Student Trigger

You are a resident medical officer of a large tertiary hospital

maternity ward. You are about to examine Jimmy for a newborn
check prior to discharge. You notice Jimmy a bit jaundiced.

Student Tasks:
1) Discuss with the examiner the causes of jaundice in a baby
2) Tell the examiner what you would like to know in history to help
you formulate your differential diagnoses
3) Tell the examiner what you would like to perform in examination
to help you formulate your differential diagnoses
4) Tell the examiner what investigations you would like to order to
help you formulate your differential diagnoses
5) Answer examiner questions

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Patient Information:
- Jimmy – 2 day old boy
- Birth history, gestational age, birth weight – born term at 39 weeks and 6
days, antenatal history not significant, birth weight 3kg
- Timing of jaundice, when jaundice started, is it worse now – only noticed
him a bit yellow starting today, was fine for the first day
- Feeding habit, volume of intake, exclusive breastfeeding, vomiting - been
breastfeeding exclusively every 3 hours, no vomiting
- Urine output and colour – haven’t noticed dark urine in nappies
- Stool - delayed passage of meconium or light coloured stool – nil
meconium, stool colour not light
- Change of behaviour - lethargy, cried becoming shrill, arching of the body
– nil particular change in behaviour since birth
- History of temperature instability – nil temperature noticed

Examiner Questions
1) Discuss with the examiner the causes of jaundice in a baby
2) Tell the examiner what you would like to know in history to help you
formulate your differential diagnoses
3) Tell the examiner what you would like to perform in examination to help
you formulate your differential diagnoses
4) Tell the examiner what investigations you would like to order to help you
formulate your differential diagnoses
5) What is an important complication of hyperbilirubinaemia?
a. Kernicterus (bilirubin encephalopathy)
6) If treatment is indicated for jaundice, what options are available?
a. Sick babies need a septic screen, antibiotics and admission
b. Full term, well appearing and afebrile neonates without significant
risk factors and bilirubin level less than the level indicated in the
graph can be discharged with GP follow-up in 1-2 days for repeat
SBR
c. Admit for phototherapy if bilirubin level is over the line as per the
jaundice bilirubin normogram

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 Expectation

Expectation

Expectation
Excellent
Meets

Above
Below
Student: Examiner:

Poor

s
CHECKLIST SCORE
Section 1: Causes
1.1. <24 hours (pathological): major incompatibilities (Rh isoimmunisation, ○
ABO), haemolysis (structural – elliptocytosis, metabolic – G6PD, Hb –
thalassaemia), sepsis ○
○ ○ ○ ○ ○
1.2. Day 1-14: (can be normal): physiological/ breastmilk jaundice, ongoing
haemolysis, sepsis, polycythaemia (GDM babies) ○
1.3. >Day 14: (pathological): Conjugated (biliary atresia, bile duct obstruction),
unconjugated (breast milk/physiological up to 6 weeks, hypothyroidism,
sepsis)
Section 2: History
2.1. Birth history, gestational age, birth weight ○
2.2. Timing of jaundice, when jaundice started, is it worse now? ○
2.3. Feeding habit, volume of intake, exclusive breastfeeding, vomiting ○
2.4. Urine output and colour (dark urine) ○ ○ ○ ○ ○ ○
2.5. Stool - delayed passage of meconium or light coloured stool ○
2.6. Change of behaviour - lethargy, cried becoming shrill, arching of the body ○
2.7. History of temperature instability ○

Section 3: Examination
3.1. Natural light ○
3.2. Pallor, petechiae, excessive bruising, hepatosplenomegaly ○
3.3. Hydration and weight status ○ ○ ○ ○ ○ ○
3.4. Plethora (polycythaemia) ○
3.5. Kramer's rule (screening bilirubin levels from head > trunk > limbs) ○

Section 4: Investigations
4.1. Transcutaneous bilirubin should be taken as in initial screen in neonates ○
<14d ○
4.2. Serum bilirubin (SBR) heel prick: Conjugated vs unconjugated bilirubin ○
4.3. LFT ○
4.4. FBC (add reticulocyte count if anaemic) ○
○ ○ ○ ○ ○
4.5. Urine culture ○
4.6. +/- TFT ○
4.7. RBC enzyme assays for G-6PD ○
4.8. Direct coombs if not already done ○
4.9. If unwell consider septic screen, TORCH screen and metabolic screen

Section 5: Questions
5.1. What is an important complication of hyperbilirubinaemia?
- Kernicterus (bilirubin encephalopathy) ○
5.2. If treatment is indicated for jaundice, what options are available? ○
- Sick babies need a septic screen, antibiotics and admission ○
○ ○ ○ ○ ○
- Full term, well appearing and afebrile neonates without significant ○
risk factors and bilirubin level less than the level indicated in the ○
graph can be discharged with GP follow-up in 1-2 days for repeat SBR
- Admit for phototherapy if bilirubin level is over the line as per the
jaundice bilirubin normogram
Empathy Score ○ ○ ○ ○ ○

Global Score: Examiners overall impression of the student’s performance independent of the checklist score
0 = Dangerous/unassessable 0 1 2 3 4 5 6
1 = Poor/Potentially harmful
2 = Unacceptable
3 = Borderline (unsure if acceptable or unacceptable) ○ ○ ○ ○ ○ ○ ○
4 = Acceptable/average
5 = Very good
6 = Outstanding
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Errors or improvement suggestions? Please message us on Facebook or osceframeworks@gmail.com
For more practice stations, summary frameworks and approaches – Visit https://osceframeworks.com
Legal Disclaimer
These practice stations are written or adapted from other sources by a group of Junior Doctors in
Australia. Whilst we have made our best efforts to ensure correct clinical information used for the
purposes of the Objective Structured Clinical Examination (OSCE), the clinical information and
guidelines may change over time and can vary between hospitals, states or countries. For this reason,
the clinical information given in these practice OSCE stations are an indicative guide only. We certainly
do not recommend you to base your management of actual patients on the information provided on
these practice stations. We suggest that you refer to local hospital guidelines, current references and
seek senior clinician’s assistance when managing actual patients.

© OSCE Frameworks
Errors or improvement suggestions? Please message us on Facebook or osceframeworks@gmail.com
For more practice stations, summary frameworks and approaches – Visit https://osceframeworks.com