F&C OSCE Notes_University of Manchester, WL Gan

Paediatrics OSCE Notes Assess the developmental milestones of this infant / child.

i. ii. iii. iv.

Gross motor Fine motor and vision Hearing, speech and language Social, emotional, behavioural development

Gross motor – observe general movement, inspect when lying supine, assess head lag when pulled to sit, assess sitting, ventral suspension and lying prone, assess legs ( knee sag, weight bears, bounces ) Fine motor – observe hands, offer toys / beads / pencil / cubes Ask about past medical history/family history/pregnancy and antenatal history/drug history. Address parent’s concern.

Walking is considered to be delayed if it has not been achieved by 18 months. Causes of delayed walking  bottom shuffler ( normal variant )  delayed motor maturation ( often familial )  severe learning disabilities ( dysmorphic features and hypotonia )  cerebral palsy ( hypertonia )  Duchenne's muscular dystrophy  hypotonia of any cause ( Down's syndrome, Prader-Willi syndrome, Trisomy 13 )  emotional deprivation or severe chronic illness. Causes of global developmental delay  prenatal – Down’s syndrome, hypothyroidism, alcohol, congenital infection, tuberous sclerosis  perinatal – hypoxic ischemic encephalopathy, hypoglycemia, hyperbilirubinaemia  postnatal – meningitis, encephalitis, hean injury, hypoglycemia, inborn errors of metabolism Features of cerebral palsy – delayed motor milestones, abnormal tone, persistence of primitive reflexes, abnormal gait, feeding difficulties, developmental delay eg. language, social

Cranial nerves examination       i. ii.    

CN I – test for smell CN II – direct and consensual pupillary reflexes to light, accommodation reflex, visual fields, red reflex CN III, IV, VI – tract eyes following an object through horizontal and vertical planes, check for squint and nystagmus CN V – clench teeth, move jaw side to side, check for face sensation ( ophthalmic, maxillary and mandibular ) CN VII – wrinkle forehead, close eyes tightly, show teeth, puff cheeks CN VIII – hearing ( normal AC > BC ) conductive deafness – Rinne : BC > AC and Weber test : louder on the affected side sensorineural deafness – Rinne : AC > BC and Weber test : louder on the normal side CN IX – levator palate; say ahh and look for palatal elevation, uvula deviation CN X – check for hoarseness of voice or stridor CN XI – trapezius and sternocleidomastoid muscle; shrug shoulders and turn head to both sides against resistance CN XII – stick out tongue and wiggle side to side, look for atrophy or deviation

The University of Manchester | W.L. Gan | 2012

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Assess the neurological function of the child.

General inspection – wasting ( LMN ), fasciculation ( LMN ), hypertrophy, Gower’s sign, gait ( ask the child to walk to the end of the room, turn round and return ), Erb’s palsy Broad based gait ( cerebellar disorder ), waddling gait ( proximal muscle weakness ) Tone – flexing and extending the wrists and elbows while pronating and supinating the forearm  Increased tone ( hypertonia ) – UMN  Decreased tone ( hypotonia ) – LMN Power – Upper limb i. Shoulder abduction – raise your elbows like wings, don’t let me push them down ii. Elbow flexion – bring your arms like a boxer, pull me towards you * stabilize the joint and compare both sides iii. Elbow extension – push me away iv. Finger extension – straighten your fingers and stop me from bending them when I push down v. Finger flexion – grab my fingers and squeeze them as hard as possible vi. Finger abduction – spread your finger wide apart and don’t let me push them together vii. Thumb abduction – raise your thumb to the ceiling and don’t let me push it down Lower limb i. ii. iii. iv. v. vi. vii.

Hip flexion – place hands on thigh, push up against my hand Hip extension – place hands under thigh, push down against my hand Knee flexion – bend child’s knee and place hand behind heel, bring your heel to your bottom Knee extensor – bend child’s knee, kick me away Ankle dorsiflexion – hold child’s medial and lateral malleoli with one hand, place ulnar part of other hand against dorsal aspect of foot, push against my hand Ankle plantarflexion – place ulnar part of hand against the plantar aspect of foot, push down against my hand Big toe extension – place finger against the big toe, push your toe against my finger

Power Grade 0 1 2 3 4 5

Description No contraction Flicker or trace of contraction Active movement with gravity eliminated Active movement against gravity Active movement against gravity and resistance Normal power

Reflexex – biceps, supinator, triceps, knee, ankle, Babinski test is not reliable in children  Hyperreflexia – UMN  Hyporeflexia – LMN Coordination Upper limb – finger nose test, dysdiadochokinesia Lower limb – heel shin test

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Sensation – light touch, vibration, proprioception Plot the height and weight on growth chart

The University of Manchester | W.L. Gan | 2012

Examine this child with asthma.

