How to make a Pediatric Clinical Examination kit?
Preparing your kit for clinical examination is a tough assignment, believe me!. The joy of clearing your theory and getting ready for another roller coaster ride is fun itself and One of the many things needed for this ride is the clinical examination kit
I strongly recommend gathering your guns beforehand for 3 simple reasons.
- As the exam dates start closing up, the time is limited and you have lots of targets to meet. You can't just afford to spend the time gathering these things in the last, can you?
- Even If you forget to collect a few things, you still have got time.
- If a certain tool is unavailable, you can make sure to obtain it somehow which is impossible at the last moment. This adds further to the increasing anxiety.
So stop being a procrastinator and start ticking your paper with the help of the following list.
Before we move on, one fun fact! The images used here are the real photos of equipment and tools, I used for my Pediatr practical exam and on top of that, I still have my kit packed in a box. Be proud of these small things and face the exam with little but not much anxiety.
I remember during my practical exam and I saw others carrying some extravaganza (mostly useless) and I was like "Oh My God" I forgot this! It is a very common scenario and most of the time harmless however there can be major catastrophes at times. It also sends a wrong clue to the examiner.
At my friend's center, not all have had the growth chart with them assuming that they will be provided. So the exam was delayed a bit as the examiners had to get them the copies. A well-organized center will have all these. Since it's never uniform ( I don't know what happens now), Better we get our own things with us.
Let us get into it! but before we start remember we have this genuine habit of forgetting things, so I will strongly recommend making a list on paper after you finish reading.
Your Exam roll number badge
|My exam roll number|
I nearly missed this, up until the last day of my exam. A Roll number holder. A properly made printed roll no. with a proper holder shows you are disciplined and serious for exams. You can write on paper and pin it, but it is not a good option, keep it printed. Don't do that!
Tools for Pediatric General examination
|A good stethoscope is a must-carry thing.|
A stethoscope preferably Littmann. If you were using some other brand it is ok, But this one thing is worth putting your money on. At some point, you will have to buy it anyway. Why not for the exam then. I am not sure but some of the examiners may like to see a good quality steth in your hands.
The Growth charts
Growth charts were a great dilemma for me during my exams. Which one to use? Use the WHO growth charts for kids up to 2 years, and for older children, you can use the CDC.
In fact, CDC itself recommends to WHO growth chart for children below the age of 2 years. For kids above the age of 2-years, of course, CDC charts.
The reasons for this are
- The CDC growth charts can be continuously used for the age groups 2-19 years. As against the WHO growth charts which provide growth monitoring only up to 5 years of age.
- For children 2-5 years, CDC and the WHO both used the same methodology in their growth charts.
WHO growth charts are available in two formats, percentile, and Z score. Carrying both is a good idea, I feel.
I had a practice with percentiles charts, so I interpreted anthropometry in percentile for my case. But the examiner did ask me how to interpret it as a Z score. Long story short, carry both CDC as well and Z score charts.
But above all, you need to practice using them regularly right from the start. So if you are a beginner and reading this, start using them from day 1 in your wards. You have a lot more things to read and practice before the exam. Get this done beforehand.
You can download the WHO growth chart from here. and CDC charts here, Get them color printed. But if you want a comprehensive WHO chart with lots of info alongside, use the RCPCH WHO growth chart for the age group 0 to 5 years
Blood pressure centile charts
Blood pressure centile charts gives you more power such as "The blood pressure falls under 95th centile for the age" This is a much better statement than "blood pressure is normal for the age". This is added to the list recently as suggested by a member in our FB study group
You can download the PDF below
Ruler scales for JVP and other measurements
|Remember two Ruler scales for JVP|
Ruler Scales! carry two of them. For unknown reasons examiners have a great affinity for asking how to measure JVP. They have this skill to identify where we make mistakes and JVP is one of them. therefore keep practicing the method of measuring JVP.
Besides these can be handy to measure lesions, liver span, and other stuff that need a measurement.
Non-stretchable measuring tape
|I got the unused disposable non-stretchable tape from the PICC line pack|
Measuring tape. Stretchable or non-stretchable? don't worry carry whichever is available for measurement of head circumference. This is the one I carried. You can easily get a nonstretchable paper tape with the central lines or PICC line kits.
Do not forget to cross the tapes while measuring the head circumference.
A hand torch
|Torch for pediatric clinical examination|
Take a very simple one and avoid the fancy. Preferably a little bigger than the pencil torch. Choose the one with yellow or daylight and not the white one as it may be uncomfortable for our little patient.
|Thermometer for clinical exam|
Thermometer preferably the one with big digits so that you don't need to struggle for reading the temperature during the limited times.
Tools for Pediatric Neurological Examination
Tongue depressor/Throat swab - for testing gag reflex
|Testing gag reflex in children|
Take disposable sticks with you. Alternatively, you can use clean earbuds on small kids. Examiner particularly asks about gag reflex in neurology cases. The testing gag reflex is an uncomfortable experience for the kid.
It is better to do gag reflex in the end after finishing all physical examinations since it may be uncomfortable and the child may stop cooperating further. Also, it is better to inform the examiner if you couldn't do it for some reason like in a patient with cerebral palsy
Tools for sensory examination - Cotton swab / Tooth pic
|cotton swab for testing sensory system in children|
Use Cotton for testing sensation or you can use an earbud with cotton on both ends to examine touch sensations. Use a toothpick for testing pain sensation.
