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Paediatric osce > Examination > Flashcards

Examination Flashcards

1
Q

How to start a NIPE?

A

WIPER

“Today I need to carry out a routine head to toe examination of your child”

Baby exposed for assessment

Encourage patients to ask questions during check

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2
Q

Questions to ask parents in NIPE?

A

Maternal:
- Pregnancy okay? - anything to note
- Breech presentation?
- Abnormailites on scan?
- Family history of hearing, hip, eye, heart, renal problems in childhood

Newborn:
- Passed meconium/ urine
- Feeding okay?

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3
Q

General inspection in NIPE?

A
  • Inspect the colour: Pallor, cyanosis, jaundice
  • Inspect posture: any gross abnormalities
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4
Q

What to assess in the head - NIPE?

A
  • Size (head circumference)
  • Shape (any abnormalities + cranial sutures)
  • Fontanelles
  • Skin (Colour, bruising/lacerations, vernix)
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5
Q

NIPE - What to assess in the face?

A
  • Appearance - any syndromic features
  • Asymmetry
  • Trauma
  • Eyes: Fundal reflex
  • Ears: In line with eyes
  • Mouth and palate: Look for clefts and inspect tongue and gums + Suckling reflex
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6
Q

What to look for in the neck and clavicles - NIPE?

A
  • Neck: Webbing, length, lumps
  • Clavicle: Examine for fracture
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7
Q

NIPE - Upper limbs?

A
  • Assess the symmetry of the upper limbs
  • Inspect the fingers
  • Inspect the palms
  • Palpate the brachial pulse in both arms
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8
Q

NIPE - Chest?

A
  • Respiratory rate (40-60bpm)
  • Work of breathing
  • Auscultate the lungs and heart (D+B)
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9
Q

NIPE - Abdomen what to inspect?

A
  • Abdominal distension
  • Umbilicus
  • Inguinal hernia
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10
Q

NIPE - Abdomen what to palpate?

A

Organomegaly
Femoral pulses

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11
Q

NIPE - Genitalia?

A

Males
- Position of urethral meatus
- Assess testicles are present

Females
- Inspect labia, clitoris

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12
Q

NIPE - Lower limbs?

A

Inspect for:
- Asymmetry
- Oedema
- Ankle deformities
- Missing digits

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13
Q

NIPE - Hips?

A
  • Barlows test
    Adduct the hip and apply pressure on knee posteriorly
  • ortolani’s test
  • Flex hips and open out, with index finger on greater torachanters
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14
Q

NIPE - back and spine?

A

Inspect the spine for:

Scoliosis
Hair tufts
Naevi
Birthmarks
Sacral pits

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15
Q

NIPE - Anus?

A

Inspect the anus for patency

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16
Q

NIPE - Reflexes?

A
  • Palmar grasp
  • Suckling
  • Rooting
  • Moro
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17
Q

To complete the NIPE?

A

Explain you are finished
Share results
Any questions?
Thank patients
Summarise findings and document findings

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18
Q

Why do you ask about breech presentation the NIPE?

A

if breech at 36 weeks gestation or delivery (if earlier) -> ultrasound scan of hips (increased risk of developmental dysplasia of the hip)

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19
Q

NIPE - Causes of asymmetrical growth restriction?

A

placental insufficiency

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20
Q

NIPE - Causes of symmetrical growth restriction?

A

Fetal factors eg. genetic abnormalities or intrauterine infection

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21
Q

NIPE - Tone?

A

Assess tone throughout and comment at the end
Low tone - may struggle painting a suck-swallow pattern
Hypotonia is common in Downs

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22
Q

What is caput succedaneum?

A
  • Diffuse subcutaneous fluid connection (crossing suture lines) caused by pressure on the presenting pare during birth
  • Resolves over few days
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23
Q

What is cephalohaematoma?

A
  • Subperiosteal haemorrhage (does not cross suture lines) which is more common with instrumental delivery and may cause jaundice
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24
Q

Subgaleal haemorrhages?

A
  • occur between he aponeurosis of the scalp and periosteum - form large fluctuant collections which cross suture lines
  • Life-threatening blood loss
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25
Q

Craniosynostosis?

A
  • One or more of the fibrous sutures fuse prematurely, changing the growth patten of the skull -> raising ICP and damage intracranial structures
  • Requires surgical intervention
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26
Q

What is a vernix?

A

A waxy or cheese like white substance found coating the skin - normal

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27
Q

Salmon patch?

