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Paediatric OSCEs
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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
Explain what you would like to examine
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
.
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
Explain what you would like to examine
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
Ask if patient has any pain anywhere before you begin!
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
To complete the examination
Thank Patient
Wash hands
Summarise Findings
.
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
Ask if patient has any pain anywhere before you begin!
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
..
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
To complete the examination
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
Explain what you would like to examine
Gain consent
Expose legs
Ask if patient has any pain anywhere before you begin!
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
Explain what you would like to examine
Gain consent
Expose arms & trunk
Ask if patient has any pain anywhere before you begin!
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