Portfolio for

Paediatric Rotation:
Formative assessment tool for paediatric
round up session
Hospital Universiti Sains Malaysia
Editor: Dr. Fahisham Taib

Co-editors: Assoc. Prof. Dr. Noraida Ramli

Professor Hans Van Rostenberghe

 First Publication January 2012

Paediatric Department, HUSM

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any

means, electronic, mechanical, photocopying, recording, or otherwise,

without prior permission of author/s or publisher.

ISBN: 978-5547-74-4

Edited by

Dr. Fahisham Taib

Prof Hans Van Rostenberghe

Assoc. Prof. Dr. Noraida Ramli

Published by:

PPSP Publications

Medical Education Department

School of Medical Sciences

Universiti Sains Malaysia Health Campus

Kubang Kerian, Kelantan Darul Naim

Published in Malaysia

1
The authors responsible for the revision are:

Prof. Dr. Hans Van Rostenberghe, Neonatologist

Prof. Dr. Zabidi Azhar Mohd. Hussin, Paediatric Neurologist

Prof. Dr Zilfalil Alwi, Paediatric Geneticist

Assoc. Prof.Dr Nik Zainal Abidin Nik Ismail, Paediatric Nephrologist

Assoc. Prof. Dr. Ariffin Nasir, Paediatric Oncologist/Hematologist

Assoc. Prof. Dr. Noraida Ramli, Neonatologist

Dr. Noorizan Abdul Majid, Paediatric Gastroenterologist

Dr. Rowani Mohd. Rawi, Paediatric Metabolic Medicine

Dr. Mohd. Suhaimi Ab. Wahab, Paediatric Pharmacology and Infectious

Disease

Col. (B) Dr. Wan Pauzi Wan Ibrahim, Paediatric Cardiologist

Dr. Salmi Abd. Razak, Paediatric Neurologist

Dr. Norsarwany Mohamad, Paediatric Oncologist/Hematologist

Dr. Suhaimi Hussain, Paediatric Endocrinologist

Dr. Nor Rosidah Ibrahim, Neonatologist

Dr. Mohd Rizal Mohd Zain, Paediatric Cardiologist

Dr. Mohamad Ikram Ilias, Paediatric Neprologist

Dr. Fahisham Taib, General Paediatrician

Dr. Azizah Othman, Clinical Psychologist

Dr. Surini Yusoff, Genetics & Research

DR. FAHISHAM TAIB

Paediatric Phase III Coordinator/ Editor

2
How to use the book
In Universiti Sains Malaysia (USM), an apprenticeship based model of training the
undergraduate students was adopted. In contrast to the old model of apprenticeship which
was teacher centred, the model currently adopted in the paediatrics department of USM was
student oriented.

Every morning, the students will spend their time in the ward. They are expected to clerk
patients and adopt a patient centred learning method. Ideally, while clerking the patient or
immediately after it, the students should be bothered by a large variety of questions (why,
how, why again, what can be done, was whatever is done optimal,....) This should help them
with focused learning regarding the disease of the patient in the evenings. The following
days they are expected to follow up the same patients and until discharge or until the
students are no longer posted to that ward.

Even though USM, medical school has since long a student centred, problem based,
integrated, community based, elective oriented and spiral approach, still many of the
students in year 4 and year 5 take an expectant attitude and hope to get most of the
knowledge directly from their teachers. It was one of the aims of the apprenticeship based
to change this expectation and guide the students in their self initiated learning, rather than
providing the knowledge for them.

An important tool for guiding the students, were clerking sheets, which were designed by the
clinical lecturers of the paediatric department. Each clerking sheet consist of a limited open
space where the students are expected to write down the most important points in history,
physical examination and management of the patient, followed by a few important questions
that the student would be expected to raise after clerking a case with that disease. Clerking
sheets were designed for a number of important and common paediatric conditions, but it
was definitely not the aim to be all-encompassing. Next to the specific clerking sheets, there
is also a universal clerking sheet which can be used for any disease. This universal clerking
sheet can be used, once the students are familiar with generating questions regarding cases
or for cases not covered within the specific clerking sheets.