General inspection – height ( long-term steroid use ), nebulisers or inhalers, spacer device, oxygen mask, IV lines, audible wheeze or cough, respiratory rate, oxygen saturation Hands – tremor ( beta agonist use ), flexural eczema, pulse Face – central cyanosis, use of accessory muscle, tracheal tug, nasal flaring Neck – cervical lymphadenopathy ENT – inflamed tympanic membrane, nasal discharge, allergic rhinitis, inflamed pharynx or tonsils ( URTI ), oral thrush ( steroid inhaler ) Chest Inspection – subcostal/intercostal recession, Harrison’s sulcus Palpation – chest expansion ( ↓ in pneumothorax, collapse ), tracheal deviation Percussion Auscultation – breath sounds, wheeze, crackles Abdomen – palpable liver edge ( hyperinflated chest ) Plot the height and weight on growth chart Investigations - peak flow, spirometer, skin prick for atopy, bronchial responsiveness / challenge Management of acute asthma 1. High flow oxygen 2. Salbutamol + Ipratropium bromide via volumetric spacer or nebulisers 3. Oral prednisolone or IV hydrocortisone 4. IV salbutamol ( bolus then infusion ) or aminophylline infusion 5. IV magnesium sulfate 6. If not responding ( 5 yr – IH SABA – IH steroid – IH LABA – oral theophylline or LRA – ↑ IH steroid – oral steroids

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The University of Manchester | W.L. Gan | 2012

Examine this child with cystic fibrosis. General inspection – nutritional status, sputum pot, nebulisers or inhalers, oxygen mask, medications ( Creon ), audible wheeze or cough, respiratory rate Hands – finger clubbing, peripheral cyanosis, tremor ( beta agonist use ), palmar erythema ( CF related liver disease ), pulse Face – central cyanosis, use of accessory muscle, tracheal tug, nasal flaring, nasal polyps Chest Inspection – portacath for IV access, subcostal/intercostal recession Palpation – chest expansion, tracheal deviation Percussion Auscultation – breath sounds, crackles Abdomen – Inspection - gastrostomy, scar ( surgery for meconium ileus ), insulin injection sites ( CF related DM ) Palpation – RIF mass ( distal intestinal obstruction syndrome ), hepatomegaly ( CF related liver disease ), spleen ( portal hypertension ) Plot the height and weight on growth chart Investigations a. Newborn screening ( immunoreactive trypsinogen ) b. Sweat test ( Cl- > 60mmol/L ) – gold standard c. Genotype

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The University of Manchester | W.L. Gan | 2012

Cardiovascular examination of a child. General inspection – respiratory distress, respiratory rate, sweating, ECG, oxygen mask Hands – finger clubbing ( cyanotic congenital heart disease ), peripheral cyanosis, splinter hemorrhages, Janeway lesions, Osler nodes, erythema and peeling of the palms ( Kawasaki disease ), pulse ( check for rate, rhythm, character eg. collapsing pulse, slow rising pulse, radio-radio delay – aortic dissection, radio-femoral delay – coarctation of aorta ), blood pressure Face – conjunctival pallor, conjunctivitis ( Kawasaki disease ), central cyanosis, malar flush ( mitral stenosis ), high arched palate ( Marfan syndrome – aortic dissection, aortic aneurysm, mitral valve prolapse, aortic regurgitation ), erythematous mucous membrane and red tongue ( Kawasaki disease ), dental hygiene ( IE ), dysmorphic features ( Down’ syndrome, Turner’s syndrome ) Neck – JVP often difficult to assess in children Chest Inspection – midline sternostomy scar, visible pulsation at the apex beat Palpation – apex beat, thrills, parasternal heave Auscultation – first and second heart sound, added heart sound, listen and time the murmur at mitral, tricuspid, pulmonary, aortic regions while palpating the carotid pulse Back Auscultate lung bases for crackles and radiation of murmur ( coarctation of aorta ), check for sacral edema Abdomen – check for hepatomegaly, femoral pulse Legs – check for peripheral edema Plot the height and weight on growth chart

Innocent murmur Systolic Soft in intensity grade 1 to 3 Localised, no radiation, poorly conducted Variable in position and respiration No other cardiovascular signs and symptoms

Pathological murmur Any diastolic Loud in intensity grade 4 to 6 Conducted all over precordium Thrill present Associated cardiovascular signs and symptoms

Cardiac disorder Atrial septal defect

Physical Signs Fixed and widely split second heart sound, ejection systolic murmur at upper left sternal edge Thrill at lower sternal edge, pansystolic murmur at lower left sternal edge Radio-femoral delay, ejection systolic murmur at infraclavicular area and under left scapula Clubbing, harsh ejection systolic murmur at left sternal edge Neonatal cyanosis, no murmur Continuous, machinery murmur at left upper chest, thrill at left infraclavicular region

Ventricular septal defect Coarctation of aorta Tetralogy of Fallot Transposition of great arteries Patent ductus arteriosus

The University of Manchester | W.L. Gan | 2012

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Abdominal examination of a child.

