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Pediatrics OSCE
Pediatrics OSCE
Pediatrics OSCE
Introduction
Before OSCE:
o Sleep well: Sleeping well is more beneficial than studying all night long.
o Bring all your equipment: Stethoscope, hammer, ophthalmoscope"
o The key to OSCE success is practice.
o Behave in a polite, professional way.
Before starting any examination:
o Wash your hands.
o Introduce yourself to the parents and the child.
o Explain to the patient, take permission and maintain privacy.
o Respect the child presence and establish a relationship.
o Consider starting with auscultation if the child is quite.
o After you finish, thank the child and cover him\her.
Contents:
o
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o
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o
o
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References:
o AlHowasi Manual of Clinical Pediatrics, 6th Edition.
o Illustrated textbook of pediatrics, 4th Edition.
Reviewed and edited by:
o Waleed Al Humaid
o Abdulaziz AlAlwan
o Abdulaziz AlTurki
o Hussain AlMulla
o Bader AlOthman
Don't forget us from your Dua'a and best of luck in your exam and your future
career.
Page |1
Page |2
Age
6 weeks
2 months
7 months
1 year
2 years
3 years
7-8 years
Language
Gurgling e.g. coo
Babbling e.g. "dad, bab, mam"
One word-sentences and using 3 words
Using 6-10 words
Two word-sentences
3 word-sentences
Simple story
Age
1-5 months
5-12 months
1 year
18 months
2 years
3 years
4 years
Fine Motor
Reach and grasp
Transfer objects to the other hand
Pincer grasp start to developPincer grasp completeBuilding 3 cube tower and hold a spoon
Building 4 cub tower
Building 7 cube tower and draw a line
Draw a circle
Draw a square and button/unbutton
Draw a triangle
Tying shoes
Age
4 months
7 months
9 months
1 year
15 months
18 months
2 years
3 years
4 years
5 years
6 years
Gross Motor
Roll over front to backRoll over back to frontSetting with support
Setting without support
Crawling
Walking few steps
Walking upstairs
Alternating walking
Riding a tricycle
Walking on one foot
Riding a bicycle
Age
4-5 months
5-6 months
6 months
8 months
9 months
1 year
18 months
2 years
3 years
4 years
5 years
Page |4
Approach to Gastroenteritis
Airway Breathing Circulation.
Assessment of dehydration:
o Mild: Everything is normal except for dry mucous membrane.
o Moderate: You see most of the signs of dehydration listed on the table
below.
o Severe: Moderate + Anuria and lethargic due to decreased end-organ
perfusion.
Management of dehydration:
o Bolus if in shock (tachycardia and hypertension): IV NS 20 ml/kg.
o Deficit: over 24 hour (the first half on the first 8 hours).
Infants (5%: 50ml/kg, 10%: 100ml/kg, 15%:150ml/kg).
>1 year (3%: 30ml/kg, 6%: 60ml/kg, 9%:90ml/kg).
o Maintenance: should be added to deficit.
100 ml/kg/day or 4 ml/kg/hour for the 1st 10 kg.
50 ml/kg/day or 2 ml/kg/hour for the 2nd 10 kg.
20 ml/kg/day or 1 ml/kg/hour for every kg.
o E.g. 4 kg with moderate dehydration:
Maintenance=16 ml/hr.
Deficit=400 ml/day (200ml/8hr= 25 and 200ml/16hr= 12.5).
The first 8 hr= 16+25= 41ml/hr.
The next 16 hr=16+12.5=28.5ml/hr.
o Use for maintenance: Dextrose 5% 1/2 Normal Saline. If high Na, NS.
o Indications for admission: Severe, systemic infection (Sheigella, E-coli),
not responding to ORS.
Page |6
Miscellaneous presentations:
The most common cause of gastroenteritis (GE) is Rotavirus.
If GE + seizure sheigella.
If GE + hemolytic uremic syndrome (low Hgb, low Plt) E-coli.
