paediatric osce

Introduction

Introduce yourself

Explain what you would like to examine

Gain consent

Place patient at 45° with chest exposed

Ask if patient has any pain anywhere before you begin!

General Inspection

Bedside for treatments or adjuncts – GTN spray, O2, Tablets, Wheelchair, Warfarin

Comfortable at rest?

SOB

Malar Flush

Chest for scars & visible pulsations

Legs for harvest site scars and peripheral oedema

..

Hands

Temperature - poor peripheral vasculature

Capillary refill – should be <2 seconds

Colour – cyanosis

Clubbing

Splinter haemorrhages, Jane-way lesions, Oslers Nodes – infective endocarditis

Palmar Erythema – hyperthyroidism, pregnancy, polycythaemia

Nicotine Staining – smoker

Pulses

Radial Pulse – rate & rhythm

Radial-Radial Delay – aortic coarctation

Collapsing Pulse – aortic regurgitation

BP – narrow pulse pressure = Aortic Stenosis | wide pulse pressure = Aortic Regurgitation

Carotid – character & volume

JVP – measure and also possibly carry out hepatojugular reflex

Face

Eyes – conjunctival pallor, jaundice, corneal arcus, xanthelasma

Mouth – central cyanosis, angular stomatitis

Dental hygiene – infective endocarditis

Close Inspection Of Chest

Scars - lateral thoracotomy (mitral valve), midline sternotomy (CABG), clavicular (pacemaker)

Apex beat – visible in aortic regurgitation and thyrotoxicosis

Chest wall deformities – pectus excavatum, pectus carniatum

Palpation

Apex beat – 5th intercostal space, mid clavicular

Heaves- left sternal edge – seen in left & right ventricular hypertrophy

Thrills – Palpatable murmurs over aortic valve & apex

Auscultation

Listen over 4 valves - ensure palpation of carotid pulse to determine first heart sound

Roll onto left side & listen in mitral area – mitral stenosis

Lean forward & listen over aortic area- aortic regurgitation

Carotids - radiation of aortic stenosis murmurs & bruits

Lung bases – pulmonary oedema

Sacral Oedema & Pedal Oedema

To complete the examination

Thank Patient

Wash hands

Summarise Findings

Say you would

Assess peripheral pulses

Carry out an ECG

Dipstick urine

Bedside Blood Glucose

Fundoscopy

Introduction

Introduce yourself


Gain Consent

Expose chest

Position at 45°

Ask patient if they have pain anywhere before you begin!

General Inspection

General appearance

Any treatments or adjuncts around bed - o2, inhalers, nebulisers, sputum pots

Does patient look SOB? - nasal flaring, pursed lips, accessory muscles

Scars

Cyanosis

Chest Wall - abnormalities or asymmetry - barrel chest (COPD)

Cachexia

Cough or Wheeze – ask to cough & assess nature (productive or dry)

Hands

Check temperature

Clubbing

Nicotine Staining

Wasting of the dorsal interossi (pancoast tumour)

Fine tremor – b2 agonist use

Flapping tremor - CO2 retention

Pulse – rate & rhythm

Pulse Paradoxus - pulse volume decreases with inspiration

Respiratory rate

Head & Neck

Conjunctival pallor - anaemia

Horner’s syndrome - ptosis, small pupil, enopthalmos (sunken eye) & loss of sweating

Central cyanosis

JVP - elevated in cor-pulmonale & severe bronchitis

Close inspection of thorax

Scars - lateral (thoracotomy)

Asymmetry - seen in lung removal

Deformities - barrel chest, pectus excavatum & carniatum

Palpation

Crico-sternal distance

Tracheal posistion

Apex beat

Chest Expansion

Percussion

Compare side to side

Supraclavicular

Infraclavicular

Chest

Axilla

Auscultate

Compare side to side

Assess volume & quality - vesicular or bronchial

Vocal resonance

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Repeat Inspection, Chest Expansion, Percussion & Auscultation

To complete my examination

Thank patient

Wash hands

Summarise Findings

Say you would;

