MRCPCH Clinical Exam

First edition 22 June 2019

Edited By
Dr Taha Darwish (MRCPCH)
 MRCPCH Clinical Exam
1-Structure of the exam: Composed of 2 Parts:
1-Taking Skills (2 Communications & 1 HTPM)……3 Stations
2- Clinical Skills……………………………….(6+1) 6 stations plus video station

2-How to prepare for the MRCPH Clinical Exam (For all stations)
1-Start your preparation early as possible
2-You should visit the Royal College of Paediatrics and Child Health
(RCPCH) website (http://www.rcpch.ac.uk/ Examinations) which has useful
information about the syllabus to help you identify gaps in your knowledge.
3-Having a clear understanding of the OSCE format will help you to focus your
revision
4-Checklist of all possible cases and topics
5-General skeleton (General approach + Specific approach)
6-Triad (Systematic approach-Accurate signs-Good behavior)
7-Practice (Alone and Group study)
8- Training and practice are the road to success (regular practice for fluency)

3-Books: 1-MRCPCH Clinical (Mark Beattie) 2-The MRCPCH clinical exam made simple
3-Short cases for the MRCPCH (Angel Thomson) 4-MRCPCH clinical examination a practical
guide 5-Clinical peadiatrics for postgraduate examination 6-Masterpass Communication
Scenarios for MRCPCH (Rebecca Casans) 7-Paediatrics Examination (Wayne Harris) 7-Circuits
for MRCPCH (Damian Roland) 9- Other books & Notes

4-Behavior & Attitude …….Flexibility

5-Look at Yourself….Ignore the others
6-Faith & Patience
The Exam is 10 Stations

1-Cardiovascular 9 mint (7+2)

2- Neurological 9 mint (7+2)

3- Developmental 9 mint (7+2)

4-Chest OR other 9 mint (7+2)

5-Abdomen OR other 9 mint (7+2)

6-Musculoskeletal OR other 9 mint (7+2)

7-Communication 1 9 mint (7+2)

8-Communication 2 9 mint (7+2)

9-History Taking and Management Plan 22 mint (13+9)

10-Video station 22 mint

Use the Anchor statements to understand what the examiners will be looking
for you, and you can use it as a ‘mark scheme’ to grade your performance when
doing the practice cases. .
Video Station
How to approach this station?

1-Preparation: Study all possible topics very well (Search for videos online)

Important Topics

-Emergency like: Croup, Severe Asthma, DKA

-Abnormal Movements (Infantile spasm, Tremors, Chorea, Dystonia,

Epilepsy…..)

-Skin Rashes (Eczema, Erythemas, Syndrome with skin manifestations and etc..)

-Special Clinical Signs

-Eye Signs

2-During the Exam

1-Read the opening Statement, the Question and the Choices then see the video

:Be a good Observer-2

:Look at the Whole Picture

(Head to toes- Any Movement-Any Connection & Surroundings)

Listen to any Sound

 Communication Skills

How to approach the Communication skills stations

{Composed of 2 parts: (Process (70%) + Contents (30%)}

Skeleton (General Approach): For all Scenarios:

Follow the 6 steps approach (General Approach 6 points)

1-Introduction

2- Body

3-Summary

4-Finalization

5-Documentation

6-Thank you

Websites for Communication topics

Patient.co.uk

Kids Health
Skeleton for Communication skills
1-Introduction (8 points):
1-View: No Barrier, Suitable distance, Proper posture and Clear voice

2-Greating: Good morning (Afternoon)

3-Introduce Yourself: I am Dr Taha ped registrar working in the hospital (one of

the team looking after Ali)

4-Confirm With Whom You Are Speaking? Excuse me; are you Mrs Samia

mother of Ali?

5-Good Rapport: How are you Mrs Samia? (Fine) thank you for coming today (for

meeting with me today)

6-Purpose of the Meeting: OK, Mrs Samia I want to speak with you about some

issues about Ali condition.

7-A good time? Is now a good time to speak(talk)?

8- Who Else can Attend? Would you like anyone to attend this meeting with

you?....if she asked why? (For support and sharing opinion)

2-Body
1-Previous Knowledge: 1st of all can you tell me how much do you know about the
current condition of Ali?...she….

2-Aknowledgement (Empathy): I am really appreciating your feeling and your

concerns. (I can understand your feelings Mrs Samia)

3-Focus on the Task (Items of the task): As you said Ali came with….and .. so
many blood tests were done and the result came showed that Ali has a condition
called Cystic fibrosis…..pause…Have you heard of it before?

OK, Mrs Samia to understand this condition I will explain for you some basic
information, so, please, feel free you can interrupt me and ask me any question at
any time ok?

(what is the condition?, clinical picture, how to diagnose?, treatment and follow
up)

-Based on history and clinical examination of Ali he has a condition called,

Constitutional growth delay,, Have you heard of it before? So, please……

-Use Normally and Abnormally Approach…when possible

-This condition is characterized by…..Did you noticed these on Ali?

4-Draw as possible (if appropriate)

5-Check understanding: I am clear so far? At this point, do you have any question?

6-Answer Qs and concerns: I can understand your feelings and your concerns.
3-Summary
OK, Mrs Samia I know that I gave you a lot of information, just in brief to put
all together, our meeting today focused on…. The main items and Actions

4- Finalization (7 Points) I will give you….

1-Another meeting to answer any other questions

2-A regular follow up so, no need to worry

3-A contact number to answer any other questions

4-written information about the condition

5-Trust websites for more information about the condition

6-Adress for Support group

7-Arrange a meeting with other families with the same condition to share

experiences and knowledge.

5-Documentation

I will document our meeting in the medical records, file of Ali ok?

6-Thank you for coming and meeting me

Types of Scenarios: (7 Types)

1-Information giving 2-Breaking bad news

3-Consent 4-Medical error
5-Education Scenarios 6-Ethical Dilemma
7-Difficult scenarios (Poor Compliant Teenager-Difficult Colleague or
Trainee)

Precautions: (Very Important 10 Points)

1-Time, Time, Time……Time Management is very important

(Cover all parts of the skeleton)(General items).No time for details

2-Focus on the Task (Any information should be Clear, Simple, Concise &

Informative) (Do not mix communication with history taking)

3- Dialogue: Not Monologue (Bilateral: Talk and Listen)

4-Your personality: Speak slowly and clearly (it is a dialogue not

a lecture) small sentences, keep eye contact, and body language

5- Draw as possible (if appropriate)

6-Support

7-Negociate (very important)

8-Empathetic but keep the Reality

9- Check understanding

10- Answer all Qs and Concerns of the mother (in a proper way)

Empathy: understanding of the feelings of the others (theraputic factor)

Sympathy: sharing the other in his feelings (not a theraputic factor)

Important Applied Scenarios
1-Breath Holding Attack 2-Laryngomalacia 3-Atopic Dermatitis 4-Contitutional Growth
delay 5-Functional Abdominal Pain 6-Acute Gastroenteritis 7-Autistic Spectrum Disorder8-
Epilepsy and Life Style 9-Evidence Based Medicine 10-Toddler Diarrhea 11-Febrile
Convulsions 12-Premature Thelarche 13-Penuts Allergy & egg allergy 14-Clinical Audit
15-General Ethical Principles 16-Non-Accidental Injury 17-Newborn with Ambiguous Genitalia
18-Inherited Condition like DS, TS, Thalssemia 19-Lumbar Puncture,,,Bone Marrow Aspiration
20-Preterm Baby 21-Education of the parents how to use a medical device 22-blood transfusion
23-research in babies and children 24- Clinical governance 25- Basic life support 26-ethics of
withdrawal 27-epilepsy and life style (protective sport equipment) 28- medications ( steroid,
vaccine, chemotherapy) 29-acute gastroenteritis 30- bronchial asthma

Out side the station

Forget the previous station
Prepare the appropriate sheet for the examiner
Recall your voice
Read quickly the scenario with concentration focusing on:
1-Names (in Arabic)
2-Type of the scenario
3-Main items (body of the topic)
4-Follow the roles of taking station
5-Time management is crucial (process and contents)
6-Do not forget that your rule is negotiation (ability to negotiate)
Education Scenarios (very important)
How to approach this station? (10 steps)

1-Introduction: 1-Greeting: Good morning Ali

2-Introduce yourself: I am Dr Taha ped registrar, may
you know me? He..Yes
3-Rapport: How are you Ali? And how is the study
(Work) in the unit?
2-Purpose of the meeting: OK, Ali, I know that you are interested in
Kwasaki disease case and want to discuss this issue together? He,,,yes
3-Aknowledge: 1st of all I am really appreciating that you keen to learn.
(He. thank you)
4-Structure of the topic: OK, Ali our agenda will focus on (definition,
clinical picture, diagnosis, ttt, complication and follow up)
5-Encourage him to ask Qs: So, please feel free you can interrupt me and ask
me any question any time ok?
6-Ask 1st then answer approach: (each item in the agenda).
Can you tell me how much do you remember about Kawasaki?
Any answer appreciate
What did you notice on his eyes?..excellent you are a good observer
7-Do you have any other Qs? If he asked any question it is a very good
question (it is a very important question)
8-Summary : OK, Ali to put all together Kawasaki disease is …..
9-Finalization: 1-I will give you a recent Article and trust Website for
more information
2-What is your opinion Ali to do a Presentation about
Kawasaki disease in the morning meeting for other colleagues?
,,,,if there is time please can you tell me what you understood from our
meeting?
10-Thank You for coming to me and you are welcome at any time and I
hope you a good luck in your future (or in your career).
Ethical Dilemma (How to approach this station?)
NB: Follow the Rules of Education Scenarios
General Ethical Principles
It is a very difficult situation and decision to tell or not to tell…so, there are
general ethical principles to guide us in the decision making process.
Have you heard of it before? No, OK, no problem, I will explain some basic
information about these principles so, please feel free you can interrupt me
and ask me any Q at any time
These principles help in decision process between the treating team Family
and the Patient (Capacity & Competence)
1-Respect for Autonomy: Have you heard of it before?
Patient has a right to be involved in his treatment with to tell
2-Respect Beneficence (Have you heard of it before?)...Doing good
3-Respect Non-maleficence (Have you heard of it before?) do no harm
4-Respect Justice (patients to be treated equal (fairness & equality))
So, what is our plan now in the decision making of this difficult situation?
We will as
So, we will ask the mother what are her concerns to not tell Ali and
negotiate with the family to tell Ali in a staged manner step by step then
build up the knowledge gradually till Ali know every things about his
condition and ways how to cop with it.
Do you agree with that will be helpful for all: Patient (Ali), Family and the
Treating Team as all of them are working for the best interest of Ali
Clinical Audit (How to approach this station?)
NB: Follow the Rules of Education Scenarios