If GE + decreased immunity cryptosporidium.
If GE then persistant diarrhea: Secondary lactose intolerance. Resolve in 3 weeks.
If GE then paralysis after 3 weeks Guillain Barre syndrome.
Page |7
Vaccination
Visit
At birth
2 months
4 months
6 months
9 months
12 months
18 months
24 months
4-6 years
Vaccine
BCG - Hepatitis B
IPV DTP - Hib - Hepatitis B - PCV 13
Oral Polio DTP - Hib - Hepatitis B - PCV 13
Oral Polio DTP - Hib - Hepatitis B - PCV 13
Measles
Oral Polio - MMR - Varicella - PCV 13
Oral Polio - DTP - Hib - Hepatitis A
Hepatitis A
Oral Polio - DTP - MMR - Varicella
Types of vaccines:
o Live attenuated: BCG, MMR, OPV, varicella, measles, rotavirus, nasal flu.
o Inactivated vaccines: IPV, HAV, pertussis.
o Protein: HBV, parenteral influenza, acellular pertussis.
o Toxoid: Diphtheria, tetanus.
o Polysaccharides: meningococcal, pneumococcal.
o Conjugated: PCV, Hib.
History: Allergy, fever, seizure, loss of consciousness, steroid, and low immunity.
o Consider the patient unimmunized unless proven.
o If delayed vaccine, explore the reason and give as much as you can.
o HBV vaccine: Should be at least 2.0 Kg or 2 months old.
o For live attenuated vaccines: Either give them together or 1 month apart.
Contraindications:
o Moderate to severe illness fever.
o Previous anaphylaxis of same vaccine or its constituent (e.g. Egg in flu
vaccine and neomycin and streptomycin- in MMR and IPV)
o Live attenuated vaccine in immunocompromised patients Except:
Steroid Therapy: Contraindicated only if high dose
(>2mg/kg/day for <10 Kg or >20 mg/kg/day for >10Kg) and
prolonged therapy (>2 weeks). Wait for 1 month.
MMR for AIDS: Give if asymptomatic + >15% CD4
Varicella for AIDS: Give if CD4 > 25%.
BCG: Give in asymptomatic patients in endemic TB countries.
Influenza vaccine: Give Inactivated (i.e. Parenteral).
o If any of the following happened after DTP (not applicable for DTaP):
Encephalopathy within 1 week.
Seizure within 72 hours.
Persistent crying for >3 hours within 48 hours.
Fever >40.5 C within 48 hours.
Shock like syndrome within 48 hours.
Pediatric Block OSCE | AlBrahim & Tarabzoni
Page |8
Newborn Examination
General Examination
o Vital signs (HR: 140-160, RR: 40-60, and temperature)
o Growth parameters: Length (50 cm), weight (2.5-3.5 Kg) and head
circumference (35 cm). Then plot them on the chart.
General Appearance
o Alertness and movements.
o Color (Cyanosed or pink).
o Respiratory distress (Flaring, retraction, cyanosis, grunting).
o Connection to monitors or IV line.
o Skin:
Pallor and jaundice.
Birth marks, hemangioma, mongolian blue spot.
Rash: e.g. Erythema toxicum.
Edema: Generalized (hydrops), localized (hands and feet in
Turner Syndrome).
Head:
o Size:
o
o
Face:
o Dysmorphic features: E.g. Down syndrome.
o Ears:
Low set ears.
Periauricular tags (Renal problem).
Tympanic membrane (dull gray).
Page |9
o Eyes:
Microphthalmia: Congenital rubella.
Buphthalmus (corneal diameter >12mm): Congenital
glaucoma.
Slant of palpebral fissure (upward or downward).
Hypotelorism or hypertelorism.
Subconjunctival bleeding (self-limiting).
Coloboma of the iris or lids (syndromes).
Aniridia (Wilm's tumour).
Red reflex (cataract if absent).
