cmecde 21546

 

Key stages for developmental assessment

• Newborn

• Supine infant (1.5–2 months)

• Sitting infant (6–9 months)

• Toddler (18–24 months)

• Communicating child (3–4 years)

The four areas in which development is assessed

• Gross motor skills

• Vision and fine movement

• Hearing and language

• Social behaviour

Before starting

• Introduce yourself to the parent and child, and confirm the child’s name and date of birth.

• Explain that you would like to ask a few questions about how the child is doing, and obtain

consent.

• Ensure that the child is comfortable. Younger children may need toys to keep them distracted.

• Ask to look at the child health record or ‘red book’.

The assessment

• Confirm the sex and preferred name of the child.

• Do not ask whether the child is ‘developing normally’. Ask instead, “Do you have any concerns

with his development?”

• Be sure to verify whether any delay is in just one area or all four (gross developmental delay).

Clinical Skills for OSCEs

160 Station 59 Developmental assessment

Table 23. Average age for the acquisition of milestones

Key stages Age Gross motor

skills

Vision & fine

movement

Hearing and

language

Social

behaviour

Newborn Birth –

1/12

Symmetrical

movements,

limbs flexed,

head lag on

pulling up

Looks at light/

faces in direct

line of vision

Startles to

noises and

voices, cries

Responds

to parents,

endogenous

smile

Supine infant 2/12 Raises head in

prone position

Eyes ‘fix and

follow’ to

midline

Coos and grunts Exogenous

smile, i.e. at

faces or objects

3–4/12 Rolls over

from supine to

prone, sits with

support

Eyes follow past

midline

Laughs

Sitting infant 6/12 Rolls over

from prone

to supine, sits

unsupported

Transfers

objects from

hand to hand

Babbles, single

syllable words

(yes, no)

Separation

anxiety

9/12 Crawls and,

from 10/12,

‘cruises’ (walks

holding on to

furniture)

Pincer grasp Double syllable

words (mama,

bye-bye)

Stranger

anxiety, plays

pat-a-cake and

peek-a-boo

Toddler 1 year Takes first steps Starts to feed

himself

Uses 10 words Onlooker and

parallel play

18/12 Runs, walks

carrying a toy

Stacks 3 cubes Uses 10–20

words

Temper

tantrums

2 years Ascends stairs

in child-like

manner, arm

throws a ball

Copies a line,

stacks 6 cubes

Uses 200 words,

pronouns,

2-word

sentences

Alone play

continued

Paediatrics and geriatrics

Station 59 Developmental assessment 161

Table 23. Average age for the acquisition of milestones – continued

Key stages Age Gross motor

skills

Vision & fine

movement

Hearing and

language

Social

behaviour

Communicating

child

3 years Climbs stairs

like an adult,

descends stairs

in child-like

manner, jumps

in one place,

rides tricycle,

catches ball

with arms

Copies a circle,

stacks 9 cubes,

builds bridge

with cubes

Uses 900

words and

understands

many more,

uses compound

sentences

Knows own

name and

gender,

understands

‘taking turns’,

i.e. co-operates

4 years Climbs down

stairs like

an adult,

hops on one

foot, throws

overhand

Copies a cross

and, from 4.5

years, a square

Tells stories Imitates

parents, has

imaginary

friends

5 years Stands on one

leg, catches ball

with hands

Copies a

triangle

Asks the

meaning of

words

Conforms with

peers

Red flags

• ‘Red flags’ that call for further investigation include the absence of:

– smiling at 2/12

– good eye contact at 3/12

– sitting at 9/12

– walking at 18/12

– 2–3 word sentence construction at 2.5 years

After the assessment

• Ask the parent if there is anything they might add that you have forgotten to ask about.

• Ask the parent if they have any specific questions or concerns.

• Thank the parent and child.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a developmental assessment station

• Late walker (>18 months).

• Visual or hearing impairment.

• Developmental disorder, e.g. autism.

• Emotional disorder, e.g. enuresis (>5 years), elective mutism, sleep disorder.

• Behavioural disorder, e.g. conduct disorder, ADHD.

• Gross developmental delay from e.g. mental retardation, genetic abnormality, brain injury,

congenital infection, endocrine disorder.