Definition: a self assessment process through systemic review of patient care against gold
standard
That is mean we are assess and evaluate our practice in a systematic way by comparing our
practice with the standard guidelines

Significance of audit
Do you agree with me that this is very important issue?
To know if we are following the best practice or not
To know the weak points of our practice and work to improve it
To improve the quality of healthcare

It is not a research
Do you know what is the different between audit and research?
Research is based on a hypothesis to create a new knowledge to define the best practice to help
in guidelines production
But audit is comparing our practice with the standard
Research can use patients but audit never

We are doing the audit process through the audit cycle

Have you heard of it?
1-Choose the topic (identify the problem) any problem in your practice
eg: we had about 100 patient with type 1 DM in the last year, how many of them admitted
again with DKA?
2-Identefy the standard guideline (like ISPD guidelines)
3-Collect the data (what we are doing) education, follow up, HbA1C)
4-Compare our practice against the standard
5-Identefy where is the weak points and make recommendations
6-Impement an action plan to apply the recommendations
7-Reaudit again to determine whether the changes were effective or not
In our hospital there is an audit department and it is a good source for information and will
able to guide you through the process
Evidence Based Medicine (How to approach this station?)

NB: Follow the Rules of Education Scenarios

Definition of EBM: clinical practice based on the best current evidence

(Up to date research findings)

There are main five steps in EBM. Have you heard of it?

1-Clinical Q (steroid in bronchiolitis)

2-Find best evidence (search for the evidence )

3-Critical appraisal: evaluate evidence for quality and usefulness

4-Appling the evidence to help your patients

5-Evaluation of your performance

Summary steps of EBM

5As (Ask, Access, Appraise, Apply, Assess)

1-Ask: focused clinical Q

2-Acquire or access information (search for the evidence)

3-Appraise your results critically (relevant, validity, significance, applicable

according our facilities and atmosphere, strength and weakness

4-Apply result to your patients

5-Assess: Evaluation of your performance through clinical audit

Evidence pyramid-publication types(for the strength and accuracy of the evidence)

Medical Error

How to approach this station?

1-Introduction: all items are very important (in the main skeleton)
2- Body= 7 Points
1- Previous knowledge then the event
2-Apologize Apologize Apologize Apologize (I apologize for this mistake)
4- Can I tell you what action taken since this event?
5-Actions for the baby:
1- Reassurance: We examined Ali and he is stable and doing well in
himself
2-We kept Ali under monitoring
3- Level of this medication
4-We informed our consultant and he will come to see Ali and our plan
of ttt was discussed with him
5- Any Medication will be given..
6-Any blood tests for Ali
7-Any Referral to other specialty
6-Actions for the event:
1-An Incident report was written about the event to be
discussed in the meeting of the department and I Will arrange a
meeting with you to tell what is the result.
2-All Procedures have been taken to prevent the recurrence of
this event.
7-Complaint: if she asked for complaint..you have a right to complain and I
will give you the pathway throw patient advice and liaison service
(PALS). She is angry…Apologize
Consent: How to approach this station?

1-Introduction: all items are very important (in the main skeleton)

2-Body 6 points:
1-Name of the Procedure:
We need to do a special procedure called lumber puncture or spinal tap..
then ask : Have you heard of it before? …..I will explain the procedure
for you please feel free you can interrupt me and ask me any question at
any time
2-Significant of the Procedure:
1-To know there is infection around the brain or not
2-If there is infection it will tell us what is the proper antibiotic,
duration of ttt and this will minimize complications (hearing, vision
and learning ability) as you know early diagnosis leading to early
ttt leading to better outcome
3-Steps and hazards &how to overcome:
We put a cream to numb the area (Draw) to minimize pain, clean the
area to minimize the infection then we use a very small and fine
needle to draw a few drops of the fluids around the cord to be
analyzed in the laboratory.
4-What is the alternative: this procedure is the only way to know if
there is infection around the brain or not.
5-Always reassure & support: I can understand your feelings and
concerns, but we are weighing between the benefits and hazards and
also we are following the international guidelines so, we are in the
proper way so, no need to worry.
6-Do you agree to give the consent for this procedure?
NB: If the procedure will be done by another team (surgery)…and also you
have an opportunity to discuss the procedure in details with the
surgical team. Plus the same pathway of the general skeleton
Poor Compliant Teenager (How to approach this station?)
1-Introduction:
Very important (As in the general scheme) (Do not forget would you like anyone to
attend this meeting with you?)
I have revised your file and I know that you have DM since the age of 6y and you
are doing well and cooping very well with Diabetes, but recently you have less number of
checking blood sugar.
2-What is your Concern?
Do you have any problem with checking blood sugar? (Explore what her concerns)
3-Acknowledge: I am really appreciating your feeling and your concerns
4-Significance (Positive): As you know checking blood sugar is very important to know
how much is the blood sugar to adjust the dose of insulin and this will keep blood sugar
controlled and this will keep our eyes, kidneys and our body healthy
She: I know all of these but I fade up
You: I know that it is not easy to deal with diabetes but you are not alone we are all
beside you supporting you
She: I told you I fade up
You: I can understand your feeling but as you know this is the nature of diabetes and
nowadays diabetes is a very common condition and we have many girls like your age
with diabetes and doing well, I can arrange a meeting with them to share experience and
knowledge if you wish
5-Hazards (Negative): as you know if we do not check blood sugar we cannot control it
and this may affect our eyes kidneys and also may lead to acidosis and admission to the
hospital
6-Safety Measurements: We should carry a bracelet card of diabetes to allow others to
help when needed.
7-Negotiate to improve the compliance: I am sure that you are a strong girl and can cope
with diabetes and overcome this situation, what do you think, how many times can you
check blood sugar? She 2 times per week
You ok, this a good start, and I will arrange a near meeting to follow up the readings and
answer any question. Is there any one at home can remind you about checking blood
sugar. She: my father you: very good
8-Support: (near appointment, regular follow up, support group, social worker, mental
health team and meeting with other families with the same condition.)
We have mental health team this team is expert in adjustment of emotions and behavior I
will give you a referral to this team if you wish..OK?
We also have a special team expert in social problems I will give you a referral to this
team if you wish? (Do not forget the skeleton (all items).
Difficult Scenarios (Colleague or Trainee)
How to approach this station?
1-Introduction: Good morning Ali, how are you? And how is the study
(work) in the unit?
2-Purpose of the Meeting: I want to discuss with you some issues about the
work in the unit, is now a good time to talk?
Ok, I have a concern that you did not write the discharge summary, did you
have any problem? He: I was very busy
3-Teamwork Spirit:
You: did you ask for help? We are one team
He: I am not interesting in pediatric I want to be a surgeon
You: I can understand you Ali, but as you know all doctors should have a
training period to learn general outline of all specialties
4-Significant of the Issue:
Then, do you agree with me that discharge summary will help the patient?
At the ER (emergency) it can save the life of the patient
At the OPD it can save time for the consultant
We are one team working together for the best interest of the patients and
best medical services.
Cooperation between all members of the team is very important for all
5-Support:
I am sure that you are a good doctor; do you have any problem at home?
I ready to help
(If he said, please this is a personal issue. say I am sorry for
misunderstanding I want to help.
(Do not forget the other items of the skeleton)
Non accidental injury (How to approach this station?)
Introduction: as general scheme
Body as in the general:
Bluish spots in a non mobile infant is a very serious issue
What is our plan of ttt
So, can I tell you what is our plan of ttt of Ali?
-Blood tests: clotting study & blood chemistry to be sure that there is no problem in his
blood leading to these spots.
-We will do X ray of the whole body (Skeletal survey) to be sure that there is broken
bone anywhere in the body.
-Eye examination by the eye doctor to be sure there is no blood clot in the back of the
eyes
-He also may need imaging of his brain (Brain Imaging)
If all above tests are normal, we have to inform the Social Service Team to be sure that
the home environment is save for Ali and also to give any support.
Support: (very important)
I am sure that you are a good mother and I am not attacking you, but our priority is the
safety and the best interest of Ali, so, we are in the same boat, and also we are following
the international standard guidelines, so we are in the proper way.
We are afraid of that Ali may be exposed to a forceful injury so, we are doing all of these
procedures for the sake of Ali and his best interest.
I can understand Mrs. Samia that it is a difficult time for you but you are not alone we are
all beside you supporting you.
Summary: To put all together just in brief our meeting focused on that Ali has bluish
spots and need:
1-Hospital admission 2-Blood tests & imaging
3-Social service team if needed (if all tests are normal)
I will another meeting with my Consultant to answer any other Qs.
You can stay in the hospital with Ali. If not you can come to the unit and see Ali and to
be updated about his condition. If she is angry I am sorry for misunderstanding, but my
priority is the safety and best of interest of Ali.
Breath Holding Attack
How to approach this station?
Follow the rules of the main skeleton (information giving scenario)
Based on history and examination of Ali has a condition called breath
holding attack. Have you heard of it before? The mother: No
Ok, I will explain the condition for you, so, please feel free you can interrupt
me and ask any Q at any time..ok?
It is a very common benign condition affecting infants and toddlers
Characterized by the following steps:
Any mild trauma or emotional upset followed by crying then by holding
breathing leading to decrease O2 to the brain leading to limpness and loss of
consciousness and may be followed by a small numbers of jerky movements
The attack lasts about 5 minutes and the child recover spontaneously
Every step chick understanding and ask (did you notice this on Ali?
Some times the condition associated with iron deficiency
No need for any investigations
The child will grow out of this episode usually by the age of 5 y
The mother: he has fits
I believe you that he has fit but not epilepsy
Epilepsy has no cause but here there is a cause
I will arrange a regular follow up for Ali so, no need to worry
General advice
1-Avoid precipitating factors as possible
2-During the attack stay calm as you know what is happening
3Notice the time, and if you can take a video by your mobile this will be helpful
Laryngomalacia
How to approach this station?
Follow the rules of the main skeleton (information giving)
Based on history and examination of Ali has a condition called
Laryngomalacia. Have you heard of it before?
It is a very common benign condition
What is normal? And what is the abnormal?
Larynx is soft, floppy, and collapse during breathing
It may be associated with noise during breathing feeding
The sound will get worse when the baby is agitated crying, feedings, during
lung illness, with activities and when lying supine
The sound will decrease on tummy position prone position
In the majority of cases it will resolve by the age of 1 and half year of
As he is feeding well, growing, normal crying, no color changes, so no need
to worry. It is a matter of time
Some infant with this condition may have some reflux and I will arrange a
regular follow up till improving
No need for any intervention
Atopic Dermatitis (Explain the name)
- it is a very common condition
- definition: inflammation of skin associated with dryness, redness and
itching
- Characterized by:
1-remission exacerbation (flare up)..Did you notice this on
Ali?
2-it has tendency to run in family
3- May be associated with other types of allergy
(Eye, nose, Asthma)
4- There many triggers (irritants) lead to flare of eczema
(soap, shampoo, wool sweater or blanket, skin infection, dust mite, inhaled
irritants like smocking, perfumes. May with some foods
The cause is unclear (unknown)
There is no cure but ttt can control or ease the symptoms
Treatment: avoid the irritant as possible
Dryness: emollients (moistening oint)
Redness: steroid
Itching: medication to control itching and nail care
It is better to sit away from anybody has cold sore (no kiss)
If it is wide spread with cold sore ask for medical advice (infection with the
eczema)
Good skin care is very important
No contraindication of any standard immunization given to children
Reducing the frequency of baths and adding oil to the bath water to prevent
dryness of the skin
 History Taking and Management Plan
Items of the Skeleton of HTMP
1-Introduction

