Sl. No. Action

• 1. Introduce yourself
• 2. Tell them that chances for a child being born with thalassemia major is 25% with every pregnancy
• 3. Do genetic studies for parents
• 4. Ask the mother the LMP
• 5. CVS can be done till 13 weeks
• 6. Risk of abortion 1%
• 7. Amniocentesis can be done at 16–20 weeks
• 8. Risk of abortion 1 in 500
• 9. Parents may wish to terminate the pregnancy if found to be affected.

Sl. No. Action

• 1. Introduce yourself.
• 2. Tell the family that the transfusion and chelation practice being followed up by the family is grossly incorrect and will lead to severe sequelae of extramedullary hematopoiesis, chronic anemia and iron overload
• 3. Keep pretransfusion Hb around 9–9.5 g%
• 4. Use prestorage leucodepleted blood or use a WBC filter to avoid febrile reactions
• 5. Use only packed RBC
• 6. Ask them why Desferal was chosen for chelation and what are the reasons of intermittent infusion
• 7. Tell them the optimal therapy will need 12–16 hours per day of infusion
• 8. Give them the option of oral chelation with Deferasirox
• 9. Counsel them that it has to be taken only once a day and chances that compliance will drastically improve with same.

• 1. Introduces himself and tries to make parents comfortable
• 2. Explain the patient that HBs Ag positivity signifies that hepatitis B virus has infected the liver
• 3. Hep B causes chronicity , cirrhosis and cancer (15–20 years later)
• 4. It's a must to investigate this child-HBc IgM, HbeAg, HBe Ab, HBVDNA
• 5. Further treatment needed only if viral replication, i.e. HBe Ag– positive/HBVDNA positive
• 6. Screen family members with HBsAg
• 7. Vaccinate other family members if not already vaccinated
• 8. Fever not related to HBs Ag +ve. Repeat Liver enzymes later once fever subsides
• 9. No contact of his blood with anyone with a cut surface, no sharing of nail cutters/comb
• 10. Specify that there's no need for isolating this child.

Sl. No. Action

Ans. 1.

• 1. Any significant birth or antenatal history
• 2. Neonatal sepsis or hospitalization
• 3. Color of stool
• 4. Color of urine.

Ans. 2.

• 1. USG abdomen fasting to look for gallbladder size volume and then repeat after feed to look for contractility of gall bladder
• 2. HIDA after 5 days of phenobarbitone to look for excretion or nonexcretion of dye
• 3. If HIDA excretory or liver biopsy is not suggestive of biliary atresia only then further investigation will be done to rule out underling cause of neonatal hepatitis
• 4. Liver biopsy to exclude biliary atresia, paucity of bile duct or neonatal hepatitis
• 5. Blood test: CBC, LFT, PT/PPTK, TSH
• 6. Urine: routine,for reducing substance.

• 1. Introduces himself and tries to make the mother comfortable
• 2. Asks about duration of onset
• 3. History of blood in urine
• 4. History of associated symptoms: fever, pain abdomen, jaundice
• 5. History of swelling on feet or periorbital edema
• 6. History of associated pallor
• 7. History of bleeding from anywhere else
• 8. History of sore throat or skin infections in recent past
• 9. History of headache/irritability/seizures
• 10. History of oliguria
• 11. Diet history—beetroot ingestion
• 12. History of similar episodes in past.

A 6: Introduction to mother

Sl. No. Action

• 1. Cry/activity of child
• 2. Rooting/Sucking/feeding
• 3. Passed urine/stool
• 4. Look for any gross congenital anomaly (structural)/hernial sites
• 5. Temperature of child, specially peripheries
• 6. Look for icterus/cyanosis-color of baby
• 7. Auscultation of chest for respiratory and CVS system
• 8. Look for congenital dislocation of hip
• 9. Respiratory rate, breathing pattern
• 10. Umbilical sepsis/superficial skin infections.

A 7: Resuscitation

Sl. No. Action

• 1. Check Ambu Bag, mask, reservoir and O2 source
• 2. Attach reservoir, and oxygen source
• 3. Correct technique of ambu bagging
• 4. Correct frequency of ambu bagging
• 5. Counting heart rate at end of 30 seconds.