Leukokoria (white ppupillary reflex): Retinoplastoma.
o Mouth:
Central cyanosis.
Large tongue: hypothyroidism, Pierre Robin syndrome.
Palate: Cleft lip and palate, high arched palate.
Neck: Normally short.
o Swelling: Goiter, thyroglossal cyst.
o Skin: Redundant (Down syndrome), webbed (Turner syndrome).
o Clavicle: Fracture.
Respiratory:
o Inspection: Movement, symmetry, and deformity (pectus, nipple space).
o Auscultation: Air entry, breath sound, and additional sounds
Cardiovascular:
o Pulse (Brachial and femoral): Rate, rhythm, volume, etc.
o Weak femoral pulse + higher BP in upper limb Coarctation of the aorta.
o Palpation: Dextrocardia.
o Auscultation: S1, S2, gallop, murmurs (innocent or pathological).
Abdomen:
o Scaphoid (diaphragmatic hernia) or distended.
o Umbilicus: 2 arteries and 1 vein, sign of infection, omphalocele.
o Organomegally and Hernia.
o Bowel sound and bruit.
Genitalia:
o
o
o
o
o
o
P a g e | 10
Musculoskeletal:
o Hands and Feet:
Size and shape.
Digits: Polydactyly, syndactyly.
Feet: Club feet (Talipes Equinovarus).
o Back:
Spina bifida: Hair tuft, dimples, hemangioma, sinus.
Mongolian spot.
Deformity: Scoliosis.
o Hips:
Barlows Test: Trying to dislocate the hip with adduction and
pushing posteriorly.
Ortolanis Test: Trying to relocate the hip with abduction
lifting the hip forward.
Neurological Exam:
o Tone: Truncal tone (head lag), ventral suspension (figure 1) and vertical
suspension (figure 2).
o Power: Observation of the movement.
o Reflexes: Knee, ankle.
o Primitive reflexes: leave it to the end.
Figure 1
Moro.
Sucking.
Figure 2
Palmer and Planter.
Stepping and Placing.
Hints:
o Be patient, gentle, and flexible.
o If the baby is quite, start with auscultation and palpation of the
abdomen.
o Adequate light, warm hands and environment are prerequisite.
P a g e | 11
Cardiovascular Examination
General Observation:
o Ill looking or well.
o Cyanosis (is seen in the tongue) and pallor.
o Connected to monitors (Read the Vitals), IV line, or Oxygen mask.
o General health (Obese, well nourished, or failure to thrive)
o Signs of respiratory distress (tachypnea, recession (intercostal, subcostal
,or suprasternal recession), nasal flaring, grunting)
o Dysmorphic features (Down, Turner, or Marfan syndroms)
Hands:
o
o
o
o
o
Pulse:
o Both brachial pulses.
Rate: For at least 30 seconds.
Rhythm: Regular or irregular.
Volume: Large in AR and PDA.
Character: Collapsing pulse, pulsus paradoxus.
o Compare with Femoral pulses (if decreased or absent coarctation of
aorta).
Blood Pressure: layingstanding.
o Children: Measured by sphygmomanometer.
o Infant: Doppler ultrasound from all limbs.
o Postural hypotension: >15 mmHg drop in systolic when standing up.
o Pulsus Paradoxus: Drop 10 mmHg with inspiration cardiac tamponade,
constrictive pericarditis, and severe asthma.
Face:
o Eyes: Pallor, jaundice.
o Mouth: central cyanosis, High arch palate (Marfans), teeth "IE".
Back:
o Auscultation: Inspiration crackles LVF.
o Sacral edema.
o Leg edema.
Pediatric Block OSCE | AlBrahim & Tarabzoni
P a g e | 12
Abdomen:
o Hepatomegaly: RVF, and Ascites.
o Splenomegaly.
Precordium Examination
Inspection
o
o
o
o
Palpation:
o Apex beat: Left 5th intercostal space, mid-clavicular line (or outer most,
lower most). Character:
Pressure loaded "forceful, sustained" AS & HTN.
