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Station 62 Paediatric examination: cardiovascular system 171
Auscultate the bases of the lungs and check for sacral oedema.
the liver edge can usually be palpated in younger infants.
Feel the temperature of the feet, palpate the femoral pulses, and check for pedal oedema.
• Ask the child and parent if they have any questions or concerns.
• Indicate that you would test the urine, examine the retina with an ophthalmoscope and, if
appropriate, order some key investigations, e.g. a CXR, ECG, echocardiogram.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a paediatric cardiovascular examination station
Ventricular septal defect (VSD)
• Pansystolic murmur best heard over the left lower sternal edge and possibly accompanied
by a palpable thrill, parasternal heave, and displaced apex beat. Most VSDs are small and
asymptomatic and may close spontaneously within the first year of life. However, a large VSD
may progressively lead to higher pulmonary resistance and, finally, to irreversible pulmonary
Patent ductus arteriosus (PDA)
• Continuous machine-like murmur best heard over the pulmonary area and possibly
accompanied by a left subclavicular thrill, displaced apex beat, and collapsing pulse. The first
heart sound is normal but the second is often obscured by the murmur. The ductus arteriosus
is a shunt that runs from the pulmonary artery to the descending aorta and which enables
blood to bypass the closed lungs in utero. A small PDA may cause no signs or symptoms and
may go undetected into adulthood, but a large one can cause signs and symptoms of heart
• Ejection systolic murmur best heard in the pulmonary area due to increased blood flow across
the pulmonary valve with an associated mid-diastolic murmur best heard in the tricuspid area
due to increased blood flow across the tricuspid valve. These murmurs, neither of which is
particularly loud, are accompanied by a wide fixed splitting of the second heart sound (S2
a displaced apex beat. The patient is often asymptomatic.
172 Station 62 Paediatric examination: cardiovascular system
• Loud ejection systolic murmur with an ejection click that is best heard in the pulmonary area.
This murmur may be accompanied by a widely split second heart sound, and by a systolic
thrill and parasternal heave. The patient is often asymptomatic.
• Ejection systolic murmur with an ejection click best heard in the aortic area and radiating to
the carotids. The murmur may be accompanied by a slow-rising pulse and a heaving cardiac
apex. The patient is often asymptomatic.
• Arterial hypertension in the right arm with normal to low blood pressure in the legs. There is
radio-femoral delay between the right arm and the femoral artery and, in severe cases, a weak
or absent femoral artery pulse. In contrast, mild cases may go undetected into adulthood.
• The tetralogy refers to VSD, pulmonary stenosis, overriding aorta, and right ventricular
hypertrophy, and there may also be other anatomical abnormalities. There is cyanosis from
birth or developing in the first year of life.
Paediatric examination: respiratory system
Read in conjunction with Station 17.
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 chest as soon as he stops
• Introduce yourself to the child and 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.
• From the end of the couch inspect the child carefully, looking for any obvious abnormalities in
• Does the child look his age? Ask to look at the growth chart.
• Is he breathless or cyanosed?
• Note the rate, depth, and regularity of his breathing.
• Look around the child for clues such as a PEFR meter, inhalers, etc.
Table 25. Normal respiratory rates in children
Age in years Respiratory rate (breaths per minute)
• Deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine.
• Asymmetry of chest expansion.
• Added sounds such as cough, croup, wheeze, stridor.
• Harrison’s sulcus (horizontal subcostal groove; in a child, suggestive of asthma).
Inspection and examination of the hands
• Take both hands and assess them for colour and temperature.
174 Station 63 Paediatric examination: respiratory system
• Determine the rate, rhythm, and character of the radial pulse (in younger infants, the brachial
• State that you would record the blood pressure.
Inspection and examination of the head and neck
• Inspect the conjunctivae for signs of anaemia.
• Inspect the mouth for signs of central cyanosis.
• Assess the jugular venous pressure and jugular venous pulse form.
• Palpate the cervical, supraclavicular, infraclavicular, and axillary lymph nodes.
Ask the child if he has any pain in the chest.
• Palpate for tracheal deviation by placing the index and middle fingers of one hand on either
side of the trachea in the suprasternal notch. (As this may be uncomfortable, it is probably best
• Palpate for the position of the cardiac apex.
• Palpate for equal chest expansion, comparing one side to the other.
• Palpate for tactile fremitus.
• Percuss the chest. Start at the apex of one lung and compare one side to the other. Do not
forget to percuss over the clavicles and on the sides of the chest. Note that percussion of the
chest is not useful in young infants.
Warm up the diaphragm of your stethoscope.
• If old enough, ask the child to take deep breaths through the mouth and, using the diaphragm
of the stethoscope, auscultate the chest. Start at the apex of one lung, and compare one side to
the other. Are the breath sounds vesicular or bronchial? Are there any added sounds?
