AMC Clinical exam preparation

amc clinical exam

A 6 week old child is brought in to your country hospital or GP ? by mom with problems with breathing.

Task- History, P/E and immediate management, outline management plan.


Me- Can I know the vital signs of my patient first ?
Examiner- PR- 190/min, RR-70/min. Can’t tell you SaO2 before history.
Me- I will give her O2
Examiner- Ok

Me- Hello, Mrs X, what brought you in here today?
RP- My baby has difficulty in feeding for about 3 days which has been progressive. She can’t suck well.

Me- Can you tell me more about that? Is it that something is disturbing her suckling or she doesn’t want to suck at all or ?
RP- She stopped feeding as she has difficult breathing. She started to have noisy breathing on feeding and she seems very breathless.

Me- Is the noisy breathing wheezing sound ?
RP- Yes, I think so

Me- Does she have any runny nose, blocked nose , cough? Choking? Does she turn blue? Feel hot? Any skin rash ?
RP- Yes, she has had runny nose for few days. Not blue. She coughs but no choking. Her chest is up and down too much and I believe she is struggling for breath.
Not hot. No skin rash.

Me- Is she wetting her nappies as usual ? What about her bowel motions?
RP- She is wetting a bit less cos she is not feeding well. Motions are normal.

Me- Can you tell me about her birth history ?
RP- Normal spontaneous vaginal delivery. Full term. 3.5 kg birth weight. No problems during pregnancy ( bleeding, high BP, infection ) .
No resuscitation after birth. Not blue at birth. No jaundice. No prolonged hospital stay.

Me- Any family history of asthma ? Inherited heart problems? Any other significant medical problems with previous children?
RP- No

Me- Growth and Development ? Immunisation?
RP- No concerns. Immunisation UTD.

Me- Can I examine your baby after washing my hand ?
RP-Yes

Examiner’s findings:

General appearance- Dyspnoeic , Accessory muscles of breathing working, No cyanosis, SaO2 before O2 87 %, now 97% with O2. Other vitals as stated above. Anterior fontanelle- normal
No signs of dehydration.
Nil anemia or jaundice. Nil skin rash.
CVS- Loud PSM at left lower sternal base without radiation.
Respiratory- Bilateral basal crepitations.
Abdomen- NAD. Hernia orifices- NAD
Spine- NAD
CNS- NAD
Me- BSL ? ( normal )

Me- Mrs X, I have just examined your baby. I believe she has a problem with her heart. Medically ,it is called heart failure. Heart is not pumping all bloods well so the blood and fluid backs up in lungs that makes her difficult breathing. From examination finding, she seems to have a hole in her heart so heart is overloaded with blood. It is inherited but it seems to have been precipitated just now by viral infection she has got.

RP- Oh, I am very concerned . Is it too serious ?
Me-Yes, it is but you have made a very good step of brining her in. Now , I am going to transfer her to tertiary hospital where Paediatric Specilists are available with air ambulance where there will be a doctor and Paramedics who are specialized in managing the sick patients on the way to hospital.
Before it comes, I will try to get a cannula if I can, will talk to Emergency Physician, and start some medications that will help to take the fluids out of the lungs .
At hospital , she will be seen by a Paediatric specialist immediately. They will run blood tests, urine tests , ECG, CXR, and Echocardiogram ( Ultrasound of heart ) which can show all the defects in the heart and also function of the heart.

And future management depends on all those results but only after stabilizing her current acute condition.
She will be in the experienced hand.
Me- Any questions
RP- No