General inspection – nutritional status ( malabsorption ), neurological status ( dehydration ), vomit bowl, nasogastric tube, catheterisation, is the child drinking and eating Hands – finger clubbing (inflammatory bowel disease, chronic liver disease), leukonychia (hypoalbuminemia), koilonychia (iron deficiency anemia), capillary refill, pulse, purpura, palmar erythema (liver disease), skin turgor (dehydration) Face – conjunctival pallor and jaundice, angular stomatitis ( iron deficiency anemia ), glossitis ( B12 deficiency ), mouth ulcer ( Crohn’s disease, Coeliac disease ), cleft palate, periorbital edema ( nephrotic syndrome ), sunken orbits ( dehydration ) Abdomen Inspection – abdominal distension, swelling, scar, distended veins, rash, gastrostomy tube, stoma bag, visible peristalsis Palpation – light and deep palpation for any mass, tenderness, rebound tenderness, guarding; assess for hepatomegaly and splenomegaly, ballot the kidneys Percussion – hepatomegaly and splenomegaly, bladder distension Auscultation – bowel sounds, renal bruit, femoral bruit Examine the external genitalia and hernia orifices. Perform urine dipstick. Plot height and weight on growth chart.

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The University of Manchester | W.L. Gan | 2012

Examination of Newborn

i. ii.

General posture and movement, skin colour ( cyanosis, pallor, jaundice ), birthmarks, eyes for size and squint Cranium – head circumference ( maximum occipital-frontal circumference normal 33-37cm ), skull shape ( doliococephaly / scaphocephaly – premature infants, brachycephaly – Down’s ), fontanelle size ( anterior 4cmx4cm – closure 9 to 18 mo; posterior 1cmx1cm – closure 6 to 8 wk ), head trauma ( caput succedaneum – poorly demarcated soft tissue swelling that crosses suture lines; cephalhematoma – well demarcated soft tissue swelling that does not crosses suture lines ) iii. Ears – position, external meatus patency, pre/post auricular skin tags iv. Face – dysmorphism, nose – cloanal atresia, chin size ( Pierre-Robin sequence – micrognathia, glossoptosis, cleft palate ) v. Neck – movement, clavicular fractures, neck mass ( thyroglossal duct cyst, vascular malformation, abnormal lymphatic tissue, dermoid cyst ) vi. Chest – shape, symmetry, RR, respiratory effort ( intercostal recession, subcostal recession, sternal recession ), apex beat, listen to the heart and lungs vii. Abdomen – shape ( scaphoid abdomen suggests the presence of congenital diaphragmatic hernia ), umbilical stump, inguinal hernia, palpate for liver – normal up to 2cm below costal margin, spleen – normal up to 1cm palpable, kidney, bladder, check absent femoral pulse for coarctation of aorta viii. Genitalia – clitoris and labia ( girls ), position of urinary meatus – hypospadias ( ventral ), epispadias ( dorsal ), descended testes ( boys ) ix. Back – patency of anus ( imperforate anus ), spine – scoliosis, kyphosis, sacral naevi/dimple/hair patch/lipoma/pigmentation ( spina bifida occulta ) x. Limbs – missing/extra digits or toes, palmar creases ( 2% normal or Down syndrome ), developmental dysplasia of the hip ( Barlow and Ortolani manoeuvre ), talipes equino varus xi. Check for tone during handling and ventral suspension (baby should be able to hold head almost horizontally), hypotonia – head lag, slips through on upright position, like ‘rag doll’ on ventral suspension, total hip abduction xii. Check absent red reflex for congenital cataract and retinoblastoma xiii. Primitive reflexes ( should be disappeared by the end of 6 months ) a. Palmar grasp b. Plantar grasp c. Moro reflex d. Rooting reflex e. Asymmetrical tonic neck reflex f. Placing reflex xiv. Head circumference, length and weight measurement and plotting on growth chart Macrocephaly ( >98th centile ) – familial, hydrocephalus, achondroplasia, neurofibromatosis Microcephaly ( 27 kg/m2, should be offered advice on how to lose weight o Risks of hypoglycaemia and its unawareness during pregnancy. o Effects of nausea and vomiting on glycaemic control. o Increased risk of having a large for gestational age baby and the possible complications of this (birth trauma, induction of labour, Caesarean section). o Diabetic retinopathy and the importance of assessment for this before pregnancy. Retinal assessment should be offered at the first pre-conception appointment (if it has not taken place within the last 6 months). It should then be offered every year if no retinopathy is found. o Diabetic nephropathy and the importance of assessment for this before and during pregnancy. This should include a measure of microalbuminuria and serum creatinine/eGFR. If serum creatinine is ≥120 μmol/L, or the eGFR is 50. For two years after the last menstrual period in woman