No model answer in source material.

No model answer in source material.

Sl. No. Action

• 1. Introduces himself and tries to make the parents comfortable
• 2. Explains: What is diabetes, type of diabetes and chronic nature
• 3. Management: Insulin, diet, lifestyle change, monitoring
• 4. Short term complications: Hypoglycemia, DKA, etc.
• 5. Long term complications: Renal, eye, cardiac, gangrene, neuro
• 6. Cause of Diabetes: Genetic/environmental/autoimmune
• 7. Risk in next child: Increased 3–6%.

• 1. Introduces himself and tries to make mother comfortable
• 2. Differentiate between hemoptysis and hematemesis
• 3. Duration of symptoms and whether its 1st time
• 4. What is the volume and color (coffee brown/red)
• 5. Bleeding from any other site/easy bruisability
• 6. Associated symptoms-fever/vomiting/jaundice/edema/abdominal distention
• 7. Associated seizure/mood change/sleep pattern change
• 8. History of drug intake NSAIDs
• 9. Any family history of bleeding
• 10. History of associated epigastric or retrosternal pain
• 11. Past history of jaundice/blood transfusion.

Sl. No. Action

• 1. Check supplies
• 2. Performs all basic steps in correct order within 20 seconds
• 3. Evaluates/ask for vitals
• 4. Decides for bag and mask ventilation (when examiner prompts hr<100/m)
• 5. Selects proper size mask
• 6. Position baby and himself correctly
• 7. Connects oxygen and reservoir
• 8. Appropriate ventilation (rate and rise)
• 9. Evaluate/asks for heart rate after 30 seconds and decides for chest compression (when examiner prompts h<60/m)
• 10. Locates compression area correctly
• 11. Uses right method of compression
• 12. Compresses consistently at appropriate rate
• 13. Check pulses
• 14. Evaluate/asks for heart rate after 30 seconds and decides for medication (when examiner prompts hr still <60/m)
• 15. Overall conduct of resucitation is fluent and is able to complete the entire process in given time.

Sl. No. Action

Ans. 1

• i. Introduces himself.
• ii. Explains that the main treatment is ORT and explains the need for rehydration.
• iii. Explains correctly the preparation of ORT—whole packet in 1 liter of water.
• iv. Advises feeding by spoon and discourages bottle feeding.

Ans. 2

• i. Stop ORT for 5–10 minutes and restart feed, give slowly spoonful every 2–3 minutes.
• ii. Advise giving small aliquots of 5–10 mL each time.
• iii. Explains the danger signs of dehydration and explains when she should seek medical attention.

Does not become better in 3 days or develops danger signs (seizure/ unconscious/rapid breathing, etc).

Encourage continuance of breast feeds/normal feeds/home available feeds.

• iv. Checks, whether the mother has understood or not.
• v. Ask the mother whether there are any doubts.

Sl. No. Action

• 1. Introduces himself
• 2. History of fever
• 3. History of constipation
• 4. History of urgency
• 5. History of malodorous urine
• 6. History of suprapubic pain
• 7. History of loin pain
• 8. Details of toilet training
• 9. Wiping from back to front
• 10. History of incontinence
• 11. History of threadworm infection
• 12. Family history of renal disease/stones
• 13. Family history of UTI/VUR
• 14. Note of thanks.

• • Remove ornaments, watch, etc.
• • Fold sleeves above the elbows
• • Perform six steps of hand washing
• • Palm to palm
• Right palm over left dorsum
• Left palm over right dorsum
• • Fingers interlace palm to palm
• • Back of fingers to opposing palms
• Rotational rubbing of right thumb
• Rotational rubbing of left thumb
• Rotational rubbing of left palm
• Rotational rubbing of right palm
• • Perform in 2 minutes
• • Air dry or dry with sterile towel or paper
• • Discard towel or paper in black bin.

Sl. No. Action

• 1. Introduces himself
• 2. Clearly explain about asthma as hyperactive airway disease
• 3. Explain that there is no curative treatment and treatment reduces the severity and complications
• 4. Explain how to use MDI
• 5. Explain preventive strategies at home
• 6. Explain danger signs or warning signs of acute attack
• 7. Explain the treatment at home and to reach nearest hospital in case of acute attack
• 8. Explain the difference between rescue and prophylactic inhalers
• 9. Explain other alternatives, and ask for any doubts and clears it
• 10. Explain the need for regular follow up
• 11. Note of thanks and availability.