Clinical Skills for OSCEs

162 Station 60

Neonatal examination

Specifications: A mannequin in lieu of a baby. The baby’s ‘mother’ is also in the room.

Before starting

• Introduce yourself to the mother, and confirm the baby’s name and date of birth.

• Explain the examination, and ask for consent.

• Wash your hands.

• Ask the mother about:

– complications of the pregnancy, if any

– type of delivery and any complications

– the baby’s gestational age at the time of birth

– the baby’s birth weight

– the baby’s feeding, urination, and defecation

– any concerns that she might have about the baby

– how she herself is coping with the new arrival

The examination

General inspection

• Although it is important to be systematic, an opportunistic approach to the examination may

be necessary.

• Note size, colour (e.g. cyanosis, jaundice), posture, tone, movements, skin abnormalities (e.g.

birth marks, petechiae, rash, haemangioma, Mongolian blue spot), and any other obvious

abnormalities (e.g. dysmorphic features or birth trauma such as forceps marks or chignon). Are

there any signs of pain or respiratory distress?

Head

• Gently palpate the anterior and posterior fontanelles for bulging (raised intracranial pressure)

or depression (dehydration).

• Measure the head circumference with the tape measure passing above the ears. Head circumference in the neonate should be 33–38 cm.

Figure 39. Neonatal examination, general order of the

examination.

Paediatrics and geriatrics

Station 60 Neonatal examination 163

Face

• Inspect the face for dysmorphological features, e.g. dysplastic or folded ears, upward slanting

palpebral fissures, and a flat nasal bridge (all may be seen in Down syndrome).

• Inspect the sclerae for redness (subconjunctival haemorrhage related to birth trauma) and the

irises for Brushfield spots (Down syndrome).

• Using an ophthalmoscope, test the red reflex (congenital cataracts if the red reflex is absent,

retinoblastoma if instead there is a white reflex) and pupillary reflexes.

• Test eye movements (squint).

• Check the patency of the ears and nostrils.

• Elicit the rooting reflex by lightly touching a corner of the baby’s mouth.

• Introduce a finger into the baby’s mouth and palpate the roof of the mouth with the finger pulp

to assess the sucking reflex and soft palate (cleft palate).

• Also examine the soft palate using a torch and spatula.

Chest

• Inspect the chest for signs of laboured breathing and for deformities, e.g. pectus carinatum,

pectus excavatum, shield-shaped chest with widely-spaced nipples (Turner syndrome).

• Take the brachial and femoral pulses, one after the other and then both at the same time

(brachio-femoral delay). Pulse rate in the neonate should be 100–160.

• Palpate the precordium and locate the apex beat.

• Auscultate the heart using the bell of your stethoscope (congenital heart defects).

• Auscultate the lungs using the diaphragm of your stethoscope. Turn the infant over and listen

over the back. The respiratory rate should be less than 60 breaths per minute.

Back

• Examine the spine, focusing on the sacral pit (neural tube defects).

• Check the position and patency of the anus (anal atresia).

• Enquire as to when the baby first passed stool. Ideally, this should have been within 24 hours

of birth.

Abdomen

• Inspect the abdomen and the umbilical stump.

• Palpate the abdomen.

• Palpate specifically for the spleen, liver, and kidneys (thumb in front, finger in the loin), and for

any masses.

• Auscultate for bowel sounds.

• Feel in the inguinoscrotal region for inguinal hernias.

• Examine the genitalia, in male infants note the position of the urethral meatus (hypospadias)

and feel for the testicles (undescended testes).

• Feel for the femoral pulses (coarctation of the aorta).

Hips

• Ortolani test. With your thumbs on the inner aspects of the thighs and your index and middle

fingers over the greater trochanters, flex the hips and knees to 90 degrees and then abduct the

hips (an audible and palpable clunk indicates relocation of a dislocated hip).

• Barlow test. Next, adduct them whilst applying downward pressure with your thumbs (an audible and palpable clunk indicates an unstable hip that can be dislocated).

Clinical Skills for OSCEs

164 Station 60 Neonatal examination

Arms and hands

• Inspect the arms and hands, paying particular attention to the palmar creases (Simian crease –

Down syndrome).

• Count the number of digits on each hand (polydactyly).

