What is Focused Clinical Examination? - Pediatric OSCE skills • DNB Pediatrics

Introduction

Focused Clinical Examination is one of the subtypes of Objective structure clinical examination. Its been there in the MRCPCH exam for some time and has been recently included in DNB practical exam by NBE.

What is a Focused clinical examination?

To put in simple words, it is an effective way of history taking and clinical assessment in a short period of time, but not missing anything related to the particular symptoms.

In focused physical examination OSCEs, you have to examine a given body part or system. It is not a head to toe examination. But, if examination of a certain system /symptoms or clinical question requires the examination of another body part or system, then it also requires to be included.

For example, an examination of Hepatomegaly will include the examination of the abdomen but also cardiovascular examination to rule out congestive cardiac failure.

What is the Objective of a Focused clinical exam?

The new type of DNB OSCE station tests clinical examination skills alongside core knowledge and the ability to apply your clinical knowledge in everyday practice. As if you sitting in your office.

A focused clinical examination format tests your collective knowledge coverage and its depth in a particular topic/System. By making sure that you have not skipped important details.

The importance of Focused clinical examination skills in DNB practicals

35% of total Observed stations are based on focused history and clinical exam. This is around 50 marks out of 150. This makes it a very important OSCE station.

So awareness and preparation of this subtype are very crucial. It is good to have sufficient practice of such stations before the exam.

What are the types of Focused clinical stations?

The Question can be asked in two different formats.

1. Stations where the diagnosis is given

you are asked to elicit and demonstrate all possible findings for a particular diagnosis. You have a standard time of 8 minutes for this.

Start like any other case, from general examination and going forward to systemic examination.
Simultaneously comment on what you are doing and what you are looking for?

Your knowledge and clinical skills both are assessed. Let us try to understand this with examples. Two birds with one stone.

Example-1. Examine for hydrocephalus (This was asked in the Nov-2015 session)

A. Begining of consultation

Greet and obtain consent from a parent and explain to a child if that is feasible. (agewise)

B. General examination -

(I will now perform the general examination)

Comment on Sensorium.
Talk about the visible large head and take HC.
Demonstrate Nystagmus
Demonstrate any visible activity, abnormal movement, etc

Vitals - Examines Temperature, Pallor, Respiratory rate, pulse, and blood pressure.

C. Examine the hydrocephalus

( I will now perform a specific examination of hydrocephalus)

Examine fontanelles
Dilated veins
Head circumference
Examine eyes and
Fundus examination.
Demonstrate specific signs of hydrocephalus - Tran illumination

D. CNS Examination

Demonstrate tone, power, and reflexes in limbs.

E. Spine examination

Demonstrate abnormal findings of the spine if any and talk about your findings.

F. Skin examination

Talk about neurocutaneous markers.

G. Other things/system to mention

Look for associated syndromic features, dysmorphic feature and anything which can be directly or indirectly associated with hydrocephalus in children.

H. Closing the consultation.

Thanks, parents
Explain your conclusion to the examiner.

Few things to remember

Do not forget to take permission from parents or patients.
Explain what you are doing at the beginning and also during examination whenever necessary.
Take care of patients' privacy and comfort while examining, make the examiner aware of this.
Do not repeat uncomfortable maneuvers repeatedly.
Explain each and everything and every step to the examiner. Like what you are doing and what are the findings etc.
Do not obstruct the view of the examiner, try not to stand between examiner and patient.

Example-2. Examine child with infective endocarditis?

Begin the consultation

Greet and obtain consent from a parent and explain the child.

General examination

Comment about the Sensorium.
Comment about hemodynamic stability and Vitals.
Check the temperature for fever.
Look skin for pallor/associated skin lesions/–petechiae/Janeways lesions/Splinter hemorrhages/Oslers nodes/clubbing etc.
Examine eyes with fundoscopy for Roths spot.

CVS examination

Look for Rhythm/Murmurs/Hyperactive precordium/ Apex impulse position.

Abdomen Examination

Look for spleenomegaly.
Palpate all peripheral pulses for presence and equality to rule out the thromboembolic phenomenon.

Closing remarks.

Thanks, parents.
Tell your findings to the examiner.

2. OSCE Stations where the Clinical sign or symptom is given

This type of scenario really makes you stretch your imaginations and think retrospectively. The most important thing while performing such stations is to be cool and do not panic.