A 15: Introduces and establishes rapport.

Sl. No. Action

• 1. Questions asked
• 2. Asks her to act out or re-create a seizure
• 3. History of aura and automatism
• 4. History of headache and vomiting
• 5. History of failure to thrive
• 6. Details of medications used that may precipitate seizure
• 7. Details of anticonvulsant therapy
• 8. Compliance of anticonvulsant therapy
• 9. Family history
• 10. Developmental history
• 11. Birth and neonatal history
• 12. Time of occurrence of seizures
• 13. Frequency of seizures
• 14. Precipitating factor like from fever
• 15. History of personality change
• 16. History of school problem
• 17. History of intellectual deterioration.

No model answer in source material.

Sl. No. Action

Present History

• 1. When did the present attack start?
• 2. Is the child is getting better or worse or no improvement?
• 3. Does the child have rapid breathing, difficulty in talking or feeding?
• 4. Any factors that triggered the present attack?
• 5. What medications has she been administered for the present attack, at what dose and frequency?
• 6. Is it associated with fever?

Past History

• 1. How long has she been a wheezer?
• 2. How frequent are these episodes?
• 3. How many days the episode last?
• 4. Are these episodes seasonal?
• 5. How often symptomatic at night?
• 6. How often absent from school?
• 7. If child is on long term medications—if she has been compliant?
• 8. If using MDI follows the right technique?
• 9. How often she has to use reliever MDI or get nebulised?
• 10. History of previous hospitalization and if she needed parenteral or oral steroids/IV medications?
• 11. History of Frequency of visits to ER
• 12. Any admission to ICU and if so if mother has been told about warning signs
• 13. History of exposure to passive smoking/pets and other triggers
• 14. Is wheeze exercise induced?
• 15. History regarding co-morbid conditions like sinusitis, GER and other allergies?

Family History

1. History of asthma or atopy in family.

A 17: Counselling regarding feeding the child and storage of breast milk.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Enquires about urination, adequate weight gain. Reassures about adequacy of breastfeeds.
• 3. Asks if mother is familiar with the technique of milk expression—if not, explains technique verbally.
• 4. Counsels correctly regarding expression and storing of breast milk: 8 hours in room temperature, 24 hours in refrigerator (non-freezer compartment).
• 5. Advises that milk should not be heated but allowed to come to room temperature spontaneously.
• 6. Advises to feed the milk with a cup and spoon or paladai.
• 7. Advises mother to continue with breastfeeding when she is at home.
• 8. Asks if mother has any doubts and encourages her to ask questions.
• 9. Wishes mother and offers a telephone number where she can have any other queries answered.

A 18: Counselling the parents of a newborn with meningomyelocele regarding the recurrence in the next pregnancy.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. States that based on history, examination and investigations, a diagnosis of meningomyelocele has been made.
• 3. Explains about the possibility of recurrence in the next pregnancy.
• 4. Explains that the recurrence can be prevented by use of folic acid.
• 5. Advises that folic acid should be started one month preceding conception in the dose of 4 mg OD and continued thereafter.
• 6. Asks if mother has any doubts and encourages her to ask questions.
• 7. Wishes mother and offers a telephone number where she can have her queries answered.

A 19: Counselling regarding breastfeeding of baby born to HIV positive mother.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains the benefits of breastfeeding for the baby. Also mention that the virus can be transmitted from the mother to the baby by breast milk.
• 3. Explains the risks of not giving breastfeeding.
• 4. Stresses the need for hygiene and exclusive feeding in case mother decides on either.
• 5. Asks if mother has any doubts and encourages her to ask questions.
• 6. Wishes mother and offers a telephone number where she can have any other queries answered.

