Paediatrics Station 2

Setting:

You are a junior doctor working in paediatric A+E. This patient has been brought in by their carer because they are concerned about the colour of her skin.

Name: Olivia Smith
Age: 12 days old

Tasks:

1. Take a history from the carer.

2. Give your preferred diagnosis to the examiner.

3. Give your immediate management to the examiner.

4. Interpret the results provided.

You are not required to examine the patient.

Briefing

Diagnosis: Breast milk jaundice

You are the mother/father of Olivia Smith (Age - 12 days)

You have presented to the Paediatric Emergency Department concerned about the colour of her skin.

Appearance and Behaviour

You should act concerned, but overall be calm and collected..

Opening statement

“I have noticed that over the last week she seems to be turning yellow”

Information to Give Freely

I’m not sure if it’s just because I am so sleep deprived from having a newborn but I do think her skin is becoming more yellow. That's the only thing that's changed though, she's completely normal for her otherwise! My husband/wife and I are concerned so we thought we would bring her in to get checked.

Presenting Complaint

Symptom - Yellowing of the skin all over her body
Onset - First noticed it 5 days ago (when Olivia was 7 days old)
Character - It isn’t blotchy, it’s the same shade all over
Associated symptoms – Olivia seems well in herself, no vomiting, feeding as normal, no pale stool or dark urine, does not appear to be in pain, no seizures or strange movements, no fever.
Radiation - Her eyes also look a little bit yellow
Timing – Constant but has been worsening over the past 5 days
Exacerbating /relieving factors - None
Severity – It isn't obviously impacting her wellbeing, but both parents are concerned

Key Paediatric History Points

Conception - Natural
Pregnancy - Mother suffered from morning sickness during the first trimester. Mother did not smoke/drink during pregnancy. No antenatal concerns. Maternal blood group is O negative.
Birth - Spontaneous Vaginal delivery at 39+5, no complications, no complications after birth, no bruising occurred during birth
Immunisations - She is too young, but we are planning to give her all of them
Nutrition/feeding - Solely breastfed since birth, feeding every 3 hours as normal
Development - No concerns, new born baby check was all normal

Past Medical History

Previous similar episodes - nil
Other medical conditions - nil
Previous surgeries - nil

Drug History

Not on any regular medications
No known drug allergies
Mother did not taking any medications during pregnancy/breastfeeding

Family History

No similar episodes on either mum or dad’s sides (eg G6PD, Gilbert, Dubin-Johnson)
Nil else relevant

Social History

Lives with Mum, Dad and older Brother Archie (4 years old) in a semi-detached house. Everybody else at home is currently well.
No smokers in the house
Pet dog - well trained, no safeguarding concerns
No previous involvement with social services. If asked, you don't feel you need any extra help at home.

Systems Review

General - not irritable, sleeping normally, not drowsy, not in pain, no rashes
GI - good appetite, breast feeds every 3 hours, 2 dirty nappies in 24 hours (normal for Olivia), stool has not changed colour or consistency, no blood in stool, gaining weight appropriately
GU - 6-8 wet nappies in 24 hours (normal for Olivia) , urine normal colour, no odd smell, no blood
ENT - No coryzal symptoms, no stridor
Cardio/Resp - No SOB, no cough, no wheeze,
Neuro - No fits, no rashes
Endo - Guthrie test was negative including for congenital hypothyroidism (a cause of prolonged unconjugated hyperbilirubinemia).

Ideas / Concerns / Expectation

Ideas - “I have heard of this happening before to my friend’s babies but I have never understood why”
Concerns - “She seems completely well in herself so I not overly concerned but I just don’t want her to look yellow”
Expectations - “I’m Hoping you can tell me what it is and give her something to make her skin not yellow anymore”

Discussion / Questions

The candidate will speak to the examiner for the remainder of the station. You have no further questions if they ask.

Please interpret these results

On clinical examination Olivia looks well. She appears well hydrated.

 

The blood tests show the hyperbilirubinaemia is UNconjugated.