During the briefing sessions for the students, the students are encouraged to make full use
of these sheets as a formative self administered assessment. It is stressed to them that the
questions provided at the bottom of the clerking sheets are not covering everything they are
supposed to know and that the questions are only meant as triggers to generate more
questions in their mind. During weekly round-up sessions these clerking sheets are used to
generate a discussion on what was learned in the last one week and to reflect on the
learning process.

This E-book comprises of the clerking sheets as designed by our lecturers. They are free to
be used by students or institutions. If you decide to make use of these resources, please let
us know at

........ or refer to this E-book in the following way.......

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Universal Clerking Sheet

Case:

Question :

a) Explain the pathophysiology of the disease

b) Discuss how would you confirm the diagnosis
c) Discuss in details about short and long term management of this conditon
d) State advice that you will give in view of this illness (medical, follow up and
socially)
e) Questions generated by the student

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Nephrology

Topic 1: Nephrotic syndrome

1) What are the criteria for NS in this patient?.

2) Can you differentiate between typical and atypical presentation of NS in this
child?
3) What is the underlying pathophysiology of oedema in this condition?
4) List potential complications of NS, giving explanation for each complication (at
least 5 points).
5) Outline medical management of this patient and how to monitor the response
to treatment. What determines the prognosis of the condition?
6) Name at least 10 potential steroid related complications in the treatment of
NS.

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Topic 2: Post-streptococcal Acute Glomerulonephritis

1) How does patient usually present to hospital? What clinical features you will
be looking for on examination and why?

2) Describe the pathophysiology of PSAGN?

3) What investigations are indicated to establish the diagnosis and expected

results for each?

4) What do you need to monitor in the ward and list potential complications that
can occur if the condition is not correctly managed?

5) Explain the rationale of instituting pharmacological treatment and its

mechanism of action in patient with PSAGN.

6) Criteria for discharge in patient with PSAGN

6
Topic 3: Urinary tract infection (UTI) in Children

1) How do you diagnose UTI in children versus newborn?

2) What are risk factors to develop UTI? Gender preference and why?
3) What are the commonest organisms responsible for UTI? Describe the
defence system that are present to protect against UTI and how does the
organism manage to breech the system.
4) How to obtain urine samples from paediatric age patient? What investigations
are available to support/confirm the diagnosis.
5) What antibiotic of choice to use and role of antibiotic prophylaxis in children.
6) What follow-up investigations need to be performed and how do you monitor
the progress.
7) Question generated by student

7
Immunology

Topic 1: Anaphylaxis

1) Definition and diagnostic criteria for anaphylaxis.

2) Outline the types of hypersensitivity, giving example for each.
3) What are the common clinical manifestations of anaphylaxis? List common
aetiological causes.
4) Outline immediate management of anaphylaxis, giving rationale for each of
the action.
5) What should be monitored in the ward? Long term follow-up and advice to
prevent similar response.

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Topic 2: Atopy Dermatitis & Eczema in Infant

1) What are the risk factors involved/predisposing factors to develop atopy

dermatitis?
2) How does the condition manifested in this age? (age/symptoms/area of
involvement)
3) What investigations are available to identify the cause?
4) Outline the principles of management of atopy dermatitis in infant.
5) Question generated by student

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Topic 3: Intravenous Immunoglobulin (IVIG)

1) What is IVIG?
2) List the medical condition that require the use of IVIG as a treatment (at least
4)
3) Discuss potential acute and long term complications of using IVIG.

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Topic 4: Immunisation

1) Discuss the difference between active and passive immunisation, giving

examples.

2) Outline the current immunisation schedule in Malaysia. What specific changes

that had been made after revision on October 2008?

3) How does a vaccine produced and from what source? Give examples for
each type.

4) What are the potential complications being immunized? Give example for
each vaccine.

5) How does BCG vaccine given?

6) Describe the natural process that usually occur after BCG vaccine is given?
How do you determine whether the immunisation given is successful or not?

