PaedSoc Guide to the Paediatrics OSCE

Summer 2019

Authors: Sajeed Ali, Alisha Burman, James Cullen, Amédine Duret, Ben Kilkelly, Tanya Li, Maria Seago, Adam Truelove, Jean Yang

This guide is aimed to help give you a starting point for your revision for the Child Health OSCE. It has kindly been put together by current 6th year students with some tips about what they found helpful during their revision and exams. Please bear this in mind when using the guide, and check MedEd or ask the assessment team for the most accurate information about your exam this summer.

The notes below are based on the OSCE Workshop that was run by PaedSoc and should cover the same material to help students who were not able to attend this workshop.

Communication Stations

(2 minutes reading time, 9 minutes history, 2 minutes viva)

History taking

Structure

The paediatric history station is very similar to the adult history stations you’ve had in the past, just with a few extra components: birth, feeding, growth, development & an expanded social history (safeguarding, home environment, etc)
A good guide can be found in many places, including here: http://www.oscestop.com/Peads_history.pdf

The history station in the paeds OSCE will most likely be from the adult parent (actor) of a child who won’t be present in the room. If the child is there, address them and such, but we would imagine that most of the information will be obtained from the adult.

Contents

As with any history, it will need to be altered depending on the presenting complaint. The Oxford Handbook of Clinical Specialties has a very good section of paediatrics which covers the conditions which are relevant to children.
It is also especially important to do a thorough systems review when taking a paediatric history as often children can present in atypical ways.

Traffic Light system

The traffic light system is used by clinicians to stratify levels of concern about a child. It has various components, many of which require a complete examination making its use limited for the history taking station. However, it would be worth knowing it roughly as it could give you a guide as to what closed questions you might need to ask and give you confidence in the viva if they were to ask you ‘are you concerned about this child’ or ‘what examination findings would make you more or less concerned’.
NICE TLS: http://bit.ly/TrafficLightSystem

[Further reading] NICE guideline about fever in a child: http://bit.ly/NICEFeverInAChild

Complex communication, triadic interview or teenager assessment: Example: teenager (with or without parent) and you are there to discuss a medical or social issue in teenager’s life

Main aim is to find out why they’ve come and to work your way through the HEADSS assessment (covered pretty well in CCS leaflet) to understand more about factors surrounding the issue Key tips:
Ensure the focus is on the teenager as a patient, don’t let the parent do all the talking ● Do remember to offer the teenager a chance to take the consultation on their own (but don’t expect the parent to leave)
Avoid making assumptions when asking questions (ie. go for open questions where possible) ● Might be worth thinking about the aspects of the HEADSS assessment that are most related to the issue and use that to guide your interview

Explanation and planning (2 minutes reading time, 11 minutes task)

Read your brief carefully! Especially note your role and your task
Practise delivering news or opening the consultation with a friend
Brainstorm all the possible reactions of the patient or parent, and questions they may ask you

Examinations

(2 minutes reading, 9 minutes examination, 2 minutes viva)

Systems

Usually a normal systems examination on a child (cardio, resp, abdo, neuro)
You will know the routine, communication is key in getting the child to follow your instructions ● You are much more likely get a child without signs, but some conditions that could pop up: murmurs (VSD, ASD), previous cardiac surgery (look for scars, related syndromes), cystic fibrosis, IBD surgery, cerebral palsy
Be aware of how to explain tasks like peak flow or inhaler use to a child

NIPE

Screening questions (signpost to your examiner – ‘I would like to ask the parents some background questions’ – and they will tell you whether this is required or not in the OSCE)
https://geekymedics.com/newborn-baby-assessment/
Practise handling a baby, doll or teddy – you should be able to confidently hold and turn a baby over while supporting its head (very obvious to the examiner if you have never tried before!)
- You may be asked to plot height, weight or head circumference
- Remember which way round Barlow and Ortolani are (think of a kind Italian doctor)
- The NIPE is a screening test, be aware of when you would refer for further investigations: https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-program me-handbook/newborn-and-infant-physical-examination-screening-programme-handbook
  - Eyes
    - Abnormality detected – ophthalmology review by 2 weeks
  - Heart =
    - Abnormality detected – senior paediatrician review, urgency varies based on clinical condition of baby:
  - Testes
    - Bilateral undescended testes – paediatric review in 24 hours
    - Unilateral undescended testes – review at 6-8 week check (if still undescended, GP review at 4-5 months, refer to surgeons by 6 months)
  - Hips
    - Abnormality detected at NIPE – USS by 2 weeks
    - Risk factors for hip abnormality (breech after 36 weeks, breech delivery, external cephalic version, family history) – USS by 6 weeks