• Assess for sacral and pedal oedema.
• Ask the child and parent if they have any questions or concerns.
• Indicate that you would like to look at the sputum pot, measure the PEFR and, if appropriate,
order some key investigations, e.g. a CXR, FBC, etc.
• Summarise your findings and offer a differential diagnosis.
Station 63 Paediatric examination: respiratory system 175
Conditions most likely to come up in a paediatric respiratory examination station
• Autosomal recessive progressive multisystem disease that is related to a mutation in the CFTR
gene and that leads to viscous secretions.
• In terms of the respiratory system, findings on physical examination may include delayed
growth and development, finger clubbing, nasal polyps, recurrent chest infections, shortness
of breath, coughing with copious phlegm production, haemoptysis, hyper-inflated chest, cor
Broncho-pulmonary dysplasia (BPD)
• Chronic lung disorder that involves inflammation and scarring in the lungs and which is
most common among children who were born prematurely and who received prolonged
mechanical ventilation for respiratory distress syndrome.
• Findings on physical examination may include delayed growth and development, shortness of
breath, crackles, wheezes and decreased breath sounds, hyper-inflated chest, cor pulmonale.
• Findings on physical examination may include signs of consolidation accompanied by
fever, lethargy, poor feeding, shortness of breath, productive cough, and, in some cases,
haemoptysis and pleuritic chest pain.
• Findings on physical examination may include shortness of breath, chest tightness, wheezing
and coughing, signs of respiratory distress such as the use of accessory muscles of respiration
and intercostal recession, hyper-inflated chest.
Paediatric examination: abdomen
Read in conjunction with Station 22.
• Introduce yourself to the child and parent, and confirm the child’s na
Paediatric examination: abdomen
Read in conjunction with Station 22.
• Introduce yourself to the child and parent, and confirm the child’s name and date of birth.
• Explain the examination and ask for consent to carry it out.
• Ensure that he is comfortable.
• From the end of the couch, observe the child’s general appearance:
– does the child look his age? Ask to look at the growth chart
– state of health/other obvious signs
• Inspect the abdomen noting any:
• Look around the child for clues such as oxygen, tubes, drains, etc.
A distended abdomen is often a normal finding in younger infants.
Inspection and examination of the hands
• Take both hands looking for:
– clubbing (malabsorption, inflammatory bowel disease, primary biliary cirrhosis)
Inspection and examination of the head, neck, and upper body
• Inspect the sclera and conjunctivae for signs of jaundice or anaemia.
the tongue (loss of appetite), and the state of the dentition.
• Examine the neck for lymphadenopathy.
• Abdominal palpation can be difficult in children if they do not relax the abdominal muscles.
Attempt to distract the child by handing him a toy or try to make him relax by coaxing him into
palpating his abdomen and then copying his actions.
Station 64 Paediatric examination: abdomen 177
Ask the child if he has any tummy pain and keep your eyes on his face as you begin
• Deep palpation – for greater precision. Describe and localise any masses.
• Liver – starting in the right lower quadrant, feel for the liver edge using the flat of your hand.
Note that in younger infants the liver edge is normally palpable (<1cm).
• Spleen – palpate for the spleen as for the liver, starting in the right lower quadrant.
be able to feel a normal kidney.
• Percuss the liver area, also remembering to detect its upper border.
• Percuss the suprapubic area for dullness (bladder distension).
• If the abdomen is distended, test for shifting dullness (ascites).
• Auscultate in the mid-abdomen for abdominal sounds. Listen for 30 seconds at least before
concluding that they are hyperactive, hypoactive, or absent.
Examination of the groins and genitalia
• Inspect the groins for hernias and, in boys, examine the testes (this is particularly important in
• Note that examination of the groins and genitalia may only need to be mentioned, as it is not
usually carried out in the OSCE setting.
• PR is not routine practice in paediatrics and should be avoided unless specifically indicated.
• Ask the child and parent if they have any questions or concerns.
• Indicate that you would test the urine and order some key investigations, e.g. ultrasound scan,
FBC, LFTs, U&Es, and clotting screen.
• Summarise your findings and offer a differential diagnosis.
178 Station 64 Paediatric examination: abdomen
Conditions most likely to come up in a paediatric abdomen station
• The majority of children with constipation do not have a medical disorder causing the
constipation. Many things can contribute to constipation such as avoidance of the toilet (for
various reasons), changes in diet or poor diet, and dehydration.
• Medical disorders that can cause chronic constipation include hypothyroidism, diabetes, cystic
fibrosis, and disorders of the nervous system such as cerebral palsy and mental retardation.