Volume loaded "displaced, non-sustained" AR & MR.
Tapping apex "palpable S1" MS.
Dyskinetic "diffuses moves" HF.
o Left para-sternal heaves: (by the heel of the hand) for RVH or LAE.
o Thrills: Palpable murmur (4/6 intensity if found).
o Palpable P2 (pulmonary HTN).
o Liver (Right HF) and spleen (IE).
Auscultation:
o Bell (low pitch diastolic murmur).
o Diaphragm (high pitch systolic murmur).
Figure 3
o Auscultate the following areas: (figure 3)
2nd Right intercostal space at sternal edge (Aortic area).
2nd Left intercostal space at sternal edge (pulmonary area).
4th left intercostal space at sternal edge (Tricuspid area).
5th left intercostal space mid-clavicular line (Apex Mitral
area).
Axilla (MR) and carotid radiation (AS).
o Also check:
Left subclavicular area (PDA).
P a g e | 13
P a g e | 14
Respiratory Examination
General Observation:
o
o
o
o
o
o
o
o
o
o
Upper limbs:
o Clubbing (Scramroth's sign): Cystic fibrosis, lung fibrosis, pulmonary
abscess, bronchiectasis, cyanotic congenital heart disease, liver cirrhosis,
inflammatory bowel disease, and celiac disease.
o Peripheral cyanosis.
o Pulse: Tachycardia, bounding pulse (CO2 retention).
o Blood pressure: Pulsus paradoxus in severe asthma.
Face:
o Central cyanosis (tongue).
o Nasal flaring.
P a g e | 15
Chest Examination
Inspection:
o
o
o
o
o
o
o
o
Respiratory Rate.
Respiratory pattern (Abdominal in infants. Thoracic after 4-5 years).
Symmetry of the chest movement (from feet side at the same level).
Deformities (Pectus excavatum, carinatum, Harrison sulci, barrel)
Use of Accessory muscles (SCM, suprasternal, intercostal, sucostal).
Scars and rash.
Absent clavicle, Rachitic rosary, supernumerary nipple (renal anomaly).
Back:
Scoliosis or kyphosis.
Position of the scapula.
Scars.
Palpation:
o
o
o
o
o
P a g e | 16
Gastrointestinal Examination
General Observation :
o
o
o
o
o
o
o
o
o
o
o
o
Hands:
Eyes:
o Scleral jaundice.
o Pale conjunctiva.
o Periorbital edema (nephrotic syndrome).
Mouth:
o
o
o
o
o
o
o
o
o
o
Genitalia:
o
o
o
o
o
o
P a g e | 17
Ambiguous genitalia.
Scrotal or labial edema or pigmentation.
Undescended testis.
Hydrocele and inguinal hernia.
Micro or macro penis and urethral orifice (hypo/epi spedias)
Signs of puberty (pubic hair, size of testes).
Pediatric Block OSCE | AlBrahim & Tarabzoni
Abdominal Examination
Inspection: From the side of the feet at the level of the abdomen
o Contour and Distention (5 F: Feces, fetus, flatus, Fat, Fluid).
o Scars: Appendectomy, peritoneal dialysis, and nephrectomy.
o Tubes (gastrostomy, nephrostomy, peritoneal dialysis).
o Obvious masses.
o Visible peristalisis.
o Caput medusa.
o Umbilicus (normal -inverted- or everted).
o Hernia (Ask the child to cough).
Palpation: Ask if there is any pain, be gentle and observe the patient's face.
o Tenderness and regidity "superficial and deep".
o Organomegaly:
a) Liver: Palpate the liver edge (2 fingers below the costal margin is normal)
Percuss for span "6-8 cm" from above and below.
b) Spleen: You can't go above it, has a notch, moves with inspiration, dull on
percussion, and enlarges infer-medially.
Palpate "pt. flat" & "pt. lying over his right side".
