OSCEs or Objective Structured Clinical Exams are the ‘practical’ exam of medical school. It aims to prepare you for the clinical and communication aspects of becoming a doctor. They can seem really difficult and stressful, but with enough practice, you are likely to score well. I hope these tips are helpful and make you feel a little less worried!

What do you need to know?

It seems obvious, but make sure you know which examinations, histories and procedures you’re expected to know and what you’re supposed to be doing in them. Check out our OSCE guides if you’re looking for help.

Practice makes perfect

Grab a fellow medic/friend/flatmate and practice regularly until your examinations are fluent and confident. Exam nervousness can affect your performance, so it’s better to be a bit overprepared than under. If your medical school allows you to practice with their equipment, then take advantage of those opportunities. If not, things like reflex hammers, blood pressure cuffs and penlights can be bought off the internet for a decent price. Remember to practice with a timer too as the minutes fly by in the real thing.

Clothes maketh the man

Dress professionally and accordingly to NHS dress code. Looking neat might not give you extra marks, but it does help you make a good first impression. Remember to tie up long hair, roll sleeves up above the elbows and take off your wristwatch.

Devil’s in the detail

Read the instructions carefully before you enter the station. It sounds silly, but people have been known to do the wrong examination in OSCEs (e.g. upper limb instead of lower limb neurological examination). If you don’t do what you’ve been asked, you just won’t get the marks.

Did you wash them?

Always begin and end a station with washing your hands! Not only is it just good clinical practice, this gives you vital and easy marks.

And so it begins…

Memorise your opening patter until it becomes second nature. This should consist of greeting the patient, introducing yourself, checking their identity, describing the procedure/examination and gaining their permission to continue. Easy marks, but important stuff.

Structure is everything

For examinations, develop an order that you are comfortable with and can remember. For details check out our OSCE clinical skills guides.

For history taking, a general structure applies:

• Presenting complaint
• History of presenting complaint
• Past medical history
• Drug history
• Family history
• Social history
• Systemic enquiry

This may change during a consultation as patients don’t necessarily follow your rules – but having a structure in place makes it easier to keep track of what you have and haven’t asked and helps you with the flow of questioning.

Take a look at our more specific communication skills guides for more details.

Fake it ‘til you make it

You may not be feeling very confident during your OSCE, but pretend you are! Stand up straight, smile when appropriate and speak loudly and clearly – being too apprehensive can give the impression you don’t really know what you’re doing and make the patient nervous too.

Manners cost nothing

Always be polite, empathetic and honest to your patient. Listen to them carefully and let them speak. Thank them and the examiner at the end of the station. After all, they’ve given up their free time to help you. A significant amount of marks are often awarded just for demonstrating these generic communication skills, so don’t neglect them!

Keep calm and carry on

Don’t worry about making mistakes during the OSCE – you haven’t got time to panic. Stay calm, take a deep breath and continue as you were.

Think again

Once you finish your examination you may have some spare time; don’t let this go to waste. Look around to see if there’s any equipment in the room you’ve not used.

If you remember something you’ve missed, then feel free to go back and do it – you’ve only got marks to gain.

Don’t waste a good mistake…

It can be easy to just wipe all memories of a bad OSCE out of your brain. However, if you write those errors down you can review them for your next exam and ensure you don’t make the same mistakes again. Talking to your coursemates about their experience can help too – no one said that you can only learn from your own mistakes.

Good luck!

This basic life support (BLS) guide aims to provide an overview of performing cardiopulmonary resuscitation (CPR) in a hospital setting, which is a common OSCE scenario.

This guide is based on the Resuscitation Council (UK) guidance and is intended only for students preparing for their OSCE exams and not for patient care.

Check out our basic life support (BLS) OSCE mark scheme here.

Chain of survival

The chain of survival refers to a series of actions that, properly executed, reduce the mortality associated with cardiac arrest. Like any chain, the chain of survival is only as strong as its weakest link.

The four interdependent links in the chain of survival are:

• Early recognition and call for help
• Early CPR
• Early defibrillation
• Early advanced cardiac life support

1. Ensure personal safety

• Check the patient’s surroundings are safe before approaching (if you injure yourself, you will not be able to help the patient, so take this seriously)
• Put on gloves (and other personal protective equipment) as soon as possible
• Be careful with sharps during resuscitation

2. Check the patient for a response

• The first step is to assess for a response.
• Gently shake the patient’s shoulders and ask loudly “Hello can you hear me?” or “Are you alright?”.
• If they respond, the patient then needs an urgent medical review with a full ABCDE assessment (see our emergency assessment guides here).

3. No response from the patient

Get help

• Shout for help: This is absolutely essential, as you will not be able to effectively assess and treat the patient alone.

Position the patient and inspect the airway

• Position the patient on their back
• Open their airway using a head-tilt and chin-lift manoeuvre
• Inspect the airway for obvious obstruction. If an object is seen to be obstructing the airway, use a finger sweep or suction to remove obstructions that are in line of sight.

Assess for signs of life

• With the airway held open (using the head-tilt and chin-lift manoeuvre), position your head looking down towards the chest, with your cheek above the patient’s mouth.
• If the patient is suspected to have suffered significant trauma (with potential spinal involvement) perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre.
• In addition, you should place two fingers over the carotid artery to assess for a pulse at the same time.

• Look, listen and feel to assess if the patient is breathing for 10 seconds (ideally, you should expose the chest to assess breathing):
  • Observe for chest rising and falling
  • Listen for any evidence of breath sounds
  • Feel for air blowing against your cheek
  • Look for any other signs of life (e.g. movement)

Agonal breathing

• If the patient has occasional, irregular gasps of breath, this does not qualify as a sign of life as it commonly occurs in cardiac arrest and is referred to as agonal breathing.

A pulse is present, but the respiratory rate is low

• If the respiration rate is below 12 – assist ventilation with bag valve mask (BVM) to maintain 10 breaths/min (re-checking the pulse every minute to ensure it is still present).
• You will likely need two people to perform effective ventilation with a BVM (one ensuring a good seal over the face and the other compressing the bag to deliver the oxygen).
• The BVM should ideally be connected to high-flow oxygen as soon as possible.

A pulse is present and respiratory rate is acceptable

• If you feel a pulse or evidence of genuine breathing, the patient would need urgent medical assessment (using an ABCDE approach) to stabilise them before further deterioration.

4. No signs of life

Call the resuscitation team (a.k.a. “crash team”)

• If there are no signs of life, you need to call for help from the resuscitation team and commence CPR.
• If more than one person is present, you can do these tasks simultaneously, however, if you are alone, you should leave the patient and get help first (as this will ensure the resuscitation team attend and can commence advanced life support).
• In a hospital, calling for help involves calling 2222 to request urgent input from the resuscitation team
• When calling 2222 it is important to clearly state your location (e.g. ward) and the type of cardiac arrest (e.g. adult or paediatric) as this will inform which team members attend.

Perform chest compressions

• The patient needs to be positioned on a flat, hard surface for effective compressions to be possible.
• Deliver 30 chest compressions followed by 2 ventilations and repeat.
• Place one hand on top of the other in the centre of the lower half of the sternum.
• Aim to compress the chest by approximately one-third of the depth of the chest wall (5-6cm), as this allows for sufficient emptying of the cardiac ventricles.
• Perform compressions at approximately 100-120 compressions per minute.
• Make sure to allow the chest to fully recoil (this allows enough time for the heart’s chambers to refill before the next compression).
• It is absolutely essential to minimise interruptions to chest compressions.
• Alternate the person performing chest compressions at 2-minute intervals (if enough team members are present)
• If tracheal intubation is performed, chest compressions should then be continued without any interruption at a rate of 100-120 a minute.

Example of chest compressions ³

Ventilate the patient

• Perform a head-tilt chin-lift manoeuvre to open the airway and allow effective ventilation.
• Pinch the nostrils closed with your thumb and index finger.
• Place your mouth tightly over the patient’s mouth (or use a pocket-mask or bag-valve-mask if available)
• Deliver 2 breaths (with an inspiratory time of approximately 1 second) and watch for the patient’s chest rising (which confirms you are ventilating them).
• Release the nostrils and observe for the patient’s chest falling as the air is exhaled.
• You should then begin performing another 30 chest compressions.
• Add supplemental oxygen as soon as you are able to.

Mouth-to-mouth ventilation

• In clinical settings, mouth-to-mouth ventilation is not often used because of clinical reasons (e.g. concerns regarding infections) or because airway equipment is available (e.g. pocket-mask, bag-mask or anaesthetic input for tracheal intubation).
• If there are clinical reasons to avoid mouth-to-mouth ventilation, perform chest compressions until help and airway equipment arrives.

Defibrillation

Attach the AED

• Once an automated external defibrillator (AED) arrives, it is import to attach the 2 self-adhesive pads immediately to the patient’s chest (as labelled):
  • ADHESIVE PAD 1: To the right of the sternum below the clavicle
  • ADHESIVE PAD 2: In the mid-axillary line with its long axis vertical and sufficiently lateral
  • If the patient is hairy, you may need to shave the areas to allow adequate contact between the pads and the skin
  • Check for piercings and remove as these can cause burns to the patient during defibrillation (however doing this should not significantly delay defibrillation)

Turn on the AED

• Turn on the AED and follow the audio-visual instructions:
  • Typically the AED will ask you to pause chest compressions whilst it performs a rhythm check.
  • It will then indicate if the rhythm is shockable or non-shockable and instruct you to deliver a shock if it is the former.
  • If a shock needs to be delivered, ensure you and no one else is in contact with the patient and press the deliver shock button on the AED
  • Re-commence CPR after the shock is delivered and follow further instructions from the AED (which will typically involve another rhythm check in 2 minutes).
• Advanced life support would be commenced once the resuscitation team arrives.

If signs of life present or the patient responds to treatment

Arrange an urgent medical assessment

• Call for urgent medical assessment which may be the same resuscitation team as for cardiac arrest, or a dedicated medical emergency team.

Assess ABCDE

Re-assess the patient using a structured ABCDE approach:

• Airway: Ensure airway patent
• Breathing: Give oxygen and monitor with pulse oximetry
• Circulation: Record blood pressure, obtain venous access, attach ECG monitoring
• Disability: Assess AVPU/GCS and check a capillary blood glucose
• Exposure: Inspect for evidence of trauma or other clues as to a diagnosis (e.g. rash or bleeding)

See our ABCDE guides here

Handover

Prepare to handover to the attending medical teams using an SBAR structure (see our guide here)

References

1. Resuscitation Council (UK). Resuscitation Guidelines 2015. Authors: Carl Gwinnutt, Robin Davies, Jasmeet Soar. Accessed August 15th 2018. Available from: [LINK].

2. By BruceBlaus [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

3. By Video by Bangkok Hospital PhuketSegment extracted and converted by Mikael Häggström [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

The Dix-Hallpike test is a diagnostic manoeuvre used to identify benign paroxysmal positional vertigo (BPPV).

The Epley Manoeuvre is used to treat BPPV once it has been diagnosed (by the previously mentioned Dix-Hallpike test).

This article provides a step-by-step guide to performing both the Dix-Hallpike test and the Epley Manoeuvre in an OSCE setting.

Introduction

• Wash hands
• Introduce yourself to the patient
• Confirm the patient’s details (name and date of birth)
• Explain what the examination will involve:
  • “Today I’ve been asked to assess you in relation to the dizziness you’ve been experiencing. The first stage involves me moving you from a sitting to lying position briskly on the examination couch. The second stage will involve me holding your head whilst asking you to roll onto your side and then to sit upright.”
  • “The aim of these procedures is to potentially diagnose and treat the underlying problem causing your dizziness, however, I can’t guarantee a an improvement in your symptoms.”