Constipation since birth may be from Hirschsprung disease (a.k.a. congenital aganglionic
• Other causes of chronic constipation include depression, drug side-effects, coercive toilet
• An autoimmune disorder of the small intestine that occurs in genetically predisposed people
of all ages, but often from infancy. It is caused by a reaction to gliadin, a prolamin (gluten
protein) found in wheat, barley, and rye, and results in villous atrophy.
• Symptoms include abdominal pain and cramping, diarrhoea, steatorrhoea, failure to thrive,
and fatigue. Signs include short stature, a distended abdomen, wasted buttocks, mouth ulcers,
• A kidney transplant has been required as a consequence of end-stage renal failure, which
may itself have been a consequence of a birth defect, a structural malformation, a hereditary
disease such as polycystic kidney disease or Alport syndrome, a glomerular disease, or a
systemic disease such as diabetes or lupus.
Paediatric examination: gait and neurological
• Introduce yourself to the child and parent, and confirm the child’s name and date of birth.
• Explain the examination and ask for consent to carry it out.
• Ensure that he is comfortable.
Examination of neurological function in children is principally a matter of observation.
If the child is old enough to obey commands, a more formal assessment of gait and
neurological function can be carried out, as in adults.
• A brief developmental assessment should be performed to enable you to gauge the child’s
subsequent performance. Ask the parent the child’s age and if there are any concerns about
the child’s vision and/or hearing.
• If the child is too young to walk, observe him crawling or playing. Is he using all his limbs
• If possible, observe the child walking and running. Common abnormalities of gait in children
– scissoring or tiptoeing gait: suggestive of cerebral palsy or of Duchenne muscular dystrophy
– broad-based gait: suggestive of a cerebellar disorder
– limp: limps have many causes including dislocated hip, trauma, sepsis, and arthritis
by ‘climbing’ up his legs) is suggestive of Duchenne muscular dystrophy.
• Inspect all four limbs, in particular looking for muscle wasting or hypertrophy. Hypertrophy of
the calves is suggestive of Duchenne muscular dystrophy.
• Assess tone and range of movement in all four limbs.
• In younger children also assess truncal tone by trying to get the child to sit unsupported.
• In young infants test head lag by lying the infant supine and pulling up his upper body by the
• Observe the child playing, and look for appropriate anti-gravity movement. A more formal
assessment can be carried out if the child is old enough to follow instructions.
• Check all reflexes as in the adult. In a younger child, prefer your finger to a tendon hammer.
180 Station 65 Paediatric examination: gait and neurological function
• Note that eliciting the Babinsky sign (extensor plantar reflex) is not very discriminative
• If the child is old enough to carry out instructions, assess co-ordination by the finger-to-nose
toys or some bricks and assess his co-ordination by observing him at play.
• Indicate that you would test sensation.
• Indicate that you would test the cranial nerves – where possible this is done as in the adult.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a paediatric gait and neurological function station
• In most cases of cerebral palsy there is a spastic, scissoring gait. The hips, knees, and ankles
are flexed, producing a crouching and tiptoeing demeanour. In addition, the hips are
adducted and internally rotated, such that the knees cross or hit each other in a scissor-like
movement. There is a similar pattern of flexion and adduction in the upper limbs.
• Severe recessive X-linked form of muscular dystrophy.
• There is rapid progression of muscle degeneration leading to generalised and symmetrical
weakness of the proximal muscles.
• Symptoms and signs include muscle wasting, pseudohypertrophy of the calves, waddling gait,
toe walking, frequent falls, poor endurance, difficulties running, jumping, or climbing stairs,
difficulties standing unaided, and positive Gower’s sign, with the child ‘walking’ his hands up
• Autosomal dominant progressive and highly variable multisystemic disease characterised by
muscle wasting, myotonia (delayed relaxation of the muscles after voluntary contraction),
cataracts, heart conduction defects, endocrine defects, and cognitive abnormalities, amongst
• The first muscles to be affected by wasting and weakness are typically those of the face and
neck (leading to a ‘fish face’ and ‘swan neck’ appearance), hands, forearms, and feet.
• The disease commonly affects adults but it has several forms and can also present as early as
Infant and child Basic Life Support
Specifications: A mannequin in lieu of an infant or child.
Figure 42. Paediatric Basic Life Support algorithm. Resuscitation Guidelines 2010.
• Ensure the safety of the rescuer and child
• Check the child’s responsiveness by gently stimulating the child and asking loudly, ‘Are you all
Do not shake infants or children with suspected cervical spine injuries.
182 Station 66 Infant and child Basic Life Support
• If the child responds by answering or moving:
– leave the child in the position in which you find him (provided he is not in further danger)
– check his condition and get help if needed
• If the child does not respond:
– turn the child onto his back and open his airway by using the head-tilt, chin-lift technique
If you suspect that there may have been injury to the neck, try to open the airway using
chin lift or jaw thrust alone. If this is unsuccessful, add head tilt a small amount at a time
• Holding the child’s airway open, put your face close to his mouth and look along his chest.
