Pediatrics OSCE

Quick Review for

Introduction  Before OSCE: o Sleep well: Sleeping well is more beneficial than studying all night long. o Bring all your equipment: Stethoscope, hammer, ophthalmoscope…" o The key to OSCE success is practice. o Behave in a polite, professional way.  Before starting any examination: o Wash your hands. o Introduce yourself to the parents and the child. o Explain to the patient, take permission and maintain privacy. o Respect the child presence and establish a relationship. o Consider starting with auscultation if the child is quite. o After you finish, thank the child and cover him\her.  Contents: o o o o o o o o o o o

History Taking in Pediatrics History Taking of Asthma Approach to Gastroenteritis Vaccination Newborn Examination Cardiovascular Examination Respiratory Examination Gastrointestinal Examination Growth Assessment Down Syndrome Type 1 DM and Diabetic Ketoacidosis

 References: o AlHowasi Manual of Clinical Pediatrics, 6th Edition. o Illustrated textbook of pediatrics, 4th Edition.  Reviewed and edited by: o Waleed Al Humaid o Abdulaziz AlAlwan o Abdulaziz AlTurki o Hussain AlMulla o Bader AlOthman  Don't forget us from your Dua'a and best of luck in your exam and your future career.

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Pediatric Block OSCE | AlBrahim & Tarabzoni

History Taking in Pediatrics  Demographics o Name, age, gender, nationality, origin, and address. o Source of history (parent, grandparent etc.).  Chief Complaint o Onset and duration using the patient's words.  History of present illness o Confirm what the patient means. o Site, onset, duration, course, frequency, and progression. o Relation to time and food. o Severity, restriction from usual activities, and school missing. o Relieving and aggravating factors. o Associated symptoms  Systemic Review o General: Interrupted or poor feeding, Change in activity (lethargy or irritability), weight changes, loss of appetite, and fever. o Gastrointestinal: Nausea, vomiting, chocking, diarrhea, constipation, abdominal pain, jaundice, bloody stool. o Respiratory: Cough difficulty breathing, audible wheeze, stridor, and runny nose. o Cardiac: Sweating on feeding, Exhaustion, shortness of breath, cyanosis. o Genitourinary: Amount of urine, dysuria, incontinence, nocturnal enuresis. o Neurological: Headache, vision problems, sensory, motor. o ENT: Ear pain, hearing problems, sore throat. o MSK: Rash, arthralgia, arthritis.  Past Medical History o Similar problem before. o Foreign body ingestion. o Chronic illness: Asthma, DM etc. o Recent Infections or travel. o Previous medical or surgical incidences. o Previous Admissions or blood transfusion.  Medication and Allergy history

Pediatric Block OSCE | AlBrahim & Tarabzoni

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 Pregnancy and Neonatal History o Pre-natal:  Medications: Folic Acid, steroid, and AEDs.  Ultrasound and follow up.  Complications during pregnancy: IUGR.  Mother illness: TORSH, gestational diabetes.  Radiation exposure. o Peri-natal:  Gestational age: Term or preterm.  Mode of delivery.  Birth weight  Any complication.  APGAR score (most mothers don’t know it). o Post-natal:  NICU Admissions (cause and duration).  Immunization History o Ask the parents to show you the card. o If missed any, ask for the reason.  Nutritional History o Breast fed or Formula? o For how long? o Frequency and amount of daily intake. o Behavior during and after feeding. o Vomiting and allergies. o If Breast fed: one or both breasts, direct or expression, difficulty in the technique, and breast disease. o If formula: What type? Who prepare it? How? o Time of weaning. o Time of introduction to solid or semi-solid food. o Supplements (e.g. Calcium).  Family and Social History o Family pedigree. o Similar problem in any member of the family. o Genetic, metabolic, or chronic diseases in the family. o Parent's age, job, education, and consanguinity. o All siblings: Either Alive, dead. o Abortion. o Accessibility to Hospital o Who’s taking care of the other siblings? o Effect of the problem to the family. o Income status (type of job, home –rented or owned-). Page |3

Pediatric Block OSCE | AlBrahim & Tarabzoni

o Growth and Developmental History:  Physical growth: Height, weight, and head circumference.  Developmental milestones: Social Response Social Smile parent's recognition Strangers anxiety Cooperate with dressing and waving bye bye Play together Color and sex Death and life