• Check if the patient has any back or neck problems (if so the examination may not be appropriate, given the significant amount of movement involved)
  • “Do you have any neck or back problems?”
  • “Do you have any pain anywhere currently?”

• Gain consent to perform the examination:
  • “Do you feel you understand what the procedure involves?”
  • “Are you ok for me to perform the procedures I discussed?”

Contraindications

There are some absolute and relative contraindications to the Dix-Hallpike/Epley maneuvres that you should be aware of. ¹

Absolute contraindications

• Fractured odontoid peg
• Recent cervical spine fracture
• Atlanto-axial subluxation
• Cervical disc prolapse
• Vertebro-basilar insufficiency
• Recent neck trauma

Relative contraindications

• Carotid sinus syncope
• Severe neck or back pain
• Recent stroke
• Cardiac bypass surgery within the last 3 months
• Rheumatoid arthritis affecting the neck
• Recent neck surgery
• Cervical myelopathy
• Severe orthopnea

Dix-Hallpike Test

Throughout this sequence of movements, make sure to warn the patient in advance of each step, so that they know what to expect.

1. Ask the patient to sit upright on the examination couch.

2. Adjust the patient’s position so that when supine, their head will hang over the edge of the bed, allowing for head extension below the horizontal plane.

3. Position yourself standing behind the patient (who should be sitting upright on the bed).

4. Turn the patient’s head 45º to one side.

5. Whilst supporting the neck, move the patient from their sitting position to a supine position (in one brisk smooth motion), ensuring their head hangs over the bed 30º below the horizontal plane.

6. Ask the patient to keep their eyes open throughout this process.

7. Inspect the patient’s eyes carefully for evidence of nystagmus for at least 30 seconds.

8. If no nystagmus is observed, the test is then complete for that side and you should carefully sit the patient up.

9. After a short break, the test should be repeated on the other side (turning the patient’s head in the opposite direction in step 4).

Positive test

If the test is positive, the patient will complain of vertigo and you should be able to directly observe nystagmus.

Nystagmus

You should note the following characteristics of the nystagmus:

• Duration
• Direction
• Latency

The typical findings in BPPV include:

• A 2-20 second latent period followed by the onset of torsional (rotary) or horizontal nystagmus:
  • Rotary nystagmus is the most common type and suggests the involvement of the superior semicircular canal
  • Horizontal nystagmus suggests the involvement of the lateral semicircular canal
• Nystagmus typically lasts 20-40 seconds
• The nystagmus typically wanes with repeated Dix-Hallpike tests

Epley Manoeuvre

When performing the Epley manoeuvre, each position should be maintained until full resolution of symptoms and nystagmus has been achieved for at least 30 seconds.

1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline.

2. Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline (still maintaining neck extension over the bed). Keep the patient in this position for 30 seconds.

3. Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards).

4. Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute.

5. Sit the patient up sideways, whilst maintaining head rotation.

6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds.

The entire procedure can be repeated 2-3 times if needed, however, this will depend on whether the patient is able to tolerate further manoeuvres (as they often precipitate vertigo).

References

1. British Society of Audiology. Recommended Procedure for Hallpike Manoeuvre. Published 2014.

This article covers clinical signs that may be found on the hands during routine clinical examination. The list of clinical signs in this article is by no means exhaustive. Each sign is grouped with the system it is usually associated with (e.g. Janeway lesions and the cardiac system). Other associations are also given.

Notably, it does not cover rheumatologic signs in the hands, such as Heberden’s nodes, or swan neck deformity.

Cardiology

Splinter haemorrhages

Dark red/brown vertical lines seen at the top of the nail. They are small emboli lodged in the nail capillaries damaging vessel walls and causing localised haemorrhage. Causes include trauma, sub-acute bacterial endocarditis, scleroderma, and other autoimmune conditions.

Splinter haemorrhages: Micro-emboli deposited in the nail bed

Osler’s nodes

These painful, small, red lesions appear on the fingers. They are the result of immune complex deposition from bacterial endocarditis.

Osler’s nodes: Patient with bacterial endocarditis ¹

Janeway lesions

Painless red spots appearing on the palms. Patients with bacterial endocarditis may develop these lesions from septic emboli causing microhaemorrhage.

Janeway lesions: Patient with endocarditis ²

Fingertip pallor

Fingers appear white and waxy as a result of vasoconstriction or vascular obstruction. Conditions associated with this include peripheral vascular disease, Raynaud’s, Buerger’s disease and CREST syndrome.

Finger pallor: Secondary Raynauds in Sjögrens syndrome ³

Respiratory

Nail clubbing

Nails have increased curvature resulting in the loss of the angle between the nail and nail fold. The exact cause is unclear but patients with clubbing have increased levels of platelets in the microcirculation around the nails resulting in the release of vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF).

Although clubbing can be the result of diseases across multiple systems, it is often related to respiratory pathology when appearing in clinical exams. It is important to remember that clubbing can, in some cases, be a normal finding.

Causes

Respiratory:

• Cystic fibrosis
• Tuberculosis
• Pulmonary fibrosis
• Bronchiectasis
• Bronchial carcinoma

Cardiac:

• Atrial myxoma
• Cyanotic heart disease
• Endocarditis
• Pericarditis

Gastrointestinal:

• Malabsorption
• Inflammatory bowel disease
• Liver cirrhosis

Nail clubbing ⁴

Carbon-dioxide retention flap (Asterixis)

Asterixis is a coarse tremor best seen with the patient’s wrists extended. It can be caused by hypercapnia, typically in conditions such as chronic obstructive pulmonary disease (COPD) and hypoventilation secondary to reduced consciousness level. Asterixis can also be caused by hyperammonaemia and uraemia.

Asterixis

Hepatology

Tendon/tuberous xanthomata

Yellow nodules typically noted over the dorsal aspects of the hands. Lipid-laden macrophages are deposited as the result of hypercholesteraemia.

Xanthomata over the knee joint ⁵

Leukonychia

These white, horizontal bands across the nails are the result of low albumin levels in the blood. This can be the result of either decreased albumin synthesis, as seen in liver disease, or the result of increased albumin loss, usually the result of kidney malfunction (nephrotic syndrome). Leukonychia may also be the result of chemotherapy treatment.

Leukonychia

Palmar erythema

Reddening of the palms from vasodilation. Associated pathology includes liver disease and resultant oestrogen excess, and hyperthyroidism.

Palmar erythema ⁶

Asterixis

This flapping-tremor is best elicited by asking the patient to fully extend their wrists and then close their eyes. It can be a sign of hepatic encephalopathy, usually related to long-term alcohol excess, and indicates high levels of ammonia in the blood sufficient to impact on the motor centres of the brain. Other causes include hypercapnia (as discussed previously) and uraemia.

Miscellaneous

Koilonychia

Classically described as ‘spoon-shaped’, these nails appear hollowed out or concave. They are associated with low levels of iron; this could be severe iron-deficiency anaemia, haemochromatosis, fungal infection, acromegaly, hypothyroidism or malnutrition.

Koilonychia ⁷

Nail pitting

Small indentions of the nail. Pathophysiology is unclear but this pitting is most commonly seen in patients with psoriasis.

Nail pitting in a patient with psoriasis ⁸

Dupuytren’s contracture

The 4th digit (or ring finger) is in a fixed-flexed position, with the tendon raised and visible on the palmar surface. This appearance is the result of thickening and shortening of the palmar fascia, possibly due to local hypoxia. Associations include smoking, alcohol use, diabetes, manual labour and trauma.

Dupuytren’s contracture ⁹

References

1. Roberto J. Galindo [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

2. Warfieldian [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

3. Intermedichbo [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

4. Desherinka [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

5. Min.neel [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons

6. DermNet, Available here: https://www.dermnetnz.org/topics/palmar-erythema/ [Creative Commons Attribution-NonCommercial-NoDerivs 3.0 (New Zealand) at https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode]

7. Corey Heitz MD. Flickr [https://www.flickr.com/photos/coreyheitzmd/15023020192] . Licence [CC2.0 https://creativecommons.org/licenses/by/2.0/].

8. DermNet, Available here: https://www.dermnetnz.org/topics/nail-psoriasis-images/ [Creative Commons Attribution-NonCommercial-NoDerivs 3.0 (New Zealand) at https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode]

9. Frank C. Müller [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

10. Examination of the Hand (The Hand in Diagnosis). Available here: http://stanfordmedicine25.stanford.edu/the25/hand.html#terrys

11. First Aid for USMLE Step 1 (2016 edition)

12. Oxford Handbook of Clinical Medicine

Editor

Fiona Kirkham

This article provides a guide to performing an examination of the oral cavity in an OSCE setting.

Check out our oral cavity examination OSCE mark scheme here.

Preparation

Ensure you have the correct equipment available:

• Gloves
• Headlight
• Tongue depressors (x2)

Introduction

• Wash hands
• Introduce yourself to the patient
• Confirm the patient’s details (name/DOB)
• Explain the examination
• Gain verbal consent
• Ask if the patient currently has any pain
• Ask the patient if they have any dentures/implants that should be removed
• Put on headlight (if available)

General inspection

Ask the patient to open their mouth and say “AHHHH”:

• Perform general inspection of the oral cavity
• Assess mouth opening for pain and trismus

Anatomy of the oral cavity ¹

Closer inspection

Using one tongue depressor to gently depress the tongue, examine the:

• Lips: colour, ulceration, swelling, angular stomatitis
• Tongue: candida, glossitis, ulceration, swelling, rarer conditions (black hairy tongue, Kaposi’s sarcoma)
• Soft palate, hard palate, uvula: swelling, ulceration, papillomas
• Tonsils and pillars: enlargement, asymmetry, peritonsillar swelling, ulceration, inflammation and tonsillar stones

Using one tongue depressor move the tongue to either side and examine:

• Buccal mucosa: ulceration, leucoplakia and trauma
• Stensen’s duct: stones and discharge

Using two tongue depressors examine the:

• Teeth, gums and alveolar margins
• Look for missing teeth, nicotine staining, swelling, leucoplakia, tooth decay, gingivitis and periodontal disease

Gingivitis

Ask the patient to lift their tongue to the roof of their mouth:

• Inspect the opening of the submandibular ducts and the floor of mouth
• Look for ulceration, stones and swellings

Salivary stone in submandibular salivary duct ²

Palpation

If permitted by the patient and examiner, proceed to bimanual palpation of the mouth.

Bimanual palpation of the mouth

Bimanual palpation technique

• Don gloves
• With one finger palpating the neck externally and the other gloved finger in the oral cavity, gently palpate any identified lumps from both sides
• Palpate the lateral wall of the mouth: parotid gland and duct
• Palpate the floor of the mouth: submandibular gland and sublingual gland
• Any intraoral swelling should be described according to site, size, thickness, colour, texture, consistency and tenderness

To complete the examination…

• Thank the patient
• Dispose of gloves and tongue depressors
• Wash your hands
• Summarise your findings to the examiner

Other examinations and investigations to suggest:

• A full examination of the neck, ears and temporomandibular joint
• Flexible nasal endoscopy
• Orthopantomogram if any poor dentition
• Ultrasound neck +/- fine needle aspiration (FNA) for neck and salivary gland lumps
• CT and MRI for any suspected oropharyngeal cancer

Example summary

“Today I performed an examination of the oral cavity on Mr Smith, a 30-year-old man who presented with a submandibular swelling. The most obvious finding on inspection was a small, erythematous swelling in the floor of his mouth. On bimanual palpation, the lump was hard, non-tender and immobile. To complete my assessment I would like to do a full examination of the neck and arrange an ultrasound scan of the lesion.”