Remember that the 6 week check is basically the same examination but you might ask the parents different background questions

Developmental assessment

Try and remember some of the key developmental milestones (these vary a lot from source to source, but this doesn’t matter as they are only median ages! Just be consistent in your own revision), as it can be difficult to remember them all! Find a set of examples below: ○ 4-6 weeks – smiles responsively
- ○ 6-7 months – sits unsupported
- ○ 9 months – get to a sitting position
- ○ 10 months – start of pincer grasp, waves goodbye
- ○ 12 months – walks unsupported, two/three words, tower of two
- ○ 18 months – tower of three/four, feeds self with spoon, points
- ○ 24 months – runs, two words together
- ○ An example table (with way too much info) can be found here:

http://mrcpch.paediatrics.co.uk/wp-content/uploads/2014/06/Development-Assessment-MRCPCH -Website.pdf

Make sure you test each domain during the exam, e.g. fine motor, gross motor, speech and language etc. It is probably best to do one ‘test’ in each domain first, before moving onto other ways to test the same domain.

○ With practice, you can focus the questions or tasks around the child’s likely age

Remember, children younger than 18 months old will have the most development in gross motor and fine motor/vision; 18 months – 2.5 years speech/language and fine motor/vision; and older than 2.5 years speech/language, social/behavioural and some fine motor (more shapes and blocks)

Practice with real children as much as possible! Project Play is an excellent way to gain practice at interacting with children.
Young children are not cooperative so you will be under time pressure in the exam. You will need to be flexible – if the child doesn’t want to make a beautiful brick tower like you had planned then move on and try something else!

A lot can be gained from inspection alone, so take early notice of the child crawling/walking/running for example

Try and present the tasks one at a time to not confuse the child
If you were unable to test something don’t be disheartened. The examiners understand that examining young children can be challenging, especially if the children have been there all day! ○ Try and see as many of the skills as you can for yourself, but don’t be afraid to ask parents if there are some skills you can’t see in the assessment, or if the child is very fed up!

At the end of the examination, suggest what other tests you would have liked to perform.

Although it won’t make or break your mark in the station, you will get some comments from the child’s parent/carer. Introducing yourself to them clearly and the odd friendly comment to them during the assessment can go a long way.

*BONUS MARKS* correct for prematurity until the age of 2 (e.g. a 9 month old baby born at 28 weeks (aka 3 months early) should only have the skills of a 6 month old baby)

Video Viva

(1 minute reading, 12 minutes viva)

Respiratory distress

Signs of respiratory distress
Know how you should manage a child in acute respiratory distress, as they may ask you about this once you have identified the patient’s signs

Neurological gaits

Know the common neurological gaits
Be able to recognise other neurological signs, such as clonus and seizures
Understand the basic management of children with neurological conditions

Plotting growth charts

Know how to plot a growth chart
Understand when you should be concerned about a child’s growth
Be able to describe how to investigate a child with poor growth, including a list of key differentials

Data interpretation

Remember general medicine and make sure you know how to interpret blood tests, ECGs and x-rays

General advice

List the MDT members who may be involved in the care of a child with any acute or chronic conditions
This is one of the more ‘knowledge-heavy’ stations – if you are struggling, just describe what you see and create a sensible differential. Don’t worry if you do not know exactly what is going on! ● Use Youtube to make sure you have seen any presentations that you may not have encountered during your Paediatrics placement

○ E.g. For respiratory distress, look at:

■ https://youtu.be/udabGpo050k

■ https://youtu.be/S3oZrMGDMMw

■ https://youtu.be/bzV1C44IPBc

Community

(4 minutes reading, 9 minutes viva)

Please see the slides for our Community Station talk:

Revision Material

Other Stations…

If you get a station that has not be described here:

DON’T PANIC, take a deep breath, you’ve got this!
Complete the task you have been given systematically, going back to general principles 3. State obvious things first, don’t dig yourself into a hole by mentioning something rare or that you don’t know much about – it likely will not be on their mark scheme, and if they quiz you further on it you’re stuck!
Sounding confident is the most important thing in these OSCEs: use structures as much as possible in your viva answers (organizing your answer by systems/local vs systemic/immediate, acute, chronic)
Smile and maintain good bedside manner throughout!

Year 5 OSCE guide