Age 6 weeks 2 months 7 months 1 year 2 years 3 years 7-8 years

Language Gurgling e.g. “coo” Babbling e.g. "dad, bab, mam…" One word-sentences and using 3 words Using 6-10 words Two word-sentences 3 word-sentences Simple story

Age 1-5 months 5-12 months 1 year 18 months 2 years 3 years 4 years

Fine Motor Reach and grasp Transfer objects to the other hand Pincer grasp – start to developPincer grasp – completeBuilding 3 cube tower and hold a spoon Building 4 cub tower Building 7 cube tower and draw a line Draw a circle Draw a square and button/unbutton Draw a triangle Tying shoes

Age 4 months 7 months 9 months 1 year 15 months 18 months 2 years 3 years 4 years 5 years 6 years

Gross Motor Roll over –front to backRoll over –back to frontSetting with support Setting without support Crawling Walking few steps Walking upstairs Alternating walking Riding a tricycle Walking on one foot Riding a bicycle

Age 4-5 months 5-6 months 6 months 8 months 9 months 1 year 18 months 2 years 3 years 4 years 5 years

Pediatric Block OSCE | AlBrahim & Tarabzoni

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History Taking of Asthma  Chief Complaint: Cough, Wheezing, and difficulty breathing.  History of present illness o Cough (onset, course, duration, dry or productive, diurnal variation). o Sputum (color, amount, blood) –not applicable for young children-. o Precipitating factors (Exercise, infection, allergen, house pets, dust mite, smoking, pollutant, perfumes, chemical irritant, dust, drug, emotion). o Severity: School absence, ER admission, ICU admission, intubation, which type of medication and frequency of ventolin. o Atopy: Eczema, conjunctivitis, and allergic rhinitis. o Frequency of attacks.  Past History: Previous admission and other chronic diseases.  Neonatal History: Gestational age, breast feeding, and bronchiolitis history.  Vaccination History: They need flu vaccine yearly extra.  Family History: Asthma and atopy.  Medication History: Asthma medications (side effects, frequency, technique).  Education: o Nature of disease: Bronchospasm and airway hyperresponsiveness. o Avoiding Precipitating factors: Exercise, infection, allergen, house pets (camel, sheep, rabbit, dog and cat), dust mite, smoking, pollutant, perfumes, chemical irritant, dust, drug, and emotion.  Spacer MDI inhalation technique o Explain why it's used and what their effects and side effects are. o Explain that there is no risk of addiction. o Explain the technique: Demonstrate and let the patient to do it.  Check the expiratory date.  Remove the cap of the inhaler & spacer then shake (3-4 times).  Attach the inhaler to the spacer.  Put the mouthpiece into the child's mouth.  Spray 1 puff into the spacer by pressing down on the canister.  Keep the spacer attached tightly to the child's nose and mouth for 5-10 seconds.  Explain that there is no risk of suffocation.  In case of more than on puff, repeat the steps after one minute.  Wipe mouthpiece and cover it &Wash it twice a week.  Wash the spacer with water weakly and let it dry by itself. o If the patient uses 2 types, use the dilator first. o If the patient uses steroid, wash the mouth after (candidiasis). Page |5

Pediatric Block OSCE | AlBrahim & Tarabzoni

Approach to Gastroenteritis  Airway  Breathing  Circulation.  Assessment of dehydration: o Mild: Everything is normal except for dry mucous membrane. o Moderate: You see most of the signs of dehydration listed on the table below. o Severe: Moderate + Anuria and lethargic due to decreased end-organ perfusion.

 Management of dehydration: o Bolus if in shock (tachycardia and hypertension): IV NS 20 ml/kg. o Deficit: over 24 hour (the first half on the first 8 hours).  Infants (5%: 50ml/kg, 10%: 100ml/kg, 15%:150ml/kg).  >1 year (3%: 30ml/kg, 6%: 60ml/kg, 9%:90ml/kg). o Maintenance: should be added to deficit.  100 ml/kg/day or 4 ml/kg/hour for the 1st 10 kg.  50 ml/kg/day or 2 ml/kg/hour for the 2nd 10 kg.  20 ml/kg/day or 1 ml/kg/hour for every kg. o E.g. 4 kg with moderate dehydration:  Maintenance=16 ml/hr.  Deficit=400 ml/day (200ml/8hr= 25 and 200ml/16hr= 12.5).  The first 8 hr= 16+25= 41ml/hr.  The next 16 hr=16+12.5=28.5ml/hr. o Use for maintenance: Dextrose 5% 1/2 Normal Saline. If high Na, NS. o Indications for admission: Severe, systemic infection (Sheigella, E-coli), not responding to ORS.