Listen, feel, and look for breathing for no more than 10 seconds.
• If the child is breathing normally:
– turn him into the recovery position
– check for continued breathing
• If he is not breathing normally or is making agonal gasps (infrequent, irregular breaths):
– carefully remove any obvious airway obstruction
– give 5 initial rescue breaths
• While performing the rescue breaths, note any gag or cough response to your action.
• To deliver rescue breaths to a child over 1 year:
– ensure head tilt and chin lift
– pinch the soft part of his nose closed with the index finger and thumb of the hand on his
– allow his mouth to open, but maintain chin lift
– take a breath and place your lips around his mouth, making sure that you have a good seal
– blow steadily into his mouth over 1–1.5 seconds, watching for his chest to rise
– maintaining head tilt and chin lift, take your mouth away from the victim and watch for his
– take another breath and repeat this sequence 4 more times
• To deliver rescue breaths to an infant:
– ensure a neutral position of the head and apply chin lift
– take a breath and cover the mouth and nasal apertures of the infant with your mouth,
making sure you have a good seal
– blow steadily into the infant’s mouth and nose over 1–1.5 seconds so that the chest rises
– maintaining head tilt and chin lift, take your mouth away from the victim and watch for his
– take another breath and repeat this sequence 4 more times
• If you have difficulty achieving an effective breath, the airway may be obstructed.
– open the child’s mouth and remove any visible obstruction
– ensure that there is adequate head tilt and chin lift, but also that the neck is not over
– if the head-tilt, chin-lift method has not opened the airway, try the jaw thrust method
– make up to 5 attempts to achieve effective rescue breaths. If still unsuccessful, move on to
• Check for signs of a circulation (signs of life).
– take no more than 10 seconds to check for signs of circulation such as movement, coughing,
or normal breathing (but not agonal gasps)
Station 66 Infant and child Basic Life Support 183
– check the pulse but take no longer than 10 seconds to do this. In a child check the carotid
pulse, in an infant check the brachial pulse
• If you are confident that you have detected signs of circulation:
– continue rescue breathing, if necessary, until the child starts breathing effectively on his own
– turn the child into the recovery position if he remains unconscious
– reassess the child frequently
– locate the xiphisternum and compress the sternum one finger’s breadth above this
– compress the sternum by one-third of the depth of the chest or more. In infants, use the tips
of two fingers or, if there are two or more rescuers, use the encircling technique with two
thumbs. In children, use the heel of one hand or, in larger children, the heels of both hands,
– aim for a rate of 100–120 compressions per minute
• After 15 compressions, tilt the head, lift the chin, and give two effective breaths.
• Continue compressions and breaths in a ratio of 15:2.
• If more than one rescuer is present, one rescuer begins resuscitation whilst another goes for
• If only one rescuer is present, he should undertake resuscitation for 1 minute before going for
assistance. It may be possible for him to carry the infant or child whilst going for assistance.
• The exception to this rule is in the case of a child with a witnessed, sudden collapse when the
rescuer is alone. In this case the cause is likely to be an arrhythmia and the child may need
defibrillation. Go for assistance immediately if there is no one to go for you.
Adapted from Resuscitation Council (UK), 2010 Guidelines.
The instructions for this station may involve explaining the immunisation programme to a parent, or
see Station 116: Explaining skills for the method.
Table 26. The UK Immunisation Schedule
2 months DTP triple vaccine (diphtheria, tetanus and
Hib (Haemophilus influenzae type b)
PCV (pneumococcal conjugate vaccine) 1 injection
3 months DTP + Hib + polio (2nd dose) 1 injection
MenC (meningitis C) 1 injection
4 months DTP + Hib + polio (3rd dose) 1 injection
12–13 months Hib/MenC (4th dose of Hib and 2nd dose of
MMR (measles, mumps, and rubella) 1 injection
2 and 3 years H. influenzae Nasal spray, annual
DTP & polio (booster) 1 injection
HPV (human papillomavirus) 3 injections over 6 months
Around 13–15 years MenC (booster) 1 injection
Around 13–18 years Diphtheria (low dose) + tetanus + polio 1 injection
Adults H. influenzae 1 injection annually if aged
PPV (pneumococcal polysaccharide vaccine) 1 injection at/after age 65
Shingles 1 injection at age 70
A vaccine is a small sample of an attenuated pathogen, the function of which is to prime the body’s
immune system to recognise the pathogen and to mount a successful defence against it. Vaccines are
programme, a number of potentially deadly infectious diseases have become uncommon in the UK.
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