References

1. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons

2. James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0, from Wikimedia Commons

3. Klaus D. Peter, Gummersbach, Germany [CC BY 3.0 de (https://creativecommons.org/licenses/by/3.0/de/deed.en)], from Wikimedia Commons

4. Clara Polo Sabat [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

5. GalliasM [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

6. DRosenbach [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0, from Wikimedia Commons

This guide discusses how to approach performing a focused examination of a patient with Parkinson’s disease.

Check out the Parkinson’s disease examination OSCE mark scheme here.

In OSCE scenarios, you may be asked to perform a focused examination to determine the presence (or absence) of a certain condition. It is important to be able to confidently elicit the main diagnostic signs of the condition. In order to do this, you need to be comfortable with the relevant basic system examination (i.e. for a Parkinson’s disease examination you need to be comfortable with performing a full neurological examination).

Note: the instructions may not be specific, for example, the station instructions may say, ‘examine this patient with a tremor’.

Parkinson’s Disease Overview

Parkinsonism is a clinical syndrome characterised by bradykinesia, rigidity, tremor and postural instability.

Idiopathic Parkinson’s disease (PD) is the most common cause of parkinsonism.

Other primary (atypical) Parkinsonian disorders can closely mimic PD, which makes a correct clinical diagnosis challenging. These include Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA), Dementia with Lewy Bodies (DLB) and Corticobasal Syndrome (CBS).

Pathology of Parkinson’s disease

• Loss of dopaminergic neurons from the pars compacta of the substantia nigra.
• Presence of Lewy bodies(eosinophilic cytoplasmic inclusion bodies), containing tangles of α-synuclein and ubiquitin. Spreading from the brainstem to the midbrain and then to the cortex as the disease progresses.

Clinical features of Parkinson’s disease

Parkinson’s is not simply a disorder of movement. Other common features include:

• Depression
• REM-sleep behavioural disorder
• Autonomic dysfunction: constipation, urinary frequency
• Anosmia
• Dementia (late feature, typically older patients)

Introduction

• Wash hands
• Introduce yourself
• Confirm the patient’s details (e.g. name and date of birth)

• Explain the examination:
  • “Today I’m going to perform an examination which will involve me first of all having a general look at you and then asking you to do some movements.”

• Gain consent:
  • “Does everything I’ve said make sense?”
  • “Do you have any questions?”
  • “Are you happy for me to go ahead with the examination?”

• You may like to ask the patient to expose their hands, wrists and elbows (watch this process, it can provide clues)
• Ask if the patient currently has any pain

General Inspection

Parkinson’s disease can be a spot diagnosis– a lot of information can be gained from watching the patient walk into the room and sit down in the chair (we will explore these signs in more detail in the formal assessment of gait).

When the patient is sitting, pay close attention to:

• Spontaneous movements and hand gestures – reduced spontaneous movements
• Eyeblink – slow/less frequent
• Facial expression – expressionless (hypomimia)
• Tremor – asymmetrical tremor at rest – see below
• Fidgeting – decreased
• Speech – soft, indistinct (hypophonia)
• Posture – flexed/stooped

Tremor

Observe tremor

A key, and easily observable sign, in Parkinson’s disease is a tremor, this is typically:

• Resting
• 4-6 Hz
• Asymmetric
• Hands – small tremor in the index finger and thumb (‘pill-rolling’), but can involve the lips, chin and legs

Note if an obvious visible tremor is present – if not, distract the patient by asking them to close their eyes and count back from 20.

Postural tremor

Test for postural tremor by asking the patient to raise their arms in front of their body and spread their fingers. Note: a resting tremor stops on initiation of movement. PD patients may have a re-emergent tremor that presents after a few seconds.

Action (kinetic) tremor

Test for action (kinetic) tremor by performing a finger-nose test – ask the patient to alternate between touching their nose with their finger and touching your finger.

• Ensure the patient stretches their arm out fully
• Slower movements can detect an action tremor more accurately
• Keep your finger in a fixed position

Differential diagnoses

Important differential diagnoses of tremor are:

• Essential tremor – fast, postural and kinetic, improves with rest, head and neck involvement
• Dystonic tremor – task-specific or task exacerbated, flurries, thumb extension

Bradykinesia

Defined as: General slowness and the paucity of movement. 

Test with rapid alternating movements– as big and fast as possible. Use at least 10-20 repetitions for each movement with one limb at a time.

Movements to assess include:

• Finger tapping – ask the patient to oppose their thumb and forefinger
• Hand grip – ask the patient to make a fist and then open their hand wide
• Pronation/Supination – ask the patient to pronate and supinate their hand rapidly
• Toe tap – ask the patient to keep their heel on the ground and tap their toes

Look for:

• Progressive reduction in speed
• Progressive reduction in amplitude
• Asymmetry
• Slowness of initiation

Extra tests to include:

• Writing a sentence and drawing a spiral – asymmetric progressive micrographia
• Undoing and doing up buttons – difficulty with buttons (functional deficit)

Tone

People with Parkinson’s typically have increased muscle tone – a.k.a rigidity. This is not velocity dependent – constant opposition to any passive movement – or direction dependent.

Assess Tone

• Perform a circular wrist movement while taking the weight of the patient’s arm – ask them to relax as much as possible (“let your arm be as floppy as possible while I take the weight”)
• You can also perform circular elbow or ankle movements

Using an activation manoeuvre can accentuate subtle rigidity associated with early Parkinson’s – ask the patient to actively tap their thigh with their contralateral arm while you perform the movement.

Feel for:

• Resistance to movement – sometimes referred to as lead pipe rigidity, although usually more subtle early on or if medicated
• Cogwheel rigidity – resistance at several points in the movement. Due to tremor superimposed upon rigidity

Gait

Assess first the patient’s ability to stand from a seated position with arms across their chest.

Stand near and keep arm behind the patient to offer support if needed!

Ask them to walk up and down the room offering to walk with them if they seem unsteady.

Assess Gait

• Initiation – slow to start walking (failure of gait ignition) and hesitancy
• Step length – reduced stride length, short steps, each step may get progressively smaller as the patient attempts to retain balance (Festinant gait)
• Heel strike – asymmetrical (only one heel strikes) or symmetrical shuffling gait
• Arm swing – reduced arm swing on one side or both
• Posture – flexed trunk and neck, flexed elbows
• Tremor – resting tremor can be observed when the patient is distracted by walking
• Turning – impaired balance on turning or hesitancy, due to postural instability

Pull test

Assess postural instability by performing the pull test.

Note: this may not be appropriate in an OSCE setting, so say to the examiner that you would like to perform this test.

To perform the pull test safely:

• Ensure you are positioned closely behind the patient and between them and a wall (if the patient falls backwards you can support them while hitting the wall
• Clearly explain the test – “I’m going to give you a quick tug on your shoulders and what I want you to do is to take one or two steps backwards to catch your balance. I will be behind you at all times and won’t let you fall.”
• Perform a test by coaching and then tugging more gently
• Quickly tug their shoulders backwards
• If normal, patient corrects their balance in one or two quick steps

To complete the examination

• Thank the patient
• Wash your hands
• Summarise your findings

Example summary

“Today I performed a neurological examination on this 75-year-old gentleman to assess for the presence of Parkinson’s disease. On general inspection, he has reduced facial expressions, reduced spontaneous movements in his arms and a soft voice. An asymmetrical tremor was noted in his left hand at rest, involving his forefinger and thumb, which was more apparent when the patient was distracted. A re-emergent tremor in his left hand was elicited upon extension of both arms. Asymmetric bradykinesia was detected on the left side with progressive slowness and amplitude of rapid alternating movements. Assessment of tone revealed rigidity in the left wrist, elbow and ankle. Observation of the patient’s gait showed a flexed neck and left arm, with a reduced arm swing and an absent heel strike on the left side. He had a short stride length and was hesitant when turning. These findings are consistent with clinical features of parkinsonism.”

Suggest further investigations and assessments

• Perform a cerebellar examination
• Measure lying and standing blood pressure – early autonomic features in multiple system atrophy
• Assess eye movements – vertical gaze palsy and slow saccadic eye movements in progressive supranuclear palsy
• Perform a cognitive assessment (e.g. MMSE) – Lewy Body dementia with parkinsonian symptoms later
• Analyze the drug chart – medications such as neuroleptics, dopamine blocking antiemetics and sodium valproate can induce a secondary parkinsonism

References

1. Ali K, et al. Practical Neurology 2015;15:14– doi:10.1136/practneurol-2014-000849
2. Kumar and Clarks Clinical Medicine, 9^thedition, 2016, Elsevier Publishing

Reviewed by

Oliver Bandmann

Professor of Movement Disorders Neurology

Editor

Fiona Kirkham

A renal system examination involves looking for clinical clues and signs related to end-stage renal disease (e.g. fistula, dialysis catheter, renal transplant), renal failure complications (e.g. fluid overload, uraemia), transplant immunosuppression side effects (e.g. tremor, striae, steroid facies) and possible cause of renal disease (e.g. diabetes, hypertension, polycystic kidney disease).

This guide provides a generic overview of the potential signs you may identify in a patient with renal disease. The commonest renal patients you’ll come across will be those with polycystic kidney disease, a kidney transplant and/or end-stage renal disease on dialysis.

Check out the renal system examination mark scheme here.

Introduction

• Wash your hands
• Introduce yourself
• Confirm the patient’s name and date of birth
• Explain the procedure – “This will involve me looking at your hands, arms, face and stomach. I’d also like to have a feel and listen to your stomach with a stethoscope. This will require exposing the stomach area.”
• Gain consent and consider a chaperone
• Position the patient (initially supine at 45°)
• Enquire about pain or other concerns prior to beginning the examination

General inspection

Around the bedside

• Oxygen, IV drips, medications, haemodialysis machine, peritoneal dialysis machine
• Urinary catheter, drains (e.g. nephrostomy)
• Fluid chart
• Capillary blood glucose machine – diabetes

Patient

• Consciousness – altered consciousness level may be present in severe or end-stage renal disease
• Nutritional/fluid status – look for evidence of cachexia due to protein-energy wasting (PEW), dehydration or fluid overload
• Overt Cushingoid appearance – may be due to steroids for renal transplant immunosuppression or other conditions (e.g. minimal change glomerulonephritis)
• Uraemic complexion – yellow skin colour may indicate advanced chronic kidney disease
• Breathlessness may be due to fluid overload (e.g. due to anuric state)
• Hyperventilation may be due to metabolic acidaemia secondary to renal failure

Hands

Flapping tremor (asterixis):

• Can indicate uraemia due to acute or end-stage renal disease
• Other causes include CO₂ retention and hyperammonemia

Pinprick skin marks from capillary blood glucose readings:

• Suggestive of underlying diabetes

Nail features:

• Beau’s lines – transverse grooves of the nailbed may indicate severe systemic illness
• Muehrke’s lines – transverse white lines of the nail may suggest hypoalbuminaemia
• Lindsay’s half-and-half nail – brown distal fingernails may indicate advanced chronic kidney disease
• Splinter haemorrhages in endocarditis from either valve disease or from dialysis catheter-associated infections

Gouty tophi:

• Common in advanced chronic kidney disease

Skin turgor:

• Useful as part of an overall hydration assessment (decreased in dehydration)

Arms

Radial pulse:

• Perform a brief assessment of rate and rhythm

Inspect for excoriation:

• Pruritus can indicate uraemia

Inspect for bruising:

• May be due to excessive corticosteroid use (i.e. immunosuppression) or platelet dysfunction observed in uraemia

Inspect for obvious warts or skin cancers:

• Associated with immunosuppression (i.e. renal transplant patients)

Inspect for an arteriovenous fistula in the wrist (radio-cephalic fistula) and antecubital fossa (brachio-cephalic or brachio-basilic fistula) or the presence of a synthetic PTFE graft in the antecubital fossa (now commonplace in haemodialysis):

• Indicates requirement of haemodialysis
• Look for needle marks indicating that the vascular access is being used
• Palpate for thrill and auscultate for a bruit (both absent if the fistula is thrombosed or surgically ligated such as after renal transplantation)

Offer to measure blood pressure (not on the side of an AV fistula):

• Elevated in hypertension, chronic kidney disease, transplant rejection or as a side effect to steroids, tacrolimus or ciclosporin for renal transplant immunosuppression
• Rarely, pulsus paradoxus (change in BP >10mmHg during breathing) can occur due to uraemic cardiac tamponade (associated with low jugular venous pressure)

Face

General

Skin colour & skin lesions:

• Yellow skin colour (uraemic complexion) – may indicate chronic renal failure
• Lesions associated with immunosuppression – SCC, BCC, in sun-exposed areas or scars from their excision, gingivostomatitis (HSV) around the mouth

Cushingoid facial appearance:

• May be due to steroids for renal transplant immunosuppression or treatment of glomerulonephritis.