2-Chronic problem

3-Acute problem

4-Systemic review

5-Neonatal history

6-Nutritional, Growth & Development and Puberty

7-Vaccination (Routine& Extra) & Allergy (Food& Medications)

8-Surgery & Hospitalization

9-Family H (Pedigree)

10-Social H (Family dynamics, School dynamics & Community)

11-Closing Qs (3)

12-Summary

13-Thank you

Precautions: very important

1-Time management

2-Focused history (focus on the DD)

3- Any complaint: -Acute or Chronic?

-1st time or happened before?

4-Problem list

A-Chronic problems
B-Acute problems
1-physical
2-psychosocial
Details of the HTMP Skeleton

1-Introduction:

1-View: No Barrier, Suitable distance, Proper posture and Clear voice

2-Greeting: Good morning (Afternoon)

3-Introduce yourself: I am Dr Taha ped registrar working in the hospital

4-Confirm: whom you are taking: Excuse me, are you Mrs Samia mother of Ali?

5-Good Rapport: How are you Mrs Samia?...(Fine) thank you for coming today

(for meeting with me today).

6-Purpose of the meeting: OK mrs samia I am here today to discuss the condition
of Ali with you

7-Permission to write down some notes: and I will write down some notes during
our taking, is it ok for you? She yes, you thank you

8-The Referring letter: OK Mrs Samia what I understood from the referring letter
that Ali has…

NB: If acute problem: please Mrs samia can you tell me what is the problem of
Ali?
2-Chronic problems ( 5 points) (very fast no time)
1-When & How diagnosed? (Clinically & Investigations (Laboratory& Imaging))
2-Medications in details (Dose, Rout, Frequency, Compliance, SE, who give)
3-Doctors involved in care of Ali (MDT) and all possible associated problems
4- Regular F/U how frequent, last appointment and any recent change in
medications?

5-Hospital admission: each time in details

3-Acute problem (5 points) (Open and Closed Qs)

1-Complete analysis of the complaint (onset, course, duration, 1st time or happened
before? relieving factors and triggering factors

2-Associated symptoms (1-of the same system 2-other systems according DD)

3-Did you ask for any medical advice?

4-Did you do any blood test? Investigations

5-Did you try any medications? What is the response?

4- Systemic review (Follow the DD) (Do not duplicate the Qs)

1-General symptoms (Fever, WT loss, Pain, pallor, headache, change in behavior

or appetite, appearance of any lumps, abnormal movement, exercise intolerance,
bleeding from any orifices. Colors: pallor, jaundice (yellowish discoloration)
cyanosis (bluish discoloration).

NB: Any Fever, Vomiting, Diarrhea, Cough

A-Any history of recent travel
B-Any history of contact with sick person
2-From head to toes (According your DD)
CNS: trauma, fits (with fever or not), abnormal movement, limping, weakness
Chest: Snoring, cough, difficulty of breathing, wheezing, chocking, ear
infection, exercise intolerance, triggers (smoking, pollution, perfumes, dust mite),
chest pain

CVS: Shortness of breath, awareness of heart beat, fainting attack

GIT: (don not forget liver and spleen) Drooling, vomiting, tummy pain, loose
motion, yellowish discoloration of skin

Genitourinary: urination: amount, frequency, color, pain, stream, bed wetting,

female discharge
MSK: skin rash, joint swelling, difficulty in waking
Skin: itching, rash, nails, teeth, mucous membrane, abnormal pigmentation
(NF1)

Immunology: any history of recurrent infection any where in the body?

Genetic: distinctive features
5- Neonatal (Pregnancy, Delivery and after birth)
Did you remember any problem during pregnancy? Full term or before his
date? Normal delivery or operation? In CP details
6-Nutrional, G&D and puberty
Nutrition: meals, snacks and supplementation
Milk: breast feedings or formula feeding

Growth (WT&HT and G chart) Development (CP in details)

If old & normal….school performance & sport and activity
Puberty (period started or not? change in body odor, voice appearance of hair)

7-Vaccination (Routine and Extra) & Allergy (Food &Medication)

8-Surgery & Hospitalization & why
9-Family H (Pedigree)

How old are you and your husband?

You and your husband are related?
Do you have any medical problem? and your husband?
How many children do you have? All are ok?
Is there any family history of the same condition?
Family history of diseases run in family (related to the problem)
10-Social H (Very important) (3 Points):
1-Family dynamics: Jobs, Housing, Accommodation, Financial
problem and support, car (yes or not? Adapted to the condition or not? Who
is taking care of other children (eg: during admission), relation between the
family members, any pets, smoking.
2-School dynamics (Type of school, Attendance, Performance,
Relationship between Ali and his teachers and peers, bullying, teasing,
Accommodation)
3-Community dynamics: Social worker, Support group, Respite care)
11-Closing Qs (3)
1-Can you tell me what is your main concern?
2-Are you concerned about any diagnosis in a particular diagnosis?
3-Do you have anything you want to tell me or ask me?
12-Summary if there is time
13-Thank you for coming and meeting me
NB: If she asked about the treatment
I will examine Ali first and discuss the condition with my consultant and
come to you again to explain the plan of treatment, ok?
 Outside the station

Names: baby (in patient or not), mother, who are you?

Complaint: its system.. Reasonable DD…to formulate Qs (Most important)

Type of problems:

Acute: Mainly diagnosis

Chronic: 1-Mainly management plan

2-Complication of the disease

3-Complication of the medication

Every ward from the mother … pick up the clues to the diagnosis or DD

Open and closed Qs ..in all complaints

Focused history

Touch every point in the mark sheet

Process and contents

Use each ward from the other to reach the diagnosis

NB: Do not forget time management: 22 mints: 13 (9+4) with the mother and

9 mints with the examiner

How to formulate the Qs? How to ask?

Before this event he was completely normal (OK) or has any medical problem?
Is there any history of..?
Please, can you tell me about this…headache, diarrhea
Did you notice any change in..?
What about his appetite?
Since diagnosis, any history of hospital admission? how many times .. and why?
Many complaints: what is your main complaint?
Psychosocial (examples):

Emotional problems (Emotional upset, Anxiety, Depression)

One parent family
Father is away most of time
Sibling with the same problem
Financial problems
Transport problems
Home: not adapted to the medical problem
Parents are not working
Frequent hospital admission
School problems: Absence, Bullying, Teasing, Performance, Not adapted to
the medial condition
 Presentation to the examiner:

Ali is 10 y old boy with the following Problems (Problem list)

Problem List:

A-Chronic problems
B-Acute problems:
1-physical
2-psychosocial

Plan of management: (5 Points)

1- Full examination focusing on…
2-Admission or not?
3- Regarding the acute problem:
-Admission or not
-Investigations (laboratory and imaging) (according
to DD and the problem list)
-Referral to other specialties

-Treatment (symptomatic and specific)

4-Regarding the chronic problems: 4 Rs

-Reeducation of the family and Ali

-Revision of the medication

-Referral to other specialties

-Regular follow up

5-Explanation of the condition to the parents

Important Topics

-All topics in pastest (Mark Beattie) (6 cases in details) (12 cases in short)

-Other topics:

1-Bed wetting 2-Obesity 3-Chronic diarrhea 4-Haematuria (red urine)

5-Chorea 6-Autoimmune hemolytic anemia 7-Sickle cell disease

8-SLE 9-Autoimmune hepatitis 10-Hypertension in children

11-Chronic renal failure 12-Thalassemia with constipation

13-Wilson disease 14-Renal tubular acidosis 15-MEN 16-Delayed waking

17-Bleeding ( haematemesis and bleeding per rectum) 18-Limping child

NB: Chronic diseases

Where is the problem?