Percuss over left costal margin-anterior Axillary line with
full expiration.
c) Kidneys: bimanual examination "balloting".
d) Bladder: percussion.
Percussion:
o Ascites (Shifting dullness & fluid thrill "huge ascites").
Auscultation:
o Bowel sounds "Exaggerated: obstruction or absent: paralytic ileus".
o Renal bruit: 2 cm lateral to umbilicus "Renal artery stenosis".
o Liver bruit "Hepatocellular carcinoma".
Hernia:
o Inspect: Any signs of strangulations (Red, Hot, Tender ER)
o Palpate:
Consistency
Tenderness
Reducible
Try to get above it (positive in hydrocele only).
Transillumination (positive in hydrocele only).
o Auscultate: Peristalsis.
Pediatric Block OSCE | AlBrahim & Tarabzoni
P a g e | 18
Rectal Examination: Use lubricant. Left lateral position with flexed knees.
o Inspection:
Anal fissures 6 & 12 O'clock (most common cause of
bleeding per rectum).
Skin tags.
Fistula (IBD).
Thread worms.
Abrasions (Child abuse).
o Palpation:
Anal tone.
Masses.
Tenderness.
Bleeding.
Splenomegaly causes:
o Infection:
Viral: Viral Hepatitis, EBV, CMV, and Rubella.
Bacterial: Typhoid, syphilis, TB, brucellosis.
Protozoa: Toxoplasmosis, malaria, schistosomiasis.
o
o
o
o
o
P a g e | 19
Growth Assessment
Height and weight:
o Ask the child to take off his shoes and jacket.
o 4 areas should touch the backside of the scale (Figure 5).
Figure 5
Head circumference:
o Encircle the tape over the babys head from the supra-orbital anteriorly
to the most prominent part of his occipital lobe posteriorly.
o It should be done 3 times to be precise.
o Normally at birth it is (35+ 2 cm)
0-3 months 2 cm/month
4-6 months 1 cm/month
6-12 months 0.5 cm/month
BMI
o BMI= weight (Kg)/height (m)2.
o BMI for >2 year old babies and percentile for < 2 years:
Obese: BMI >30 or >95th.
Overweight: BMI 25-30 or 85th-95th.
Normal: BMI 18-25 or 5th-85th.
Underweight: BMI <18 or <5th.
Parental height
o (father's height + mother's height + 13)/2
Pediatric Block OSCE | AlBrahim & Tarabzoni
Short Stature:
o Causes:
Genetics.
Constitutional and Small for gestational age.
Chronic illness e.g. chronic renal failure, celiac disease.
Syndromes: Turner's syndrome.
Endocrine: Hypothyroidism, GH deficiency,
Hypoparathyroidism.
Social deprivation.
o History:
Onset and previous measurement of weight and height.
Growth velocity: 25 cm for 1st year, 12.5 cm for 2nd year, 4-5
cm/year till puberty.
Chronic illness.
Endocrine: Neonatal hypoglycemia, constipation.
Birth weight and mode of delivery.
Family history: Parent's height, diseases, social.
o Examination:
Growth charts plotting.
Chronic illness: Joint deformity, dysmorphism.
Endocrine: Goiter, midline defect.
Upper to lower segment: 1.7:1 in newborn, 1:1 in adult.
Funduscopy: Optic atrophy.
Tanner staging.
o Investigation:
Bone age: Left wrist X-ray.
CBC: Anemia.
Renal function test.
TSH, free T4, IGF1.
Urine analysis (Chronic UTI) and stool ova and parasite.
Antigliadin and endomysial antibodies: Celiac disease.
ABG: RTA
Skull X-Ray (pituitary view): Craniopharyngioma.
Chromosomal: Turner Syndrome.
P a g e | 21
Features:
o Facial:
o GIT:
Alopecia.
Hyperkeratosis.
Soberrhic dermatitis.