Feet

• Inspect the feet for deformities such as club foot and ‘sandal gap’ and test their range of movement.

• Count the number of digits on each foot (polydactyly).

Posture and reflexes

• Head lag. Lay the baby supine and pull up the upper body by the arms – the head should first

‘lag’ back, then straighten and fall forward.

• Ventral suspension. Hold the baby prone – the head should lie above the midline.

• Moro or startle reflex. Lift the head and shoulders and then suddenly drop them back – the

arms and legs should abduct and extend symmetrically, and then adduct and flex (NB. This test

should be conducted as safely and sensitively as possible. For instance, it could be carried out

with the baby only slightly raised from the cot mattress.).

• Grasp reflex. Place a finger in the baby’s hand – the hand should close around your finger.

Ortolani test

Barlow test Figure 40. The Ortolani and Barlow tests.

Paediatrics and geriatrics

Station 60 Neonatal examination 165

After the neonatal examination

• State that you would also measure and weigh the baby and record your findings on a growth

centile chart.

• Summarise your findings.

• Reassure the mother, and tell her that you are going to have the baby examined by a senior

colleague.

Figure 41. Eliciting the Moro reflex.

Clinical Skills for OSCEs

166 Station 61

The six-week surveillance review

Specifications: A mannequin in lieu of a baby. The six-week ‘baby check’ is part of the Newborn and

Infant Physical Examination programme. It involves a physical examination and review of development.

However, it is also an opportunity to give health promotion advice and for the parent or parents to

express concerns.

Before starting

• Introduce yourself to the parent, and confirm the baby’s name and date of birth.

• Explain the nature of the examination and obtain consent.

• Ask for the child health record or ‘red book’.

The history

• Ask for the exact age, sex, and preferred name of the child.

Main concerns

• Ask if the parent has any specific concerns.

Past medical history

• Birth history:

– pregnancy

– gestation

– delivery

– birth weight

– neonatal history

• Present health:

– current health status, including feeding regimen and weight gain

– medication

– social history

The examination

PART 1 – DEVELOPMENTAL ASSESSMENT

Motor skills

• Symmetrical limb movements.

• Head lag.

Vision and fine movement

• Looks at light/faces.

• Follows an object.

Hearing and language

• Responds to noises/voices.

• Normal cry.

• Ask parent if they are concerned about the baby’s hearing.

Paediatrics and geriatrics

Station 61 The six-week surveillance review 167

Social behaviour

• Smiles responsively.

PART 2 – PHYSICAL EXAMINATION

• Wash your hands

General inspection

• Overall size and colour, i.e. is the baby cyanosed or jaundiced?

• Skin abnormalities such as birth marks, petechiae, or rash.

• Other obvious abnormalities such as dysmorphic features.

• Posture, tone, and movements.

• Signs of respiratory distress

Growth

• Weight.

• Length.

• Head circumference.

• Plot findings on a centile chart.

Head

• Palpate the fontanelles.

Face

• Eyes: red reflex, pupillary reflexes, and eye movements (squints).

• Ears.

• Mouth – use a pen torch (high arched or cleft palate).

Chest

• Feel for the radial and femoral pulses.

• Auscultate the heart.

• Auscultate the lungs.

Back

• Examine the spine, particularly the sacral pit.

Abdomen

• Inspect and palpate the abdomen.

• Examine the external genitalia.

Hips

• Abduct the hips (Ortolani test, see Figure 40).

• Next, adduct them whilst applying downward pressure with your thumbs (Barlow test, see

Figure 40).

Clinical Skills for OSCEs

168 Station 61 The six-week surveillance review

After the surveillance review

• Discuss your findings with the parent.

• Use the opportunity for health promotion, e.g. immunisations, breastfeeding, car safety, accident prevention, risks of passive smoking, reducing the risk of sudden infant death syndrome,

services available for the parents of young children.

• Consider maternal mental health. How is mum coping? Is there any suggestion of postnatal

depression?

• Elicit any remaining concerns that the parent may have.

• Thank the parent.

169Paediatrics and geriatrics

Station 62

Paediatric examination: cardiovascular system

Read in conjunction with Station 13.