Hypertrichosis:

• Can occur in patients on ciclosporin for renal transplant immunosuppression

Hearing aid:

• May suggest Alport’s syndrome

Eyes

Conjunctival pallor:

• Anaemia due to chronic renal failure

Calcification of cornea (band keratopathy):

• Rarely due to elevated blood phosphorus in renal failure

Periorbital oedema:

• Can be seen in nephrotic syndrome

Mouth

Gingival hypertrophy:

• A potential side-effect of immunosuppressants for renal transplant

Uraemic fetor (breath smelling like ammonia):

• Occurs due to uraemia and is seen in end-stage renal disease

Neck

Assess jugular venous pressure (JVP)

1. Ensure the patient is positioned at 45°

2. Ask the patient to turn their head away from you

3. Observe the neck for the JVP – located inline with the sternocleidomastoid

4. Measure the JVP – number of centimetres from the sternal angle to the upper border of pulsation

A raised JVP may indicate – fluid overload, right ventricular failure, tricuspid regurgitation

Other

Look for the presence of an indwelling dialysis catheter at the base of the neck or front of the chest wall.

Inspect for a small horizontal scar at the base of the neck:

• It may be a parathyroidectomy scar (performed for renal hyperparathyroidism)
• May have scars around the base of neck from previous dialysis catheters

Chest

Inspection

Obvious warts or skin cancers:

• Can be caused by immunosuppression (i.e. in the context of renal transplant)

Excoriations:

• Pruritus can indicate uraemia

Bruising:

• May be due to steroids for renal transplant immunosuppression

Percuss

Dull area of percussion on the chest wall:

• May occur if hypoalbuminaemia or fluid overload causes pleural effusion

Palpate

Palpate the apex beat:

• Normally located in the 5th intercostal space in the mid-clavicular line
• Palpate the apex beat with your fingers (placed horizontally across the chest)
• Displacement may indicate fluid overload or heart failure

Auscultate

Auscultate heart sounds:

• Note any added sounds which may indicate heart failure and/or fluid overload
• A friction rub may suggest uraemic pericarditis

Auscultate lung bases:

• Bibasal crackles may suggest pulmonary oedema secondary to fluid overload
• Vocal resonance may indicate a pleural effusion (e.g. nephrotic syndrome)

Abdomen

Inspection

Position the patient flat with their abdomen fully exposed. Look for striae associated with corticosteroid use or abdominal wall oedema associated with fluid overload.

Abdominal distension:

• Intrabdominal masses (i.e. polycystic kidneys)
• Ascites (i.e. nephrotic syndrome)
• Indwelling peritoneal dialysis fluid (look for peritoneal dialysis catheter)

Scars:

• Rutherford-Morrison (‘hockey-stick’) scar for renal transplant
• Bilateral iliac fossae scars from a simultaneous pancreas-kidney transplant (for a patient with type 1 diabetes)
• Peritoneal dialysis catheter insertion scar near the umbilicus
• Nephrectomy scar in the flank
• Lipodystrophy marks from insulin injections for diabetes

Other:

• Tenckhoff catheter in situ for peritoneal dialysis
• Nephrostomy tube(s) in situ

Palpation

Light and deep abdominal palpation

Palpate the 9 abdominal regions lightly then deeply:

• If a palpable mass is present, consider a polycystic kidney
• A palpable mass and scar in the right or left iliac fossa is suggestive of renal transplant

Ballot the kidneys

1. Place your left hand behind the patient’s back, at the right flank

2. Place your right hand just below the right costal margin in the right flank

3. Press your right hand’s fingers deep into the abdomen

4. At the same time press upwards with your left hand

5. Ask the patient to take a deep breath

6. You may feel the lower pole of the kidney moving inferiorly during inspiration

7. Repeat this process on the opposite side to assess the left kidney

If the kidney is palpable describe the size and consistency:

• Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis
• A unilaterally enlarged, ballotable kidney can be due to a renal tumour

Percussion

Shifting dullness

1. Percuss from the centre of the abdomen to the flank until dullness is noted

2. Keep your finger on the spot at which the percussion note became dull

3. Ask the patient to roll onto the opposite side to which you have detected the dullness

4. Keep the patient on their side for 30 seconds

5. Repeat your percussion in the same spot:

• If fluid was present (ascites) then the area that was previously dull should now be resonant
• If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)

Auscultation

Auscultate for a renal bruit just above and lateral to umbilicus on both sides:

• A bruit may indicate renal artery stenosis (a possible cause of hypertension or renal failure)

Other

Palpate for sacral and lower limb oedema:

• May indicate fluid overload in nephrotic syndrome or glomerulonephritis or renal impairment

To complete this examination

• Thank the patient
• Allow them time to re-dress
• Wash hands
• Summarise findings

Suggest further assessments and investigations

• Blood pressure – if not already performed (not on the side of the AV fistula)
• Fundoscopy – to assess for the presence of hypertensive or diabetic retinopathy
• Urinalysis – to screen for evidence of infection and to assess for haematuria/proteinuria associated with glomerular disease
• 24-hour urine collection – to assess various urinary compounds and the degree of proteinuria or spot urine protein-creatinine ratio or albumin-creatinine ratio
• MSU – if a urinary tract infection is suspected
• U&Es – to assess renal function
• Bicarbonate – to check for acidaemia
• Bone profile – to assess the levels of calcium, phosphate and PTH (secondary and tertiary hyperparathyroidism)

Reviewed by

Dr Ian Logan

Consultant Nephrologist 

Dr Paul Callan

Consultant Cardiologist

Paediatrics is full of respiratory presentations and thus, respiratory examinations. This guide provides an overview of how to perform a paediatric respiratory examination in an OSCE setting.

It is important to be flexible when examining a child, adjusting your approach whilst taking into consideration the patient’s age, personality and how unwell they are.

Be opportunistic in your examination – i.e. taking advantage of periods of quiet to listen to the chest, open mouth yawns or cries to look at the throat. Remember, parents and carers can also be a great asset – helping to explain the next step in the examination and position the child as you need them. Work as a team!

Check out our paediatric respiratory examination mark scheme here.

Introduction

• Wash your hands
• Introduce yourself to both the parents and the child
• Explain what the respiratory examination will involve
• Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform a respiratory examination, which will involve observing your child, feeling their pulse and listening to their breathing with my stethoscope.

Are you happy for me to carry out the examination?

General Inspection

Appearance and Behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour:

• How alert is the child?
• How active is the child?
• Do they look ‘well’ or ‘sick’? (see this useful resource)
• Do they appear to be a normal colour? (e.g. pallor, cyanosis)
• Do they have an obvious rash?
• Do they appear a healthy weight?

Pay attention to features that may indicate the presence of an underlying genetic condition:

• Stature (e.g. tall/short)
• Syndromic facial features
• See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with respiratory system pathology.

Sounds

Note any audible sounds as you observe the child and consider what underlying pathology they may indicate:

• Cough with wheeze – asthma, viral-induced wheeze
• Productive cough – lower respiratory tract infection
• Barking cough – croup, laryngomalacia
• Dry cough – allergies, tuberculosis
• Hoarse voice – laryngitis
• Hot potato voice – peritonsillar abscess
• Acute stridor – croup, foreign body, bacterial tracheitis, epiglottitis
• Chronic stridor – laryngomalacia, subglottic stenosis

Equipment

Observe for any equipment in the patient’s immediate surroundings and consider why this might be relevant to the respiratory system:

• Mobility aids – a neuromuscular disorder
• Feeding tubes (NG/NJ/Gastrostomy) – ex-premature infant, cystic fibrosis
• Oxygen saturation monitor or oxygen cylinder – chronic lung disease
• Tracheostomy – upper airway obstruction – each child in the UK should have a box of emergency tracheostomy equipment (often blue/red in colour) – see our tracheostomy overview guide

Medications

Note any medications by the bedside or in the patient’s room and consider what underlying diagnoses they may indicate:

• Antibiotics – pneumonia, bronchiectasis, cystic fibrosis
• Inhalers – asthma
• Pancreatic enzymes – cystic fibrosis

Hands

Inspect the hands

• Peripheral cyanosis – hypoxia, hypothermia
• Finger clubbing – bronchiectasis, cystic fibrosis, primary ciliary dyskinesia
• Eczema – increased likelihood of asthma and hayfever (atopy)
• Tremor – beta 2 agonist use (e.g. salbutamol)

Pulses

• Radial pulse (femoral pulse in babies) – assess rate and rhythm

Face

Observe the child’s facial complexion and features, including their eyes, ears, nose, mouth and throat.

General

• Nasal flaring/grunting – increased work of breathing
• Micrognathia (undersized jaw) – associated with a wide range of genetic syndromes (e.g. Pierre Robin, Noonan, Marfan)

Eyes

• Conjunctival pallor – anaemia

Ears

• Hearing aids – primary ciliary dyskinesia

Mouth

• Central cyanosis – bluish discolouration of the lips and/or the tongue – persistent pulmonary hypertension, bronchospasm, lower respiratory tract infection
• Cleft palate
• Tip: Ask the child to see how long their tongue is or how big their mouth is.

Nose

• Deviated nasal septum
• Nasal polyps – atopy, cystic fibrosis

Throat

• Inspect the throat using a pen torch and tongue depressor (this is often best left until the end of the examination of young children, as it is likely to upset them)
• Tonsillar hypertrophy – recurrent tonsillitis, airway obstruction

Neck

• Inspect tracheal position
• Palpate the cervical lymph nodes
• Lymphadenopathy may indicate infection (most commonly) or malignancy

Expose the Chest

Ask the parent or child (if appropriate) to expose the child’s chest.

Observe the chest, paying particular attention to the respiratory rate and work of breathing.

Respiratory rate

• Count the respiratory rate whilst observing the child.
• The range of a normal respiratory rate varies significantly depending on the age of the child, so make sure to take this into account.

Work of breathing

Assess for signs of increased work of breathing.