Pediatric Block OSCE | AlBrahim & Tarabzoni

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 Oral rehydration solution (ORS) o ORS is the best to replace ongoing loss except for persistent vomiting, intolerance to oral feeding, or severe dehydration. o ORS: small, frequent, 2-3 minutes after vomiting. o 2 types of ORS (Pedialyte – high in sugar-, WHO –high in salt-).  Investigations: o CBS and differentials. o Electrolytes (K, Na). o BUN and Creatinine. o Glucose (DKA is a differential diagnosis of GE). o Urine analysis and culture. o Blood culture.  -

Miscellaneous presentations: The most common cause of gastroenteritis (GE) is Rotavirus. If GE + seizure  sheigella. If GE + hemolytic uremic syndrome (low Hgb, low Plt)  E-coli. If GE + decreased immunity  cryptosporidium. If GE then persistant diarrhea: Secondary lactose intolerance. Resolve in 3 weeks. If GE then paralysis after 3 weeks  Guillain Barre syndrome.

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Pediatric Block OSCE | AlBrahim & Tarabzoni

Vaccination Visit At birth 2 months 4 months 6 months 9 months 12 months 18 months 24 months 4-6 years

Vaccine BCG - Hepatitis B IPV – DTP - Hib - Hepatitis B - PCV 13 Oral Polio – DTP - Hib - Hepatitis B - PCV 13 Oral Polio – DTP - Hib - Hepatitis B - PCV 13 Measles Oral Polio - MMR - Varicella - PCV 13 Oral Polio - DTP - Hib - Hepatitis A Hepatitis A Oral Polio - DTP - MMR - Varicella

 Types of vaccines: o Live attenuated: BCG, MMR, OPV, varicella, measles, rotavirus, nasal flu. o Inactivated vaccines: IPV, HAV, pertussis. o Protein: HBV, parenteral influenza, acellular pertussis. o Toxoid: Diphtheria, tetanus. o Polysaccharides: meningococcal, pneumococcal. o Conjugated: PCV, Hib.  History: Allergy, fever, seizure, loss of consciousness, steroid, and low immunity. o Consider the patient unimmunized unless proven. o If delayed vaccine, explore the reason and give as much as you can. o HBV vaccine: Should be at least 2.0 Kg or 2 months old. o For live attenuated vaccines: Either give them together or 1 month apart.  Contraindications: o Moderate to severe illness ± fever. o Previous anaphylaxis of same vaccine or its constituent (e.g. Egg in flu vaccine and –neomycin and streptomycin- in MMR and IPV) o Live attenuated vaccine in immunocompromised patients Except:  Steroid Therapy: Contraindicated only if high dose (>2mg/kg/day for 20 mg/kg/day for >10Kg) and prolonged therapy (>2 weeks). Wait for 1 month.  MMR for AIDS: Give if asymptomatic + >15% CD4  Varicella for AIDS: Give if CD4 > 25%.  BCG: Give in asymptomatic patients in endemic TB countries.  Influenza vaccine: Give Inactivated (i.e. Parenteral). o If any of the following happened after DTP (not applicable for DTaP):  Encephalopathy within 1 week.  Seizure within 72 hours.  Persistent crying for >3 hours within 48 hours.  Fever >40.5 C within 48 hours.  Shock like syndrome within 48 hours. Pediatric Block OSCE | AlBrahim & Tarabzoni