Do a full cardiovascular examination if indicated

Introduction

Introduce yourself


Gain consent

Expose chest & abdomen (waist band down to level of the iliac crests for full view of abdomen)

Position patient flat with arms by side, legs uncrossed and head on pillow


General Inspection

Look around bedside for treatments or adjuncts - sick bowls, feeding tubes, stoma bags, drains

Scars

Abdominal Distention – ascities

Jaundice

Masses

Dressings - biopsies (liver)

Tattoos or Needle Track Marks – Hepatitis

Excoriations – pruritis

Inspection

Hands

Clubbing

Koilonychia & Leukonychia

Palmar erythema

Duputrons contracture.

Flapping Tremor

Arms

Bruising

Petechiae

Muscle wasting

Excoriations

Axillae

Lymphadenopathy

Hair loss

Acanthosis nigricans (darkened pigmentation)- can be a sign of malignancy in the GI tract

Eyes

Jaundice – look down

Anemia - look up

Xanthelasma – seen in Chronic Liver Disease

Mouth

Angular Stomatitis

Oral candidiasis

Mouth ulcers

Tongue – glossitis

Neck

Cervical Lymph Nodes

Virchow’s node - left supraclavicular fossa – gastric malignancy

Chest

Spider naevi – increased oestrogen in CLD – more than 3 significant

Gynacomastia

Hair loss

..

Close inspection of abdomen

Scars

Masses

Abdominal distention – ascites

Striae – chronic Liver Disease

Caput Medusa – portal hypertension

Stomas

Palpation

Ask about tenderness

Look at patients face

Start palpation furthest from sites of pain

Light palpation - tenderness, guarding, rebound, obvious masses

Deep Palpation – detailed description of mass,

Liver – start in right iliac fossa

Spleen – start in right iliac fossa

Kidneys – ballot both kidneys between your hands

Aorta – press either side midway between xiphisternum and umbilicus

Percussion

Liver - up from right iliac fossa then down from right side of chest

Spleen – start in right iliac fossa

Shifting Dullness – ascites

Auscultation

Bowel sounds

Renal & Aortic Bruits


Thank Patient

Wash hands

Summarise Findings

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Say you would

Check Hernial Orifices

Perform a Digital Rectal examination

Perform an examination of the External Genitalia

Introduction

Introduce yourself

Explain what you would like to examine - I’m going to be testing the nerves that supply your face

Gain consent

Position patient on chair at eye level with you approximately one arm length away


General Inspection

General appearance – well/unwell

Facial asymmetries?

Abnormal position of eyes or head?

Abnormality of speech or voice?

Signs around bed - hearing aid, glasses

I – Olfactory Nerve

Ask if there has been any change in sense of smell? - last thing you remember smelling?

Tell the patient to close their eyes & ask them to identify different smells - coffee, vinegar etc

II – Optic Nerve

Pupils

Size

Position

Ptosis?

..

Visual Acuity

Snellen chart at 6m

Ask patient to cover one eye and read down from top of chart

Record the lowest line read correctly

..

Pupillary Reflexes

Direct- shine torch into eye from the side – look for pupillary constriction in that eye

Consensual - shine torch into eye from side – look for pupillary constriction in opposite eye

Swinging Light Test- move light in from side of each eye rapidly – relative afferent pupillary defect

Accommodation – focus on distant point – then focus on finger – constriction & convergence

..

Colour Vision

Say you would use Ishihara chart (usually don’t have to actually carry this out, just offer)

Visual Fields

Visual Neglect

1. Ask patient to focus on your nose

2. Wiggle finger either side of patients head

3. Can patient identify both fingers moving simultaneously?

..

Detailed Visual Fields

1. Ask patient to cover right eye, whilst you cover your left

2. Tell them to focus on your nose and to say when your finger comes into their view

3. Test temporal & nasal visual fields

4. Repeat on the opposite eye and note any defects

..