A

Red or pink patches - often on infants eyelids, head or neck - caused by congenital capillary malformation
Fade by age of 2

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28
Q

Haemangiomas?

A
  • Blood vessels which form a raised lump on the skin which appears soon after birth
  • Typically enlarge over first 6-12 months but shrinks to nothing by 7
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29
Q

Port wine stain?

A
  • red/purple marks on the face and neck which are typically present from birth and do not regress
  • Port-wine stains can sometimes be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome.
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30
Q

Slate-grey nevus?

A
  • Benign, flat, congenital birthmark with wavy borders and irregular shape, usually located over the sacrum
  • It is most commonly blue in colour and can be mistaken for a bruise
  • They normally disappear within 3-5 years after birth
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31
Q

Absence of the fundal reflex in children?

A

congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma

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32
Q

What is ankyloglossia?

A

tongue-tie

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33
Q

lump in the left posterior triangle of the neck?

A

Cystic hygroma

Cystic hygromas are benign but can be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid

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34
Q

single palmar crease - associated with?

A

Down’s syndrome

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35
Q

Hair tufts and sacral pits?

A

neural tube defects (e.g. spina bifida)

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36
Q

Neurological - General inspection?

A

Can be done with the child on the parents lap
Observe play:
- Attention span
- Gross and fine motor coordination
- Problem solving

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37
Q

Neurological - Olfactory nerve I?

A
  • Close eyes and detect a smell
  • not done on small children/infants
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38
Q

Neurological - Optic nerve II visual acuity?

A
  • Infant: watch reach for objects of varying size
  • > 6mo: observe reaching for scraps of paper <5mm on dark background
  • Older children: Snellen chart
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39
Q

Neurological - Optic nerve II visual fields?

A

Introduce objects into peripheral field of vision while child focuses on object directly in front of them

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40
Q

Neurological - Optic nerve II pupillary reflexes?

A

Direct pupillary reflex
Consensual pupillary reflex

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41
Q

Neurological - Optic nerve II fundoscopy?

A

Offer

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42
Q

Neurological - Oculomotor, trochlear and abducens nerves (III,IV, VI)

A
  • Inspect for ptosis
  • Assess extra ocular eye movements (H movement with bright toy)
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43
Q

Neurological - Trigeminal nerve (V)?

A
  • Sensory function - assess response to light touch, rooting reflex in babies
  • Motor function - open mouth against resistance
    Offer jaw jerk
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44
Q

Neurological - Facial nerve (VII)

A
  • Inspection: asymmetry and compare nasolabial folds
  • Motor function: observe or ask to copy you
45
Q

Neurological - Vestibulocochlear nerve (VIII)?

A
  • Infants: Soft sound near ear (Alerting response)
  • > 5-6mo: localise sound
  • School age: as adult
46
Q

Neurological - Glossopharyngeal and vagus (IX,X)

A
  • Observe swallowing
  • Observe movement of soft palate (Say ahh and watch uvula)
  • Listen to voice

Offer Gag reflex

47
Q

Neurological - Accessory nerve (XI)

A
  • If child old enough, ask them to shrug shoulders up
  • Turn head against resistance
48
Q

Neurological - Hypoglossal nerve (XII)

A
  • Inspect tongue for fasciculations
  • Ask to stick out
49
Q

Cardiovascular - Introduction

A

WIPER

“Today I’d like to perform an examination of your child’s heart, this will involve me watching your child, then feeling for pulses and listening to their chest with my stethoscope”

50
Q

Cardiovascular - General inspection

A

Equipment: oxygen, mobility equipment
Medications: any at the bedside
Appearance and behaviour:

  • Activity/alertness
  • Cyanosis/Pallor/oedema
  • Shortness of breath
  • Rashes
  • Weight

Syndromic features

51
Q

Cardiovascular - Hands inspections?

A

General observations:
- Colour
- xanthomata
- Arachnodactyly
- Thumbs present

Finger clubbing

52
Q

Cardiovascular - Hands palpation?

A
  • Temperature
  • Capillary refill time
  • Pulses - radial, radio-radio delay
53
Q

Cardiovascular - Neck?