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Newborn Examination  General Examination o Vital signs (HR: 140-160, RR: 40-60, and temperature) o Growth parameters: Length (50 cm), weight (2.5-3.5 Kg) and head circumference (35 cm). Then plot them on the chart.  General Appearance o Alertness and movements. o Color (Cyanosed or pink). o Respiratory distress (Flaring, retraction, cyanosis, grunting). o Connection to monitors or IV line. o Skin:  Pallor and jaundice.  Birth marks, hemangioma, mongolian blue spot.  Rash: e.g. Erythema toxicum.  Edema: Generalized (hydrops), localized (hands and feet in Turner Syndrome).  Head: o Size:

o o

o

o

 Microcephaly: TORSH, familial.  Macrocephaly: Hydrocephalus, familial achondroplasia. Shape: e.g. Brachycephaly. Fontanelles: Soft, not pulsating or bulging.  Anterior: wider and closes around 1 year.  Posterior: smaller and closes around 2-4 months. Sutures (coronal and sagittal):  Wide: hydrocephalus, rickets.  Ridging: Craniosynstenosis. Masses  Cephalohematoma: Blood collection under the periosteum which does not cross suture lines. Might lead to jaundice.  Caput succedaneum: Skin edema of the presenting part.  Subglial hematoma: Dangerous, boggy around the head.

 Face: o Dysmorphic features: E.g. Down syndrome. o Ears:  Low set ears.  Periauricular tags (Renal problem).  Tympanic membrane (dull gray). Page |9

Pediatric Block OSCE | AlBrahim & Tarabzoni

o Eyes:  Microphthalmia: Congenital rubella.  Buphthalmus (corneal diameter >12mm): Congenital glaucoma.  Slant of palpebral fissure (upward or downward).  Hypotelorism or hypertelorism.  Subconjunctival bleeding (self-limiting).  Coloboma of the iris or lids (syndromes).  Aniridia (Wilm's tumour).  Red reflex (cataract if absent).  Leukokoria (white ppupillary reflex): Retinoplastoma. o Mouth:  Central cyanosis.  Large tongue: hypothyroidism, Pierre Robin syndrome.  Palate: Cleft lip and palate, high arched palate.  Neck: Normally short. o Swelling: Goiter, thyroglossal cyst. o Skin: Redundant (Down syndrome), webbed (Turner syndrome). o Clavicle: Fracture.  Respiratory: o Inspection: Movement, symmetry, and deformity (pectus, nipple space). o Auscultation: Air entry, breath sound, and additional sounds  Cardiovascular: o Pulse (Brachial and femoral): Rate, rhythm, volume, etc. o Weak femoral pulse + higher BP in upper limb  Coarctation of the aorta. o Palpation: Dextrocardia. o Auscultation: S1, S2, gallop, murmurs (innocent or pathological).  Abdomen: o Scaphoid (diaphragmatic hernia) or distended. o Umbilicus: 2 arteries and 1 vein, sign of infection, omphalocele. o Organomegally and Hernia. o Bowel sound and bruit.  Genitalia: o o o o o o

Sex and ambiguity. Urethral meatus: Hypospadias and epispadias. Scrotum: Un-descended testis, hydrocele. Imperforate hymen and fusion of labia. Anus: Imperforate anus. Hyperpigmentation of the genitalia: CAH and High ACTH.

Pediatric Block OSCE | AlBrahim & Tarabzoni

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 Musculoskeletal: o Hands and Feet:  Size and shape.  Digits: Polydactyly, syndactyly.  Feet: Club feet (Talipes Equinovarus). o Back:  Spina bifida: Hair tuft, dimples, hemangioma, sinus.  Mongolian spot.  Deformity: Scoliosis. o Hips:  Barlow’s Test: Trying to dislocate the hip with adduction and pushing posteriorly.  Ortolani’s Test: Trying to relocate the hip with abduction lifting the hip forward.  Neurological Exam: o Tone: Truncal tone (head lag), ventral suspension (figure 1) and vertical suspension (figure 2). o Power: Observation of the movement. o Reflexes: Knee, ankle. o Primitive reflexes: leave it to the end. Figure 1  Moro.  Sucking. Figure 2  Palmer and Planter.  Stepping and Placing.  Hints: o Be patient, gentle, and flexible. o If the baby is quite, start with auscultation and palpation of the abdomen. o Adequate light, warm hands and environment are prerequisite.