Part of the disease (one of its components)

Complication of the disease it self

Complication of the medication

Jargons and Words (If you forget and said a jargon say I am sorry I mean….)
MDI: a team of expert specialists
Endocrinology: hormone or gland doctor
Pulmonologist: lung or chest doctor -Ophthalmology: eye doctor - ENT: ear doctor
Cardiologist: heart doctor-Orthopedics: bone doctor-Hematology: blood doctor
Gastroenterologist: digestive system doctor
Neurologist: nervous system doctor-Brain ventricles: water (fluid) space in the brain
Esophagus: food pipe-Trachea: air pipe -Blood vessels: blood pipe
Abdominal pain: tummy ache or tummy pain
Convulsions: fits -Febrile convulsion: fever fits
Gene therapy not jargon- Genetic condition: the same
Mutation: spontaneous change in the genetic material or faulty gene from no where
BGA&SE: blood chemistry and salts
Inherited disease: a condition that runs in families
Metabolic disease: problem in blood chemicals called enzymes
Chromosomes: filament like structures carrying our genes
Genitalia: private organs or area-Uterus: womb-Axilla: armpit -Anus: back passage
SAN: electrical generator-Echo: heart scan or image-VSD: hole in the heart
ECG: heart graph- EEG: brain graph- Ventilator: breathing machine
Investigations: tests-CBC: blood picture test
Autoimmune: self destruction-Cell: the smallest part in the body
Edema: swelling-Bone marrow: the factory of the blood cells
Bacteria: bug or germ-Rectum: back passage
IVIG: purified Ab will be given
Autoimmune disease: by unknown cause the defense system is dealing with himself as a
foreigner
Neuroblastoma: a lump in his tummy
 Clinical Skills
To Be a Good Doctor: (triad)
1- Knowledge 2- Clinical Skills 3- Appropriate Attitude & Behavior
To pass the exam: (tetrad)
1- Good rapport 2- Smooth technique
3- Accurate findings 4-Consistant interpretation
Follow the 6 steps approach (General Approach 6 points)

1-Introduction (8 points)

1- Greeting

2-Introduce yourself

3-Consent (permission)

4-Rapport

5-Wash your hand

6-Exposure

7-Position (patient and you)

8-Ask for pain

2- General Observation (4 points)

1-Orientation and interaction

2-Growth parameters

3-Dysmorphic features

4-Connections and surroundings (you will comment if present)

NB: Try to pick up the diagnosis at step 1 and 2 if you cannot stuck with the
approach and you will reach.
3-Examination (Structured Approach): No running commentary

Hand …. Then Head …then Neck …then Chest & Heart …then Abdomen …then

lower limb..then Back… then Cover then Thank you

4-I want to complete my examination by examination of…..

5-Present Your Findings (in a professional way) 4 Points:

1-General findings on observation (Growth parameters &Dismorphism)

2-Important Positive finding going with the diagnosis or DD

3-Important relevant Negative findings

4-Overall conclusion

I have examined Ahmed 5 y old boy. He looks thriving ( appropriately

growing) for his age although I want to plot his WT, HT and HC in appropriate

growth chart for his age and sex, he has no apparent dysmorphic features ,,,,,

And he has: Positive finding with no: Important Negative, so, my provisional

diagnosis going with…..

(Do not describe all the details of the examination, only important signs for

diagnosis or differential diagnosis)

NB: No time (time management is very important)

6-Management: Be Logic and Professional (Do not forget the Reality)

There are 2 Approaches:

1-Thorough history - Investigations -Multidisciplinary team approach

2-I Will Revise the file and ….

4 Mint waiting (Outside) (very important)

-Take deep breath (some Rest)

-Forget: 1- The previous station
2- The examiner
-Recall your voice, activity and confidence
-General scheme according to the station & the task
-In all stations listen carefully to the opening statement:

(Name, Age, Sex, and Task)

-Follow the 6 steps approach (very important)

NB: Try to pick up the diagnosis at step 1 and 2 if you cannot stuck with
the approach and you will reach the diagnosis.
 Cardiovascular System

NB: Stuck With your Approach (General& Specific):

1-General Scheme

2- Cardiovascular Approach

Checklist of possible cases: Algorithm

Dysmorphic or not then Cyanosed or not

Dysmorphic….Specific syndrome….Possible diagnosis

=Cyanotic One of Three:

1-Fallot Tetrology

2-Complex Cyanotic CHD

3-Eisenmenger Syndrome

=Non Cyanotic:

Is there scar or not?

Is there thrill or not?

Aortic Stenosis, VSD, Pulmonary Stenosis, PDA, Coarctation of Aorta

Corrected cyanotic CH
Systematic Approach:
Listen carefully to the Opening Statement (Name, Age, Sex and Task)
Hand:
1- Clubbing 2-Cyanosis 3-Deformity
4- Pallor 5- Signs of IE
6-Both hands are warm denoting good perfusion

7-Pulse: 8-respiratory rate( finish the watch)

1-Measure the pulse, Start Rt hand first to count the pulse

2-Pulse in both hands

3- Water hummer pulse

Then Head (3 things)

Dysmorphism -1

Eye (jaundice and pallor) -2

Mouth (cyanosis and oral hygiene)-3

Then: Expose the chest

Inspection (3 things): Deformity (Pectus excavatum or carinatum, Harrison

sulcus) (from the side and end of the bed), Scars, Pulsations

Palpation: (7 things in order) (the most important are Apex site and Thrill)

1-Respiratory rate (RR)(if not done)

2-Both hands for apex then localize the apex (Site and Characters)
count (Displaced apex….cardiomegally)

Hyperactive apex…..volume overload (VSD, MR)

Forceful apex…………pressure overload (AS)

3-Lower Lt sternal thrills

 4-Rt ventricular Heave

5-Upper lf sternal thrills

6-Suprasternal thrills

7-Carotid thrills

Auscultation (6 points in order):

1-Apex

Heart sounds

Murmurs …axilla

2-Lower Lt sternal border

3-Lf 2nd intercostals

4-Rt 2nd intercostals

5-Carotid

6-Then RT side of chest (Do not miss Dextrocardia)

Then: Abdomen: Liver (HF) and Spleen (IE)

Then lower limb for Clubbing and Edema

Then: Examine the back (4 points)

1-Deformity 2-Radiation of the murmur

3-Fine basal Crepitations 4-Sacral edema (After permission)

Then: Cover the child; thank him while smiling to him in a confident way

NB: Keep enough time for Palpation and Auscultation (The diagnosis)

Then Look at the examiner and start to talk:

I want to complete my examination by (4 points)

1-Measuring blood pressure in the 4 limbs

2-Femoral pulsation to rule out radio femoral delay

3-Measuring oxygen saturation in the 4 limbs

4- Temp.Chart and Urine dipstick.

Then: Present Your Findings

I have examined Ali 5 y old boy (Blond wards are most important)

1-Growth parameters, 2-Dysmorphism, 3-Clubbing, 4-Cyanosis, 5-scars (if

present),

6-Deformity (if present), 7-thrills (if present), 8-Heart sounds, 9-Murmurs

So, this is a case of non cyanotic CHD most probably VSD (NO abbreviations),
with no evidence of HF or IE

What’s your management plan?

-Thorough history

-Investigations: CBC (Ht in TOF), Chest X ray, ECG, ECHO, catheter

-I will treat Ali through a multidisplinary team which composed of:

1-My consultant (coordinator of the team)

2-Cardiologist (head of the team)

3-Dietician to optimize nutrition

4-School (if appropriate)

5-Psychosocial support for Ali and his family

6-Regular follow up in the OPD

Important Notes:
 -Scar: I want to measure its length

1- Middle thoracotomy scar (open heart surgery) cyanotic CHD ( or any bypass
surgery)

2- Rt thoracotomy scar: Mod. BT shunt- TOF repair- Rt lobectomy

3-Lt thoracotomy scar: Mod. BT shunt- PDA ligation- PA banding

Coarctation repair- Left lobectomy

-Small scars most probably chest tube scar.

-Abnormal limbs >> back defect>> VACTERL

-Jaundice: Alagille syndrome

-Cyanosed child with features of trisomy 21>>Eisenmengar

-Ejection murmur on 2nd Rt ICS without radiation with no thrill>>>

innocent murmur

-Teenager with pansystole on the apex propagated to the apex>>>

Rheumatic HD (D J criteria)

-Diastolic murmur max. Over the Lt 3rd space + water HP>>>AR>>

Marfan ?

-Absent Lt or Rt brachial pulse with Lt Or Rt thoracotomy

scar>>Classical BT shunt >>>>> child is dusky or cyanosed

-Absent Lt brachial pulse with Lt thoracotomy scar in a pink child>>

subclavian flap repair for coarctation.

-Weak pulse with scar in a cyanosed child>>> mod. BT

 -Weak pulse with no scar>>>> AS?

-Clubbing, cyanosis, conjunctival injection>> TOF or CCHD

-Right ventricular heave>>>PS, TOF, AVSD & Eisenmenger.

-Epigastric pulsations +Right ventricular heave>>>right ventricular

hypertrophy.

