Focused Clinical Examination - Pediatric OSCE skills

Introduction

Focused Clinical Examination is one of the subtypes of Objective structure clinical examination. Its been there in the MRCPCH exam for some time and has been recently included in DNB practical exam by NBE.

In focused physical examination OSCE, you have to perform examination required based on history and clinical clues. Remember it is not a head to toe examination. Examination based clinical question might require the examination of more than one system or body part or system.

For example, an examination of Hepatomegaly will include the examination of the abdomen but also cardiovascular examination to rule out congestive cardiac failure.

What is the Objective of a Focused clinical exam?

The new type of DNB OSCE station tests clinical examination skills alongside core knowledge and the ability to apply your clinical knowledge in everyday practice.

A focused clinical examination format tests your collective knowledge and its depth on a particular topic/System.

The importance of Focused clinical examination skills in DNB practicals

35% of total Observed stations are based on focused history and clinical exam. This is around 50 marks out of 150 which makes it a very important OSCE station.

Aawareness and preparation of this OSCE subtype is very crucial. It is good to have sufficient practice of such stations before the exam.

What are the types of Focused clinical examination OSCE?

The Question can be asked in two different formats.

You will be asked to elicit and demonstrate all possible findings for a particular diagnosis. You have a standard time of 8 minutes for this.

1. Start like any other case, from general examination and going forward to systemic examination.
2. Simultaneously comment on what you are doing and what you are looking for?

Your knowledge and clinical skills both are assessed. Let us try to understand this with examples.

OSCE practise station-1. Examine a child with hydrocephalus

Note that this question was asked in the Nov-2015 session

Step1- Begining of consultation

Greet and obtain consent for examination from a parent/caregivers and explain the purpose if possible

Step2- General examination

1. Comment on Sensorium.
2. Talk about the visible large head and take HC.
3. Demonstrate Nystagmus, proptosis if present
4. Demonstrate any visible abnormal movement etc.

Take vitals- Temperature, Pallor, Respiratory rate, pulse, and blood pressure.

Look for associated syndromic features, dysmorphic feature and anything which can be directly or indirectly associated with hydrocephalus in children.

Step3- Examine the hydrocephalus

1. Examine fontanelles
2. Dilated veins
3. Head circumference
4. Examine eyes and
5. Fundus examination.
6. Demonstrate specific signs of hydrocephalus - Tran illumination

Step4- CNS Examination

Demonstrate tone, power, and reflexes in limbs.

Step5- Spine examination

Demonstrate abnormal findings of the spine if any and talk about your findings.

Step6- Skin examination

Talk about neurocutaneous markers.

Step7- Closing the consultation.

Thanks, parents/Caregivers. Explain your conclusion to the examiner.

OSCE practise station-2. Examine child with infective endocarditis?

Step1- Begin the consultation

Greet and obtain consent from child/parents/caregivers

Step2- General examination

1. Comment about the Sensorium.
2. Comment about hemodynamic stability and Vitals.
3. Check the temperature for fever.
4. Look skin for pallor/associated skin lesions/–petechiae/Janeways lesions/Splinter hemorrhages/Oslers nodes/clubbing etc.
5. Examine eyes with fundoscopy for Roths spot.

Step3- CVS examination

Look for Rhythm/Murmurs/Hyperactive precordium/ Apex impulse position.

Step4- Abdomen Examination

Look for spleenomegaly.
Palpate all peripheral pulses for presence and equality to rule out the thromboembolic phenomenon.

Step5- Closing remarks.

1. Greet parents/child/caregiver.
2. Explain the findings to the examiner.

This type of scenario really makes you stretch your imaginations and think retrospectively. The most important thing while performing such stations is to be cool and do not panic.

Take 30 sec to think and make at least 3-4 significant possible differential diagnoses from given information. The differentials can include some nonspecific or minor D/Ds as well

Now start tracing these differentials in a retrospective fashion similar to the case-examination format.

