMINATION AND INVESTIGATION FINDINGS

EXAMINATION FINDINGS OF NOTE

To be given after the completion of the history or at 3 minutes, whichever comes first.

  • General inspection: Happy, alert child with pallor
  • Peripheries: Brittle nails, pale palmar creases and conjunctivae.
  • Cardiac: flow murmur

Investigations:

FBC and iron studies:

  • Hb: 70 (120 – 15 g/L)
  • Hct: 39 (36 – 45 L/L)
  • MCV: 70 (80 – 96 fl)
  • MCH: 23 (27 – 33 pg)
  • WBCs: 6.5 (3.5 – 9.8 x10^9/L)
  • Platelets: 350 (150 – 400 10^9/L)
  • Serum Iron: 60 (60 – 150 umol/L)
  • Serum Ferritin: 10 (20 – 200 umol/L)
  • Serum Transferrin: 3.5 (2 – 4 g/L)
  • Transferrin Saturation: 6 (16 – 60%)

Peripheral Blood Film

NOTES

Time Management and Planning for More Advanced OSCEs

As you get into the more senior years of your degree, your OSCEs are likely to become more complicated and will ask more of you in one station. The OSCE above is a common example of one that could be expected of a fourth/fifth year. It asks you to take a focused history, ask for and interpret investigation findings (with the help of the examination findings) and explain the diagnosis and management of a condition to a patient. The key for this kind of OSCE is time management.

Reading Time

Use your reading time effectively. From the stem, write out a series of differential diagnoses andframe your questioning around this. At the end of the day, you’re trying to rule them out so you can arrive at a final diagnosis quickly. Make sure to note how long you have for each section of the OSCE and write this on your page.

Focused History

If the OSCE requires a focused history, it is exactly that – a focused history. Most likely the rest of the history information relevant to the case will be given in the stem, which should help guide you to what is missing. Don’t waste time asking information you already know because you think it will make you look like you’re thorough – the information in the stem is there for a reason! Your aim is to obtain the supporting information for the diagnosis you think it most likely is and rule out red flags

Your systems review/cluster questions do not need to be extensive, but merely there to show the examiner you are thinking of other important conditions and making an effort to rule out the most likely ones. If you feel your differential list is too long, use other clues like the time course of the symptoms or medical history to cut it down. For example, in this station there is not much point in asking acute conditions such as appendicitis or the flu as they are unlikely to have caused symptoms for 3 months.

Investigations

In the investigations section, you are likely to be able to win back a bit of time. This OSCE probably doesn’t need more than 30 seconds to ask and interpret the findings. The key here is to look for the salient findings rather than reading down the list out loud to the examiner. This should still be done systematically but read, then speak! At the end of your interpretation, make sure to give an overall impression/diagnosis based on the investigations.

Explanation and Management

This will be the hardest section to keep to time. Make sure you have a good timer/clock/watch that you can use to check your timing. Split your time between the sections based on how much talking you think you’ll need to do (do this in reading time). You want to be clear and give the key points, so avoid rambling. You can always go back at the end if you have extra time and add this is better than missing a whole section! Make sure you give the patient a few opportunities to ask questions and check their understanding. This is good for two reasons. Firstly, it is just good practice to ensure your patients know what you’re talking about and shows you care that they understand. Secondly, it gives the simulated patient a chance to potentially give you a clue if you are heading in the wrong direction. Most of the time, they will just say they understand and you can move on rapidly to your next section.Good luck!

REFERENCES

  • Film image: http://www.flickr.com/photos/euthman/4422704616 taken by Ed Uthman
  • Royal Children’s Hospital Clinical Practice Guidelines: Iron Deficiency Anaemia Royal Children’s Hospital
  • Parent Information Sheet: IronIllustrated Textbook of Paediatrics 5th Edition: Iron Deficiency Anaemia
  • BMJ Best Practice: Iron Deficiency Anaemia