Fundoscopy

Mention but usually not required in OSCE

III, IV, VI – Occulomotor, Trochlear & Abducens Nerves

Eye movements

1. Draw a “H” in the air with your finger

2. Ask patient to follow your finger with their eyes (keeping head still)

3. Look for asymmetries and enquire about any double vision..

Nystagmus

1. Put your finger at the upper-outer extreme of a patients view

2. Ask them to follow your finger with their eyes (head still)

3. Move finger to lower-inner extreme then back to starting posisition

4. Look for nystagmus (one beat is normal)

Cover Test

Mention you would do this

Don’t usually have to carry it out

V – Trigeminal Nerve

Sensory

Test light touch & pin prick sensation

Test face comparing side to side in 3 regions

Opthalmic (forehead), Maxillary (cheek) and Mandibular (jaw)

Ask if each side feels the same or different to the other

..

Motor

Masseter muscle – ask to clench teeth and palpate muscle bulk

Ask patient to open mouth & not let you close it

..

Reflexes

Jaw jerk - ask patient to open mouth a little bit and tap your finger which is placed over their chin

Corneal reflex - touch cornea using a wisp of cotton wool (Not in OSCE! Just mention it)

VII – Facial Nerve

Inspect patients face at rest for asymmetry

Ask patient to…

Raise eyebrows

Scrunch eyes - “scrunch up your eyes and don’t let me open them”

Blow out cheeks – “blow out your cheeks and don’t let me deflate them”

Bare teeth – “can you do a big smile for me”

Purse Lips

Inspect external auditory meatus for any signs of herpes zoster – can cause Bell’s Palsy

Any hearing changes? - facial nerve supplies stapedius – results in Hyperacusis

Any taste changes? - supplies taste sensation to the anterior 2/3 of the tongue (via chorda tympani)

VIII – Vestibulocochear Nerve

Gross hearing testing

Ask patient to close eyes

Whisper a number into each of the patients ears

Ask them to repeat

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Rinne’s Test

Use 512HZ tuning fork

Place in front of ear – air conduction

Then place on mastoid process - bone conduction

Ask which is louder -air should be louder than bone

..

Weber’s Test

Place 512HZ tuning fork in centre of forehead

Ask patient where they hear the sound

The normal result is for the patient to hear the sound in the middle (equally in both ears)

If the patient hears the sound on a particular side it may indicate a lesion on the opposite side

..

Vestibular Testing – turning test

Ask patient to march on spot with arms out and eyes closed

Patient should remain in same position normally

If they start to turn in a particular direction it may indicate a lesion on that side

IX & X – Glossopharyngeal & Vagus Nerves

Symmetry of soft palate & uvula – can use tongue depressor and ask patient to say “ahhh”

Gag reflex – you wont do this in the OSCE, but just make sure you mention it!

Ask patient to cough - damage to nerves IX & X can result in a “bovine” cough

Swallow – can ask patient to take a drink of water (rarely done, just mention you could)

XI – Accessory Nerve

Ask patient to shrug shoulders & resist you pushing down – trapezius

Ask patient to turn head to 1 side & resist you pushing it to the other - sternocleidomastoid

XII – Hypoglossal Nerve

Inspect tongue for Wasting & Fasciculations at rest

Ask patient to protrude tongue – any deviation?

Ask patient to push tongue against inside of cheek and resist you pushing from the outside


Thank patient

Wash hands

Summarise findings

.

Say you would…

Do further testing of any nerves that had abnormal results

MRI if indicated

Lower limb exam

Introduction

Wash hands

Introduce yourself


Gain consent

Expose legs


Inspection

Signs around bed - walking stick, wheelchair, catheter

General Appearance – well/unwell

Muscle Wasting - lower motor neurone lesion

Fasciculation’s – lower motor neurone lesion

Tremor – parkinsons, benign essential tremor

Abnormal posture

Tone

Leg roll - roll the patients leg & watch the foot, it should flop independently of the leg

Leg lift – briskly lift leg off the bed at the knee joint, heel should remain in contact with the bed

Clonus – rapidly dorsiflex the ankle & look at the calf for rhythmical contractions (>3 is abnormal)

Power

Test muscle power in the following groups using the MRC scale (1-5)

Hip

Flexion - “raise your leg off the bed and stop me from pushing it down”

Extension – “stop me from lifting your leg off the bed”

Leg

Flexion - “move your heel towards your bottom and don’t let me stop you”

Extend knee – “don’t let me push your heel towards your bottom”

Ankle

Dorsi-flexion – “point your toes towards your head and don’t let me push them down”

Planter-flexion- “press down on my hand with the sole of your foot”.