If you are asked to examine the cardiovascular system of a younger child (an unlikely event), be

prepared to change the order of your examination and to modify your technique as appropriate. For

example, you may need to examine the child on his parent’s knees or auscultate his heart as soon

as he stops crying. As in all paediatric stations, the quality of your rapport with the child will be of

considerable importance.

Before starting

• Introduce yourself to the child and the parent, and confirm the child’s name and date of birth.

• Explain the examination and ask for consent to carry it out.

• Position the child at 45 degrees, and ask him to remove his top(s).

• Ensure that he is comfortable.

The examination

General inspection

• From the end of the couch, inspect the child carefully, looking for any obvious abnormalities

in his general appearance and in particular for any dysmorphic features suggestive of Down

syndrome (e.g. oblique eye fissures, epicanthic folds, Brushfield spots, flat nasal bridge, Simian

crease), Turner syndrome (e.g. short stature, low-set ears, webbed neck, shield chest), or Marfan

syndrome (e.g. tall stature, elongated limbs, pectus carinatum or pectus excavatum).

• Does the child look his age? Ask to look at the growth chart.

• Is he breathless or cyanosed?

• Look around the child for clues such as a oxygen, PEFR meter, inhalers, etc.

• Inspect the precordium and the chest for any scars and pulsations. A median sternotomy or

thoracotomy scar under the axillae may indicate the repair of a congenital heart defect such as

a patent ductus arteriosus or a ventricular septal defect.

Inspection and examination of the hands

• Take both hands and assess them for:

– colour and temperature

– clubbing (cyanotic congenital heart disease)

– nail signs

• Determine the rate, rhythm, and character of both radial pulses (in younger infants, the brachial

pulses). Take both femoral pulses at the same time to exclude a radiofemoral delay (coarctation

of the aorta).

• Indicate that you would record the blood pressure in both arms. If you are asked to record the

blood pressure, remember to use a cuff of appropriate size.

Clinical Skills for OSCEs

170 Station 62 Paediatric examination: cardiovascular system

Table 24. Normal pulse rates in children

Age in years Pulse (beats per minute)

< 1 100–160

2–4 90–140

4–10 80–140

> 10 65–100

Inspection and examination of the head and neck

• Inspect the conjunctivae for signs of anaemia or jaundice.

• Inspect the mouth and tongue for signs of central cyanosis and a high arched palate (Marfan

syndrome).

• Assess the jugular venous pressure (difficult in very young infants).

• Locate the carotid pulse and assess its character.

Palpation of the heart

Ask the child if he has any pain in the chest.

• Determine the location and character of the apex beat. In children (up to 8 years), this is found

in the fourth intercostal space in the mid-clavicular line.

• Palpate the precordium for thrills and heaves.

Auscultation of the heart

Warm up the diaphragm of your stethoscope.

• Listen for heart sounds, additional sounds, and murmurs. Using the stethoscope’s diaphragm,

listen in:

– the aortic area

– the pulmonary area

– the tricuspid area

– the mitral area

(See Station 13, Figure 7.)

• Any murmur heard must be classified according to:

– timing (systolic or diastolic)

– grading (I–VI)

– site (aortic, pulmonary, tricuspid, or mitral)

– radiation (carotids or axilla, or no radiation)

Innocent murmurs are common in childhood

Innocent murmurs are:

• Systolic.

• Low-grade.

• Heard over only a relatively small area.

• Asymptomatic.

cmecde 125

 

Clinical Skills for OSCEs

150 Station 54 Lump in the neck and thyroid examination

Conditions most likely to come up in a lump in the neck and thyroid examination station

Toxic goitre:

• diffuse (Graves’ disease), multinodular, toxic nodule (see above).

Hashimoto’s thyroiditis (see above)

Physiological goitre of puberty or pregnancy (or both)

Thyroglossal cyst:

• fibrous cyst that forms from a persistent thyroglossal duct.

• midline lump in the region of the hyoid bone that is smooth and cystic and usually painless.

• moves upwards upon swallowing and upon tongue protrusion.

Enlarged lymph nodes

NB. Other, less likely, possibilities include thyroid carcinoma, branchial cyst, cystic hygroma

(lymphangioma), carotid body tumour, and sternocleidomastoid tumour.

