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.
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.
What are the types of Focused clinical stations?
The Question can be asked in two different formats.
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.
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.
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.
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.
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.
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.
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.
Other articles by Kishor
- Observed OSCE stations - OSCE Guide
- Body language in Practical exam
- Previous year OSCE questions
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