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Pediatric Block OSCE | AlBrahim & Tarabzoni

Cardiovascular Examination  General Observation: o Ill looking or well. o Cyanosis (is seen in the tongue) and pallor. o Connected to monitors (Read the Vitals), IV line, or Oxygen mask. o General health (Obese, well nourished, or failure to thrive) o Signs of respiratory distress (tachypnea, recession (intercostal, subcostal ,or suprasternal recession), nasal flaring, grunting) o Dysmorphic features (Down, Turner, or Marfan syndroms)  Hands: o o o o o

Clubbing (cyanotic heart disease) and splinter hemorrhage (IE). Pallor (palmer crease). Peripheral cyanosis. Osler’s nodes (painful, red, raised nodes due to IE). Tendon xanthomas over bony prominence (in elbow, due to familial hyperlipidemia).

 Pulse: o Both brachial pulses.  Rate: For at least 30 seconds.  Rhythm: Regular or irregular.  Volume: Large in AR and PDA.  Character: Collapsing pulse, pulsus paradoxus. o Compare with Femoral pulses (if decreased or absent  coarctation of aorta).  Blood Pressure: laying–standing. o Children: Measured by sphygmomanometer. o Infant: Doppler ultrasound from all limbs. o Postural hypotension: >15 mmHg drop in systolic when standing up. o Pulsus Paradoxus: Drop 10 mmHg with inspiration cardiac tamponade, constrictive pericarditis, and severe asthma.  Face: o Eyes: Pallor, jaundice. o Mouth: central cyanosis, High arch palate (Marfan’s), teeth "IE".  Back: o Auscultation: Inspiration crackles  LVF. o Sacral edema. o Leg edema. Pediatric Block OSCE | AlBrahim & Tarabzoni

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 Abdomen: o Hepatomegaly: RVF, and Ascites. o Splenomegaly.

 JVP in older children: o JVP: Which is visible not palpable, 2 pulse/cycle, decrease with respiration. Should be < 8 cm.  kussmaul's sign: JVP increases with inspiration  constrictive pericarditis or RVH.  a-wave: Atrial contraction, v-wave: Atrial filling.  Cannon a-wave: complete heart block, giant a-wave: TS, giant v-wave: TR.

Precordium Examination  Inspection o o o o

Asymmetry: Bulge of left chest due to cardiomegaly. Deformity: Pectus excavatum, carinatum, Harrison sulcus. Scars: Median sternotomy, left axillary. Visible pulsation and apex beat (neck pulsation: AR)

 Palpation: o Apex beat: Left 5th intercostal space, mid-clavicular line (or outer most, lower most). Character:  Pressure loaded "forceful, sustained"  AS & HTN.  Volume loaded "displaced, non-sustained"  AR & MR.  Tapping apex "palpable S1"  MS.  Dyskinetic "diffuses moves" HF. o Left para-sternal heaves: (by the heel of the hand) for RVH or LAE. o Thrills: Palpable murmur (4/6 intensity if found). o Palpable P2 (pulmonary HTN). o Liver (Right HF) and spleen (IE).

 Auscultation: o Bell (low pitch diastolic murmur). o Diaphragm (high pitch systolic murmur). Figure 3 o Auscultate the following areas: (figure 3)  2nd Right intercostal space at sternal edge (Aortic area).  2nd Left intercostal space at sternal edge (pulmonary area).  4th left intercostal space at sternal edge (Tricuspid area).  5th left intercostal space mid-clavicular line (Apex – Mitral area).  Axilla (MR) and carotid radiation (AS). o Also check:  Left subclavicular area (PDA). P a g e | 13

Pediatric Block OSCE | AlBrahim & Tarabzoni

        

 On the back between scapulas (COA).  Right 5th intercostal space – mid-clavicular line (Suspected Dextrocardia). o Listen for 1st and 2nd heart sounds (splitting if present). o Added sounds:  Pericardial rub, gallops.  S3 (early in diastole) + S4 (late in diastole).  Click: Mid-systolic click in mitral prolapse.  Opening snap: Diastolic in mitral stenosis. o Murmur: Site, timing, radiation, grade (1-6... >4 thrill), character (rumbling: MS, harsh: AS & VSD, blowing: MR). VSD: pan-systolic over the tricuspid area. PDA: continuous over the pulmonary area. AS: Harsh ejection systolic, radiating to the carotids best heard on the aortic area. MR: Blowing pan-systolic, radiating to the axilla best heard on the apex. AR: Diastolic decrescendo, best heard on the aortic area. MS: Rumbling diastolic, best heard on the apex associated with opening snap. Innocent murmur: Soft, systolic, left sternal, and asymptomatic. Maneuvers: left lateral position "apex", sitting with full expiration "AR & rub". For your information, see the table below: Presystolic murmur: Mitral/Tricuspid stenosis Pan-systolic: Mitral/Tricuspid Regurgitation Ejection systolic: Aortic stenosis Pulmonary stenosis (spilling through S2) Diastolic murmur: Aortic/pulmonary regurgitation Opening snap: Mitral stenosis Mid-diastolic inflow murmur Continuous murmur: Patent Ductus Arteriosus