151Ophthalmology, ENT, and dermatology

Station 55

Dermatological history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questionsto uncover the nature of hisskin problem,

and obtain consent.

• Ensure that he is comfortable.

The history

• Name and age.

Presenting complaint

• Use an open question to ask the patient to describe his skin problem.

History of presenting complaint

Ask about:

• When, where, and how the problem started.

• What the initial lesions looked like and how they have evolved. Are the hair and nails also

involved?

• Symptoms: especially, pain, pruritus (itching), blistering, and bleeding.

• Aggravating factors such as sunlight, heat, soaps, etc.

• Relieving factors, including any treatments so far.

• Effect on everyday life.

• Details of previous episodes, if any.

Past medical history

• Previous skin disease.

• Atopy (asthma, allergic rhinitis, childhood eczema).

• Present and past medical illnesses.

• Surgery.

Drug history

• Prescribed and OTC/complementary medications, including topical applications such as gels

and creams.

• Cosmetics and moisturising creams.

• Relationship of symptoms to use of medication.

• Allergies.

Family history

• Has anyone in the family had a similar problem?

• Medical history of parents, siblings, and children, focusing on skin problems.

• Sexual contacts.

Clinical Skills for OSCEs

152 Station 55 Dermatological history

Social history

• Occupation (in some detail). Has the patient’s occupation exposed him to any allergens or

irritants? Have colleagues been suffering from similar symptoms? Do the symptoms improve

during holiday periods?

• Hobbies (in some detail). Have the patient’s hobbies exposed him to any allergens or irritants?

Has he been using sunbeds?

• Home circumstances.

• Alcohol use.

• Smoking.

• Recent travel, especially to the tropics.

Systems review

(If appropriate.)

After taking the history

• Ask the patient if there is anything that he might add that you have forgotten to ask about.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a dermatological examination.

153Ophthalmology, ENT, and dermatology

Station 56

Dermatological examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Ask him to undress to his undergarments and temporarily cover him up with a sheet or blanket.

• Ensure that he is comfortable.

• Ask him to report any pain or discomfort during the examination.

• Ensure that there is adequate lighting.

The examination

• Describe the distribution of the lesions: are they generalised or localised, symmetrical or asymmetrical, affecting only certain areas, e.g. flexor or extensor surfaces. Make a point of looking at

all parts of the body.

• Describe the morphology of the individual lesions, commenting upon their colour, size, shape,

borders, elevation, and spatial relationship. Use precise dermatological terms. The ‘Handbook

for medical students and junior doctors’ by the British Society of Dermatologists (freely available

online) contains a useful glossary of dermatological terms with accompanying images.

• Note any secondary skin lesions such as scaling, lichenification, crusting, excoriation, erosion,

ulceration, and scarring.

• Palpate the lesions (ask the patient if this is OK first). Assess their consistency. Do they blanch?

• Examine the finger nails and toe nails.

• Examine the hair and scalp.

• Examine the mucous membranes.

• Check for lymphadenopathy, if appropriate (e.g. if considering infection or malignancy).

• Check the pedal pulses, if appropriate (e.g. if considering vascular insufficiency or diabetic foot).

After the examination

• Offer to help the patient to put his clothes back on.

• Thank him.

• Ensure that he is comfortable.

• Wash your hands.

• Summarise your findings and offer a differential diagnosis.

Examiner’s questions: Differentiating skin cancers

BCC (75% of skin cancers) most often looks like a pearly bump or nodule on sun-exposed areas of skin.

Bleeding or crusting may develop in the centre of the tumour, as in the photograph below. In contrast,

squamous cell carcinoma (SCC, 20% of all skin cancers) most often looks like a red, scaling, thickened

patch, sometimes with bleeding, crusting, or ulceration. Although less common than either BCC or SCC,

malignant melanoma is more commonly fatal. Pigmented lesions of the skin should be suspected to

be malignant melanomas if they are asymmetrical, if they have irregular borders, if their colour varies

from one area to another, or if their diameter is larger than that of a pencil eraser (6 mm). This is easily

remembered as A, B, C, D.