-Normal Apex age <4y lf 4th intercostal space just outside MCL

Age > 4y 5th intercostal space in the MCL

MCL (Nipple line)

-Ventricular enlargement:

=RT Ventricular enlargement: apex displaced outward and diffuse (2

spaces)

=Lf Ventricular enlargement apex displaced downward and outward

and localized (1 space)

-MR….Systolic thrill (with the apex slap)

-MS...Diastolic thrill (before the apex slap)

Notes on VSD:

-Small VSD (S2 not loud)

-Large VSD: P: S flow ratio>2:1, tachypnea, tachycardia, liver enlarged,S2 high,

diastolic murmur on apex, affecting growth, active pericorduim>>>> operated

before 6 month of age

-In a case of TOF:

1) In the management add: Ht in CBC .monitor viscosity and

coagulation profile .Advice parents about hypercyanotic spells:

Squatting- Oxygen-Morphine -B-blocker-NaHCO3-Noradrenaline

2) Complications of TOF:

Cyanotic Spells- Brain abscess-Strokes-IE-

-PDA: big pulse volume (easily palpable pulse) put PDA in your mind

Congenital Rubella syndrome: PDA

Small head

-Syndromes: Down, Noonan, Turner, William, Alagille

Indications for IE prophylaxis

1- Congenital heart disease:
1-All cyanotic CHD
2-Prothetic valve
3-H/O IE
4-Heart transplant
5-Non-cyanotic CHD after surgery for 6 months
2-Aquired heart disease :( Rheumatic, Kawasaki)
If associated with valvular lesions.
 Chest examination
NB: - Follow the 6 steps approach

-Try during general observation to pick up the diagnosis

-Introduction: as before

-General observation: as before

-Hand to head the head to toe then the back

Systematic approach: Follow the following sequences:

Hand: clubbing, cyanosis,

Lf arm: Pulse eczema, BCG scar

Face: dimorphism, Eyes: jaundice, pallor, Mouth: central cyanosis,

Neck: LNs (should be done) Trachea: central? (Ask the child)

Then local chest examination

1-Inspection:

-AP diameter increased (hyperinflation)

-Deformity (pectus carinatum or excavatum, Harrison’s sulcus)

-Scar, central line and gastrostomy tube

2- Palpation:

-RR
-Locate the apex (with two hands) please exclude Dextrocardia
-Chest expansion
3-Percussion: (compare) (ask the child): Supraclavicular, direct on the clavicles,
one RT and one LT mid clavicular then mid axillary. Dr: Taha Darwish( 65823256)

4-Auscultation: (compare) One RT and one LT mid clavicular then mid axillary.
Then abdomen: palpate for the liver if palpable span

Then lower limb

Then the back:

- Inspection (Hug your self-No scars)

- PALPATION: Chest expansion

-Percussion: (compare) between scapulae then symmetrical bilateral

below the scapulae

-Auscultation: (compare) fair air entry bilaterally with bilateral

scattered crepitations

Then thank you

I want to complete my examination by examination of:

1-ENT 2-O2 saturation 3-peak flow meter

4-inspection of sputum sample 5-pubertal assessment

Present your findings

I have examined Ali 6 years old boy

Growth parameters, dimorphism, positive findings, important negative

I heard wheezes all over the chest with prolonged expiratory phase, decrease air entry bilateral?
Crackles??

So, is a case of chronic obstructive lung disease most probably a case of bronchial asthma (no
clubbing) or chronic suppurative lung disease mostly CF (clubbing)

How to manage Ali?

1-Thorough history

2-Investigations

3-MDT
 Abdominal examination
Systematic approach (How to approach this station?)

NB: - Follow the 6 steps approach

-Try during general observation to pick up the diagnosis

-Introduction: as before

-General observation: as before

-Hand to head the head to toe then the back

Follow the following sequences:

Hands: clubbing, deformity, koilonychia , leukonychia, palmar erythema, multiple scars in the
dorsum of the hands

Arm: Scratch marks, tendon xanthomas (hypercholesterolaemia)

Face: dimorphism, rounded full face

Eyes: jaundice, pallor, kisser fleshier ring

Mouth: oral ulcers

Tongue: Macroglossia (hypothyroidism, Beckwidth-Wiedemann, mucopolysaccaridoses, Pomps’s GSD,

Amyloid, haemangioma, lymphagioma)

Neck: LNs (should be done)

Chest: Spider navi, gynaecomastia, central line, chest symptoms (cystic fibrosis)

Then local abdominal examination:

1-Inspection: Bulging (feet and side of the patient), scars, dilated veins, umbilicus,
pigmentation

2-Palpation: PAIN superficial and deep in systematic manner (Liver, spleen, kidneys)

Palpate systematically. You may start from left iliac fossa and proceed in the
direction above.
 3-Percussion: for ascites

4-Auscultation: intestinal sound and renal bruit

Then Lower limb: edema, clubbing, erythema nodosa, ulcers

Then back: deformity, skin rash, renal bruit, sacral edema

I want to complete my examination by examination of:

Hernia orifice, External genitalia, Perianal area, pubertal stage, Inspection of urine and stool

NB: For renal examination: -BP -Urinalysis -Assess for signs of steroid toxicity

Present your findings

I have examined Ali is 10 y old boy

Growth parameters, dimorphism, positive finding, important negative (He has no

lymphadenopathy or stigmata of chronic liver disease)

So, my provisional diagnosis is….

How to manage Ali?

1-Thorough history and genetic counseling 2- Investigation 3-MDT

Checklist of possible cases:

1-Hemolytic anemias: (Thalassemia, Sickle cell anemia, heriditary spherocytosis, sickle
thalassemia)

-Thalssemia major: ++++spleen +liver

-Sickle cell anemia: ++liver spleen not palpable

-Hereditary spherocytosis: +++spleen liver not palpable

2-Chronic liver disease: portal hypertension, Liver transplantation

GSD, Wilson disease, Alagille syndrome, Post kassi

3-IBD 4-Cystic fibrosis

5-Renal transplantation, Nephrectomy

NBs:

1-Hemolytic anemias
-Thalassemic features: head bossing, prominent maxilla, malocluded teeth, hyperpigmented skin

-Hemolytic anemia:
pallor, Jaundice, Spleenomegaly, Hemolytic facies (frontal bossing, prominent maxilla,
maloccluded teeth, hyperpigmented skin), No lymphadenopthy, No stigmata of chronic liver
disease

-He has no lymphadenopathy or stigmata of chronic liver disease

-Thalassemia TTT

Supportive treatment in the form of: folic acid, vaccinations, monitoring growth and
development of complication

1-Thorough history and genetic counseling

2- Investigation in the form of CBC, blood film, retcs, Hb electrophoresis

3- MDT (my consultant, hematologist, endocrinologist cardiologist dietician and

Psychosocial support and regular follow up)

-Regular blood transfusion keeping Hb > 10 gm

-Iron chelating agent

-Spleectomy in case of hyperspleenism or huge spleen

-Bone marrow transplantation in special cases

-Regular follow up and monitoring any complications (iron overload, hazards of blood
transfusion)

-Complication of thalassemia

1-Hemosiderosis: iron overload

-Cardiomyiopathy--Liver cirrhosis

- Endocrinopathy: Hypopuitutarism, Hypothyroidism, Hypoparathyroidism,

Bronzed diabetes and delayed puberty

2- Hazards of blood transfusion: infection and iron overload

3-Gall bladder stones: pigmented gall stones

4- Complication of the chelating agent:

Eye, ear, skin, GIT symptoms, neutropenia, nephropathy

Over chelation: reduce zinc, copper, selenium, ionized calcium

5-Pulmonary hypertension

6-Extramedullry extension: bone fracture, osteoporosis, Poor dentition

7- Aplastic crisis

-Chelating agents:

SC infusion: Deferoxamine( desferal): red color urine, hyperpigmented skin, hearing and
visual problems

Should be started after about 1 y of chronic transfusion this correlate with serum ferritin
1000mic/dl

Post splenectomy events: infection, immunization, increased platelets (increase risk for
thrombotic events)

-Hereditary spherocytosis:

1-Chlecystectomy, spenectomy (its implication)

2-Treatment: folic acid supplementation as for all hemolytic anemias

3 -Life long penicillin prophylaxis

4 -Vaccination against encapsulated organisms(meningococci, pneumococci, H.influanza )

-Hyperspleenism: triad spleenomegally, pancytopenia, active bone marrow (increased retics)

2-Chronic liver disease

-Hepatomegally: liver span..liver is soft or firm, smooth rounded border(sharp border in

cirrhosis) and not tender

-Finger clubbing + hepatomegally: CF, IBD, chronic liver disease, celiac disease

-Percussion for ascites: From umbilicus down to suprapubic area…if dullness then go to the
flanks then If flanks is dull Turn the patient to the other side while you are putting your hands on
the dull area wait 30 seconds then percuss from the flanks to the umbilicus
-Splenomegally: spleen is palpable about 5cm below costal margin and was firm, smooth not
tender

-Portal hypertension: -Spleenomegally, ascites, portosystemic shunts (caput medusa, esophageal

varices, and hemorrhoids)

-He has stigmata of chronic liver disease in the form of:

Muscle wasting, Jaundice, pallor, palmar erythem, clubbing, leukonychia, spider navi, ascites,
caput medusa, peripheral edema, Skin: bruises, scratch marks, petichea

-Work up of portal hypertension:1-Search for the cause

2- Search for the complications

Causes of portal hypertension:

1-Prehepatic -Portal vein thrombosis (thrombophilia), postnatal

umbilical vessel catheterization, sepsis
2-Hepatic – cirrhosis, congenital hepatic fibrosis
3-Posthepatic – Budd-Chiari syndrome, (hepatic vein obstruction), heart failure
-Hands: flapping tremors (encephalopathy)

-GSD: full rounded face, short stature, hepatomegally( liver span…, no lyphadenopathy, no
stigmata of chronic liver disease

Teenager: pall, oral ulcers, growth delayed puberty roll out IBD and I want to complete my
examination by examination of: LNs, perianal area for skin tag, anal ulcer, abscess, and sinus, or
anal fissure, pubertal assessment

-Dilated vein (show the examiner):

-Caput medusa: (PH):
1-Site around the umbilicus
2-Direction of blood flow away from the umbilicus
-Side of the abdomen:
1-SVC obstruction: Flow of blood inferiorly
2-IVC obstruction: Flow of blood superiorly
-Acute liver cell failure: Encephalopathy-Coagulopathy- Hypoglycemia- Increased ammonia

-Complication of renal transplant: rejection, infection, recurrent (autoimmune) complication of

drugs

-In any case of HSM: is there any signs of portal hypertension or chronic liver disease