Take 30 sec to think and make at least 3-4 significant possible differential diagnoses from given information. The differentials can include some nonspecific or minor D/Ds as well

Now start tracing these differentials in a retrospective fashion similar to the case-examination format.

Look for specific findings or clues which can lead to these differentials. The following example will clarify this.

Example 1 - Examine this 3 yr old child with tremors.

Let us think of possible D/Ds for tremors in a 3 yr old.

Cerebellar disorder.
Liver cell failure. Hypoglycemia.
Nebulisation with asthalin in asthma.
Metabolic encephalopathy.

Though cerebellar disorder comes first in mind, think of a less common diagnosis simultaneously.

Greet and obtain consent from a parent and explain what are you doing.
Look for the sensorium, for example, agitation in asthma due to CO2 retention, and depressed sensorium in metabolic encephalopathy.
Check Vitals comment on tachypnea in asthma.
Perform Examination and comment on titubations/swaying/ tremors/nystagmus/other associated abnormal involuntary movements.
Examine for signs of liver cell failure.
Examine Skin for neuro-cutaneous markers.
Neurological examination, focus on all cerebellar signs/ tone/ power /reflexes /speech /gait etc.
Respiratory examination for signs of asthma. Acidotic Pattern of breathing for metabolic disorder presenting with tremor.
GIT examination - Rule out hepatomegaly for storage disorders, liver cell failure, and ascites.
Close the consultation by thanking the parents and the child.
Explain your final findings and thought about the case to the examiner.

Example-2. Examine an 8-year-old female child with short stature.

Think for 30 seconds. Your differentials can be

Familial short stature
Constitutional
Syndromic short stature
GHD
Hypothyroidism
Cushing's syndrome
Nutritional
Chronic liver disease

Greet and obtain consent from parents and explain to parents and child (if age appropriate) about what you are going to do.

A. Start with anthropometry.

Prove it a short stature - First, take anthropometric measures and prove it as short stature, also ask for parents height and previous height records to begin with.

Find out US : LS ratio - if affected, favors skeletal dysplasias, hypothyroidism, etc.

Short stature with obesity is always endocrinal or syndromic and not nutritional.

B. General examination

Vitals - Pulse will be low in hypothyroidism, Blood pressure will be low in cushings. Explain these to the examiner.
Demonstrate skin signs of nutritional deficiency so as to support or rule out nutritional causes.
Look for Dysmorphic features from head to toe (Genetic syndromes)
Midline defects like cleft palate, micropenis, single central incisor- Growth hormone deficiency.
Webbed neck, wide-spaced nipples with increased carrying angle in female child-Turners syndrome
Coarse skin, neck swelling- Hypothyroidism
Demonstrate Jaundice, spider nevi for Chronic liver failure.
Purplish striae, central obesity, buffalo hump, proximal muscle weakness- Cushing's
Signs of vitamin deficiencies – Malabsorption, Rickets.

C. Organ-specific examination

1. CNS

Demonstrate tone, reflexes, comment on the significance, for example, delayed relaxation of tendon jerks - hypothyroidism

2. Respiratory examination

The pattern of breathing- acidotic in metabolic diseases resulting in growth failure.

3. GIT

Palpate for liver and look for fluid as a sign of chronic liver disease.

Thanks, parents and close the consultation.

Tell your findings to the examiner.

These are just examples to give you a feel of how the stations can be. The best approach is to think of possible stations and have a basic infrastructure of how you are going to proceed while facing a particular OSCE station.

The crux is you should able to think of all aspects from all systems which are directly and remotely connected with a given clinical scenario or question.

Here is a list of similar questions based on the focused clinical examination which can be asked in the DNB or MRCPCH exam. Repeated practice of such types of OSCE will definitely help you in scoring more.

4yr old child is unable to walk. Perform relevant examination.
Examine a 5 yr old child with recurrent wheezing episodes.
This is a 7-year-old child with splenomegaly. Examine for relevant findings
Here is a 3-year-old child with cystic fibrosis. Perform focused clinical examination.
Examine this 9-year-old child with Wilson's disease.
A 12-year-old female with SLE, Perform focused clinical examination

Watch the space for more on OSCE.