Clinical Skills for OSCEs

154 Station 56 Dermatological examination

Figure 38. (A) Basal cell carcinoma (BCC). Reproduced under a Creative Commons License from: http://commons.

wikimedia.org/wiki/Category:Basal-cell_carcinoma#mediaviewer/File:Basaliom_am_Nasenrücken_2.JPG. (B)

Squamous cell carcinoma. Reproduced from http://commons.wikimedia.org/wiki/Category:Squamous-cell_

carcinoma_of_the_skin#mediaviewer/File:Squamous_Cell_Carcinoma.jpg

Conditions most likely to come up in a dermatological examination station

Psoriasis:

• chronic, autoimmune skin disease.

• plaque psoriasis is most common type (c. 90%).

• red plaques with silvery scales due to inflammation and excessive skin production.

• frequently on the extensor aspects of elbows or knees, but can also affect any area including

the scalp, palms, and soles.

• may be accompanied by nail dystrophy.

• may be accompanied by joint inflammation (psoriatic arthritis).

• may be aggravated by stress, alcohol, smoking, and certain drugs, e.g. lithium, beta blockers,

chloroquinine.

(A)

(B)

Ophthalmology, ENT, and dermatology

Station 56 Dermatological examination 155

Eczema:

• most common types are atopic or flexural eczema and irritant-induced contact dermatitis.

• recurrent dryness, itching, and skin rashes that may be accompanied by redness,

inflammation, cracking, weeping, blistering, crusting, flaking, and skin discoloration.

• frequently on the flexor aspects of joints (cf. psoriasis).

Acne vulgaris:

• changes in the pilosebaceous units as a result of increased androgen stimulation.

• comedones (blackheads), inflammatory papules, pustules, and nodules that affect the face

and neck and also the chest, back, and shoulders, and that can result in scarring.

• usually appears during adolescence and may persist into early adulthood.

Rosacea:

• chronic condition that primarily affects fair-skinned people and that is 2–3 times more

common in women.

• peak age of onset is 30–50.

• typically begins as flushing and redness centrally on the face.

• may be accompanied by telangiectasia, red domed papules and pustules, red gritty eyes,

burning and stinging sensations, and, in some advanced cases, a red lobulated nose

(rhinophyma).

• may be aggravated by stress, sunlight, cold weather, alcohol.

Skin cancer (see Examiner’s questions above)

Clinical Skills for OSCEs

156 Station 57

Advice on sun protection

Read in conjunction with Station 116: Explaining skills.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Tell him what you are going to explain, and determine how much he already knows.

• Enquire about and explore any concerns that he may have.

The advice

Explain that there are three types of ultraviolet radiation from the sun: UVA, UVB, and UVC.

• UVA and UVB can cause skin cancer (think UV-’Bad’).

• UVC does not reach the surface of the earth and is therefore of no concern.

Explain that, other than causing skin cancer, UV radiation can also cause the skin to burn and (horror!)

to age prematurely.

UV levels depend on a number of factors such as the time of day, time of year, latitude, altitude, cloud

cover, and ozone cover.

Explain that there are three principal methods of protecting against the sun’s rays:

1. Avoid the outdoors and seek shade. The sun’s rays are most direct around midday and so one

should avoid being outdoors from around 11 am to 3 pm.

2. Cover up (clothing should include a wide-brimmed hat and sunglasses that conform to British

and European Standard BS EN 1836:2005).

3. Use sunscreen.

• A sunscreen’s star rating is a measure of its level of protection against UVA.

• A sunscreen’s sun protection factor is a measure of its level of protection against UVB.

• Use a sunscreen that has a star rating of at least three stars *** and an SPF of at least 15.

• The sunscreen should be applied thickly over all sun-exposed areas, and re-applied regularly.

It is important to stress that sunscreens should not simply be used as a means of spending

more time in the sun.

Finally advise the patient to report any moles that change in size, shape, colour, or texture.

After giving the advice

• Summarise the information and ensure that the patient has understood it.

• Tell him that, if anything, he can remember ‘Slip, slap, slop’ – slip on some clothes, slap on a hat,

and slop on sunscreen.

• Ask him if he has any questions or concerns.

• Give him a leaflet on sun protection.

157Paediatrics and geriatrics

Station 58

Paediatric history

General points:

• As a rule of thumb, the older the child the more he should be involved in the history-taking

process. Try to surreptitiously (indirectly) assess the child’s capacity.