-Anatomy of the abdomen:

RUQ Epigasreic area LUQ

Rt loin centeral Lt loin

Rt iliac fossa suprapubic Lt iliac fossa

3--Scar for: (transverse or horizontal in …. Area): cholecystectomy, splenectomy,

appendicectomy, nephrectomy, liver transplant, renal transplant

Nephrectomy: rt or lt lateral thoracolumbar scar about 7 cm

Renal angle scars / Laparoscopic surgery / Liver Biopsy

Groins – inguinal hernia repair, renal transplant (will also be palpable mass)
Below right subcostal margin – (Kocher’s incision) – think cholecystectomy, especially in
sickle cell disease, any liver procedure, e.g. hemi-hepatectomy for hepatoblastoma
‘Rooftop scar’ – liver transplant
Transverse upper abdominal incision – repair of congenital diaphragmatic hernia – more
common on the left
Upper abdominal midline incision – Nissen’s fundoplication
Small right upper transverse incision – Ramstedt’s pyloromyotomy
Umbilicus – consider gastroschisis or exomphalos, umbilical hernia repair
Laparoscopy scars – more common, very small and multiple (often one at umbilicus)
Lateral thoracolumbar incision – nephrectomy

Topics should be studied well:

-Hemolytic anemias

-Hb electrophoresis, blood films in all types of hemolytic anemia

-Causes of hepatomegally, splenomegaly, HSM

- Portal hypertension in details

-Wilson disease

-Cystic fibrosis

-GSD type 1(a,b)

-Scars of the abdomen

-Renal transplant
-Biliary atresia

-MPS

Abdominal scars

NB: CF (CF team)

1-Through family history, genetic counseling, neonatal history, surgical

history, diet (high calorie high protein) medications (pancreatic enzyme
supplements, vitamins, and antibiotics), physiotherapy and compliance.
 2-Hospital admission , saturation monitoring, Sweat test, blood cultures,
sputum culture, inflammatory markers, immunoglobulins, peak flow, PFT,
CBC, x ray chest

3-MDT (CF TEAM) in the form of my consultant, pulmonologist,

phisotherapist, gastroenterologistand, hepatologist, endocrinologist,
dietician, psychologist and school

Checklist of possible cases (the most important is Kartagner syndrome)

NB: Chest case + dextrocaredia with or without clubbing diagnosis is
Kartagner syndrome
1-Hyper expanded chest with clubbing: chronic suppurative lung disease
CF, primary ciliary dyskinesia, immunodeficiency, aspiration syndromes
(TOF, GERD, FB)
2-Hyper expanded chest without clubbing: chronic obstructive lung disease.
(Br. Asthma)
3-Hyper expanded chest without clubbing + sings of prematurity: preterm
with chronic lung disease
Ex preterm feature 1- small for age 2- long narrow head 3- small scars in the
dorsum of the hands
4-Hyper expanded chest, clubbing and dextrocardia: kartagner
(examine the abdomen).

NEUROLOGICAL EXAMINATION

1-General Scheme

2-SYSTEMATIC APPROACH:

Listen carefully to the opening statement (Name, Age, Sex and Task)
 Be confident, smiling and look around you and patient (seriously)

1-Outside the bed

Exposure (No Sandals No Trousers) Adolescent Above the Knee

Ask if he can sit, Stand or Walk (if appropriate)?

Gait Examination: (Spastic, Ataxic, Waddling)

Spastic Gait: joints are flexed or extended (Hemiplegia (Unilateral or Double)

Diplegia)

Ataxic Gait :(Cerebellar, Ataxia Telanjetasia (Red Eyes), Frederick ataxia, ataxic
CP)

Waddling Gait (Gower sign, tongue for fasciculation, winging scapula)

NBs:

Hemiplasic Gait: Circumduction, flexion arm, extention hip, extention knee,

planter flexion and scrapping the floor.

Diplegic Gait: flexion hip, flexion knee, scissoring , tip toe.

Ataxic Gait: unsteady wide based gait, TRUNKAL ATAXIA,

High steppege Gait

Waddling gait: DMD ( calf), SMAIII (Scapula, Tongue)

Non Painful Gait (+ve Tendelenberg gait) e.g. CHD, slipped CFE, muscle
dystrophy

Painful Gait ( Antalgic or – ve Trandenelberg Gait) e.g. infection, trauma,

musculoskeletal).

Gait is the key

Help him; Be Around him with your arms

Normal walking…go and come

Tip toe, Tandem, Heel, Run

Squatting test if appropriate

Special test according what you are suspect from the gait

Fogs test (Hemiplegia)

Gower’s sign (Waddling gait)

Romberg’s sign (Ataxia)

On Standing: Turn around him 360 degrees (Inspection) as expected:

Leg Length Discrepancy, Scar, Deformity, Rash, Muscle Wasting

Back Examination: From up Downward:

Head size, V-P shunt, Hearing aids, Symmetry of the shoulders and
hips, SCOLIOSIS

Then:

2-On bed

Thank you Ahmed, can you lie down on the bed?

1ST Lower limb

1--Confirm LL are Symmetrical or Not

 (I would like measure their true length from the ASIS to the medial
maleolus)

2-ThenTone

(Rolling, Shacking, Movement Around The Joints) Ask 1st about pain

3-Then Clonus

4-Then Power: Start by: move your leg up ( (3&>) Then start against
resistance proximal to distal)

5-Then Reflexes ( Hummer, Your Eyes, Comparing)

6-Then Babiniski reflex

7-Then Coordination

8-Then Sensation (in LMNL)(Touch, Pain, Position, Vibration)

2nd upper limb

Go to upper limb examination (Tone, Power, DTR, and Coordination)

3rd Head

The Head if related

Then Thank him and help in wearing, Then turn to the examiner.

Summary (in brief)

Outside the bed

1-Waking (Gait) 2-Special test

3-Standing (360 degree) 4-Back
 On bed
1-Symmetry 2-Tone
3-Clonus 4-Power
5-Reflexes 6- Babiniski
7-Coordination 8-Sensation
Diagnosis: UMNL, LMNL, Ataxia

COMMON CASES
1-Hemiplasia (unilateral or double)
2-Spastic diplegia
3-Spina bifida
4-Ataxia
5-DMD
6-CP
7-Floppy child

Scoliosis
Signs of Scoliosis
-Uneven shoulders
- Uneven hips
- Curve in spine
- Bending over (Leaning forward) Rib hump

Side effects of scoliosis

-Chronic Headache
-Back Pain and Neck Pain
-Restrictive Lung Disease
-Psychological

Hemiplegia (Rt)

I want to complete my examination by examination of:

1-Cranial nerves (Facial & Hypoglossal).
2-Formal Visual and Hearing assessment.
3-Skin for NCS
4-Full developmental assessment.
5-True length of LL to R/O leg length discrepancy.
6-Complete CVS examination
(If you have time mention all)
Tel me your findings:
I have examined Ali 6 y old boy, he looks small for his age,
although I want to plot his WT, HT and HC in appropriate growth
chart for age and sex. He has no apparent dysmorphic features.
Ali has Rt sided Hemiplegic Gait, Weakness, Muscle wasting
Hypertonia, Hyperreflexia, Clonus, Upgoing Babeniski in the Rt
side of the body compared to the Lf side. So this is a case of
UMNL in the form of Rt sided hemiplasia.

How to manage?
1-Thorough history.
2-Investigations in the form of:
 -Laboratory: CBC, blood film, Coagulation profile, protein
C,S. Anti thrombin three levels, Sickle cell screening
-Radiological: MRI, MRA, MRV
3-I will manage Ali through MDT approach which composed of:
1-My consultant is the coordinator of the team.
2-Pediatric neurologist head of the team
3-Physiotherapy
4-Occupational therapy
5-Ophthalmology
6-ENT
7-Orthopedic
8-Dietician to optimize nutrition
9-Speech and language therapy
10-Psychosocial support for Ali and his family
11-Regular follow up

NB:
-Rt handed or Lt handed (dominant hemisphere) affecting
writing (school implication)
 -Hemiplegia UL>LL
-Hemiplegia unilateral or bilateral (double)

-Site of the lesion:

-Internal capsule associated facial and hypoglossal in the
same side of the hemiplegia (NB: Lower half of the face)
-Brain stem (Crossed hemiplegia): Hemiplegia in one side
and cranial N palsies on the opposite side
-Midbrain (CN 3) Eyes
-Pons (CN 6 7) Face
-Medulla (CN 9,10,11,12)(Bulbar)
-Causes of Hemiplegia ( Congenital and Acquired)

Diplegia (Spastic Diplegic CP)

Diplegic gait, Bilateral LL muscle wasting, weakness,
hypertonia, hyperreflexia, clonus, upgoing of Babiniski, joint
contracture (flexion deformity), Scar for tendon release
(Common), Compared to UL So, this is a Case of UMNL in the
form of Diplegia ( diplegic CP)
Heel waking (important), scissoring ( internal rotation of hips),
Talipes Equino Varus.

