CLINICAL PROCEDURE OSCE STATIONS


Practice OSCE station on common procedure  in pediatric practical examination, these are points to remember just before examination, the clinical procedure should be read in detail

Don't forget to mention
Prior written consent must be taken for all procedure
Dont foget to
wear gloves and explain asepsis

Dont foget to discard biomedical waste appropriately
Here is how to

1. LIVER BIOPSY

INDICATIONS:
Cirrhosis of liver
Cryptogenic cirrhosis
Ccf
Biliary cirrhosis

CONTRAINDICATIONS:
Bleeding diathesis
Severe hepatocellulare jaundice
Infection of liver, peritoneum, billiary tract, right lung base, rt. Subhepatic abcess
Hydatid cyst of liver
Hemangioma of liver
Chronic passive congestion of liver
Gross ascites

STORAGE DISORDER:
Hemochromatosis
Glycogen storage disease
Wilson’s disease

PROCEDURE:
Premedication : Atropine if indicated
Sedation: Ketamine/ Midazolam/ Fentanyl/ Propofol as suitable
Position: Supine with arms behind head at edge of table.
Sterilization & local anesthetic
Site : 9th or 10th space-midaxillary area
Biopsy with needle
Liver tissue to be put in formalin
T.B. Seal
Vitals for 4 hrs & nbm till 4 hrs

COMPLICATIONS:
Hemorrhage
Infection
Injury to liver, gallblader, colon, kidney, blood vessels & nerves
Precipitation of hepatic coma

2. LUMBER PUNCTURE

INDICATION
Diagnostic
Therapeutic: chemotherapy, antibiotics

PROCEDURE:
Needles: LP needle short 21-23 gauge for infants, long 21 gauge for children
Position: knee drawn up & head flexed restrain in lateral recumbant position,  Small infants: sitting with leaning forward position
Site: interspace between l3-l4 or l4-l5
Sterilisation & local anesthesia
‘Give up’ sensation – dura pierced
T.B.Seal
Head low position post procedure
Vital monitoring

PREREQUISITE
Imaging/ Fundus examination to rule out raised ICP
Rule out coagulopathy/ Thrombocytopenia

COMPLICATIONS
Dry tap
Blood stained
Trauma
Subarachnoid hemorrhage
Headache (reduced by keeping head low or plenty of fluids
Infection (usually gram negative bacilli)
Medullary herniation
Injury to blood vessels,spinal cord or intervertebral disc

CONTRADICTIONS
Increased ICT
Bleeding diasthesis
Local infection

3. THORACOCENTESIS

INDICATIONS
Diagnostic
Therpeutic: Massive pleural effusion, Pleural effusion or pneumothorax causing respiratory compromise, Tension pneumothorax

POSITION
Sitting with leaning forward
Supine in small infants

SITE
fifth to sixth intercostal space in posterior axillary line

PROCEDURE
Premedication and Sedation
Sterilization and local anesthesia
Large 18-22 G needle for centesis and mallecot or ICD tube for drainage
Underwater seal
X ray after procedure
Vitals monitoring

COMPLICATIONS
Pleural shock due to vagal stimulation
Pnemothorax
Intercostal vessels and nerve injury
Infection
Hemoptysis
Subcutaneus emphysema
Air embolism
Pulmonary edema
Circulatory collapse

4. ABDOMINAL PARACENTESIS

INDICATIONS

Diagnostic:
Therapeutic:
Marked abdominal distension with respiratory distress
Edema refractory to medical therapy

CONTRAINDICATIONS
Bleeding diasthesis
Severe jaundice with impending hepatic coma

PROCEDURE
Supine or semi reclined position with back rest

SITE
Midway between umblicus and anterior superior iliac spine
Evaluate bladder before procedure
Premedication – atropine and sedation
Sterlisation and local anesthetic
Large bore needle or IV canula using ‘Z’ techniqu
Don’t remove large volume or too rapidly which might precipitate shock
Tincture benzoin seal
Vitals monitoring

COMPLICATIONS
Shock, if too rapid removal or large volume is tapped
Acute liver cell failure and precipitation of hepatic coma
Infective peritonitis
Perforation of visceral organ
Protein depletion

5. PERICARDIOCENTESIS

INDICATION
Diagnostic
Theuraptic: Cardiorespiratory embarresment or tamponade

SITE
Anterior fifth ICS outside apex beat, but inside outer edge of dullness
Epigastric (PREFERRED) between ensiform cartilage and left costal margin
Posterior: Near inferior angle of scapula
Sternal: Fourth left ICS lateral to sternum

PROCEDURE
Supine position
premedication and sedation
Sterilization and local anesthetic
Epigastric lateral to xiphoid cartilage at 45degree posteriorly towards MCL with negative suction
Seal with tincture benzoin
Vitals monitoring

COMPLICATIONS
Arrhythmias: ventricular tachycardia
Penetration of cavity of heart
Hemopericardium
Infection
Shock

6. BONE MARROW ASPIRATION

INDICATIONS

DIAGNOSTIC
Aplastic anemia
Megaloblastic anemia
Aleukemic leukemia
Myelofibrosis, myelosclerosis
Multiple myeloma
Helpful but not essentially diagnostic -refractory anamia
Iron deficiency anemia(to diferrentiate from other hypochromic anemia)
ITP, agranulocytosis, hypersplenisim
Infilterative disease-Gaucher, Niemann pick
Leukemia
Undiagnosed fever

PROGNOSTIC
Aplstic anemia
Leukemia
Agranulocytosis
Theuraptic indication- bone marrow transplantation

CONTRAINDICATION
Blood dyscrasia

PREREQUISITE
PT/PTT, platelet count, BT/CT

SITES
Iliac crest
1 cm below iliac crest about 1-2cm posterior to mid axillary line
Prone or side position
Preferred over two years
Tibia
Upper third of medial shaft

PREFERRED LESS THAN 2 YRS
Sternum
Lumbar spinous process

PROCEDURE

Position: For Iliac crest, 1 cm below iliac crest about 1-2cm posterior to mid axillary line in Prone or side position
Pre medication and sedation
Local anaesthesia upto periostium
Puncture  with screwing motion with Bone marrrow Jamshidi trephine biopsy needle
(18-20G marrow needle for smaller children can be used)
Loss of resistance after entering cavity
Attach to 10-20cc syringe with negative suction
Immediately make slide
Local pressure for 5 mins
TB Seal
vitals monitoring

COMPLICATIONS
Dry Tap
Pain, bleeding
Hematoma
Infection(osteomyelitis)

WHAT TO LOOK FOR IN MARROW
Number and type of erythropoietic, megakaryocytic and leucopoietic cell linenage
Cellularity
Myeloid erythroid ratio(normal 3:1 to 4:1)
Tumor and plasma cells
Parasites, ld bodies, malarial parasite

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