A 20: Counselling the parents about the further management of baby with thalassemia.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. States that based on history, examination and investigations, a diagnosis of thalassemia has been made.
• 3. Explains the need for blood transfusions and hepatitis vaccinations for the infant and need to maintain the Hb above 9 gm/dL.
• 4. Explains that cure can be achieved by bone marrow transplantation from a sibling.
• 5. Explains to them that prenatal testing is available in the next pregnancy.
• 6. Suggests the role for cord blood collection from the next child, which can be used for stem cell transplantation to this infant.
• 7. Asks if mother has any doubts and encourages her to ask questions.
• 8. Wishes mother and offers a telephone number where she can have any other queries answered.

A 21: Counselling the mother regarding hepatitis B positivity.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains that HBsAg positivity means that the hepatitis B virus has infected the liver.
• 3. Explains that hepatitis B can cause chronic liver disease which may, at a later stage, lead to cirrhosis and cancer.
• 4. Stresses the need to investigate the child further with HBc IgM, HBeAg, anti HBe and HBVDNA.
• 5. States that further treatment will be given only if HBeAg or HBVDNA is positive.
• 6. States the need to screen family members for HBsAg and vaccinate those negative.
• 7. States that there should be no contact of his blood with a cut surface, nail cutters, combs.
• 8. Explains that there is no need to isolate the child, or his utensils, eating, play or toilet area, etc.
• 9. Asks if mother has any doubts and encourages her to ask questions.
• 10. Wishes mother and offers a telephone number where she can have any other queries answered.

A 22: Examination and assessment of the patient with renal failure for volume overload or depletion.

Sl. No. Action

• 1. Introduces himself, asks for a chaperone (if indicated) and asks for permission to examine.
• 2. Checks tongue and axilla for moistness.
• 3. Checks ankles and sacrum for edema.
• 4. Checks for elevated JVP—in the sitting, semi reclining and lying positions.
• 5. Checks pulse and blood pressure. Blood pressure to be checked in lying and standing positions to check for postural hypotension.
• 6. Covers the patient and thanks him.

Imp: Do not waste time trying to take a history or doing a thorough general examination.

A 23: History for recurrent headache.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for chaperone if male candidate.
• 2. Asks about onset duration, location, severity and progression.
• 3. Asks about timing and duration of each episode, any precipitating events or relieving events, any change in the character of the pain during the past six months.
• 4. Asks about quality of pain, throbbing, increases during straining, change in characteristics of headache.
• 5. Asks about associated neurological features like loss of consciousness, seizures, weakness of any part of the body, visual, hearing or other cranial nerve deficits.
• 6. Asks about any discharge from ears, difficulty in reading, toothache, features of sinusitis.
• 7. Asks about associated systemic symptoms like vomiting and its pattern, fever, weight loss.
• 8. Asks about past history of similar events.
• 9. Asks about family history of headache.
• 10. Asks about any investigations that were done and about their results.

A 24: Counselling for febrile seizures.

• 1. Establishes rapport. Greets the mother, introduces himself/herself. Asks for chaperone if male candidate.
• 2. States that based on history and physical examination, the child has been diagnosed as having simple febrile seizures.
• 3. Explains that this condition occurs in some children, who are otherwise normal, between the ages of 9 months to 5 years.
• 4. States that the seizure has a tendency to recur in case of future fever in 30–50% of children after a first febrile seizure.
• 5. Explains that a doctor should be consulted at the earliest in case of fever or recurrence of seizures. Explain that other than fever medications, the child may be given short term oral diazepam during the febrile illness to prevent the seizure.
• 6. Explains that the seizure generally occurs during the height of fever and that future episodes of fever should be treated by using antipyretics and tepid sponging as and when they occur.
• 7. Explains that in case of a seizure, the child should be kept in the sidelying position and neck slightly extended. Stresses that no object or food or drink should be put into the mouth at that time.
• 8. Reassures the mother that the condition has an excellent prognosis for long-term neurodevelopment.
• 9. Asks if mother has any doubts and encourages her to ask questions.
• 10. Wishes mother and offers a telephone number where she can have any further queries answered.

