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

(cannot control him; annoys parents; parents are frustrated; teachers not having same problem)

Examination Findings (eye contact, seems like happy child; can

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

Advise parents about your diagnosis o 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

o 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 o Physical examination

Growth charts Check hearing and vision School performance

o 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 attacks are more than 1 minute, o loses consciousness or gets drowsy, bite his tongue

or incontinent

Review

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 Listen to your child. Dont interrupt him in between. o Be patient if he gets stuck with a word. Please dont

finish his sentences for him. o Repeat what he has said o Reassure him and be supportive. o Dont criticize him for not being fluent. o Dont allow any family member to tease him. o Dont push him to speak o 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. RCH

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. Task

Relevant history

Management

No physical examination required

Answer parents questions Hx:

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?

Mx:

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-month-old 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

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) Mx:

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 How has your baby been since birth? o Immunizations up to date? o Nutrition o Development o Allergies o Rashes

Physical examination: o General appearance, o vitals, o 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

Ask examiner for typical physical features of down syndrome

Counsel 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 Heart disease (VSD), o hypothyroidism, o cataracts, o hearing problems, o spinal or backbone defects (atlanto-axial instability),

and o abdominal ultrasound (duodenal atresia) o 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.

o Usually, these kids have limited intellectual ability but they are usually very compliant, cheerful and happy kids.

o 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. 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 Reduced absorption of Food o Cystic Fibrosis o 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 History

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 cystic fibrosis, o galactosemia, o hypothyroidism, o 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. Task

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?

How is everything with you dad? How is your mood? Do you feel low? Hows your sleep and appetite?

Assessment:

o Growth assessment o Nutritional assessment (vitamin D) o Developmental assessment o 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 CXR and PPD Mantoux test; Quantiferon gold test

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

Investigations: 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:

o Refer to dietitian o Monitor growth and development o Time table to re-immunize. Contact camp to track o Dental issues o Mental health assessment refer to

psychologist o Paperwork for centerlink o Advise for English class