General signs of increased work of breathing

• Difficulty speaking (or feeding)
• Expiratory grunting (increasing positive end-expiratory pressure)

Recession

• Tracheal tug
• Supraclavicular recession
• Intercostal recession
• Subcostal recession

Use of accessory muscles

• Nasal flaring
• Abdominal breathing
• Head bobbing (secondary to sternocleidomastoid contractions)

Chest wall shape

Observe the shape of the child’s chest, looking for any abnormalities:

• Asymmetry of chest wall movement – pneumothorax, consolidation
• Harrison’s sulcus (indrawing of the chest wall from long term diaphragmatic tug) – poorly controlled asthma
• Chest hyper-expansion (barrel chest) – asthma, chronic respiratory obstruction
• Pectus excavatum (hollow chest) and pectus carniatum (Pigeon chest) – Marfan syndrome, Noonan syndrome, Osteogenesis imperfecta

Examine the Chest

Palpation

Assess chest expansion

• Place your hands on the child’s chest, inferior to the nipples
• Gently wrap your fingers around either side of the chest
• Bring your thumbs together in the midline, so that they touch
• Observe the movement of your thumbs, they should move apart equally
• If one of your thumbs moves less, this suggests reduced expansion on that side
• Reduced expansion can be caused by lung collapse, pneumonia and restrictive lung disease

Palpate the apex beat

Palpate the cardiac apex, noting its position:

• Normal position – 5^th intercostal space, midclavicular line
• Left displacement – cardiomegaly
• Right displacement – dextrocardia, diaphragmatic hernia

Percussion

• Warn the child before beginning percussion – ‘I’m going to play your chest like a drum!’
• Perform percussion gently, comparing one side to the other.
• Percussion is often not performed on younger children

Percussion technique

1. Place your non-dominant hand on the chest wall

2. Your middle finger should overlie the area you want to percuss (between ribs)

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger

4. The striking finger should be removed quickly, otherwise, you may muffle resulting percussion note

Types of percussion note

• Resonant – this is a normal finding
• Dullness – this suggests increased tissue density – consolidation, fluid, tumour, collapse
• Stony dullness – this suggests the presence of a pleural effusion
• Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – pneumothorax

Auscultation

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.

Suggest listening to their chest, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.

Auscultate the chest in a systematic manner:

• Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths
• Auscultate each side of the chest in a symmetrical pattern, comparing side to side
• Pay attention to the inspiratory and expiratory sounds at each placement
• Note the quality and volume of breath sounds
• Note any additional sounds
• Repeat auscultation on the posterior aspect of the chest

Vesicular breath sounds

• Low frequency, non-musical sound, barely audible at rest
• A normal finding
• Be aware that harsh breath sounds from the upper airway are readily transmitted to the upper chest in infants, which can be misinterpreted as abnormal added sounds.

Bronchial breath sounds

• Higher pitched, harsh breath sounds
• Normal to be heard over the trachea
• If heard elsewhere, they are suggestive of consolidation
• Length of inspiration and expiration is equal

Crackles

• Coarse crackles – consolidation, pulmonary oedema
• Fine crackles – pulmonary fibrosis

Wheeze

• High pitched expiratory sound
• Distal airway obstruction
• Polyphonic – asthma
• Monophonic – foreign body

Vocal resonance

• Increased – consolidation
• Reduced – effusion

Stridor

• Harsh, low pitched inspiratory noise from upper airway obstruction

Pleural rub

• Inflamed pleura secondary to pneumonia or pulmonary embolism

Reduced air entry

• Pneumothorax
• Consolidation
• Asthma – severe
• Pleural effusion

Diagram of areas to percuss and auscultate on the anterior chest (repeat on the posterior chest)

To Complete the Examination…

• Ensure the child is re-dressed after the examination
• Thank the child and/or parents
• Explain your findings to the parents and/or child
• Ask if the parents and/or child have any questions
• Wash your hands

Further clinical assessments to consider

• ENT Examination
• Cardiovascular examination
• Abdominal examination
• Neurological examination
• Assess inhaler technique
• Lung function testing

Further investigations

• Record a full set of vital signs (including pulse oximetry)
• Assess peak expiratory flow rate
• Send a sputum sample for culture
• Plot the height and weight on a growth chart
• Consider the need for a venous blood gas
• Consider the need for a chest x-ray

Syndromes that may impact the respiratory system

Below is a non-exhaustive list of clinical syndromes which can be associated with respiratory system pathology. The features of the syndrome relevant to the respiratory system are shown in bold.

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar

References

• RCPCH. Spotting the sick child [LINK]
• Lissauer, T., Clayden, G., & Craft, A (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
• Robertson (2017). Paediatric Respiratory History and Examination. Royal Children’s Hospital Melbourne.[LINK] (Accessed 4 Mar 19)
• Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.
• Taylor, Gfeller, & Ring (date unknown). Respiratory Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 4 Mar 2019)
• Whitehouse & Ng (2019). Respiratory Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics.[LINK] (Accessed 4 Mar 2019)

Photo credits

• Rijksmuseum (2019). Portret van Johannes Kojo, en face. Adapted by Geeky Medics – Available at:[LINK] [Accessed 25 Mar. 2019].

A paediatric abdominal examination is generally performed in one of three major clinical settings – as part of a routine clinical examination, in the assessment of an ‘acute abdomen’ or in cases of recurrent abdominal pain, distension or constipation.

Care must always be taken to make sure no undue pain or discomfort is caused to the child. Rapport and trust can be lost very quickly and further examination might then be impossible.

Check out our paediatric respiratory examination mark scheme here.

Introduction

• Wash your hands
• Introduce yourself to both the parents and the child
• Explain what the abdominal examination will involve
• Gain consent from the parents/carers and/or child before proceeding.

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

Are you happy for me to carry out the examination?

General Inspection

Appearance and Behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour:

• How alert is the child?
• How active is the child?
• Do they appear to be a normal colour? (e.g. pallor, jaundice, cyanosis)
• Do they have an obvious rash?
• Do they appear a healthy weight?
• Do they look in pain?
• Overall, do you think the child looks ‘well’ or ‘sick’

Pay attention to features that may indicate the presence of an underlying genetic condition:

• Stature (e.g. tall/short)
• Syndromic facial features
• See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with gastrointestinal system pathology.

Equipment

Observe for any equipment in the patient’s immediate surroundings and consider why this might be relevant to the gastrointestinal system:

• NG/NJ tube – bowel obstruction, short bowel syndrome, inflammatory bowel disease, gastroesophageal reflux, glycogen storage disorder, chronic liver disease, malignancy, anorexia
• Gastrostomy – typically only used in an NG/NJ is needed for more than 6 weeks – indicative that the child has a chronic condition
• Colostomy/Ileostomy – inflammatory bowel disease, malignancy
• Stool sample pot
• Intravenous lines/drip
• Medication
• Special feeds or milks

Medications

Note any medications by the bedside or in the patient’s room and consider what underlying diagnoses they may indicate:

• Laxatives (e.g. Movicol/Senna) – constipation
• Antiemetics (e.g. Ondansetron) – nausea/vomiting
• Pancreatic enzymes – cystic fibrosis

Hands

Inspect the hands

• Finger clubbing – cystic fibrosis, liver disease, inflammatory bowel disease
• Koilonychia (spooning of the nails) – iron deficiency
• Leukonychia (whitened nail bed) – hypoalbuminaemia
• Palmar erythema – chronic liver disease, polycythaemia, Kawasaki’s disease, thyrotoxicosis
• Peripheral oedema – nephrotic syndrome, liver disease

Pulses

Radial pulse (femoral pulse in babies) – assess rate and rhythm

Face

Observe the child’s facial complexion and features, including their eyes, ears, nose, mouth and throat.

General

• Oedema – nephrotic syndrome, liver disease
• Pallor – anaemia

Eyes

• Conjunctival pallor – anaemia
• Scleral icterus – jaundice – hepatic pathology, haemolysis
• Aniridia (partial or complete absence of the coloured part of the eye) – Wilm’s tumour, WAGR syndrome
• Kayser Fleischer rings – Wilson’s disease
• Neuroblastoma – loss of the eye’s red reflex
• Xanthelasma and corneal arcus – hyperlipidaemia

Mouth

• Angular stomatitis – inflammation of the corners of the mouth – iron deficiency or vitamin b12 deficiency
• Glossitis – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency 
• Aphthous ulcers – benign, Crohn’s disease, Bechet’s disease
• Dental caries – neglect, gastroesophageal reflux disease
• Macroglossia – Down’s syndrome, hypothyroidism, mucopolysaccharidoses, Beckwith-Wiedemann syndrome
• Pigmentation/Polyps – Peutz-Jeghers syndrome
• Tip: Ask the child to see how long their tongue is or how big their mouth is

Neck

• Palpate the cervical lymph nodes
• Palpate supraclavicular lymph nodes
• Lymphadenopathy may indicate infection (most commonly) or malignancy (e.g. Virchow’s node)

Expose The Abdomen

Ask the parent or child (if appropriate) to expose the child’s abdomen.

If possible, the child should lay on a bed at 45-degrees initially for inspection and then lay flat for the examination of the abdomen (however, this is often difficult to achieve in reality).

Inspect the abdomen for any abnormalities:

• Distension – constipation, Hirschsprung’s disease, ascites, organomegaly, malignancy
• Striae – obesity, Cushing’s syndrome
• Caput medusae – portal hypertension
• Spider naevi (may be noted on abdomen or chest) – chronic liver disease
• Hernia – inguinal, umbilical
• Drains/tubes/access – gastrostomy, central venous catheter, ileostomy, colostomy
• Scars (see diagram below)
• Tip: The abdomen is normally protuberant in toddlers and young children.

Examples of scar locations

Examine The Abdomen

Preparing to palpate the abdomen

• Kneel down and/or raise the bed, your face is level with the child’s face.
• Use warm hands, explain and relax the child.
• Keep the parent close at hand.
• Abdominal wall muscles must be relaxed for palpation to be effective. Ensure the child is lying down entirely flat, with their hand by their sides. Take away any pillows or cushions.
• Expose the abdomen entirely, lower the trousers and underwear, cover the child with a sheet.

Light palpation

• Perform light palpation of the 9 abdominal regions, whilst looking at the child’s face and assessing for rigidity, tenderness, guarding and palpable masses.
• Avoid mentioning to word “pain” or “hurt” (e.g. “Is this painful?” “Does that hurt?”) when examining young children, as this can often provoke fear and upset. Instead, observe the child’s body language and facial expressions to determine if they are in pain.
• Guarding is suggestive of peritonitis and indicates the need for urgent surgical review.

Deep palpation

• Repeat palpation of the 9 abdominal regions, this time applying greater pressure to better assess intra-abdominal structures (continue to observe the child’s face for signs of discomfort).
• If any masses are identified, determine their location, approximate size, shape, consistency and mobility.

Tenderness

• Localised in appendicitis (RIF), hepatitis (RUQ) and pyelonephritis (flank).
• Generalised in mesenteric adenitis and peritonitis.

Guarding

• Pain on coughing, moving about/walking/bumps during a car journey suggests peritoneal irritation.
• A child walking, whilst being flexed forwards suggests psoas irritation (e.g. appendicitis).
• Incorporating play may be used to elicit more subtle guarding.
• “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

Abnormal masses

• Wilm’s tumour – renal mass, sometimes visible, does NOT cross the midline
• Neuroblastoma – irregular firm mass, may cross the midline, the child is usually very unwell
• Faecal masses – mobile, non-tender, indentable, often in the LIF
• Intussusception – acutely unwell, the mass may be palpable, most often in RUQ

Liver palpation

• Palpate from the right iliac fossa and locate the edge of the liver with the tips or sides of your fingers (ask the child to take deep breaths if appropriate).
• The liver edge may be soft or firm and you will be unable to get above it. The edge will move with respiration.
• Measure in centimetres the extension of the liver edge below the costal margin in the mid-clavicular line.
• Percuss downwards from the right lung to exclude downward displacement due to lung hyperinflation (i.e. in bronchiolitis).
• Dullness to percussion can help delineate the upper and lower border. Record the span of the liver (in cm).
• Tip: Young children may be more cooperative if you palpate first with their hand or by putting your hand on top of theirs.