A 25: Counselling of a case of nephrotic syndrome on steroids.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains that based on history, examination and investigations, the child has a kidney disease called nephrotic syndrome in which the child loses protein in the urine.
• 3. States that the treatment for the disease has been started and that in a few days, the swelling over the body will gradually decrease and disappear. Emphasizes the need to continue treatment as per instructions from the doctor and that medications should not be stopped or modified without the doctor's instructions.
• 4. Explains that the child's urinary protein needs to be checked every day and result recorded in a notebook, which needs to be shown to the doctor at each visit. Emphasizes on weight and blood pressure monitoring on weekly/biweekly basis from nearby hospital.
• 5. Explains method of testing urine for protein using dipstick.
• 6. Says that the child's treatment will continue for about six months and that regime would be changed depending upon the child's urine protein response.
• 7. Explains that the child can eat normal home food and attend school. Emphasizes that the child should not take added salt for his diet.
• 8. Explains that the child should be brought back immediately if she has abdominal pain, vomiting, fever, recurrence or increase in swelling.
• 9. Asks if mother has any doubts and encourages her to ask questions.
• 10. Wishes mother and offers a telephone number where she can have her queries answered.

A 26: Counselling for diagnosis of acute leukemia.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains that based on the history, examination and investigations, the child has been diagnosed as having acute lymphoblastic leukemia. Explains that this condition is a form of cancer of the blood. It is not

• transmitted from any of the parents and they should not be blamed or made guilty.

• 3. States that the condition is potentially curable with treatment and that the treatment will continue for about three years.
• 4. States that the treatment would include intravenous, oral and intrathecal medications and radiation therapy and that would cause side effects like loss of hair, nausea vomiting, diarrhea, bleeding and recurrent infections, which may require repeated hospitalizations.
• 5. Explains that the child must continue the treatment regularly and report to the hospital whenever instructed.
• 6. Explains that subsidized rail fare is available to children suffering from cancer and to their families.
• 7. Asks if mother has any doubts and encourages her to ask questions.
• 8. Wishes mother and offers a telephone number where she can have her queries answered.

A 27: Use of rotahaler device.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Takes the rotahaler device and dismantles it. Shows the parts to the child and shows how to reassemble it.
• 3. Takes one rotacapsule and places it with the clear end downwards in the slot provided.
• 4. Shows the child how to rotate the upper part of the rotahaler so that the capsule breaks.
• 5. Asks the child to let out his breath and place the mouthpiece of the rotahaler in his mouth ensuring that the lips are closed around the mouthpiece.
• 6. Asks him to take a deep breath through the mouth and hold the breath for a count of five.
• 7. Asks the child to check that no dry powder remains in the lower chamber of the rotahaler. Dismantles the rotahaler and removes the upper and lower parts of the rotacapsule.
• 8. Tells the child that he must gargle his mouth and throat with plain water after having taken the dose.
• 9. Asks if child has any doubts and encourages him to ask questions.
• 10. Wishes the child and offers a telephone number where she can have her queries answered.

A 28: Use of MDI device with spacer.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Dismantles the MDI device and shows how it functions by reassembling it and releasing a puff into the air.
• 3. Teaches the child how to assemble the spacer and fit the MDI device to the spacer.
• 4. Tells the child to release her breath and place the mouthpiece of the spacer in her mouth, taking care that lips form an effective seal.
• 5. Presses one puff of the MDI into the spacer and asks the child to breathe in slowly over a count of five and hold her breath till a count of five. Repeat with second puff if required.
• 6. Tells the child that she must gargle her mouth and throat with plain water after taking the MDI.
• 7. States that the child must continue taking the medications as prescribed by the doctor.
• 8. Asks if mother has any doubts and encourages her to ask questions.
• 9. Wishes mother and offers a telephone number where she can have her queries answered.

A 29: Dietary advice for celiac disease.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
  • 2. Explains that based on history, clinical examination and investigation results, the child has celiac disease, a condition in which the child is unable to digest wheat and wheat products.
  • 3. Explains that the treatment of this condition is to exclude wheat and wheat products completely from the diet, in addition to items made from oats and barley for the rest of his life.
  • 4. Names a few wheat containing materials not to be taken like atta, maida, sooji, dalia and foods like chapattis, roti, bread, biscuits, upma, noodles, halwa, etc.
  • 5. States that alternative foods in the form of rice, maize (makki), jowar, bajra and sago can be eaten without any restriction and stresses that their nutritional value is as good as wheat products.
  • 6. Suggests to the mother that the best way to control the diet of a child in the family is if all the family members adhere to the same diet so that it does not place a psychological stress on the child.
• 7. Explains to the mother that the diet will have its full effect in about three months.
• 8. States that the child would have to undergo repeated testing after a period of three months.
• 9. Asks if mother has any doubts and encourages her to ask questions.
• 10. Wishes mother and offers a telephone number where she can have her queries answered.