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Cardiovascular
Topic 1: Kawasaki Disease

History & Physical Examinations

1. List of Differential Diagnoses

2. What is the pathophysiology of this condition
3. What are the risk factors associated in this condition?
4. What symptoms and signs were typical, which were atypical
5. How do you confirm the diagnosis?
6. Investigations
Why the investigation was indicated for this patient?
What was the result and how to interpret it?
7. Outline the management of the patient.
8. Would there be any alternative possible treatment for this condition.
9. Name of drug used.
What was the indication in this patient
Why the doctor chose this drug (comparison with other possible drugs for
this conditon)
What is the mechanism of action
What are the side effects
10. Questions formulated by student:

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Topic 2: Acute Rheumatic Fever

History & Physical Examinations

11. List of Differential Diagnoses

12. What is the pathophysiology of this condition
13. What are the risk factors
14. What symptoms and signs were typical, which were atypical
15. How to confirmed the diagnosis
16. Investigations
Why the investigation was indicated for this patient?
What was the result and how to interpret it?
17. Outline the management of the patient.
18. Would there be any alternative possible treatment for this condition.
19. Name of drug used.
What was the indication in this patient
Why the doctor chose this drug (comparison with other possible drugs for
this conditon)
What is the mechanism of action
What are the side effects
20. Questions formulated by student:

13
Topic 3: Infective Endocarditis

History & Physical Examinations

21. List of Differential Diagnoses

22. What is the pathophysiology of this condition
23. What are the risk factors
24. What symptoms and signs were typical, which were atypical
25. How to confirmed the diagnosis
26. Investigations
Why the investigation was indicated for this patient?
What was the result and how to interpret it?
27. Outline the management of the patient.
28. Would there be any alternative possible treatment for this condition.
29. Name of drug used.
What was the indication in this patient
Why the doctor chose this drug (comparison with other possible drugs for
this conditon)
What is the mechanism of action
What are the side effects
30. Questions formulated by student:

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Neonates

Topic 1: Infant of diabetic mother (IDM)

a) List 3 likely cause of respiratory distress in a term IDM

b) State 1 important metabolic complication related with IDM & its

pathophysiology

c) Discuss the management of b

d) Perform a routine postnatal examination on an IDM and state the important

examinations directly related to this risk factor and why

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Topic 2: Drug side effects (a must answer Q)

Look at the medication sheets of a baby in NICU. Find any 2 of these drugs an
aminoglycoside, penicillin, vancomycin, erythromycin, dopamine, dobutamine,
frusemide. Aminophylline. Write the summary of the patient

a) State the indication of the drug that youve chosen

- specifically related to the baby
- other indications

b) State the mode of action of the drugs

c) List side effects of the drugs

d) State how you are going to monitor the possible side-effects (either via
clinical/ laboratory)

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Topic 3: Meconium aspiration syndrome (MAS)

a) State the cause of meconium-stained liquor in the baby

(note: MAS is a not a full diagnosis we need to find the reason why the baby
passed out meconium in-utero)

b) List the other possible causes of MAS

c) Discuss the neural pathway involved when a fetus passed out meconium in-
utero

d) Discuss the complications of MAS

e) Review the CXR of the baby list the abnormalities seen

f) Youre the house-officer in charge of the delivery of a baby and noticed that
the liquor was meconium stained. Discuss how you should resuscitate the
baby once he is born.

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Topic 4: Acute surgical condition in a newborn - 1

Discuss the history of a term baby who presented with abdominal distension

a) State important antenatal history

b) List the possible differential diagnosis

c) List important physical signs that need to be elicited and reasons

d) List the urgent investigations (with reasons)

e) Outline the immediate management (other than informing the Paediatric

surgeon)

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Topic 5: Acute surgical condition in a newborn - 2

A premature baby with necrotizing enterocolitis (NEC)

a) List other important physical signs

b) State the risks factor of NEC in this baby

c) Discuss the stages of NEC

d) Find a radiograph of a baby with NEC and discuss the abnormalities

e) Outline the management of this baby

f) State the complications

g) List important preventive measure

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Topic 6: Perinatal asphyxia

a) Estimate the Apgar score of the baby

b) Define perinatal asphyxia

c) Discuss the Sarnat Sarnat criteria of hypoxic ischemic encephalopathy(HIE)

and state at what stage this baby is in

d) Discuss the possible cause of oliguria/ anuria in this child

e) Discuss the cause of tense anterior fontanelle in a child with severe HIE
(please palpate at least 10 normal anterior fontanelle)

f) Discuss whether this incidence can be prevented

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Topic 7: Summary of a baby with neonatal jaundice

1. List the important histories and physical examinations in this patient (list the
important positives and negatives)
(** to help you draw bilirubin metabolism)

