CEX Flashcards
History
REALLY FOCUSED AND LISTENING!!!!
Intro - Hi Im georgina a 5th year medical student, so Im here today to ask a few questions about why __ is in hospital and to complete an examination on ___.
(address child first, and also family)
Name, age, ethnicity
How many days in hospital so far?
Reason for coming to hospital?
HPC
ROS (FRED V CAWP) (a- abnormal behaviour, W - weight, P - poo, pee, pain)
Other ROS (bottom)
History in hospital!!! (CITY)
(what have doctors said cause is? what investigations so far? what treatments so far? getting better, worse, same?)
PMH (pregnancy problems, birth - age, weight, delivery, , medical conditions since birth)
Meds, Allergies, Immunisations
Fam history medical problems (asthma, seizures, genetic conditions)
Developmental and Growth
- Normal growth?
- Consistent with other children their age?
- Hearing and vision
- Gross motor - roll over, sit up, pull up, crawl, walk
- Fine - hold things, pass between hands, throw, pincer grip
- Social -Smile, stranger anxiety
- language - babble, words, words together
Social (HLCCPS DW)
-Home, living, caregiver, car, phone, smoking, daycare/school (how often), work
HEADSSS
ROS to remember
Cardio - blue, exercise tolerance, heart murmurs, Rhumatic fever, fainting, chest pain, fam hist congenital (BERM FFP)
Urinary - pain, amount, frequency smelly, blood, wetting bed?
Neuro - (AMS, photophobia, headache, seizures, faints, funny terns, behavioural change)
ENT - (earache, pulling at ears, throat infection, snoring or heavy breathing, difficulty swallowing)
Joints/Limbs (gait, limb pain, swelling)
Resp - cough, wheeze, increased WOB, asthma, eczema, allergies
Gastro - Diarrhoea, constipation, blood, vomiting. abdo pain
Neuro/Developmental exam on Baby
End of bed (posture, deformities)
(__ is alert, settled, no respiratory distress, well perfused.
His posture is good, he is lying on his back with spontaneous movements and no apparent deformities) (or - facial features look different from parents)
Observation (fully expose) - no muscle wasting, fasciculations or scars.
- Move arms and legs up and down (normal, increased or decreased tone)
- Plantar reflex and grasp reflex
- Head lag (now i am testing head lag, and baby is almost supporting head)
- Sit up (baby cannot sit up unsupported)
- Vertical suspension (Baby has good tone in vertical suspension)
- Cannot stand unsupported
- Flip over - horizontal position, good tone.
- Observation of back - spine is straight, no rashes, spots or scars seen
Developmental (do above)
- Gross motor - above - within age ranges
- Fine motor - get them to play with toy to assess his fine motor skills - (or ask parents - pass from hand to hand, throw toy away, pincer grip/semi pincer grip)
- Smile or noises - observe these (and ask parent), stranger anxiety
I will now briefly examine the cranial nerves 1 - cannot do 2 -Eyes -observation - pupils are same size, well aligned, red reflex, at end - do Fundoscopy. 3,4,6 - fix and follow 5 - cannot do 7 - normal movements of the face 8 - newborn screening hearing test ? 11,12 - cannot do 9,10-gag reflex
Summary
S - J is a 5 month old NZ european baby, who presented to hospital with a __ week history of ___ and ___ and developmental delay. He has been there for ___ days, with a diagnosis of ___ and has been improving on ____ treatment.
B - On a background of term birth, normally fit and well and up to date with immunisations.
A - On examination, __ was alert, no resp distress, warm and well perfused, normal posture and no deformities. There were no abnormalities found on Neuro exam, with good tone and reflexes. (Or — the main findings on neuro exam where….). __ Meets appropriate developmental milestones (or does not reach appropriate milestones for age)
R - Working diagnosis is-______
Other differential diagnosis is ___
Investigations
- nerve stimulator test
- EEG
- CT/MRI
Management plan
Neuro - Child
- Lower limb
- Upper limb
- Cranial nerves
Lower limb exam
- On lower limb Neuro exam, patient has normal posture, no deformities, muscle wasting or fasciculations. There was no significant findings on examination with normal tone, power, reflexes and ordination and sensation.
- Or - on Lower limb Neurology exam, main findings were - weakness to proximal muscles, increased tone.
Upper limb
-same as adult
Cranial
-same as adult
Dermatomes, myotomes
Lower limb Dermatomes - L2 -L5, S1
Upper limb - C4, T2.