Look for specific findings or clues which can lead to these differentials. The following example will clarify this.

OSCE practise station-3. Examine this 3 yr old child with tremors

The trick here is to have a think about possible D/Ds for tremors in a 3 yr old.

1. Cerebellar disorder
2. Liver cell failure
3. Hypoglycemia
4. Nebulisation with asthalin in asthma.
5. Metabolic encephalopathy.

Though cerebellar disorder comes first in mind, think of a less common diagnosis simultaneously.

1. Greet and obtain consent from a parent and explain what are you doing.
2. Look for the sensorium, for example, agitation in asthma due to CO2 retention, and depressed sensorium in metabolic encephalopathy.
3. Check Vitals comment on tachypnea in asthma.
4. Perform Examination and comment on titubations/swaying/ tremors/nystagmus/other associated abnormal involuntary movements.
5. Examine for signs of liver cell failure.
6. Examine Skin for neuro-cutaneous markers.
7. Neurological examination, focus on all cerebellar signs/ tone/ power /reflexes /speech /gait etc.
8. Respiratory examination for signs of asthma. Acidotic Pattern of breathing for metabolic disorder presenting with tremor.
9. GIT examination - Rule out hepatomegaly for storage disorders, liver cell failure, and ascites.
10. Close the consultation by thanking the parents and the child.
11. Explain your final findings and thought about the case to the examiner.

OSCE practise station-4. Examine an 8-year-old female child with short stature.

Have a think for 30 seconds. Your differentials can be

1. Familial short stature
2. Constitutional
3. Syndromic short stature
4. GHD
5. Hypothyroidism
6. Cushing's syndrome
7. Nutritional
8. Chronic liver disease

Greet and obtain consent from parents, explain to parents and or a child every step that you are doing. In short continue communicating whenever needed

Step1- Start with anthropometry.

A. Prove it a short stature - First, take anthropometric measures and prove it as short stature, also ask for parents height and previous height records if available.

B. Find out etiology based on examination and clinical clues. Find out US : LS ratio - if affected, favors skeletal dysplasias, hypothyroidism, etc.

Short stature with obesity points toward endocrine or syndrome rather than nutritional etiology.

Step2- General examination

1. Vitals - Pulse will be low in hypothyroidism, Blood pressure will be low in cushings. Explain these to the examiner.
2. Demonstrate skin signs of nutritional deficiency so as to support or rule out nutritional causes.
3. Look for Dysmorphic features from head to toe (Genetic syndromes)
4. Midline defects like cleft palate, micropenis, single central incisor- Growth hormone deficiency.
5. Webbed neck, wide-spaced nipples with increased carrying angle in female child points towardTurners syndrome
6. Coarse skin, neck swelling- Hypothyroidism
7. Demonstrate Jaundice, spider nevi for Chronic liver failure.
8. Purplish striae, central obesity, buffalo hump, proximal muscle weakness- Cushing's
9. Signs of vitamin deficiencies – Malabsorption, Rickets.

Step3- Organ-specific examination

1. CNS

Demonstrate tone, reflexes, comment on the significance, for example, delayed relaxation of tendon jerks - hypothyroidism

2. Respiratory examination

The pattern of breathing- acidotic in chronic metabolic diseases resulting in growth failure.

3. GIT

Palpate for liver and look for fluid as a sign of chronic liver disease.

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These are just examples to give you a feel of how the stations can be. The best approach is to think of possible stations and prepare a basic infrastructure of how you are going to proceed while facing a particular OSCE station.

The crux is you should able to think of all aspects from all systems which are directly and remotely connected with a given clinical scenario or question.

Want more OSCE practise stations?

1. Observed OSCE stations - OSCE Guide
2. Body language in Practical exam
3. Previous year OSCE questions

Author

Kishor L Giri | DNB Pediatric

Kishor completed his Pediatric residency at Jehangir Hospital, Pune and currently working as Pediatricican in Navi Mumbai. Majority of his articles are focused on clinical aspects and tips for the exams.