History Common Cases

This station is difficult to prepare for in terms of specific content. Better, rather to concentrate on developing your generic history taking skills for your clinical practise, which will be rewarded in the exam also. The station guide should be of use.

For cases, examination centres will bring children and their parents from outpatients or from the wards. The actual diagnosis is less important than the need to explore a complex story and obtain relevant background information. Rather than discuss multiple conditions in outline, this page will describe a candidate encounter with a representative patient.

Readers may choose to look through this account with the station guide in their minds, to see how the candidate might score.

 

The Candidate (C) enters the room and introduces herself to a woman (W) sitting next to the cot of an infant (I). The infant is approximately 4.5 Kg, and the candiate notices that I is playing with her hands, and is connected to a fluid pump delivering TPN. C explains to W that she has come to find out more about why I is in hospital and to explore what can be done to help I. C checks this is okay with W. W agrees. C now checks that W is in fact the mother of I, and finds out what I is called and how old I is.

C now sits down close enough to W to make normal conversation easy, and spends a few moments saying hello to I and commenting on how alert and interactive I is. C now asks W to explain what the problem that has brought I into the hospital is. C sits attentively during the period W explains the story, nodding or commenting empathically where appropriate. Occasionally C may interupt to clarify some aspect (such as the amount of weight loss or chronology). After this C expands further areas of the history that were not brought out in the initial story.

At this stage, C has found out that I is 7 months old and came into hospital after she developed a temperature of 38.9 C, measured on her home thermometer. She had shaking and looked very pale. Mum noted she had become quite drowsy and was not interested in playing. W explained that I has a short intestine after being born with her intestines outside the abdomen. I needed an operation at birthto save her life when she was 2 weeks old. W explains that she has had several similar episodes in the past each requiring antibiotics, and thinks this is caused by another “line infection”.

C then asks about the TPN, finding that I has been requiring TPN since birth, although the requirement for this has reduced to about a half of the fluid intake – the rest is a special mik called neocate. C clarifies the volume of milk I has each hour and how it is given (finding it is given every three hours).

C then suggests that she ask a few other questions about I to get a better idea of her background.

C enquires more about the neonatal period, learning that the patient was born at term, but had the condition identified on scan, and that there was nothing else abnormal seen. C asks W to tell her about the birth. She is told that the birth was by caesarian section. (C wonders about asking about whether it was a general anaesthetic, emergency, epidural etc, but decides this information is not at all likely to alter how she would be managed). C now asks what happened after she was born, and W tells her that I was taken to an incubated and the intestines wrapped in some plastic wrapping. She was taken to operation the next day.

C realises she need to know a bit more about the operation – was a significant amount of gut removed, how much is left, what about the ileo-caecal valve, but realises that W may not know these facts. Rather than peppering W with closed questions, C asks W what she knows of the operation, and finds out that “12 inches of the small gut was removed as this had died” and that other areas were not healthy at that stage. 

C now asks about management in the neonatal unit and discharge planning, finding that she was not discharged until 4 months of age, that a feeding catheter was put in her neck vein after 6 weeks. W was then trained to use these and, once support at home was ready, I went home.

C empathises with W – it must have been really hard with such a sick baby and waiting for her to come home. W explains that it was hard on her partner and her older daughter, as they saw little of her during this time. Now the elder daughter (C finds out her name and that she is 3 years old) can’t quite understand what she is and isn’t allowed to do with her baby sister.

C now wants to establish the effect of the TPN and short gut on I. She asks W if there are other organs affected, such as the liver; she asks about weight gain and asks some developmental screening questions, finding that W did not know of any other problems apart from infections related to the line, that her weight gain initially was poor, but better now. Still she has not got back to the bottom of the growth chart.

C asks W if there is anything else that W feels is important she has not told her as yet. C recaps the interview and explains to W that it appears that I is doing pretty well with growth; that it looks as if this episode is due to an infection of the central venous feeding line; that blood tests should be able to confirm this and that antibiotics are likely to clear it up.

C concludes the interview asking W if there is anything W wants to ask, and then thanks W for her time before saying goodbye.

 

 

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