Causes of hepatomegaly

There are several potential causes of hepatomegaly including:

• Infection – congenital, infectious mononucleosis, hepatitis, malaria
• Haematological – sickle cell anaemia, thalassaemia
• Malignancy – leukaemia, lymphoma, neuroblastoma, Wilms tumour, hepatoblastoma
• Metabolic – glycogen and lipid storage disorders, mucopolysaccharidoses
• Cardiovascular – heart failure
• Apparent hepatomegaly – chest hyper-expansion (e.g. bronchiolitis/asthma)

Splenic palpation

• A palpable spleen is at least TWICE its normal size.
• Palpate from the right iliac fossa towards the left upper quadrant (ask the child to take deep breaths if appropriate).
• The edge is usually soft and you will be unable to get above it.
• The splenic notch is occasionally palpable if markedly enlarged.
• The spleen should move with respiration.
• Measure the degree of extension below the costal margin (in cm) in the mid-clavicular line.
• Percuss to delineate the lower border (splenic tissue will be dull to percussion)

Causes of splenomegaly

There are several potential causes of splenomegaly including:

• Infection – infectious mononucleosis, malaria, leishmaniasis
• Haematological – haemolytic anaemia
• Malignancy – leukaemia, lymphoma
• Other – portal hypertension, Still’s disease
• Apparent splenomegaly – chest hyper-expansion (e.g. bronchiolitis/asthma)

Kidneys

• The kidneys are not usually palpable beyond the neonatal period unless they are enlarged or the abdominal muscles are hypotonic.
• Palpate the kidneys by balloting bi-manually in each hypochondrium.
• You can ‘get above them’ (unlike the spleen or liver).
• Tenderness implies inflammation.
• Unilaterally large – hydronephrosis, cyst or tumour
• Bilaterally large – hydronephrosis, kidney stones, polycystic kidneys

Ascites

• Ascites may be present in cirrhosis, hypoalbuminaemia, infection or malignancy.
• The presence of shifting dullness is highly suggestive of ascites

Assessing for shifting dullness

It is usually not possible to formally assess for shifting dullness in young children, due to issues with co-operation. However, in older children, it may be possible.

1. Percuss from the centre of the abdomen to the flank until dullness is noted

2. Keep your finger on the spot at which the percussion note became dull

3. Ask the patient to roll onto the opposite side to which you have detected the dullness

4. Keep the patient on their side for 30 seconds

5. Repeat your percussion in the same spot

6. If fluid was present (ascites) then the area that was previously dull should now be resonant

7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)

Auscultation

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

Suggest listening to their abdomen, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.

Perform auscultation of the abdomen, listening for

• Normal bowel sounds – should occur a minimum of every 2 minutes
• ‘Tinkling’ bowel sounds – obstruction
• Absent bowel sounds – peritonitis/ileus

Genital examination

A genital examination is often performed routinely in infants and young children, however in older children or teenagers it should only be performed if relevant (i.e. vaginal discharge, suspicion of inguinal hernia or perineal rash).

Male genital examination

• Ensure normal penile and scrotal development
• Assess for penile abnormalities – hypospadias, chordee
• Assess for descended tests – with one hand over the inguinal region, palpate the testicles with the other hand (record if testis descended, retractile or impalpable)
• Note any scrotal swelling – hydrocele, hernia

Female genital examination

• Confirm the external genitalia look normal

Rectal examination

• Not routinely performed and if indicated, it should be performed by a specialist who has experience interpreting findings
• Confirm the anus looks normal and perforate
• Anal skin tags (Crohn’s)
• Anal prolapse
• Staining of underwear (may suggest constipation)

Lower limbs

• Inspect for ankle oedema (nephrotic syndrome/liver disease)

To Complete the Examination…

• Ensure the child is re-dressed after the examination
• Thank the child and/or parents
• Explain your findings to the parents and/or child
• Ask if the parents and/or child have any questions
• Wash your hands

Further clinical assessments to consider

• Nutritional assessment
• Examination of hernial orifices
• Pelvic examination in female adolescents if indicated

Further investigations

• Record a full set of vital signs
• Plot the height and weight on a growth chart
• Perform urinalysis
• Stool analysis

Syndromes that may impact the gastrointestinal system

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar

References

• Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
• Miin Lee & Fawbert (2014). Abdominal Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics [LINK] (Accessed 22 Mar 2019)
• Paeds.co.uk (2009) Surgical Scars – Abdomen. Paeds.co.uk the online paediatrician’s encyclopaedia. [LINK] (Accessed 4 Mar 2019)
• Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.

Photo credits

1. “Eyes wide open” by Jim Champion, Flickr is licensed under CC BY-SA 2.0
2. “Livia Fair 5 days old” by Jon Haynes Photography, Flickr is licensed under CC BY-SA 2.0
3. Photo by Irina Murza on Unsplash

The paediatric cardiovascular exam can be a logistical minefield, requiring a good understanding of cardiac anatomy and possible congenital anomalies. With babies especially, it’s important to be opportunistic with your examination – doing the three ‘quiet things’ first: auscultation of heart sounds, auscultation of breath sounds and palpation of femoral pulses.

With all children, don’t expect to follow a pre-defined order. Be creative and playful, making the examination into a game involving parents, siblings and the toys available to you.

Check out the paediatric cardiovascular examination mark scheme here.

Introduction

• Wash your hands
• Introduce yourself to both the parents and the child
• Explain what the cardiovascular examination will involve
• Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform an examination of your child’s heart, which will involve first watching your child, then feeling their pulse and listening to their chest with my stethoscope.

Are you happy for me to carry out the examination?

General Inspection

Appearance and Behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour:

• How alert is the child?
• How active is the child?
• Do they appear to be a normal colour? (e.g. Is there any pallor, cyanosis or jaundice?)
• Do they have an obvious rash?
• Do they appear a healthy weight

Pay attention to features that may indicate the presence of an underlying genetic condition:

• Stature (e.g. tall/short)
• Syndromic facial features
• See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with cardiovascular system pathology.

Equipment

Observe for any equipment in the patient’s immediate surroundings and consider why this might be relevant to the cardiovascular system:

• O2 saturation probe and monitor
• Oxygen mask, nasal prongs, oxygen tank and other breathing support
• Intravenous medication
• Wheelchair

Medications

Note any medications by the bedside or in the patient’s room and consider what underlying diagnoses they may indicate:

• Anticoagulants (e.g. Warfarin/Heparin) – artificial heart valves
• Antihypertensives (e.g. ACE inhibitors) – hypertension
• Diuretics (e.g. Furosemide) – heart failure

Hands

Inspect the hands

• Peripheral cyanosis – cyanotic congenital heart disease, hypothermia
• Finger clubbing – infective endocarditis, cyanotic congenital heart disease
• Osler’s nodes (tender red nodules on finger pulps/thenar eminence) – infective endocarditis
• Janeway lesions (non-tender maculopapular erythematous palm pulp lesions) – infective endocarditis
• Splinter haemorrhages (reddish/brown streaks on the nail bed) – infective endocarditis
• Absent thumbs – Holt-Oram syndrome

Pulses

Radial pulse (femoral pulse in babies) – assess the rate, rhythm and character

Radio-radial or radio-femoral delay:

• Palpate both radial pulses simultaneously (or contralateral radial and femoral pulses)
• The pulses should occur at the same time in a healthy child
• A delay may suggest aortic coarctation 

Jugular Venous Pressure (JVP)

Assessment of the JVP is only performed in children older than 8 years old.

1. Ensure the patient is positioned at 45°

2. Ask the child to turn their head away from you

3. Observe the neck for the JVP – located inline with the sternocleidomastoid

4. Measure the JVP – number of centimetres from the sternal angle to the upper border of pulsation

A raised JVP may indicate, fluid overload, right ventricular failure or tricuspid regurgitation.

Face

Observe the child’s facial complexion and features, including their eyes, ears, nose, mouth and throat.

General

• Malar flush – mitral stenosis
• Nasal flaring/grunting – congenital cyanotic heart disease, heart failure

Eyes

• Conjunctival pallor – anaemia
• Scleral icterus – jaundice

Mouth

• Central cyanosis – bluish discolouration of the lips and/or the tongue – cyanotic congenital heart disease
• Angular stomatitis – inflammation of the corners of the mouth – iron deficiency 
• High arched palate – suggestive of Marfan syndrome – increased risk of aortic aneurysm/dissection
• Dental hygiene –important if considering sources for infective endocarditis
• Tip: Ask the child to see how long their tongue is or how big their mouth is

Expose the Chest

• Ask the parent or child (if appropriate) to expose the child’s chest.
• Observe the chest, looking for any scars or visible pulsations.
• Note the shape of the chest wall.
• Tip: If you ask a child to show you their tummy they’ll almost always lift their top up to expose their chest as well.

Chest wall shape

Observe the shape of the child’s chest, looking for any abnormalities:

• Pectus excavatum (hollow chest) and pectus carniatum (Pigeon chest) – Marfan syndrome, Noonan syndrome
• Pre-cordial bulge – cardiomegaly
• Visible ventricular impulse – normal in thin children, can be associated with left ventricular hypertrophy

Chest wall scars

1. Sternotomy

• All complex cardiac surgeries
• Pulmonary atresia banding

2. Right thoracotomy

• Blalock–Taussig shunt (used to increase pulmonary blood flow for palliation in duct-dependent cyanotic heart defects like pulmonary atresia)
• Pulmonary atresia banding
• Non-cardiac – lobectomy, tracheoesophageal fistula repair

3. Left thoracotomy

• Patent ductus arteriosus ligation
• Blalock–Taussig shunt
• Pulmonary atresia banding
• Coarctation of aorta repair
• Non-cardiac – lobectomy

4. Pacemaker or implantable cardioverter-defibrillator scar

5. Chest drain scars

Palpation

Start with the abdomen and then work up to the chest. If appropriate, ask the child what they ate for their last meal and try to ‘find it’. If you can’t ‘find it’, you’ll have to listen – leading you to auscultation (sneaky right?).

Abdomen

Liver

In a healthy child, the liver edge may be palpated up to 2cm below the costal margin. If the liver edge is more prominent, it would suggest the presence of hepatomegaly. Heart failure is a potential cause of hepatomegaly.

1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger)

2. Press your hand into the abdomen as the child breathes in

3. Feel for a step, as the liver edge passes below your hand

4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher 

If you feel the liver edge, note the following:

• The degree of extension below the costal margin
• The consistency of the liver edge (smooth/irregular)
• Tenderness – suggestive of hepatitis 
• Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation

Spleen

If hepatomegaly is present, you should also assess for splenomegaly. See the paediatric abdominal examination guide for details on how to perform splenic palpation.

Chest

Palpate the apex beat

Palpate the cardiac apex, noting its position.

Normal position:

• <7 years old: 4^th intercostal space, to the left of the midclavicular line
• >7 years old: 5^th intercostal space, midclavicular line

Abnormal position:

• Left displacement – cardiomegaly, pectus excavatum, scoliosis
• Right displacement – dextrocardia, left diaphragmatic hernia, collapsed lung on right, left pleural effusion, left pneumothorax

Assess for heaves and thrills

Heaves:

• A parasternal heave is a precordial impulse that can be palpated
• Parasternal heaves are present in patients with right ventricular hypertrophy
• Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
• If heaves are present you should feel the heel of your hand being lifted with each systole
• Tip: Instead of the heel of your hand, use your fingertips with babies and younger children

Thrills:

• A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
• You should assess for a thrill across each of the heart valves in turn
• To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed

Auscultation

Auscultate the heart

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.