2. State 3 important investigation if the baby has hemolytic jaundice

3. Describe the mechanism of phototherapy

4. Recall how exchange transfusion is done include indication, amount of

blood required, complications)
** also check what screening is done for a donors blood
** how do you check a pack of packed cell before transfusion is given

5. Discuss on bilirubin encephalopathy sign/ symptoms, complication, risk

6. Discuss important long term follow-up in a child who has had severe neonatal
jaundice

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Haemato-oncology
Topic 1: Haemophillia

Clerking space

Questions

1. What is the pathophysiology of this condition

2. What are symptoms and signs

3. How to confirm the diagnosis

4. How was the patient treated, would there be any alternative possible
treatment for this condition?

5. What is the mode of inheritance

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6. Questions formulated by student:

Factor VIII

Clerking space (history and physical signs of patient who received the drug)

a) What was the indication in this patient

b) Why the doctor chose this treatment (comparison with other possible
treatment for this conditon)

c) What is the mechanism of action

d) What are the side effects

e) Questions generated by students:

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Investigation - PT,aPTT and Factor VIII level

Clerking space (patients history and physical signs who underwent the
investigation):

Questions

a) Why the investigation was indicated for this patient?

b) What was the result and how to interpret it?

c) Questions generated by student.

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Topic 2: Thalassaemia

Clerking space

Questions

a) What is the pathophysiology of this condition

b) What are the types of thalassaemia

c) What are symptoms and signs

d) How to confirm the diagnosis

e) How was the patient treated, what is the aim of treatment

f) Questions formulated by student:

25
Chelating agents (Desferrioxamine, deferasirox, deferiprone)

Clerking space (history and physical signs of patient who received the drug)

a) What was the indication in this patient

b) Why the doctor chose this drug (comparison with other possible drugs for this
condition-what other choices?)

c) What is the mechanism of action

d) What are the side effects

e) Questions generated by students:

26
Investigations:

Clerking space (patients history and physical signs who underwent the
investigation):

Questions

a) Why the investigation was indicated for this patient?

b) What was the result and how to interpret it?

c) Questions generated by student.

27
Topic 3: Acute Leukaemia

Clerking space

Questions

7. What are symptoms and signs

8. How do you explain clinical finding (pathophysiology) to parents

9. What confirmed the diagnosis

10. How was the patient treated, would there be any alternative possible
treatment for this condition?

11. Questions formulated by student:

28
29
Name of drug used:
Dexamethasone/Methotrexate/Cyclophosphamide/Vincristine/Asparaginase

Clerking space (history and physical signs of patient who received the drug)

a) What are the side effects

b) Questions generated by students:

30
Investigation: Bone marrow aspiration & lumbar puncture

Clerking space (patients history and physical signs who underwent the
investigation):

Questions

a) Why the investigation was indicated for this patient?

b) What was the result and how to interpret it?

c) Questions generated by student.

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Topic 4: Glucose 6 Phosphate Dehydrogenase deficiency

Clerking space

Questions

1. What is the pathophysiology of this condition?

2. What are symptoms and signs?

3. How to confirm the diagnosis?

4. How was the patient treated, would there be any alternative possible
treatment for this condition?

5. What is the mode of inheritance?

6. What is your advice upon discharge?

7. Questions formulated by student:

32
Respiratory
Topic 1: Asthma

List likely reasons that trigger or cause of uncontrolled asthma

State most important advice that you are going to give to the parents/patient

Discuss the mode of delivery of medications to asthmatic patient

State the management of acute exacerbation of asthma

Questions generated by the student

33
Topic 2: Drug side effects

Look at the medication sheets of this patient with respiratory illness. Find any 2
of these drugs. Write the summary of the patient

State the indication of the drug that youve chosen specifically in relation
to the patient

State the mode of action of the drugs

List side effect of the drugs

State how you are going to monitor the possible side-effects (either via clinical/
laboratory)

Question generated by students

34
Topic 2: Pneumonia

g) State the organisms contributing for LRTI

h) List the possible sequalae of this condition

i) Discuss known method of prevention of LRTI

j) How do you describe X ray of the chest of this child

k) Question generated by student

35
Infectious Disease
Topic 1: Dengue Infection

Clerking space

Questions

a) What are symptoms and signs of this condition?