Pediatric Block OSCE | AlBrahim & Tarabzoni

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Respiratory Examination  General Observation: o o o o o o o o o o

General appearance (well or ill). Alert, responsive, and speech ability. Connected to O2 mask. Pallor or cyanosis. Built and nutrition. Respiratory Rate Respiratory distress (tachypnea, retraction, flaring, grunting). Mouth opened or drooling. Audible wheezes, snoring, or stridor. Comment about cough if present: Barking, whooping, dry, or wet.

 Upper limbs: o Clubbing (Scramroth's sign): Cystic fibrosis, lung fibrosis, pulmonary abscess, bronchiectasis, cyanotic congenital heart disease, liver cirrhosis, inflammatory bowel disease, and celiac disease. o Peripheral cyanosis. o Pulse: Tachycardia, bounding pulse (CO2 retention). o Blood pressure: Pulsus paradoxus in severe asthma.

 Face: o Central cyanosis (tongue). o Nasal flaring.

 ENT: (Do it at the end) o Ear: Pull the ear upward, backward, and laterally.  External canal: Wax or foreign body.  Tympanic membrane: Light reflex, color, bulging, retracted, perforation, or discharge. o Nose:  Foreign body, foul smell, nasal discharge, bleeding, turbinate hypertrophy, polyps, mucosal edema, and color of mucosa. o Throat:  Gag reflex, tonsillar enlargement, and exudate.

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Pediatric Block OSCE | AlBrahim & Tarabzoni

Chest Examination  Inspection: o o o o o o o o

Respiratory Rate. Respiratory pattern (Abdominal in infants. Thoracic after 4-5 years). Symmetry of the chest movement (from feet side at the same level). Deformities (Pectus excavatum, carinatum, Harrison sulci, barrel) Use of Accessory muscles (SCM, suprasternal, intercostal, sucostal). Scars and rash. Absent clavicle, Rachitic rosary, supernumerary nipple (renal anomaly). Back:  Scoliosis or kyphosis.  Position of the scapula.  Scars.

 Palpation: o o o o o

Position of the trachea. Apex beat. Tenderness. Tactile fermitus (99 - older children only). Chest expansion (older children only).

 Percussion: (supraclavicular, clavicle, intercostals-4 region) always compare. o Normally  resonant. o Air "pneumothorax, emphysema or GIT"  hyper resonant. o Liver, tumor, fibrosis, and infection  dull. o Fluid "pleural effusion"  stony dullness.  Auscultation: (usually by using the diaphragm of your stethoscope). o Breath sounds: (figure 4)  Intensity "high or low air entry". Figure 4  Normally vesicular.  Bronchial  consolidation.  Crackles: Course "bronchiectasis". Fine "fibrosis".  Wheezes: Asthma, COPD, tumor "airway obstruction". o Vocal fremitus (99 or 44) "clear if consolidation".

Pediatric Block OSCE | AlBrahim & Tarabzoni

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Gastrointestinal Examination  General Observation : o o o o o o o

Ill or well looking. Alert and responsive. Comfortable or in respiratory distress. Connected to IV lines or monitors. Nutritional status: Obese, thin, muscle bulk, and skin fold. Hydration status. Pale or jaundice.

o o o o o

Clubbing (IBD, liver disease). Koilonychias (spooning of the nails due to iron defeciency). Palmar erythema (chronic liver disease). Flapping tremor (hepatic encephalopathy). Purpura (chronic liver disease).