Suggest listening to their chest, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.

Tip: Play a game to see who can stay quiet the longest – involve the parents!

Areas of the heart to auscultate

Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope:

• Mitral valve – 5th intercostal space – midclavicular line (apex beat)
• Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge
• Pulmonary valve – 2nd intercostal space – left sternal edge
• Aortic valve – 2nd intercostal space – right sternal edge

Listen over each area with both the bell (for low pitched sounds – gallops and split S2) and the diaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).

Tip: Complex cardiac anomalies may cause you to hear multiple dynamic murmurs (e.g. Tetralogy of Fallot)

Auscultate the lungs

• Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths
• Auscultate each side of the chest in a symmetrical pattern, comparing side to side
• Pay attention to the inspiratory and expiratory sounds at each placement
• Note the quality and volume of breath sounds
• Note any additional sounds
• Repeat auscultation on the posterior aspect of the chest
• Coarse bibasal crackles may be a late sign of pulmonary congestion secondary to congestive heart failure.

To Complete the Examination…

Assess for oedema

• Ask the parents if the child looks puffy or swollen.
• Inspect the limbs, sacral area and face – affected areas will depend on the age of the child and mobility status.
• Peripheral oedema often occurs in right-sided heart failure.

Final steps

• Ensure the child is re-dressed after the examination
• Thank the child and/or parents
• Explain your findings to the parents and/or child
• Ask if the parents and/or child have any questions
• Wash your hands

Further clinical assessments to consider

• Abdominal examination (hepatomegaly)
• Peripheral vascular examination (oedema)
• Inguinal examination (central venous access scars, femoral pulses)

Further investigations

• Record a full set of vital signs (including pulse oximetry)
• Plot the height and weight on a growth chart
• Urine dipstick (proteinuria)
• ECG

Extra information

Murmurs

More than 50% of children will have a murmur at some point while congenital heart disease is present in less than 1% of children. The table below includes a non-exhaustive list of murmur characteristics and underlying causes. 

Syndromes that may impact the cardiovascular system

Below is a table containing a non-exhaustive list of syndromes that can impact the cardiovascular system.

The features of each syndrome relevant to the cardiovascular system are shown in bold.

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar

References

• Bishop (2011). Cardiac Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK] (Accessed 18 Mar 2019)
• Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
• Miin Lee (2013). Cardiovascular Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics. [LINK] (Accessed 18 Mar 2019)
• Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.
• Towers, A (2015). Examination: cardiovascular, Don’t Forget the Bubbles. [LINK](Accessed 18 Mar 2019)

Photo credits

1. Ragesoss, Physical exam of a child with stethoscope on the chest, Colour, CC BY-SA 3.0. Available at: [LINK]

Examining the neurological system is different in young children compared with older children and adults. The components of the complete exam are extensive and usually cannot be performed in a classical fashion. This approach may be carried out on a cooperative school-aged child – but always be mindful of keeping the examination fun.

Observation is key. Make the most of every opportunity to examine the child. See how they play, taking into account handedness and motor deficits. These observations, especially in younger children, will ultimately give you the best insight into their daily functioning and paint a broad picture of their neurological function.

Tips include:

• Using items such as a tennis ball, small toys (including a toy car), bells, bubbles and an object that will attract the child’s attention (like a pinwheel).
• Be mindful to postpone uncomfortable tasks until the end, such as head circumference, fundoscopy and sensory testing.

You can access the Paediatric Neurological Examination OSCE Mark Scheme here.

Introduction

• Wash your hands
• Introduce yourself to both the parents and the child
• Explain what the neurological examination will involve
• Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform a neurological examination, which will involve me testing the nerves that supply different parts of the body.

Are you happy for me to carry out the examination?

General Inspection

With toddlers – the initial phase of observation is best done with the child in the parent’s lap. Through minimising apprehension, assessment of higher cortical function, muscle tone and tendon reflexes becomes easier.

Higher cortical functions

Observe the child during play:

• Attention span
• Gross and fine motor coordination
• Problem-solving abilities

Observe for age-appropriate milestones (see our guide on Developmental Milestones)

Cranial Nerves

Testing in infants is often by observation for specific movements and responses, which is ultimately less reliable. In older children, it may be possible to formally assess at least some cranial nerves, however, this very much depends on the exact age of the child, their current state and the environment. We have provided a guide to each of the cranial nerves below, however, it is unlikely you will be able to carry out a complete neurological assessment in one sitting with most children.

Olfactory nerve (I)

The olfactory nerve is responsible for the sense of smell.

Assessment

• Test the ability to detect a smell with eyes closed (i.e. chocolate).
• This is not checked in small children or infants.
• Olfaction can be impaired after closed head injury and in infants with arhinencephaly-holoprosencephaly.

Optic Nerve (II)

The optic nerve is responsible for vision and afferent pupillary light reflexes

Testing visual acuity

• Infant – observe the infant reach for objects of varying size
• >6 months old – observe reaching for scraps of paper less than 5mm in size when placed on a dark background
• Older children – standard recognition of letters, numbers or shapes on a Snellen chart (see our guide to visual assessment)

Visual fields

• Introduce objects into the peripheral field of vision as the child focuses on an object held directly in front of them.
• Note if the child becomes aware of the peripheral object (e.g. turning head towards it).

Pupillary reflexes

To best see pupillary reflexes the room should be dimly lit.

Direct pupillary reflex (afferent CN II, efferent CN III):

• Shine a light into the pupil and observe constriction of that pupil.
• Sluggish reaction or lack of constriction may suggest pathology (optic nerve, brainstem, drugs)

Consensual pupillary reflex:

• Again shine a light into the pupil, but this time observe the contralateral pupil.
• A normal consensual response involves the contralateral pupil constricting.
• Lack of a normal consensual response may suggest damage to one/ both optic nerves or damage to the Edinger-Westphal nucleus

Fundoscopy

Often difficult, requiring patience. If in doubt, it is often best to arrange for a specialist to do this examination using equipment designed specifically for children.

Assess for red reflex:

• Position yourself at a distance of around 30cm from the child’s eyes.
• Looking through the ophthalmoscope and ensure the light is directed into the pupil. Observe for a reddish/orange reflection in the pupil.
• An absent red reflex may indicate the presence of cataract, or in rare circumstances neuroblastoma.

Move in closer and examine the eye with the ophthalmoscope::

1. Move in closer whilst maintaining the red reflex and examine the retina with the ophthalmoscope. You may need to change the focus wheel to account for the difference in glasses prescription between the child and yourself. Approach from an angle slightly temporal to the child.

2. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches point like arrows towards the optic disc).

3. Assess the optic disc (colour/margin/cupping).

4. Assess the retinal vessels for pathology (e.g. arteriovenous nipping/neovascularization/haemorrhages).

5. Finally, assess the macula by asking the patient to look directly into the light:

• Drusen are typically noted in macular degeneration
• A cherry-red spot is typically noted in central retinal artery occlusion

Oculomotor, Trochlear & Abducens nerves (III, IV, VI)

Functions of CNII, CNIV and CNVI

• III: Eyelid elevation, eye elevation, ADduction, depression in ABduction, efferent to pupil
• IV: Depression in ADduction
• VI: Eye abduction

Inspect for ptosis

• Look for evidence of eyelid asymmetry suggestive of ptosis
• Causes include sympathetic paralysis from lesions of cranial nerve III, Horner’s syndrome, myopathies, myasthenia gravis and structural eye lesions (e.g. neurofibroma).

Assess extraocular eye movements

• Test horizontal, vertical and oblique planes of eye movement (drawing an imaginary “H” and asking the child to “follow my finger” achieves this)
• Tested by assessing the child’s ability to track brightly coloured soft toy or soft light

Abnormal eye movement findings:

• Down and out – paralysis of the inferior oblique muscle (III)
• Laterally – paralysis of medial rectus (III)
• Upwards – paralysis of inferior rectus (III)
• Down and inwards – paralysis of superior rectus (III)
• Upwards and out – paralysis of superior oblique (IV)
• Inwards – paralysis of lateral rectus (VI)
• Opsoclonus: Occult neuroblastoma – chaotic bursts of eye movements, often associated with myoclonus
• Up gaze paresis: Parinaud syndrome
• Impaired down gaze: Niemann Pick Type C disease
• Oculomotor apraxia: Delayed initiation of eye movement and jerky pursuit movements. Seen in Joubert syndrome or oculomotor apraxia-ataxia syndrome.

Trigeminal nerve (V)

The trigeminal nerve provides facial and corneal sensation, in addition to motor innervation to the muscles of mastication.

Assess sensory function

• Assess response to light touch over the 3 divisions of the face using a piece of cotton wool
• In a baby, the presence of the rooting reflex confirms intact facial sensation
• Assess the corneal reflex (afferent V, efferent VII) – this is rarely performed in practice

Assess motor function

• Ask the child to open their mouth against resistance
• Jaw jerk reflex (tests sensory and motor function) – rarely performed

Facial nerve (VII)

The facial nerve provides motor innervation to the muscles of facial expression and is also involved in taste sensation.

Inspection

• Inspect the child’s face for asymmetry
• Compare the nasolabial folds to identify subtle asymmetry

Assess motor function

• It is difficult to formally assess the power of the facial muscles, particularly in children.
• Instead, observe their facial expressions for any asymmetry (e.g. when smiling, crying etc)
• In older children, you may be able to ask them to copy your facial expressions (e.g. blowing out your cheeks, showing teeth, screwing up eyes, wrinkling forehead)

Vestibulocochlear nerve (VII)

The vestibulocochlear nerve is responsible for balance and hearing.

Assessment

• Infants: Make a soft sound close to the ear (i.e. rustling of paper). The child should show an ‘alerting response’.
• >5-6 months: Localise the sound to a specific quadrant.
• School-age children: Softly whispering a number approximately 30 cm from the ear. Rinne and Weber’s can also be used.
• Vestibular function: Poor head control, truncal unsteadiness, gait ataxia, nausea, vomiting and horizontal nystagmus may indicate vestibular system dysfunction.
• See our guide to hearing assessment for more details

Glossopharyngeal, Vagus nerve (IX, X)

The glossopharyngeal (IX) and vagus (X) nerves have various functions including:

• IX: Sensation from soft palate, taste fibres
• X: Palatal movement, vocal cords, cough

Assessment

Observe the child swallowing:

• Observe the child drinking or eating
• Dysfunction swallowing may present with salivary drooling, pooling of saliva and coughing during feeding

Observe the movement of the soft palate:

• Observe the uvula and ask the child to say “AAH” (if possible)
• Unilateral CNX lesions result in deviation of the uvula to the side contralateral to the lesion

Listen to the child’s voice:

• Hoarseness may be due to unilateral dysfunction of the recurrent laryngeal nerve (X)
• Bilateral dysfunction results in a bovine cough

Gag reflex

• Assesses both the afferent pathway of CN IX and efferent pathway of CN X
• Be aware of this test, however, it is rarely performed in practice

Accessory nerve (XI)

The accessory nerve provides motor innervation to the trapezius and sternocleidomastoid muscles, which assist with head-turning and shoulder shrugging.

Assessment

Test elevation of shoulders:

• If the child is old enough, ask them to scrunch their shoulders up towards their ears (demonstrate for them)

Test turning the neck against resistance:

• If the child is old enough, ask them to look over their shoulder whilst you observe the sternocleidomastoid muscle
• Small child: When supine, gently push the head laterally while supporting the shoulder.

Hypoglossal nerve (XII)

The hypoglossal nerve is responsible for the movement of the tongue.