A 30: Counselling the mother for cyanotic breath holding spell.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains that based on the history and investigations, the child has breath holding spells.
• 3. Explains that breath holding spells are a benign behavioral disorder that occurs in toddlers are usually predictable and are usually precipitated by scolding or upsetting the child.
• 4. Reassures the mother that the spells are not life threatening and do not signify an underlying illness.
• 5. Advises the mother that if undue attention is paid to the spells, the spells will persist or increase. Advises the mother that the way to reduce the frequency of the spells is to pay as little attention to them as possible so as not to create reinforcement.
• 6. States that if the child becomes unconscious during a spell, she should place him in a safe location in a sidelying position so that he does not aspirate his secretions.
• 7. After the child becomes conscious, the mother and other family members should leave the child alone for some time and not pay undue attention by refusing to cuddle, play, or hold the child for a given period of time until recovery is complete.
• 8. Asks the mother if she has any doubts and encourages her to ask questions.
• 9. Wishes mother and offers a telephone number where she can have her queries answered.

A 31: Counselling the mother having a baby with non-dysjunctional Down's syndrome.

Sl. No. Action

1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.

• 2. Explains that based on the history and investigations, the child has been diagnosed as having Down's syndrome.
• 3. Explains the chromosomal basis of Down's syndrome.
• 4. Explains about the developmental outcome of the infant.
• 5. States that the infant will have to regularly monitored for development of leukemia, hypothyroidism and other medical conditions.
• 6. Explains that the disorder can recur in the next offspring and that the recurrence risk is 1%.
• 7. Advises the mother that antenatal genetic testing will permit diagnosis of the condition in the next offspring. Advises that this can be done at 10–12 weeks of gestation.
• 8. Asks the mother if she has any doubts and encourages her to ask questions.
• 9. Wishes mother and offers a telephone number where she can have her queries answered.

A 32: Counselling regarding ORS therapy.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate. Praise the mother for bringing the baby to hospital.
• 2. Explains that based on the history and examination, the child has lost fluid and salt from the body.
• 3. Explains that these need to be replaced by providing salt and sugar containing fluids like ORS to the baby. No tea juices etc. ORS is the best medicine for this baby.
• 4. Shows the mother how to take a packet of ORS and dissolve the entire contents in the required amount of water (if the packet is for one liter, the contents have to be put in a one liter bottle of water. If the packet is for 200 mL, the amount will be shown on a glass).
• 5. Asks the mother to repeat the procedure in front of him.
• 6. Tells the mother that the ORS can be stored for 8 hours at room temperature and for 24 hours in the refrigerator.
• 7. Tells the mother that the ORS is to be fed to the child in small sips with a katori spoon or paladai. Shows the approximate level upto which the mother has to give ORS in the next four hours (500mL).
• 8. Tells the mother that there may be a transient increase in stools or vomiting when ORS is started. Tells the mother that she should continue giving ORS. Asks mother to monitor the stool, urine and vomit output.
• 9. Asks the mother if she has any doubts and encourages her to ask questions.
• 10. Wishes mother and offers a telephone number where she can have her queries answered.

A 33: History for severe pallor.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Asks about onset of pallor—sudden or gradual.
• 3. Asks about history of any bleeding or bluish spots on the body.
• 4. Asks about any history of associated symptoms—fever, weight loss.
• 5. Takes history of jaundice.
• 6. Asks for history of blood transfusions.
• 7. Asks for history suggestive of worm infestation.
• 8. Asks history of birth, community/geographical background, consanguinity.
• 9. Asks about family and dietary history.
• 10. Asks about history of drug intake.