Upper limb reflex Reflex
- Biceps- C5/C6
- Triceps - C7
- Supinator Jerk C5/C6
Upper limb myotomes
- Shoulder abduction C5
- Elbow flexion - C5/C6
- Elbow extension - C7
- wrist extension - C6
- finger extension - C7
- Thumb abduction - T1
- Finger abduction - T1
Lower limb reflex
- Knee jerk - L3/L4
- Ankle Jerk S1
Lower limb myotomes
- Hip flexion - L1/L2
- Hip extension - L5/S1
- Knee flexion - L5/S1
- Knee extension - L3/L4
- ankle dorsiflexion - L4
- Big toe extension - L5
- Ankle plantar-flexion - S1
Developmental milestones
Gross motor
- roll over - 3months
- lift head lying down - 4 months
- sit up - 6 months
- get into sitting position 9 months
- Pull to stand - 9 months
- walking 12-15 months
- 18 months - not walking is major red flag
Fine
- reaches for objects - 5 months
- transfers object form hand to hand - 6 months
- immature pincer - 9 months
- pincer grip 12 months
Speech 3 months - vocalises 8 months - double babble 12 months - 2-3 words 2 years - link 2 words 3 years - links 3 words.
Social -6 weeks - smile 4 months - laughing -stranger anxiety - 7 months, wares off 2-3 years - 2 and a half - potty trained -3 years - dress
Causes of developmental delay
Chromosomal abnormalities - downs, fragile X
Prenatal injury - fetal alcohol sundrome, TOURCH infections
Perinatal injury - asphyxia, birth trauma
Post natal injury - meningitis, neglect, non-accidental injury
Autism
Nuerocutenaous syndromes - neruoirbomatosis, tuberous scelrois
CNS malformation - NTD, hydrocephalus
Endocrine/metabolic - PKU, hypothyroid
-familial speech delay
Selective mutism/ anxiety
Visual/hearing problems
Investigations
- Blood - rule out medical cause - TFT, urine screen, metabolic tests
- Brain imaging - CT/MRI
- ages and stages questionnaire
- genetic testing
- audiology or ophthalmology
Management
- SLT
- audiogram
Differentials of Neuro problems
Upper motor neuron
- Cerebral palsy
- Spinal muscular atrophy,
UMN/LMN -Spina bifida
Lower motor neuron
- guillian barr, peripheral nerophathy, trauma, myasthenia garvis
- muscular dystrophy (duchens)
Cranial nerves
3 - ptosis
nystagmus
Uvuula - goes away from weakness
tongue - deviates towards weakness
Autism signs
- 12 months - age does not babble, point to objects or use gesture
- 18 months - no meaningful words
- 24 months - does not use 2 words spontaneously
- loss of language or social skills at any age
Causes of abnormal gait
Septic arthritis Osteomyelitis Rheumatic fever Transient synovitis Trauma (including non-accidental trauma) Malignancies
Neurological causes:
Guillain Barre syndrome
Cerebral palsy
Cerebrovascular accidents
Hip pain
Developmental dysplasia,
Perthe’s dsease or
slipped upper femoral epiphysis can cause hip pain.
Rheumatic ferver diagnosis and management
Rheumatic fever Diagnosis and Management
Major criteria
Carditis Polyarthritis Sydenhams chorea (basal ganglia of brain) Erythema marginatum Subcutaneous nodules
Minor criteria
- Fever
- Polyarthralgia
- History of rheumatic fever
- Raised acute phase reactants (ESR,CRP)
- Prolonged PR interval on ECG
2 major (from above) OR
1 major and 2 minor
AND
Evidence of a preceding streptococcal infection
- rising or elevated streptococcal antibody titires (either antistreptolysin O or antiDNase B)
OR
- Positive group A streptococcus throat culture
Investigaitons rhematic fever
Request FBC, ESR, Streptococcal titres, throat swab
- ECG.
- antinuclear antibodies.
- cardiological assessment with an echo cardiogram to exclude carditis
Managemnet - Oral penicillin for 10 days,
- then Benzathine penicillin injectins IM for 28 days for at least 10 years or 21 .
- promote good dental hygiene
Mitral valve most commonly affected or aortic (and due to cronic damage - get stenois sand regurg ) –> chornic rhematic heart disease
_Prevent streptocola infections - get IM per monht
Causes of joint pain
septic arthritis, reactive arthritis, osteomyletis, hrehmatic fever, trauma, growing pains, non-acidental injury, juvenile chornci arhtirtis, chrons dsiease, henoch-schonlein purapura, spsoraitic arthirits, malignajcy