Vitiligo.
o Skin:
o Others:
Mortality:
o Congenital heart disease.
o Infection and respiratory disease.
Sports:
o Atlanto-axial instability: Restricts them from certain sports that involve
stress to the head & neck such as:
Gymnastics
Diving
High jump
Soccer
Diagnosis:
o CHROMOSOMAL ANALYSIS (47, XY or XX, +21).
o YOU CAN NOT DIAGNOSE DOWN SYNDROME BASED ON CLINICAL
FEATURES.
P a g e | 23
Type 1 Diabetes
Etiology:
o T-cell mediated autoimmune destruction of islet cell cytoplasm, insulin
autoantibody.
Pathophysiology:
o Diabetes:
Hyperglycemia osmotic dieresis; when renal threshold
for glucose reabsorption is reached (180 mg/dl)
glycosuria.
Loss of fluid, electrolyte, calories, and dehydration.
o DKA:
Accelerated lipolysis and impaired lipid synthesis
lincreased free fatty acids ketone bodies metabolic
acidosis (aggrevated by lactic acidosis due to dehydration)
and Kussmaul respiration (to wash out CO2) decreased
consciousness.
K level could be high in the blood due to acidosis but
depleted intracellular K.
Clinical presentation:
o Polyuria, polydipsia, polyphagia, weight loss
o 20-40 % initially present with diabetic ketoacidosis which should be
suspected in any patient presented with:
Dehydration.
Acidotic (Kussmauls) breathing, with a fruity smell
(acetone).
Abdominal pain and\or distension.
Vomiting.
Altered mental status ranging from disorientation to coma.
P a g e | 24
Diagnosis of diabetes:
o Symptoms + Random glucose > 200 mg/dl or 11.1 mmol/l.
o Fasting blood sugar > 126 mg/dl or 7 mmol/l.
o 2 hour OGTT 200 mg/dl or 11.1 mmol/l.
Diagnosis of DKA:
o Hyperglycemia: of > 300 mg/dl & glucosuria (could be normal due to
insulin given at home).
o Ketonemia and ketonuria.
o High anion gap metabolic acidosis: pH < 7.3, serum bicarbonate < 15
mmol/l. Anion gap >10.
o Anion gap= [Na]+[K] [Cl]+[HCO3].
o (This is usually accompanied with severe dehydration and electrolyte
imbalance).
Management of DKA:
o History: Symptoms of hyperglycemia, precipitating factors, diet and
insulin dose.
o Examination:
Look for signs of dehydration, acidosis, and electrolytes
imbalance, including shock, hypotension, acidotic
breathing, CNS statusetc.
Look for signs of hidden infections (Fever strongly suggests
infection) and If possible, obtain weight.
o Quick Diagnosis:
In known diabetic children confirm: hyperglycemia,
ketonuria and acidosis.
In newly diagnosed diabetic children: be careful not to miss
it because it may mimic serious infections like meningitis.
Blood glucose level (using glucocheck) glucosuria, &
ketonuria (using dip stick) must be measured in the ER and
treatment should be started without waiting for Lab results
which may be delayed.
o Lab investigation:
Plasma & urine levels of glucose & ketones.
ABG, Electrolytes (including Na, K, Ca, Mg, Cl, PO4, HCO3).
Complete Blood Count with differential.
Further tests e.g., cultures, X-rays are done when needed.
P a g e | 25
o Fluid:
P a g e | 26
Complication of insulin:
o Hypoglycemia (sweating, irritability, tremor, anxiety, palpitation,
confusion, seizure, coma).
o Weight gain: It can be avoided with good diet and exercise.
o Lipoatrophy and lipohypertrophy.
Outpatient care:
o Follow up every 3-4 months with HbA1C.
o Check clinically and biochemically for the associated condition e.g.
hypothyroidism every 1-2 years, celiac disease, and vitiligo.
Complications of diabetes:
o Retinopathy, neuropathy, nephropathy, and failure to thrive.