Big Toe

Flexion- “push down on my hand with your big toe”

Extension- “don’t let me push your big toe down”

Reflexes

Knee Jerk (L3,L4)

Ankle (L5,S1)

Plantar (S1)

Sensation

Soft touch – cover various dermatomes comparing leg to leg

Sharp – cover various dermatomes comparing leg to leg

Vibration – 128hz tuning fork on base of big toe

Proprioception – use the big toe

Co-ordination

Heel to shin test -“run your heel down the other leg from the knee & repeat in a smooth motion”

Gait

Ask patient to walk to the end of the room and back

Comment on – speed, smoothness, spacing of feet and any unsteadiness

To complete the exam…..

Thank patient

Wash Hands

Summarise Findings

.

Say you would…

Perform a full neurovascular exam of all limbs

Test Cerebellar Function

Upper limb exam

Introduction

Wash hands

Introduce yourself


Gain consent

Expose arms & trunk


Inspection

Signs around bed - wheelchair, walking stick, splints

General appearance – well/unwell

Muscle wasting - lower motor neurone lesion

Fasciculation - upper motor neurone lesion (i.e Multiple Sclerosis)

Tremor – parkinsons, benign essential tremor

Abnormal posture

Tone

Support the patients arm by holding their hand & elbow

Tell the patient to relax and allow you to fully control their arm

Move the arm’s muscle groups through their full range of movements

Is the motion smooth or is there some resistance (i.e led pipe rigidity)

Power

Shoulders (deltoids)

Abduction – “Don’t let me push your shoulders down”

Adduction – “Don’t let me push your shoulders up”

Arms (biceps & triceps)

Flexion – “Don’t let me pull your arm away from you”

Extension - “Don’t let me push your arm towards you”

Wrist

Extension - “Cock your wrists back & don’t let me pull them down”

Flexion - “Point your wrists downwards & don’t let me pull them up”

.

Fingers

Finger Extension – “Put your fingers out straight & don’t let me push them down”

Finger Flexion – “Put your fingers out straight & don’t let me push them up“

Finger Abduction – “Splay your fingers & don’t let me push them together”

Finger Adduction – “Hold this paper between your fingers & don’t let me pull it out”

Thumbs - “Point your thumbs to the ceiling and don’t let me push them down”

Pincer Grip

Get the patient to place there thumb & index finger together

Attempt to pull them apart

Power Grip

Get the patient to grip your fingers tightly

Attempt to remove your fingers from their grasp

If your fingers can easily escape it suggests an abnormally weak grip

Reflexes

Biceps (c5, c6) – hyperreflexia, hyporeflexia?

Triceps (c7) - hyperreflexia, hyporeflexia?

Supinator (c6) - hyperreflexia, hyporeflexia?

Sensation

Soft touch (cotton wool) – cover the dermatomes & compare side to side

Sharp & Dull touch (neurotip) - cover the dermatomes & compare side to side

Vibration (128HZ) – test over bony prominence at base of the thumb

Proprioception – ask patient to close eyes – move finger- ask patient if it’s up or down

Co-ordination

Pronator Drift – “close eyes & put your arms outstretched in front of you, palms facing up”

Finger to Nose – “touch your nose then my finger as fast as you can repeatedly”

Dysdiadokinesia - ask patient to rapidly pronate & supinate one hand on the back of the other

To complete the exam

Thank patient

Wash Hands

Summarise Findings

.

Say you would…

Perform a full neurovascular examination of the upper limbs

Perform a full neurological examination if indicated