A

Measure the JVP (<8 years old)

54
Q

Cardiovascular - Face

A

General inspection: Malar flush, nasal flaring/grunting
Eyes: Conjunctival pallor, xanthelasma, kayser-fleischer rings
Mouth: Central cyanosis, angular stomatitis, high arched palate, dental hygiene

55
Q

Cardiovascular - Chest inspection

A
  • Any evidence of previous surgery
  • Pectus excavatum/carniatum
56
Q

Cardiovascular - Chest palpation

A
  • Abdomen: Liver, spleen
  • Chest: palpate the apex beat, heaves and thrills
57
Q

Cardiovascular - chest Auscultation

A
  • Heart
  • Lungs
58
Q

Cardiovascular - Final steps

A

Assess for oedema

59
Q

Causes of raised JVP?

A
  • Right sided heart failure
  • Tricuspid regurgitation
  • Constrictive pericarditis
60
Q

Pectus excavatum associated with?

A
  • Marfan syndrome
61
Q

Pectus carniatum associated with?

A

Noonan syndrome

62
Q

Where should the apex beat be?

A

<7 years old: 4th intercostal space to the left of the midclavicular line.
>7 years old: 5th intercostal space in the midclavicular line.

63
Q

Causes of left displacement of apex beat?

A

cardiomegaly, pectus excavatum and scoliosis.

64
Q

Causes of a right displaced apex beat?

A

dextrocardia, left diaphragmatic hernia, collapsed right lung, left pleural effusion and left tension pneumothorax.

65
Q

CHARGE syndrome features?

A

Heart:
- TOF
- Patent ductus arteriosis
- VSD
- ASD
- AVSD

  • Coloboma
  • Choanal atresia
66
Q

DiGeorge features?

A

Heart:
- VSD
- TOF
- Interrupted aortic arch

Other:
- Hearing loss
- Cleft palate
- Micrognathia
- Hypolastic malar

67
Q

Fetal alcohol spectrum disorder features?

A

heart:
- VSD
- ASD

Other:
- Microcephaly
- IUGR
- Smooth philtrum
- Joint abnormality

68
Q

fragile X syndrome features?

A

Heart: Mitral valve prolapse

Other
- Macrocephaly
- Prominent ears and jaw
- Macroochidism

69
Q

Marfan syndrome features?

A

Marfanoid habitus (tall, long limbs)

Hypermobility

Arachnodactyly

Chest wall deformities

Aortic dilatation/regurgitation

Mitral prolapse

70
Q

Noonan syndrome features?

A

Turner phenotype

Pulmonary stenosis

Hypertrophic cardiomyopathy

71
Q

Turner syndrome features?:

A

Short stature

Delayed puberty

Webbed neck

Shield chest

Coarctation of the aorta

Aortic stenosis

72
Q

Williams syndrome features?

A

Short palpebral fissures

Upturned nose

Cupid bow lip

Supravalvular aortic stenosis

Pulmonary stenosis

73
Q

Abdominal exam - introduction

A

WIPER

“Today I would like to perform an examination of your child’s abdomen which will involve first observing your child, then gently feeling their tummy”

Gain consent

Any pain?

74
Q

Abdominal exam - general inspection

A

Equipment: NG/NJ tube, IV lines, bags, special feeds
Medications: Pancreatic enzymes (CF)

Appearance and behaviour
- Activity/alertness
- Jaundice/pallor
- Weight

Syndromic features

75
Q

Abdominal exam - Hands inspection

A

General observations
- Pallor
- Peripheral oedema

Nail signs
- Koilonychia
- Leukonychia

Finger clubbing

76
Q

Abdominal exam - Hands palpation

A

Pulse - radial

77
Q

Abdominal exam - Face

A

General appearance: Oedema, pallor

Eyes: Conjunctival pallor, scleral jaundice, anirida, Kayser fleischer rings, xanthelasma

Mouth: Angular stomatis, glossitis, Oral candidiasis, ulceration, macules, dental caries, macroglossia

78
Q

Abdominal exam - Neck

A

Left supraclavicular lymph node

Palpate lymphadenopathy

79
Q

Abdominal exam - Abdomen inspection

A
  • Scars
  • abdominal distension
  • Caput medusae
  • Hernias
  • Drains/tubes/stomas
80
Q

Abdominal exam - palpation

A

Preparation: Kneel down, use warm hands, relax
Light palpation
Deep palpation

Liver palpation
Spleen palpation
Kidney ballot

81
Q

Abdominal exam - percussion

A
  • Liver
  • spleen
  • Ascites
82
Q

Abdominal exam - Auscultation

A

Start by showing the child your stethoscope and demonstrate

  • Bowel sounds
83
Q

Abdominal exam - Genital examination

A

Done in infants and young children - only if relevant in older children

male: assess fro penile abnormalities, descended testes, scrotal swellings

Female: Abnormal discharge

84
Q

Abdominal exam - Rectal examination

A

If indicated inspect anus for relevant findings:
- Imperforate anus
- Anal skin tags
- Anal prolapse
- Staining of underwear (suggests constipation)

85
Q

Abdominal exam - Final steps

A

Lower limbs inspected for pedal oedema

86
Q

Peripheral oedema - abdo exam?