 Hands:

 Eyes: o Scleral jaundice. o Pale conjunctiva. o Periorbital edema (nephrotic syndrome).  Mouth: o o o o o o o o o o

Pigmentation of the lips (Peutz-Jeghar’s syndrome). Angular stomatitis (riboflavin defeciency). Mouth ulcers (IBD). Dental hygiene. Gingivitis hypertrophy (phenytoin). Teeth pigmentation (yellowish: iron supplements or tetracycline), Cleft lip and palate/cleft palate, Strawberry tongue (Kawasaki, scarlet fever). Koplik’s spots in buccal mucosa (measles). Exudate over tonsils.

 Neck and chest: o Spider nevi. o Prominent veins.

 Genitalia: o o o o o o P a g e | 17

Ambiguous genitalia. Scrotal or labial edema or pigmentation. Undescended testis. Hydrocele and inguinal hernia. Micro or macro penis and urethral orifice (hypo/epi spedias) Signs of puberty (pubic hair, size of testes). Pediatric Block OSCE | AlBrahim & Tarabzoni

Abdominal Examination  Inspection: From the side of the feet at the level of the abdomen o Contour and Distention (5 F: Feces, fetus, flatus, Fat, Fluid). o Scars: Appendectomy, peritoneal dialysis, and nephrectomy. o Tubes (gastrostomy, nephrostomy, peritoneal dialysis). o Obvious masses. o Visible peristalisis. o Caput medusa. o Umbilicus (normal -inverted- or everted). o Hernia (Ask the child to cough).  Palpation: Ask if there is any pain, be gentle and observe the patient's face. o Tenderness and regidity "superficial and deep". o Organomegaly: a) Liver: Palpate the liver edge (2 fingers below the costal margin is normal) Percuss for span "6-8 cm" from above and below. b) Spleen: You can't go above it, has a notch, moves with inspiration, dull on percussion, and enlarges infer-medially.  Palpate "pt. flat" & "pt. lying over his right side".  Percuss over left costal margin-anterior Axillary line with full expiration. c) Kidneys: bimanual examination "balloting". d) Bladder: percussion.  Percussion: o Ascites (Shifting dullness & fluid thrill "huge ascites").  Auscultation: o Bowel sounds "Exaggerated: obstruction or absent: paralytic ileus". o Renal bruit: 2 cm lateral to umbilicus "Renal artery stenosis". o Liver bruit "Hepatocellular carcinoma".

 Hernia: o Inspect: Any signs of strangulations (Red, Hot, Tender  ER) o Palpate:  Consistency  Tenderness  Reducible  Try to get above it (positive in hydrocele only).  Transillumination (positive in hydrocele only). o Auscultate: Peristalsis. Pediatric Block OSCE | AlBrahim & Tarabzoni

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 Rectal Examination: Use lubricant. Left lateral position with flexed knees. o Inspection:  Anal fissures 6 & 12 O'clock (most common cause of bleeding per rectum).  Skin tags.  Fistula (IBD).  Thread worms.  Abrasions (Child abuse). o Palpation:    

Anal tone. Masses. Tenderness. Bleeding.

 Back exam, lymph nodes, and joint exam.  Urinalysis  Hepatomegaly causes: o Infection:  Viral: Viral Hepatitis, EBV, CMV, Rubella.  Bacterial: Typhoid, syphilis, TB, brucellosis.  Protozoa: Toxoplasmosis, malaria, schistosomiasis. o o o o o o

Hemolytic: Thalassemia & Sickle Cell anemia. Collagen vascular disease: SLE, IBD, juvenile chronic arthritis. Cancer: Leukemia, lymphoma, Neuroblastoma, histocytosis. Cardiac: CHF, constrictive pericarditis, IVC obstruction. Metabolic: Glycogen storage disease, galactosemia, Gaucher's disease. Liver disease: choledochal cyst, biliary atresia, polycystic disease.

 Splenomegaly causes: o Infection:  Viral: Viral Hepatitis, EBV, CMV, and Rubella.  Bacterial: Typhoid, syphilis, TB, brucellosis.  Protozoa: Toxoplasmosis, malaria, schistosomiasis. o o o o o

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Hemolytic: Thalassemia, hemolytic anemia and Sickle Cell anemia. Collagen vascular disease: SLE, juvenile chronic arthritis. Cancer: Leukemia, lymphoma, histocytosis. Metabolic: Glycogen storage disease, Gaucher's disease, Niemann-pick. Portal Hypertension: portal vein thrombosis, cirrhosis, hepatic vein obstruction (Budd-Chiari syndrome), CHF, constrictive pericarditis. Pediatric Block OSCE | AlBrahim & Tarabzoni

Growth Assessment  Height and weight: o Ask the child to take off his shoes and jacket. o 4 areas should touch the backside of the scale (Figure 5).

