How to make a Pediatric Clinical Examination kit?

Paediatric clinical examination kit
The examination kit I prepared for my exam.


Preparing for your clinical exam is not less than a festival. The joy of clearing your theory and getting ready for another roller coaster ride is fun itself. One of the things which we need to be ready with is the examination kit useful for pediatric clinical examination.

I strongly recommend gathering your guns beforehand for 3 simple reasons.

  1. As the exam dates start closing up, the days become even shorter, you have lots of targets to meet and you can't afford to spend a whole day gathering these things, can you?
  2. If you forget a thing or two, you have a good time to get those.
  3. We have most of these things already but not all. At the last moment, It might be difficult to get the missing ones. This adds further to the already increasing anxiety.

So stop being a procrastinator and start ticking your paper with the help of the following list.

The fun part is that the images here are the real photos of equipment and tools, I used for my DNB 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.

First, and foremost since we are gifted with the genuine habit of forgetting things before and during exams, make a formal list of these on paper.

I remember when I reached my practical center and I saw others carrying this and that, I was like "Oh My God" I forgot this! It is very common but sometimes there can be major catastrophes. At my friends center, not all have brought the growth chart 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.

Your Exam roll number badge

DNB exam roll number badge
My exam badge

I literally missed this, up until the last day of my exam. The Roll number holder. A properly made printed roll no. in bold 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. Don't do that !.

Tools for Pediatric General examination

Your Stethoscope

pediatric stethoscope for examination

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 get it. Why not for the exam then. I don't for sure but I guess some of the examiners might mind this, but I am not sure.

The Growth charts

Growth chart for assessment of growth in children

A growth chart, was a great dilemma for me in my exams, which one to use? Use the WHO growth charts for babies up to 2 years, and for older children, u can use CDC.

This is what is the best explanation for this. CDC itself recommends the use of the WHO growth chart for children below the age of 2. For kids above the age of 2-years, it suggests using CDC charts.

The reasons are

  1. The CDC growth charts can be used continuously used for the age groups 2-19. As against the WHO growth charts which provide growth monitoring only up to 5 years of age.
  2. For children 2-5 years, CDC and the WHO both followed the same methodology in their growth charts.

The reason why the WHO growth charts are better for growth monitoring below the age of 2 years.

WHO growth charts are available in two formats, percentile, and Z score. Carrying both is a good idea, I guess.

I had a practice with percentiles more, 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 as 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 age group 0 to 5 years

Ruler Scales for measuring JVP

pediatric examination kit for measuring jvp
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, therefore keep practicing the method of measuring JVP.

Besides these can be handy to measure lesions and other stuff that need a measurement.

Non-stretchable tape

non stretchable tape for head circumference measurement
I got the unused disposable non-stretchable tape from the PICC line pack

Measuring tape. Stretchable or non-stretchable? don't worry carry whichever 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 lines we assist or put in PICU or NICU.

Do not forget crossing the tapes while measuring for a little show-off...

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 the little patient of ours.

Thermometer

Pediatric examination kit - Thermometer

Thermometer preferable with big digits so that you don't need to struggle for reading the temperature during the limited times.

Tongue depressor/Throat swab - for testing gag reflex

how to test 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 CP cases. The testing gag reflex is an uncomfortable experience for the kid.

You may choose either not to do or do it in the last after finishing all your examination for the continued cooperation. Also, it is better to inform the examiner if you couldn't do it.

Tools for Pediatric Neurological Examination

Tools for sensory examination - Cotton swab / Tooth pic

cottom 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

reflex hammer for 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...

I had a bigger one but I got an opportunity to buy that smaller one, in the pic.

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

  1. How hard you strike the fork.
  2. 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 tools - A Bell or Rattle

how to do 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 distraction test. It can be used for up to 2 years.

It basically tests the ability of a child to turn towards the sound. It is quite subjective.

You can use things for sound stimuli like rattles, voice, drums also. Establish the minimum level of hearing to comment.

Tools for testing smell and taste sensations -Cranial nerve examination

testing smell and taste senastion in children

Carry salt and sugar pouches for assessment of taste. Do not forget to take parents/carer and 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. Don't take unpleasant things with you for testing this.

Tools for Neuro-development.

for Measuring French or Amiel-Tison angles - Compass and protractor

measurement of Amiel-Tison angles use compass and protractor in children

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 this.

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 measure 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

Shape and color identification

Kit for assessment of developmental age
The toy doll I carried for the exam - P.S. This was a gift )

Get a small colorful toy doll, use it to ask about various parts in its body, It can also help engage the kid while examining. use ball and squares for identification of shapes.

Counting numbers


Things like square playing blocks or cubes can be used to assess how many things a child can cunt up to for developmental age assessment.

Cubes for developmental age assessment

how to make pediatric clinical examination kit


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

Ophthalmoscope for fundus 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-have for the Pediatric clinical examination.

Otoscope for an ear examination

I did not carry any otoscope with me. If you have well and good but you can always ask for it if needed. Perform this after finishing the rest of the examination, it can be quite uncomfortable for the child.

Books you should carry along

We all have a tendency to carry lots of books. Just remember we all are exhausted near exams and it is impossible to carry all the resources. This may not be relevant to others but for DNB the practical center will be in different cities or states, 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.

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.

Summary

In 2021, you must add a mask and your disinfectant hand rub to the list too. Try to get familiar with your equipment as early as possible. Don't worry if you cannot get some of these, it happens, don't be stressed. Ask for it. And after all the precautions some might still forget a thing or two, don't panic, it doesn't decide your result at all.

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!

Must Read

  1. Collection of all useful tips for exam - Exam corner
  2. The books you must read for Pediatric clinical examination
  3. Preparation and revision in last hours

auhtor

About Author

Ajay Agade | DNB FNB Fellowship in Pediatric pulmonology

Ajay is a Paediatric Intensivist, currently working in Pediatric Respirology & LTV at Great Ormond Street Hospital NHS, London