A

Nephrotic syndrome (loss of albumin) and liver disease (reduced production of albumin)

87
Q

Causes of pallor in child - Abdo exam?

A
  • Malignancy
  • GI bleeding
  • Malnutrition
88
Q

Leukonychia causes?

A

Associated with hypoalbuminaemia eg. nephrotic syndrome

89
Q

Koilonychia causes?

A

Associated with iron deficiency anaemia eg. malabsorption in chrons disease

90
Q

relevant causes of finger clubbing in abdo exam?

A
  • Cystic fibrosis
  • Inflammatory bowel disease
91
Q

Aniridia?

A

Partial or complete absence of the coloured part of the eyes - associated with WAGR syndrome (worry about wilms tumour)

92
Q

Ulcers?

A

Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.

93
Q

Hyperpigmented macules?

A

Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.

94
Q

Dental caries?

A

gastroesophageal reflux disease (acid erosion)

95
Q

How to investigate guarding?

A

“Can you jump up and down?” – a child will not be able to jump on the spot if they have localised guarding.

“Blow out your tummy as big as you can, then suck it in as far as you can” – this will elicit pain if there is peritoneal irritation.

96
Q

Causes of hepatomegaly?

A
  • Infection: Congenital, mono, hepatitis, malaria
  • Haematological: Sickle cell anaemia, thalassaemia
  • malignancy: Leukaemia, lymphoma, neuroblastoma, wilms, hepatoblastoma
  • metabolic: glycogen and lipid storage disorders
  • Cardiovascular: HF
  • apparent hepatomegaly: Chest her expansion (eg. bronchiolotis/asthma)
97
Q

Cause sof kidney enlargement?

A

Unilaterally enlarged: hydronephrosis, cyst, tumour
Bilaterally enlarged: hydronephrosis, kidney stones, polycystic kidneys

98
Q

Respiratory exam - Introduction

A

WIPER

” I would like to perform a respiratory examination, which will involve observing your child, feeling their pulse and listening to their breathing with my stethoscope?”

Gain consent from parent/child

Pain?

99
Q

Respiratory exam - General inspection

A

Equipment: Mobility aids, feeding tubes, o2 monitor
Medications: inhalers

Appearance and behaviour:
- Activity/alertness
- Cyanosis/pallor
- Weight
- SOB

Syndromic features

Sounds:
- Cough and wheeze
- Hoarse voice
- Stridor

100
Q

Respiratory exam - Hands inspection

A
  • General observations: Colour, tremor, eczema
  • Finger clubbing
101
Q

Respiratory exam - Hands palpation

A

Radial pulse

102
Q

Respiratory exam - Face

A

General appearance: Nasal flaring, micrognathia
Eyes: Conjunctival pallor
Ears: Hearing aids (Primary ciliary dyskinesia)
Nose: Deviated nasal septum, polyps
Mouth: Central cyanosis, cleft palate
Throat - pen torch and tongue depressor - look for tonsillar hypertrophy

103
Q

Respiratory exam - Neck

A
  • Tracheal position
    -Lymph nodes
104
Q

Respiratory exam - Chest inspection

A
  • Scars
  • Pectus excavatum/carinatum
  • Assymtry of chest wall movement
  • Harrisons sulcus
  • Chest hyper expansion

Resp rate

Work of breathing

105
Q

Respiratory exam - Chest palpation

A
  • Palpate apex beat
  • Assess chest expansion
  • Percussion (“I’m going to play your chest like a drum”)
106
Q

Respiratory exam - chest Auscultation

A

Start by showing the child your stethoscope and demonstrate it on your own chest and/or on one of their toys to familiarise them with this piece of equipment

Vocal resonance

107
Q

Respiratory exam - Posterior chest

A

Repeat front chest exam

108
Q

Respiratory exam - final steps

A
  • Oedema

Paediatric osce (5 decks)

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