STATION THREE
CANDIDATE INSTRUCTIONS:
You are a member of the paediatrics team. You have been called to see Dakota, a 2 day old baby staying in maternity ward with his mother Ms Sparkle. The midwife has stated concern he may be jaundiced.
Take a short targeted history from Dakota’s mother pertinent to your diagnosis and management.
You will then be prompted by the examiner 3 steps in investigating and managing this patient.
More information will be provided by the examiner along the way. Allocate 6 minutes to this part.
Do not read below until instructed to do so by the examiner.

INFORMATION SHEET TO BE PROVIDED TO CANDIDATE:
Results
● Baby appears well, jaundice extending to umbilicus
● FBE – Hb lower limit of normal, otherwise unremarkable
● Unconjugated Bilirubin – elevated
● Conjugated Bilirubin - normal
● Direct Coombs Test Positive
● CRP normal
● G6PD Normal

PATIENT INSTRUCTIONS:
The candidate will take a history from the patient’s mother. 2 minutes should be allocated, maximum time allowed is 3 minutes.
Name: Diamond Sparkle, son’s name is Dakota
HOPC ● Baby was born 2 days ago
● Normal term vaginal delivery, nil complications
● Has noticed him being yellow since birth
Maternal Hx
Baby Hx
- If asked where, state has been spreading down chest
● Otherwise has been behaving well, nil concerns
● Full breastfeeding at the moment
● First wet nappy and passed meconium, nil concerns
● Birth weight 3.5kg
● Otherwise has been well
● G1P1 – first baby, normal pregnancy
● GBS positive – given 1 dose antibiotics
● Type O+
● Doesn’t know blood group
● Normal perinatal scans during pregnancy
● Nil family history of relevant genetic conditions

EXAMINER INSTRUCTIONS:
The candidate will take a history from the patient’s mother. 2 minutes should be allocated, maximum time allowed is 3 minutes.
After the candidate has completed taking a history, ask the following question:
“State what would be your next steps in managing this baby.”
(Allocate marks on marking guide)
Ask the candidate to read below the stem on their candidate information sheet.
“Based on these results, explain the likely diagnosis and its implications to Dakota’s mother.”
(Allocate marks on marking guide)
Results
●
●
Baby appears well, jaundice extending to umbilicus
FBE – Hb lower limit of normal, otherwise unremarkable
●
●
●
Indirect Bilirubin – elevated
Direct Bilirubin - normal
Direct Coombs Test Positive
G6PD Normal ●
“Despite an initial improvement with phototherapy for the past 2 days, today the baby’s bilirubin remains elevated. He has also been reported as acting lethargic with a concern of low temperature. Explain to the examiner what you would do next.”
(Allocate marks on marking guide)

EXAMINER MARKING GUIDE:
Criteria
History
 Noticed him being yellow since birth (0.5)
 Established baby’s behavior, feedling and bowels/urine: Full breastfeeding (0.5), first wet nappy and passed meconium (0.5)
 Perinatal/birth history: Born 2 days ago (0.25), Birth weight 3.5kg (0.25) NVD at term, nil complications (0.5)
 Maternal history: G1P1 (0.25), GBS +ve (0.5), O+ (0.5), Baby blood group – unknown, normal antenatal scans (0.25), Nil FHx (0.25)
Management

Check vital signs (1)

Perform exam, mentioning baby’s level of activity (0.5), levels of jaundice present
(0.5)

Blood tests – FBE, SBR, CRP, blood group, Direct Antiglobulin Test/Coombs test,
G6PD (max. 1.5, with 0.25 awarded for each)

Serum bilirubin should then be checked with a graph for the treatment threshold for phototherapy (0.5)
Diagnosis and Explanation
 Establish diagnosis is ABO incompatibility (0.5)

Explanation of blood groups: Antigen-antibodies with A and B blood groups (0.5), present antibodies in mother can travel to son and cause haemolysis (0.5), note ABO incompatibility can be present in a first normal pregnancy due to antibody sensitisation from food

Explanation of jaundice: Bilirubin is the breakdown of red blood cells and is what is causing him to be yellow (0.5)

Perinatal and postnatal prognosis of baby: Overall good prognosis (0.5), Risk is that the haemolysis causes anaemia, as well as bilirubin building up causing kernicterus
(reassure that this risk is rare and treatable) (1), With phototherapy this condition will subside and have no long-lasting consequences (0.5)
Communication skills to patient
Next Steps
 Exclude sepsis (0.5), Re-examine baby – including vital signs, conscious state
(lethargy, irritability, seizures), colour, perfusion, potential focus of infection (1),
Should be transferred to appropriate treatment ward – special care nursery at minimum (0.5), Repeat bloods – include FBE, SBR, CRP, 2 sets of blood cultures, blood gas, glucose and TFTs (1), Antibiotics should be commenced – must say that they are started without being delayed by investigations (1), Recommended antibiotics – IV Benzylpenicillin + gentamicin for 48 hours then reviewed (0.5),
Consider increasing phototherapy (0.5), LP if suspecting meningitis or initial blood cultures positive (1)
Total
Marks
/4
/4
/4
/2
/6
/20