b) How to confirm the diagnosis?

c) How to do Hess Test?

d) How was the patient treated?

e) What are the complications related to this infection and pathophysiology?

f) What are WHO classifications of dengue infection?

g) What are the important parameters in the FBC to look for during monitoring?

h) Questions formulated by student:

36
Question 2: Snake bite

a) List 2 main complications of this bite

b) List 2 other common types of poisonous snake in Malaysia with its main
complications

c) Discuss the management of this child in the emergency department.

d) Was the child managed in intensive care? If yes what was the indication

e) Was the child given anti-venom? List 3 side effects of anti-venom and its
pathophysiology.

f) Discuss the protocol that needs to be observed during administration of anti-

venom (To answer this Q, you need to know the answers for (e)

37
Development/Genetic/Community Paediatrics
Topic 1: Developmental delay

Question:

1. Systematically list the possible causes of his problem

2. Briefly discuss developmental milestone giving a brief definition of the four

components of developmental milestone assessment: gross motor; fine
motor; language/speech and personal social.

3. Discuss the questions that you would ask during history taking to assess his
developmental milestone.

4. List THREE (3) causes of the following type of developmental delay

5. For each of the causes you have listed in question 1, state what questions
you would ask to determine whether they are the causes of his problems

38
Topic 2: Down Syndrome

1) List and give a brief explanation of all the physical abnormalities and
conditions that could be associated with Down syndrome

2) What laboratory test would you do to confirm the diagnosis of Down syndrome
and briefly explain the principle of the test?

3) The THREE (3) causes of Down syndrome are trisomy 21, mosaic and
translocation.
a. Describe meiosis, mitosis, fertlisation and early zygotic development
focusing on the changes occurring to the chromosomes
b. Explain the pathophysiology of three causes mentioned above, giving
detail of the errors that might have occurred during cell division and
early zygotic development.
c. Discuss the risk of recurrence (mums next pregnancy) for each of the
three causes mentioned above
4) Discuss how you would you manage the patient focusing on the following
aspects:
a. Patients baseline assessment to determine whether the patient has
conditions that could be associated with Down syndrome
b. Genetic counseling
c. Psychosocial counseling
d. Clinical follow up
Who should be following up the child

39
 How should the patient be monitored (general health and detection of
complications)
e. Rehabilitation
f. School placement
g. Occupational training

Topic 3: Child abuse

Find a patient with this diagnosis write the history in the box given and answer the
subsequent questions.

Clerking space

Questions

1. List down other features of child abuse (physical/sexual).

2. Complications of child abuse.

3. Risk factors to be abused.

4. Outline the principle of management of child abuse

5. Questions formulated by student:

40
Neurology

1. Febrile Seizures

a) State the definition of febrile seizure

b) List its classification
c) Explain the typical course of febrile seizures
d) Discuss the management with regards to this patient
e) List factors that increase the risk of further seizure activity
f) Questions formulated by student

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2. Meningitis/ Encephalitis

a) Discuss the pathophysiology of this condition

b) List typical pathogens by age group
c) Describe the typical presentation of bacterial meningitis
d) Discuss how a patientss age affects the presentation and outcome of
bacterial meningitis
e) State the confirmatory investigation and its expected findings for each
different pathogen groups
f) Outline the principle of treatment
g) State the possible complications

42
3. Cerebral Palsy

a) What was his/her primary diagnosis and what age was he/she
diagnosed?
b) State the definition of CP
c) Discuss the classification of cerebral palsy
d) List the risk factors. Identify the insult/ possible cause in your patient
e) Describe the identified co-morbidities in this patient
f) Outline the principle of management

43
4. Childhood Epilepsy

a) State the definition

b) State the classification of seizure type (according to ILAE)
c) Discuss the differential diagnosis of seizures according to age group
d) A two-year old child presented with recurrent afebrile seizures
i. Describe the expected abnormal signs you look for
ii. List the investigations you would like to perform
e) State the principles of anticonvulsant therapy for epilepsy
f) List the common side effects for each anticonvulsant

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5. Acute Flaccid Paralysis

a) Briefly discuss the protocol for AFP surveillance in Malaysia

b) A seven-year old suspected to have Guillain Barre syndrome
i. Describe the typical presentation
ii. State the important complication that can occur
iii. List the investigations and their expected findings
iv. Outline the principles of management

