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Paediatric OSCE

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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 2 Bedside for treatments or adjuncts – GTN spray, O , 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 .
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