Ataxia Approach
Ataxic gait (wide based gait)..Tandem (cannot) gait ….Romberg
test …Stand (360 degree)…Back (scoliosis)
1-Cerebellar Ataxia ( -ve Romberg’s)
Hypotonia, hyporeflexsia, weakness, and signs of
incoordinations in the form of
1-Ataxic gait 2-Nystagmus 3-Dysarthria 4-Dysmetria
5-Intention tremors 6-Dysdiadokokinesia >7y
2-Freidrick Ataxia( +ve Romberg’s) ( >10y)
-Hereditary ataxia (AR) Frataxin gen on chromosome 9
-Degeneration of Posterior Column , Corticospinal,
Spinocerebellar.
-Pes cavus and Scoliosis -Bilateral muscle wasting and
weakness distal > proximal -Absent DTR and absent position
sensation(Joint position)
-Up going Babniski. And he has signs of incoordinations in
the form of..
-MRI Spine: Atrophy of spinal cord
-Genetic Test for Frataxin gene on chromosome 9
(Aaxia, Scoliosis, Optic Atrophy, Cardiomyopathy, Diabetes
mellitus, Deafness, Pes cavus).
So, these manifestations going with Freidrick Ataxia

3-Ataxia Telangectasia (Red eyes) <5y

-One of the DNA Repair Disorders (Remember FAXB)
-Cerebellar ataxia + Telangectasia
 -Hereditary Ataxia (AR chromosome 11)
-Neurodegenerative disorder (Spinocerebellar Degeneration)
associated with Immunodeficiency and risk of Malignancy.
-Telangectasia (Eyes, Ears, Checks)
-Hypotonia, Hyporeflexsia, Weakness, and Signs of Incoordinations
in the form of…..
-Vision, hearing, liver spleen lymph nodes , alpha fetoprotein , LDH,
uric acid blood film
-Immunodeficiency assay
-Full developmental assessment (developmental delay)

4-Ataxic CP( Ataxia+Diplegia)

Diplegia + Signs of Incoordinations

Tests for Incoordinations

- Heel to Knee test -Finger to finger & finger to nose

-Dysdiadekokinesia( >7y)
Causes of Ataxia

a) Acute: Infection, Drugs, , Vascular

b) Intermittent: migraine, Metabolic
c) Chronic: neonatal encephalopathy, FA, AT, Wilson, cerebellar
malformation ( Dandy walker)

Duchene muscle dystrophy

Waddling gait ….Gower sign…Stand (360 degree)(Tongue for

fasciculations) Winging of scapulae …..Back (Scoliosis)
 -Lumbar lordosis
-Back (Scoliosis)
-Muscle Wasting and Weakness Bilateral, Symmetrical and Proximal more
than Distal. -Prominent calf muscles

-Reflexes ( usually lost in knees and may be preserved in ankles)

MANAGEMENT:

1) Thorough history and Genetic Counseling.

2) Investigations in the form of genetic test (xp21)>>DNA (decreased

dystrophin gene), CPK, EMG, muscle biopsy

3) MDT Approach.

-Kugelburg Wallender Disease (SMA111)

+ Gower’s, waddling gait ( as DMD)

Hypotonia, hyporeflexia, and decreased PROXIMAL muscle power.
Tongue Fasciculations and Winging of Scapula,

-Limb girdle muscle dystrophy like DMD

To Differentiate>>> DNA, EMG and NCS)

-Expressionless face:

Myotonic dystrophy-Congenital myopathy

Myathenia gravis- Fascioscapulohumeral MD Dr: Taha Darwish (65823256)

Spina Bifida
-General approach

-LL: Neurological Approach (LMNL)

 -Back

-Head (VP shunt)

-UL ( Spared)

-Abdomen

-Hypotonic Posture, Absence of Voluntary Movements

-Muscle wasting(distal>proximal)

-Arnold Chiari Malformation type II

-Sensation

-8Ss+CCNW

Head 3: (Shunt, Squint, Sunset eyes)

LL 2: (Sores, Sensory level)

Back 2: (Scar and Scoliosis)

Abdomen (Sphincteric dysfunction) (Neurogenic bladder and Patulous

anus)

Catheter-Contracture-Nappies-Wheel chair

-Management (History , Investigations, and MDT)

-Urologist (Intermittent cath.) and antibiotic prophylaxis

(Blood Pressure, Urine dipstick)

NB: Club foot (Talipus Equinoverus) frequently associated with spina bifida

Cerebral Palsy (CP)

-Talk to the child ( Raport and dysarthria, Mentality)

 -Head: teeth, drooling or anything abnormal in his face ( Adenoid facies or
Abnormal respiratory noises or snoring if he is sleeping), shunt.
-Exclude Hearing loss, Speech disorder, visual loss
-He is not following…. formal visual assessment
-He has a windswept deformity (risk for DDH), multiple joints contractures
-Back ( scoliosis), still in nappies, gastrostomy, bed sores…..
-Wheel Chair
I want to complete my examination by

Formal assessment of hearing, vision Cranial nerves (pseudobulbar palsy)

(feeding problems) and Complete developmental assessment.

N.B. If associated With Choreoathetotic mov, Dystonic movement ……

lesion involved the Extrapyramidal tract.( Kernectirus).

Types of CP:

1-Spastic 2-Ataxic 3-Dyskinetic 4-Mixed

Musculoskeletal system
NB:

1-Follow the general rules of clinical examination (6 points approach)

2- PGALS (Pediatric Gait, Arms, Legs & Spine)? Screening process

School aged child (4y or above)

When to do PGALS: (Open Q): Musculoskeletal examination

General Approach For Joint Examination:

Systematic approach: Follow the following steps: Look, feel, move (active then
passive) measurement, assess function, joint specific test, examination of joint above and
joint below, healthy then diseased side, always compare both side for symmetry.

1-Screening questions (3): Pain, Dressing (UL), climbing stairs (LL) only in
PGALS, but in others ask only for pain

2-General assessment (anatomical position) 360 degrees (Front, side, back)

and Look for: (4 points)

1-General observation & Surroundings

2-Limbs for: 1-any asymmetry, 2-leg length discrepancy,

3-muscle wasting, 4-scar, 5- rash 6-Bruises, 7-nails deformity, 8-heel

3-Joints for: swellings, flexion deformity (from side)

4-Back for: deformity and scoliosis

3-Gait:
NB: During walking is there any pain? And look at his face (pain expression)

Normal gait, tip toe waking, heel waking

Antalgic gait: Trendelenberg test

NB: 1-Antalgic gait,,,, Trendelenberg test,,,negative,,, Rhumatological disease

2- Nonantalgic gait,,, Trendelenberg test,,, positive ,,,Myopathy

Then On bed:

Systematic approach:
 Knee joint:

Look for: Leg length (symmetrical or not)

Feel: Temp (hotness), tenderness, effusion, any synovial thickening

Effusion: 1- Patellar tap (absent or present)

2-Bulge sign: milk the inner side upward then milks the

lateral side downward, (bulging in the inner side)

Move:
1-Active movement: move your leg up (healthy first or both together), then out,
then in, then towards your chest, then extend knee, then ankle flexion (dorsi and planter),
then in then out
Look for: limitation of movement (bilateral, symmetrical or not)

2-Passive movement: you are the one who is moving (do not cause pain) (do same
action as in active movements and start with the healthy limb). Passive (the same range of
active mov)

Type of Movement (flexion, extension, adduction, abduction, internal rotation,

external rotation)

4-Measurement: if appropriate

5-Function: (gait): done

I want to complete my examination by examination of other joints by PGALS

screening, formal examination of the eyes, complete examination of skin LNs, liver and spleen,
pubertal assessment, and signs of steroid toxicity

Present your findings:

Growth parameters, dysmorphism, then positive findings, then important
negative. Ali has a swelling of lf knee, with flexion deformity, limitation of range of movement,
muscle wasting, and any side effects of medications.

How to manage Ali?

1- Thorough history 2-Investigations 3-MDT

Hand Examination: (6 points)

Exposure of hands: you should expose the elbow joints bilaterally

Follow the following steps: 1-Look, 2-feel, 3-move, 4-function, 5-special test, 6-
examination of Elbow joint

1-LOOK: Nails abnormality, swelling, flexion deformity, ulnar deviation, radial deviation of
the hand, scars, muscle wasting.

2-FEEL: (Pulse+ 4Ts) Temp, Tenderness, Touch, Test

NB: Palpation should be done using a bimanual technique

Start from the wrest then metacarpophalangeal joints then proximal interphalangeal joints
then distal interphalangeal joints ,

NB: 1- Sensation: (the patient is closing his eyes)

Thenar or index finger for Median nerve

Hypothenar or little finger for Ulnar nerve

Snuff box (web between index and thumb) for Radial nerve

2-Use a systematic approach to ensure you palpate all joints

3-Feel any joint for: swelling, tenderness and fluctuation

4-Watch the patient face for signs of pain

5- Fingers: ‫سبت االصبع بأيدك اليمين من الجنب وبأيدك الشمال اضغط من فوق ومن تحت‬

6-Wrist: ‫أمسك من الجنب بأيدك الألثنين وأضغط من فوق ومن تحت‬

7-Test: 1-Tinel’s sign: hyperextention of the wrist + tapping on MN>>> pain and
parathesia on MN distribution.

2-Phalen’s test: flexion of the wrist 90 degree for one minute>> same effect

3-Carpal compression: 30 seconds>> same effect

3-MOVE:

1. Active: all directions

Make a fist>>> Medial and ulnar nerve assessment
Make a star>>>Radial ( thumb) and radial ( digit abduction)
 Make a circle
Then test coordination
Pincer grip
2. Passive: all (ask for pain and look to the face)

4-Function of the hand:

1-Drawing and writing

2-Power grip

3-Pincer grip

4-Buttoning and unbuttoning

5-Special test: (done with feeling) Tinel’s test (a sign of carpal tunnel syndrome)
Tinel’s sign: hyperextention of the wrist + tapping on MN>>> pain and
parathesia on MN distribution.

6-Examination of Elbow joints

.