45
6. Approach to floppy infant

a) State the sign and symptom suggestive for floppiness in an infant

b) State the pattern of weakness and its localization in the floppy infant
c) List initial work up based on clinical presentation
d) List at least TWO examples of the disease for each different disorder
according to aetiologic considerations

46
Endocrinology

1. Thyroid disease

h) What causes thyroid disease in this child?

i) What are the clinical manifestations that you found?
j) What findings suggest thyroid disease?
k) How do you assess/investigate thyroid status?
l) What is the treatment for congenital hypothyroidism?
m) Why do you need to identify cases with congenital hypothyroidism as
early as possible?

47
2. Juvenile Diabetes Mellitus (type 1)

a) What causes diabetes ?

b) What are the characteristics of type 1 and type 2 diabetes?
c) How is type 1 diabetes diagnosed?
d) How does type 2 diabetes affect children?
e) How is blood glucose level used in the diagnosis of diabetes?
f) How should you manage the case?
g) What are the guidelines for blood glucose control?
h) What are the consequences of poor diabetic control?
i) When does diabetic ketoacidosis (DKA) occur as an acute complication
of diabetes?
j) Does hypoglycemia have adverse consequences for young children?
k) What behavioural and emotional problems will need attention in patient
with diabetes?
l) When is hospitalization requires for patients with diabetes, and why?

48
3. Congenital adrenal hyperplasia

a) Clinical presentations in neonatal period and later onset

b) Important points in the family history
c) Adrenal crisis in relation to both genders
d) Clinical Progression during clinic visits: growth and development
e) Replacement therapy
f) Complications related to under or over treatment

49
 Clerking Sheet: Psychology

Psychological Coping for Children in Hospital

1. Background information:

(Childs name, age, home, schooling, number and order of siblings, best friends,
hobbies, ambitions, etc)

(Parents name, age, job, number of children, ages, etc)

2. Illness and hospitalization:

(Diagnosis, duration of illness, brief treatment methods i.e. Involves invasive

procedure?)

(Reason for current hospitalization, frequency of hospitalization, duration of current

hospitalization)

Distribute handouts to parents.

50
3. Children reactions to hospitalization:

(Ask child/ and or parents what they like and hate about hospitalization/ illness; what
they feel most difficult to cope with, what they feel just fine/ OK)

(Ask parents what are their children reactions to illness and hospitalization, any
changes in childrens behavior, what behaviors they find difficult to manage, ask if
they know why this happen)

4. Parents efforts

(Ask parents what they have been doing to handle with these difficult behaviors,
what works well, what did not, suggestions from other parents, relatives to handle
the children?)

5. Students observation probable reasons for difficult behavior:

(Based on information gathered from both parents and child, and your observation of
the childs behavior in the ward, suggest the most probable reasons for childrens
difficult behavior/ reactions and state cope-activities (1 or 2) that you would like to
apply to help the child)

51
6. Suggest and demonstrate ways to enhance coping:

(Explain possible reasons for childrens misbehavior to parents, recommend 1 or 2 to

cope-activities, and demonstrate the activities by doing it to the child)

7. Outcome/ Responses/ Feedback

(Observe or ask directly parents and child about the cope-activities)

Parents:

Child:

8. Students Reflection

(State what you have learnt about coping activities, about yourself i.e. strength/
weaknesses etc)

AO-31082010

52
 PROPOSAL PREPARATION FOR A SCIENTIFIC RESEARCH

Year 4 Paediatric Posting-Introduction to undergraduate research

(Exercise)

Class will be divided into 3 groups-10 students per group

1. Suggestion of a topic

2. Aim and objective/s

3. Background of study
a) Data from previous studies
b) Problem statement

4. Hypothesis/es

H0:

H1:

53
 5. Methods
a) Description in brief
- Sample selection
- Sample size calculation if necessary
- Techniques that will be used
- Statistical analysis, etc.
- Operational definition should be included where necessary.
b) Inclusion and exclusion criteria
c) Flowchart
d) Gantt chart

6. Expected outcome

7. References

Questions to be considered:

1. Ethical issue Yes No

2. Budget Yes No

3. Time Reasonable Unreasonable

54
55