Assessment

• Inspect the tongue when inside the mouth for fasciculations
• Ask the child to stick out their tongue – unilateral lesion results in deviation of the tongue to the affected side
• Check whether the tongue can be equally protruded on both sides

Upper and Lower Limb Examination

This portion of the examination requires an assessment of muscle tone, strength, reflexes and sensation of the upper and lower limbs.

Upper motor neuron (UMN) lesions

Lesions result in loss of muscle strength and dexterity distal to the injury, hypertonia and hyperreflexia.

Due to the corticospinal tract crossing at the pyramidal decussation, UMN lesions will present with contralateral deficits for lesions above the pyramids and ipsilateral defects for lesions of the spinal cord.

Spinal cord lesions will also present with LMN findings at the level of the injury due to damage to the ventral root or ventral nerve at that level.

Lower motor neuron (LMN) lesions

Lesions result in muscle fasciculations and atrophy, loss of strength, decreased tone and absent deep tendon reflexes.

Inspection

Begin by inspecting the limbs for symmetry, muscle bulk and posture.

Look for any evidence of abnormalities:

• Asymmetry at rest in infants – may suggest hemiparesis
• Opisthotonus – persistent arching of the neck and trunk due to bilateral cerebral cortical dysfunction
• Abducted hips or ‘frog-legged’ posture – hypotonia
• Making a fist with the hand or holding the thumb adducted across the palm during quiet wakefulness – suggesting corticospinal tract involvement
• Tremor – rhythmic, fine amplitude flexion-extension movements of the distal extremity
• Myoclonus – quick, non-stereotyped jerks around a segment of the body
• Athetosis – slow, sinuous movement of the distal extremity with pronation of the distal extremity
• Chorea – rapid, quasi-purposive, non-stereotyped movements of a segment of the body that is generally proximal
• Tics – highly stereotyped and repetitive movements
• Muscle atrophy – may be segmental or generalised – neuropathy, myopathy or disuse
• Pseudohypertrophy – bulky appearance of muscle with associated weakness  
• Fasciculations – ripple-like movements of the muscles that accompany degeneration of anterior horn cells
• Stereotyped hand wringing movements and bruxism – may be seen in Rett syndrome

Muscle tone

Muscle tone is assessed by passively taking the limb through a range of motion – including the shoulder, elbow and wrist bilaterally in the upper limb and the hip, knee and ankle bilaterally in the lower limb.

Spasticity

• Felt as an increase in tone varying with the force applied and the velocity of movement
• Often considered ‘clasp knife’ and tends to accompany pyramidal tract lesions

Rigidity

• Increased tone that does not vary with velocity or position
• Suggests an extrapyramidal lesion

Clonus

• Position the child’s leg so that the knee and ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
• Rapidly dorsiflex and partially evert the foot
• Keep the foot in this position
• Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion (>5 is abnormal)
• Sustained clonus is abnormal at all ages

Power

Much of this assessment may not be possible in the majority of young children, however, we have provided it for older children who are capable of following instructions.

The assessment of muscle power in young children is less formal and involves comparing the strength of their natural movements between sides.

The MRC scale for muscle power is used to formally score the strength of particular muscle groups, however, it is less useful in the context of young children and therefore we have not included details.

Upper limb power

• Assess power one side at a time and compare like for like.
• Remember to stabilise and isolate the joint when testing.
• The following are a test of some of the main movements of the upper limbs, sufficient to show most pathology.

Shoulders:

• ABduction (C5) – “Don’t let me push your shoulders down”
• ADduction  (C6/7)– “Don’t let me pull your arms away from your sides”

Elbow:

• Flexion(C5/6) – “Don’t let me pull your arm away from you”
• Extension(C7) – “Don’t let me push your arm towards you”

Wrist:

• Extension (C6) – “Cock your wrists back and don’t let me pull them down”
• Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up”

Fingers: 

• Finger extension (C7) – “Put your fingers out straight and don’t let me push them down”
• Finger ABduction (T1) – “Splay your fingers and don’t let me push them together”
• Thumb ABduction (C8/T1) – “Point your thumbs to the ceiling and don’t let me push them down”

Lower limb power

• Assess one side at a time and compare like for like.
• Remember to stabilise the joint whilst testing power.

Hip:

• Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down”
• Extension (L5/S1) – “stop me from lifting your leg off the bed”
• ABduction (L4/5) – “push your legs out”
• ADduction (L2/3)  – “squeeze your legs in”

Knee:

• Flexion (S1) – “bend your knee and stop me from straightening it”
• Extension (L3/4) – “kick out your leg”

Ankle:

• Dorsiflexion (L4) – “keep your legs flat on the bed…cock your foot up towards your face…don’t let me push it down “
• Plantarflexion (S1/2) – “push down like on a pedal”
• Inversion (L4) – “push your foot in against my hand”
• Eversion (L5/S1) – “push your foot out against my hand”

Big toe:

• Extension(L5) – “don’t let me push your big toe down”

Reflexes

Upper limb reflexes

For each of the reflexes, ensure the child’s upper limb is completely relaxed

Hold the tendon hammer at the end of the handle and allow gravity to aid a good swing onto your finger.

If a reflex appears absent: make sure the child is fully relaxed and then perform a reinforcement manoeuvre – ask the child to clench their teeth together, whilst you hit the tendon.

1. Biceps reflex (C5/6) – located in the antecubital fossa

2. Triceps reflex (C7) – place forearm rested at 90º flexion – tap your finger overlying the triceps tendon

3. Supinator reflex (C6) – located 4 inches proximal to the base of the thumb

Lower limb reflexes

1. Knee jerk (L3/4)

2. Ankle jerk (L5/S1)

3. Plantar reflex (S1):

• Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe, then medially under the toes
• Observe the great toe
• Normal result = Flexion of the great toe and flexion of the other toes
• Abnormal (Babinski sign) = Extension of the great toe and spread of the other toes – upper motor neuron lesion

Sensation

Sensory information is carried by 2 major pathways and should be tested systematically through examining Touch, Pain, Temperature, Vibration and Proprioception in the upper limb and lower limb.

It’s easy to get bogged down in examining sensation. Check at least one modality each from the dorsal columns and spinothalamic tracts. Demonstrate normal sensation on the child’s sternum and ask them if it feels the same on the limb.

Much of the detailed assessment below is not possible in younger children and therefore gross assessment of sensation should be adopted.

Light touch sensation

Light touch sensation assesses the dorsal/posterior columns and spinothalamic tracts.

1. Touch the child’s sternum with the wisp of cotton wool to confirm they can feel it

2. Ask the child to say yes when they are touched

3. Using the wisp of cotton wool, gently touch the skin

4. Assess each of the dermatomes of the upper and lower limbs

5. Compare left to right, by asking the child if it feels the same on both sides

Pin-prick sensation 

Pink-prick sensation assesses the spinothalamic tracts.

• Repeat the previous assessment steps, but this time using the sharp end of a neuro-tip.
• If loss of sensation is noted distally, test for “glove” distribution of sensory loss (peripheral neuropathy) by moving distal to proximal. 

Vibration sensation

Vibration sensation assesses the dorsal/posterior columns.

1. Ask the child to close their eyes

2. Tap a 128 Hz tuning fork

3. Place onto the child’s sternum and confirm they can feel it buzzing

4. Place onto the distal interphalangeal joint of the forefinger/distal phalanx of the great toe and ask them if they can feel it buzzing

5. If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints (interphalangeal joint of thumb → carpometacarpal joint of thumb → elbow → shoulder)

Proprioception

Proprioception assesses the dorsal/posterior columns.

1. Hold the distal phalanx of the thumb/great toe by its sides

2. Demonstrate movement of the thumb/great toe “upwards” and “downwards” to the child (whilst they watch)

3. Then ask the child to close their eyes and state if you are moving the thumb/great toe up or down

4. If the child is unable to correctly identify the direction of movement, move to a more proximal joint (finger > wrist > elbow > shoulder)

Gait

Observe the child walking (if able) – posture, arm swing, stride length, speed, symmetry, balance and abnormal movements

Some common types of gait abnormality to observe for:

• Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or sensory ataxia. Often won’t be able to tandem gait either. With sensory ataxia, the child will watch their feet intently to compensate for proprioceptive loss. In a cerebellar lesion, they may veer to one side.
• High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of ankle dorsiflexion). Also won’t be able to walk on their heel(s).
• Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Caused by proximal lower limb weakness (e.g. myopathy).
• Hemiparetic: one leg held stiffly and swings round in an arc with each stride (circumduction).
• Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting. Feet may be inverted and “scissor”.

Cerebellar Examination

Cerebellar function should be assessed as part of a complete neurological examination.

If the child is unable to follow instructions – noting how a child reaches for and manipulates toys can be used as a crude assessment of coordination.

See our Cerebellar Examination guide for more information (adapting it as appropriate to the age of the child).

Neurological Examination of the Infant and Primitive Reflexes

See our guide to the Newborn Infant Physical Examination (NIPE), which covers basic neurological assessment of the infant, including primitive reflexes.

Cognitive Assessment

Younger children

• Has the child met appropriate developmental milestones?
• Careful questioning of parents – a history of loss or plateauing of developmental milestones is a red flag that should be investigated in greater detail.
• See our Developmental Milestones guide.

Children aged >7 years:

• The mini-mental state examination (MMSE) may be used, with modifications available for children of different ages/stages (e.g. MMSPE for preschool-aged children).

To Complete the Examination…

• Ensure the child is re-dressed after the examination
• Thank the child and/or parents
• Explain your findings to the parents and/or child
• Ask if the parents and/or child have any questions
• Wash your hands

Further clinical assessments to consider

• Skin assessment – both the skin and the nervous system develop from ectoderm during embryogenesis, so dermatological findings can sometimes relate to underlying neurological disease (e.g. Café au lait spots in neurofibromatosis and Ash-leaf spots in tuberous sclerosis)
• Assessment of the back – scoliosis or a patch of hair which may indicate an undetected vertebral anomaly (e.g. spina bifida)
• Cardiovascular examination – important if considering causes of loss of consciousness or a thromboembolic source of stroke
• Abdominal examination – important if considering metabolic diseases (e.g. hepatomegaly in glycogen storage disorders)

Further investigations

• Record a full set of vital signs
• Plot the height and weight on a growth chart
• Blood tests – FBC, U&Es, CRP, Autoantibodies
• Lumbar puncture (e.g. meningitis, encephalitis)
• Neuroimaging (CT/MRI)
• EEG (seizures)
• Nerve conduction studies

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar

References

• Acedillo, R (2011). Pediatric Neurological Exam Checklist. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 20 Mar 2019)
• Bishop & Statham (2011). Neurology Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 20 Mar 2019)
• Hills, W. Pediatric and Infant Neurologic Examination. OHSU. [LINK] (Accessed 20 Mar 2019)
• Kotagal (2019). Detailed neurologic assessment of infants and children. Nordli Jr. (ed). UpToDate. Waltham MA. [LINK](Accessed 20 Mar 2019).
• Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
• Miin Lee (2014). Neurological Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics. [LINK](Accessed 20 Mar 2019)
• Snowdon, D (2006). Neurological examination.
• Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.

Image references

1. Photo by Caleb Woods on Unsplash
2. Photo by Christian Bowen on Unsplash

Assessing growth is a key component of the paediatric exam. The measurement of height, length, weight and head circumference appears deceptively simple but requires accuracy, adaptability of method and patience to ensure it is done correctly.

With all children, don’t expect to follow a pre-defined order. Be creative and playful, making the examination into a game involving parents, siblings and the toys available to you.

Introduction

• Wash your hands
• Introduce yourself to both the parents and the child.
• Explain what the growth assessment will involve and explain why the measurement is required.
• Gain consent from the parents/carers and/or child before proceeding.