Temperature sensation can be tested with a cold metal object like a tuning fork.
Reflex Hammer for testing Deep tendon reflexes
|Hammer for testing Deep tendon reflexes in children|
Practice appropriate techniques while eliciting reflexes. Read it from Hutchinson, examiners always keep an eye on our methodology, even though they might not express it at that particular time. So watch it...
Tuning fork for Deep sensation (Vibration) and hearing assessment
|Tuning fork for testing vibration and hearing|
Ideally, you should have all three, 126 Hz, 256 Hz, and 512 Hz. For vibration ideally use 126 Hz to start with and then 256Hz if impaired. But honestly, I took only the 256Hz and 512Hz in my exam.
How long a normal human feel sensory vibrations depends on
- How hard do you strike the fork?
- Age of person.
So You should know your own tuning fork perception and the usual time it takes to fade away.
For hearing assessment, use a 512 Hz tuning fork. Know Rinne and Webers test by heart as it can be confusing to explain to examiners during the viva, at least I use to always get confused with this one.
|Hearing assessment in children|
I used this bell for the distraction test. Something like a bell or small drum can be used for hearing assessment for 6 to 8-month-old using a distraction test. It can be used for up to 2 years.
It basically tests the ability of a child to turn towards the sound and is quite subjective.
You can use things for sound stimuli like rattles, voice, and drums also. Establish the minimum level of hearing to comment.
Tools for testing smell and taste sensations -Cranial nerve examination
|Testing smell and taste sensations in children|
Carry salt and sugar pouches for assessment of taste. Do not forget to take the parents/carer and or the child's permission. Make sure the child has a good understanding or capacity to understand what are you going to do and what is the purpose.
The coffee powder can be used for the assessment of smell. For older children, maybe a mild perfume can be used. Don't take unpleasant things with you for testing this.
Tools for Neuro-development.
For Measuring French or Amiel-Tison angles - Compass and protractor
|Compass and protractor for measuring Amiel-Tison angles.|
French angles or Amiel-Tison angle basically measure the degree of passive movement at various joints. Initially used for newborns, the age group now is expanded up to infants. This is one of the good reference articles to know more about Amiel-Tison angles.
They measure the capacity of muscle to lengthen and therefore give useful insight into the tone of an infant objectively removing the subjective feel of the examiner.
French angles are ideally measured using a goniometer. The measurement needs practice, take the help of images to get a feel of various curvatures and normal angles.
Examiner might ask about how to measure passive tone specifically. We can use a protractor and compass for this. While this may be a bit difficult without practice, explaining how to do it and being able to explain its significance is a necessary clinical skill.
Also in OSCE, we can get an observed station asking to test both active and passive tone specifically. I had one OSCE spot on testing active tone in a 6-month-old infant ( mannequin)
Assessment of developmental age
|The toy doll I carried for the exam - P.S. This was a gift :)|
Get a small colorful toy doll, and use it to ask about various parts in its body for development assessment, It can also help engage the kid while examining. use ball and squares for identification of shapes.
|Blocks and cubes for developmental assessment|
Things like square playing blocks or cubes can be used to assess how many things a child can count up to for developmental age assessment.
Cubes for counting
|Blocks for assessment of development|
Wooden blocks are ideal but not mandatory as they are not easy to find. The plastic ones available at any toy shop will do. I got the wooden block from my seniors but I carried the colorful plastic ones as kids prefer to play with them.
Assessment of Writing Skills
Get colorful sketch pens than a pencil or pen. Nothing more than colorful pens amuses small kids. One more thing to get more co-operation in the examination. Observe how the kid is holding these for commenting on grip etc too.
Tools for Eye and Ear examination
|Opthalmoscope for pediatric fundus examination|
As far as an ophthalmoscope is concerned you can carry it if you have, but it isn't mandatory. It will be provided on demand. What is more important is to know the right technique.
Practice throughout residency is more important. It's one useful habit focused on the exam. Opthalmology colleagues will always have these and they can help learn the right technique.
I find Hutchinson's clinical methods the best resource for learning ophthalmoscope use and its interpretation in common conditions. Here is the List of books you must-read for the Pediatric clinical examination.
Otoscope for an ear examination
Clinical Books you should carry
We all have a tendency to carry lots of books. Remember we all are exhausted near exams and it is impossible to read everything a day or two before. This may not be relevant for MD students but for DNB the practical center will be in a different city or state, so you better plan your luggage.
Make a list of books which you want to carry beforehand and include max books that cover the clinical aspects in entirety like those which cover everything or most of the things. Easy for revision at the last minute.
Here is the list of clinical books I read for my DNB exam
Your Examination Hall Ticket/entry pass
Do not forget to carry your examination hall ticket, your travel ticket, and a pen drive with you, You never know when it can be a savior.
That all about the important things/tools you must carry for the pediatric clinical examination before going to the exam hall. I am sure few things will be missed and I hope u people will add them using the comment below. Happy studying!
Ajay Agade | DNB(Pediatrics), FNB(Pediatric Intensive Care), Fellowship in Pediatric pulmonology and LTV
Ajay is a Paediatric Intensivist, currently working in Pediatric Pulmonology & LTV at Great Ormond Street Hospital NHS, London