Focused Clinical Examination OSCE

  Dr Kishor Giri

Pediatric Focused Clinical Examination is a new sub type of question brought forward by National Board Of Examinations in recent Pediatric practical examination under  observed OSCE examination. 

To emphasize importance of this types of observed stations i would like to recollect here that observed stations approximately form 35% of total marks of OSCE, that is around 50 marks out of 150.

So awareness of this subtype is very crucial.

In case-taking the whole clinical knowledge of subject is tested in prospective aspect in the form of coverage while in OSCE the accuracy of knowledge is tested in the form of depth. Previously observed clinical scenarios used to have a case format given and they use to ask to look for specific system.

But focused clinical examination format makes you to apply your knowledge retrospectively and it also checks depth of knowledge in particular topic.

Two grossly different formats are asked.

A. Diagnosis is given
you should be able to elicit and show all possible findings of that condition in the given subject in given standard time of 8 minutes.
You should start like any other case, starting from general examination and going to systemic examination and simultaneously commenting of what you are doing and for what you are looking for ? Your knowledge and clinical skills , both are assessed. I will explain with example.

1. Examine for hydrocephalus (Nov-2015 session)
Greet and obtain consent from parent and explain child.
Gen examination- sensorium/large head/nystagmus/visible leg activity
Vitals- PR/RR/ BP
Examine for hydrocephalus- AF/ dilated veins/ Take head circumference / eyes ( check with fundoscope)
Specific signs of hydrocephalus- Transillumination
CNS findings- LL tone/power/reflexes
Associated spine and skin examination.- neurocuteneous markers.
Look for associated syndromic features- murmers/ meningocele/ eyes/ dysmorphic features
Thanks parents.
Tell your findings to examiner.
2. Examine child with infective endocarditis? (Nov-2015 session)
Greet and obtain consent from parent and explain child
General examination- sensorium/comment about hemodynamic stability
Vitals- PR/RR/ BP.
Check temperature for fever
Look skin for pallor/associated skin lesions/–petechiae/janeways lesions/splinter haemorrhages/oslers nodes/clubbing.
Examine eye –with fundoscope for roths spot
CVS examination- look for rhythem/murmurs/hyperactive precordium/ position of apex.
P/A- look for spleenomegaly.
Palpate all peripheral pulses for presence and equality to r/o thromboembolic phenomenon.
Thanks parents.
Tell your findings to examiner.

B. Clinical symptom/ sign is given
This type of scenarios really make you stretch your imaginations and think retrospectively. After getting such type of osce first most importent thing to do is to be cool and do not panic. take 30 sec. And make atleast 3-4 significant possible D/Ds from given information and also keep in mind some non specific or minor D/Ds.
Then go on tracing these D/ds retrospectively in case-examination format.
Look for specific findings of these possible D/Ds in the examining field. I will explain with example.

1. Examine 3 yr old child with tremors.

First 30 sec think possible D/Ds which can have tremors in 3 yr old child. Here are the D/Ds in this case.
      1. Nebulisation with asthalin
      2. Hypoglycemia
      3. Cerebellar disorder
      4. Metabolic encephalopathy- Though cerebellar disorder seems to be first to come in mind, you should also think of other systems too in broader aspect)
Greet and obtain consent from parent and explain child.
General exam for titubations/swaying/ tremors/nystagmus/other associated abnormal involuntary movements
Look for sensorium- agitated- Asthama, CO2 retention
Dull- metabolic encephalopathy
Vitals- PR /RR-tachypnea in asthama / BP.
Skin- for neuro cuteneous markers/signs of liver cell failure.
CNS- all cerebellar signs/tone/power/reflexes/speech/gait
RS- air entry- asthama
Pattern of breathing- acidotic in metabolic acidosis.
GIT- palpate for liver and look for fluid
Thanks parents.
Tell your findings to examiner

2. Examine 8 year old female child with short stature.

D/Ds will be

  1. Familial short stature
  2. Constitutional
  3. Syndromic
  4. GHD
  5. Hypothyroidism
  6. Cushings syndrome
  7. Nutritional
  8. Chronic liver disease
  9. Chronic liver failure

Greet and obtain consent from parent and explain child 
First take anthropometric measures or make an attempt to prove it as short stature, also ask for parents height and previous height records. 
US:LS ratio affected (skeletal dysplasias, hypothyroidism)
Short stature with obesity is always endocrinal or syndromic and never nutritional
Vitals- PR- (low in hypothyroidism), RR
BP- (affected in cushings, CRF)
Dysmorphic features (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
Jaundice, spider nevi, bleeding tendancies- Chronic liver failure
Purplish striae, central obesity, buffalo hump,proximal muscle weakness- Cushings
Signs of vit deficiencies – Malabsorption, Rickets.
CNS- Low intelligence- hypothyroidism
Delayed relaxation of tendon jerks- hypothyroidism
RS - Pattern of breathing- acidotic in metabolic acidosis.
GIT- palpate for liver and look for fluid
Thanks parents.
Tell your findings to examiner

These were some of examples which i brought forward just to give you an idea about approach to focused clinical examination pattern in pediatric OSCE.

The crux is you should able to think of all aspects from all systems pertaining to given clinical scenario or question.

Here are more questions to make you think. Repeated practice of such types of OSCE will definitely help you in scoring more.
1. 4yr old child is unable to walk. Do the relevant examination.
2. 5 yr old child with recurrent wheezing episodes.
3. 7 year old child with spleenomegaly.
4. 3 year old child with cystic fibrosis.
5. 9 year old child with Wilsons disease
6. 12 year old female with SLE

We will come with more of such examples and their answers next time.
Focused Clinical Examination OSCE Focused Clinical Examination OSCE Reviewed by Author on 18 July Rating: 5

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