• Observe the child’s behaviour and interaction with the parent as you take the history.

• The parent’s concerns and the child’s concerns are likely to differ: try as much as possible to

address both.

Before starting

• Introduce yourself to the parent and child (in that order), and confirm the child’s name and

date of birth.

• Explain that you are going to ask some questions and obtain consent.

• Ensure that the patient is comfortable; younger children may need some toys to keep them

distracted.

The history

• Verify the sex, and preferred name of the child.

• Confirm the relationship of the accompanying adult or adults.

Presenting complaint and history of presenting complaint

• Ask about the nature of the presenting complaint and how it has affected the child’s daily routine. Start by using open questions and then explore the symptoms as you might in any other

history. Ask about onset, duration, previous episodes, pain, associated symptoms (e.g. nausea,

vomiting, diarrhoea, urinary frequency, constipation, altered consciousness), and treatments.

Do not under any circumstances denigrate, or omit to address, the parent’s concerns.

Systems review

• The major systems should be covered briefly, placing the emphasis on areas of particular relevance.

– general health: liveliness, change in behaviour, feeding, fever

– ENT: sore throat, earache, infections, deafness, nose bleeds

– CVS and RS: breathing problems (feeding problems in young infants), shortness of breath,

exercise tolerance, colour changes (blue attacks, pallor), cough, croup, wheeze, stridor, chest

infections, heart murmurs

– GIS: weight gain, feeding, vomiting, diarrhoea, constipation, jaundice, abdominal pain

– GUS: frequency, discharge, enuresis

– NS: headaches, fits, visual disturbances, balance and coordination, muscle problems

– MSS: limps, joint stiffness, pain, swelling, redness

– skin: rash, eczema

Past medical history

Use the mnemonic ‘BINDS’, trying to be as age-appropriate as possible.

• Birth history:

– Maternal obstetric history: gestation at delivery, mode of delivery, place of delivery, complications before, during, and after delivery, drug history and smoking and drinking during

pregnancy

Clinical Skills for OSCEs

158 Station 58 Paediatric history

– Early paediatric history: birth weight, neonatal problems, admission to special care or neonatal unit

• Immunisations: are immunisations up to date? Have there been any problems?

• Nutrition and growth: is the child eating and drinking? For an infant, enquire whether he is

breast- or bottle-fed, how much he consumes (quantify), and how often. Ask for the child health

record or ‘red book’ and survey the growth charts, immunisation history, and any other entries.

• Development: do not ask whether the child is ‘developing normally’. Ask instead, “Do you have

any concerns with his/her development?”

• Social: is the child sleeping through the night? Is he playing as he usually does? Is he thriving at

nursery or school?

• Medical: asthma, diabetes, epilepsy, previous hospital admissions and surgery.

Drug history

• Prescribed and over-the-counter medications.

• Allergies.

Family history

• Health of parents and siblings, especially if an infective aetiology is being considered.

• Congenital/genetic abnormalities (“Are there any illnesses that run in the family?”).

• Consanguinity (“Prior to getting married, were you and your partner related in any way?”).

Social history

• Parental occupation.

• Details of home life, siblings.

• Behaviour at home and at school.

• Pets and smokers in the home (if relevant).

After taking the history

• Ask the parent and child if there is anything that they might add that you have forgotten to ask about.

• Ask the parent and child if they have any specific questions or concerns.

• Thank the parent and child.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a paediatric history station

• Respiratory conditions, e.g. asthma, upper respiratory tract infection.

• Headache.

• Behavioural problems, e.g. enuresis.

• Fits, e.g. febrile convulsions, epilepsy.

• Childhood infections/rashes and immunisation compliance (see Station 67: Child immunisation

programme).

159Paediatrics and geriatrics

Station 59

Developmental assessment

Development in the early years of life is fairly consistent from child to child. Any significant deviation

from this pattern requires further investigation or at least close follow-up.

The developmental assessment is usually performed alongside a general paediatric history (see Station

58). However, in an OSCE setting, you may simply be asked to watch a short video and answer some

questions about it. If you are asked to carry out a developmental assessment, remember to tailor your

assessment to the age of the child, and that much of the assessment can be carried out by observation

alone.