 Length and weight: (for small babies) o Lay the baby over their special scale. o Extend all the limbs with the help of the mother . o Weight at birth above 2.8 Kg:  First 3 months  30g/day  Second 3 months  20g/day  Third 3 months  15 g/day  Fourth 3 months  10 g/day

Figure 5

 Head circumference: o Encircle the tape over the baby’s head from the supra-orbital anteriorly to the most prominent part of his occipital lobe posteriorly. o It should be done 3 times to be precise. o Normally at birth it is (35+ 2 cm)  0-3 months  2 cm/month  4-6 months  1 cm/month  6-12 months  0.5 cm/month

 How to plot the chart: o Choose the correct chart:  Depending on the gender and age (Blue: Boys. Pink: Girls).  Special charts (Down, Turner, Preterm babies). o Write the full name of child and the age. o Plot the height, weight, and head circumference. o See the corresponding percentile and write it down. o Have at least 3 plots with one month apart to see the progression.

 BMI o BMI= weight (Kg)/height (m)2. o BMI for >2 year old babies and percentile for < 2 years:  Obese: BMI >30 or >95th.  Overweight: BMI 25-30 or 85th-95th.  Normal: BMI 18-25 or 5th-85th.  Underweight: BMI 300 mg/dl & glucosuria (could be normal due to insulin given at home). o Ketonemia and ketonuria. o High anion gap metabolic acidosis: pH < 7.3, serum bicarbonate < 15 mmol/l. Anion gap >10. o Anion gap= [Na]+[K] – [Cl]+[HCO3]. o (This is usually accompanied with severe dehydration and electrolyte imbalance).

 Management of DKA: o History: Symptoms of hyperglycemia, precipitating factors, diet and insulin dose. o Examination:  Look for signs of dehydration, acidosis, and electrolytes imbalance, including shock, hypotension, acidotic breathing, CNS status…etc.  Look for signs of hidden infections (Fever strongly suggests infection) and If possible, obtain weight. o Quick Diagnosis:  In known diabetic children confirm: hyperglycemia, ketonuria and acidosis.  In newly diagnosed diabetic children: be careful not to miss it because it may mimic serious infections like meningitis.  Blood glucose level (using glucocheck) glucosuria, & ketonuria (using dip stick) must be measured in the ER and treatment should be started without waiting for Lab results which may be delayed. o Lab investigation:  Plasma & urine levels of glucose & ketones.  ABG, Electrolytes (including Na, K, Ca, Mg, Cl, PO4, HCO3).  Complete Blood Count with differential.  Further tests e.g., cultures, X-rays are done when needed.

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Pediatric Block OSCE | AlBrahim & Tarabzoni

o Fluid:

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 If in Hypovolemic shock, 0.9% saline as a bolus (20 ml/kg).  If Dehydration without shock Calculate the deficit as per the degree of dehydration (mild, moderate, and severe). Administer 0.9% NS 10 ml/kg/hour for an initial hour, to restore blood volume and renal perfusion. The remaining deficit should be added to the maintenance, & replaced over 36-48 hr. To avoid rapid shifts in serum osmolality (cerebral edema) 0.9% Saline can be used for the initial 4-6 hours, followed by 0.45% saline.  Keep the child NPO till pH is >7.3 and bicarbonate is >15.  If the child is comatose, ABC. o Electrolyte: Start after 1 hour.  Potassium: Regardless of K conc. at presentation, total body K is low. So, as soon as the urine output is restored, potassium supplementation must be added to IV fluid at a conc. of 20-40 mmol/l (4-6 mEq/kg/24 hr at a rate of maximum 0.5 mEq/kg/hr). o Insulin: Start after 1 hour.  Start infusing regular insulin at a rate of 0.1U/kg/hour using a syringe pump. Optimally, serum glucose should decrease in a rate no faster than 100mg/dl/hour to prevent cerebral edema.  Continue the Insulin infusion until acidosis is cleared: pH > 7.3, bicarbonate > 15 mmol/l, normal anion gap 10-12.  If blood glucose