A 34: History for hematemesis.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Explains about the difference between hematemesis and hemoptysis. Asks for color of blood-altered, fresh and volume.
• 3. Asks about duration of symptoms and whether it is the first time.
• 4. Asks about history of any bleeding from any other site including blood in stools or bluish spots on the body.
• 5. Takes history of associated symptoms fever/vomiting/jaundice/ edema/abdominal distension/chronic cough.
• 6. Asks for history of neurological problems, altered sleep pattern or mood.
• 7. Asks for history of drug intake—NSAIDs, steroids.
• 8. Asks for associated symptoms—epigastric or retrosternal pain.
• 9. Asks about family history of bleeding.
• 10. Asks about history of blood transfusion.

A 35: History for seizures.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Asks the attendant to recreate the seizure.
• 3. Asks how the seizure started and what the child was doing at the onset of seizure to identify any precipitating factors. Asks for aura.
• 4. Asks if the convulsion was focal or generalized, its progression and postictal stage, automatism. If loss of consciousness present then for how long.
• 5. Asks if the seizure was associated with uprolling of eyes, tongue bite, bladder, bowel incontinence, postictal neurological deficit.
• 6. Asks about associated symptoms—fever, failure to thrive, ear discharge, loose stools.
• 7. Asks about previous seizures, their type, frequency and treatment. Any investigations done in past especially neuroimaging and lumbar puncture.
• 8. Asks about history of anticonvulsant medications—dosage and compliance.
• 9. Takes developmental history- asks about any regression of milestones/ personality or intellectual deterioration.
• 10. Takes neonatal and perinatal history. Enquire about family history of seizures.

A 36: Performs the following tests after introducing himself/herself and taking permission to examine from the patient:

Sl. No. Action

• 1. Tandem walking.
• 2. Disdiadochokinesis.
• 3. Synkinesis (mirror image movement).
• 4. Hand pats.
• 5. Repetitive and successive finger movement.
• 6. Arm pronation—supination movement.
• 7. Foot taps.
• 8. Hopping.
• 9. Elicit choreoathetosis by extension of arms.

A 37: History for recurrent wheezing.

• 1. Establishes rapport. Introduces himself/herself. Asks for a chaperone if male candidate.
• 2. Asks when the present attack started and what is the progression of the attack.
• 3. Asks for history of rapid breathing and difficulty in talking or feeding.
• 4. Asks for any factors that triggered the present attack and about medications taken for the attack.
• 5. Asks for history of associated fever.
• 6. Asks about how long the patient has been wheezing and about frequency, seasonality, nocturnal symptoms and school absence.
• 7. Asks about long-term therapy, drug compliance and about correctness of use of MDI.
• 8. Asks about frequency of acute attacks, frequency of use of reliever medications/nebulization/hospitalization.
• 9. Asks about history of precipitating factors, presence of pets, passive smoking in the house.
• 10. Asks about associated allergies, sinusitis, gastroesophageal reflux.
• 11. Asks about family history of atopy, skin allergy.

A 38: Examination of abdomen.

Sl. No. Action

• 1. Establishes rapport. Introduces himself/herself.
• 2. Takes permission, undresses the child. Keeps genitalia covered with a sheet.
• 3. Inspects from the foot/head end for movements/peristalsis. Observes umbilicus. Inspects genitalia by briefly uncovering them.
• 4. Gently palpates the abdomen quadrant by quadrant, keeping the flat of the palm and fingers in contact with the abdominal wall.
• 5. Palpates the abdomen for liver, spleen, any masses. Does bimanual palpation of the kidneys.
• 6. Palpates the genitalia and hernia sites.
• 7. Percusses the abdomen for presence of free fluid. Percusses for bladder dullness. Percusses the renal angles.
• 8. Auscultates four quadrants of the abdomen.
• 9. Covers the child and thanks him.

A 39: Examination of ear.

• a. Introduces himself and establishes rapport with patient.
• b. Takes permission to examine.
• c. Asks mother to hold child with one hand and head with other.
• d. Starts careful examination of pinna and surrounding scalp.
• e. Examines external meatus.
• f. Checks otoscope for adequacy of light.
• g. Pulls pinna horizontal and backwards.
• h. Introduces otoscope gently held like pen with ulnar palm touching head of child.
• i. Examines the ear drum.

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