Checklist of possible cases: (May be other)

-JIA, -Hand examination, -SLE, -Psoriatic arthritis
-Hemophilia -Dermatomyositis -HSP -Isolated knock knee
-Arthrogryposis – Hypermobility-Scoliosis (Klippel Fiel syndrome)

NB: Follow your approach pick up the diagnosis or DD then collect the findings that
support the diagnosis (going to specific diagnosis) then present these findings and
important negative of DD

NB:
Flexion deformity: ‫الزم تبص من الجنب علشلن تشوف ال‬

NBs:

1-Musculoskeletal examination of lower limb:

1-Pain 2-Gait 3-Stand 360 degree

 2-HSP: 1-He has palpable purpuric, non-blanching rash in the back of LL
up to……
2- Blood pressure and urine analysis
3-Dermatomyositis:
1-Periorbital edema
2-Heliotropic facial rash
3-Gottron papules
4-Calcinosis (cutanous and SC) and contractures
5-Proximal muscle weakness (Gower sign) with pain
6- Course: remissions and exacerbations
4-SLE:
1-Malar rash: spare the eyelid and naso labial fold
2-Blood pressure and urine analysis
5-Hemophilia:
1-this is a case of chronic arthropathy most propably due to recurrent
hemartharosis due to hemophilia
2-Genetic counseling
3-Hemophilia medical alert bracelet
4-Hematological causes of joint disease: hemophilia and sickle cell
anemia

6-Micrognathia: can be seen in long standing JIA (tempromandibular joint)

7-Club foot –operated talipes equinoverus

8- Osteogenesis imperfecta
Examples of the opening statement:
Clumsy gait- frequent falling-inability to walk-Inability to write( examine UL) -Examine
the locomotor system -Musculoskeletal system= locomotor system
Remember
MSK with: Rickets-Skeletal dysplasia-Angular deformity of lower limbs
Syndromes: eg: seckel dwarfism(bird head syndrome)

www.arthritis researchuk.org/health

In brief:
Look, feel, move, measure, and function for: look for
Swelling, deformity, limitation of range of movement, leg length discrepancy, muscle wasting,
side effects of medications
Steps of PIGALS

1-Observe the patient walking.

2-Walk on your heels.
3-Walk on your tip-toes.
4-Put your hands out in front of you.
5-Turn your hand over and make a fist.
6-Touch the tips of your fingers.
7-Squeeze MCPJs.
8-Put your hands and wrists together.
9-Put your hands back to back.
10-Reach up as far as you can.
11-Look at the ceiling.
12-Put your hands behind your neck.
13-Place your ear on your shoulder.’
14-Open your mouth wide and place 3 fingers inside.
15-Feel for effusion at the knee.
16-Bring your ankle up to your bottom.
17-Passive movement of hip and knee including rotation of hip.
18-Observe curvature of spine from the side and behind.
19-Bend forwards.

Development

1- Introduction (Outlines):
 1-Focus on the opening statement: (name age sex task)

-The task (one task or double task)

-If not clear clarify (motor assessment= Gross + fine)

-Double task: Motor assessment (Gross + fine),

Fine motor and Speech, Fine motor and Social)

2-Introduction

3-General observation

4-Tools (speak with him during collecting your tools)

5-Systematic approach:

Start from the age you expect (?)

Then go up or down according the response,

Try 1st then anther trial

Then ask the mother (you should use the mother)

6- Structured presentation:

Introduction

Mention 3 positive

Mention 2 negatives

Other developmental areas

Other related areas

2-Checklist: 6 Cases

1-Fine motor & vision (the most important)

 2- Gross motor

3-Hearing and speech

4- Social, playing and cognition

5-Autistic child

6-Non mobile child or infant

Summary:

Tools….Systematic approach… your attitude…..Presentation….Discussion

1-Fine motor & Vision (The most important one)

 Tools (picture book, cubes, paper and pens, toy scissor, form board, beads and threads)

Systematic approach:

1- Introduction: talk with him (he is hearing and seeing you) (glasses & hearing aids)

2-Cubes play:

1-One cube (RT & LF) to rule out hemiplegia

2-Buildings: 1-tower 2-train 3- bridge 4- steps

3-Paper play:

1-Copy shapes (circle, cross, square, triangle) 2-Draw man test

3-Cut by scissor toy 4- Turn pages (picture book)

4-Thread in beads:

1- Large beads 2- Small beads

5-Fit form board:

1- He can fit 2 simple form board 2- complex form board

Presentation:

I have examined Ali 5y old boy with features of trisomy 21, Today he demonstrated that he can
build…he can copy a circle and also he can thread large beads. But he is unable to build a stair or copy
across, so his fine motor developmental age is around…..And I want to complete my examination of other
developmental areas, formal vision and hearing assessment and plot his growth parameter in appropriate
growth chart

Management: How to manage Ali?

I will manage Ali throw the developmental team which MDT composed of:
1-My consultant is the coordinator of the team

2-Developmental pediatrician is the head of the team

3-Physiotherapy

4-Occupational therapy

5-Speech and language therapy

6-Ophthalmology

7-ENT

8-Play therapist

9-Health visitor

10-Special need teacher

11-Psychosocial for Ali and his family

12-Other specialties according to the case

Fine motor & Vision

1 YEAR

A) Cubes:

- Bangs together

- Casting

- Points by index

- Object permanence

B) Hundreds and thousands, counter or make a small paper:

- Crude pincer grip

 1 1/2 YEARS

A) Cubes:

- Builds a tower of 3 cubes

- Puts cubes in a container and gets it out

B) Paper and Crayon:

-Draws a vertical line

-Draws To and fro scribbles

C) Book:

- Turns many pages together

D) Hundreds and thousands, counter or make a small paper:

- Fine pincer grip

2 YEARS

A) Cubes:
- Builds a tower of 6 cubes (age in years × 3).

B) Paper and Crayon:

-Draws a horizontal line

-Draws a circular scribbles

-Writes T and V letters

C) Book:

- Turns 1 Page

D)Simple form board:

Fits 2 shapes: circle and square

3 YEARS

A) Cubes: (3 things):

- Builds a tower of 9 cubes (age in years × 3)

- Builds a Bridge of 3 cubes.

- Train

B) Paper and Crayon: (3 things):

- Copies a circle

- Writes T, V and H letters (3 letters).

- Draws 3 parts in draw a man test:

C) Scissor:

- Can cut the paper

D) Large threads and beads:

- Can lace large threads in large beads

E) Simple Form Board:

- Fits 3 shapes: circle, square and triangle.

4 YEARS

A) Cubes:
- Builds a tower of 12 cubes (age in years × 3)

- Builds a stair of 6 bricks

B) Paper and Crayon:

- Copies a square

- Writes X and O letters.

- Draws 4 parts in draw a man test:

C) Small threads and beads:

- Can lace small threads in small beads.

E) Complex Form Board:

- Fits six shapes

5 YEARS

A) Cubes:

- Builds a tower of 15 cubes (age in years × 3)

- Builds a stair of 10 bricks

B) Paper and Crayon:

- Copies a triangle

- Writes C, U, Y, L and A letters.

- Draws a man test:

2-Gross motor
4 Items:
1-Leg play

2-Ball play

3-Stair (Ladder) play

4-Tricycle play

1-Leg play: (Stand, Walk, Run, Jump)

- Forward walking: 1 year

- Backward Walking: 1 1/2 year

- Side Walking: 3 years

- Forward Tandem Walking: 4 years

- Backward Tandem Walking: 5 years

- Tip toe standing: 2 years

- Tip toe walking: 3 years

- Tip toe running: 4 years

- Stands on one foot for 1 sec: 3 years

- Stands on one foot for 5 sec: 4 years

- Jumps (in place): 2 years

- Runs stiffly: 2 years

- Runs smoothly (fast): 3 years

- Hops: 4 years - Skips: 5 years

Steps:
 Walking (forward, backward, side)

Running (smoothly or stiffly (then jump in place if stiffly)

Standing on tip toe

Walking on tip toe

Running on tip toe

Standing on one foot (how many seconds)

Hop

Tandem gait (forward and backward)

Skipping
NB: Share the mother (You can ask the mother to do every thing)

2-Ball play:

- Kicks a ball (standing): 2 years

- Kicks a ball (running): 4 years

- Throws a ball: 2 years

- Catches a ball:

Front out stretched arm: 3 years

Up out stretched arm: 4 years

Near to the body (front of the chest): 5 years

- Bounces and catches a ball: 5 years

NB: All leg play can be done with the ball

3-Stair play (ladder): (History if no stair) (Do not forget to clarify)

- Climbs stairs with assistance: 1 1/2 year

- Climbs stairs in a child manner: 2 years

- Down stairs in a child manner: 2 1/2 years

- Climbs stairs in a adult manner and down stairs in

a child manner: 3 years

- Climb and down stairs in adult manner: 4 years

4-Tricycle play: He can pedal a tricycle (3y)

He can pedal a bicycle (6y)

2years, 2.5 y, 3y, 4y, 5y (leg ply, ladder, ball, tricycle)

3-Hearing and speech

Introduction:

Startle response (6 weeks)

Turn to the sound (3-6 m)

Babbling (6 m)

Use mum and dad nonspecifically (9 m)

Use mum and dad specifically (1y)

1st ward other than mum and dad (1y)

Understand simple commands (1-1.5 y)

At least 3 wards (1.5 y)

Points to body parts (3parts eye, nose, mouth) (1.5y)

Points to familiar objects and pictures (1.5-2y)

Plurals (2y)

Give name (2y)

2 wards sentence (2y)

Can follow 2 steps task (2y)

Name familiar objects and pictures 2.5-3y)

Prepositions (3y)

Know his sex (3y)

Colors (3y)

3 ward sentence(3y)

Can follow 3 steps task (3y)

Count up to 10(4y)

Can name shapes (4y)

Can tell story and rhymes (4y)

Fluent clear speech (5y)

MILESTONES OF SPEECH ASSESSMENT

1YEAR

- Says Mama and Dada meaningfully.

- Turns to name ( by examination)
- Understands words

1 1/2 YEAR

- Says Mama, Dada and another word

- Points to 3 parts of the face (by examination).
- Obeys simple commands (by examination).

2 YEARS

- Says his name (by examination).

- Understands many words (by examination).

- Uses plurals e.g. books (by examination).

- Says 2 words sentence (by examination).

3 YEARS

- Says full name (by examination).

- Says age and sex (by examination).

- Says 3 words sentence (by examination).

- Says prepositions e.g. up and down (by examination).

- Says nursery rhymes (songs) (by examination).

4 YEARS
- Counts 1-10 by 1 hand (by examination).

- Says address (by examination).

- Says sentence of 4 words (by examination).

5 YEARS

- Counts 1-10 by 2 hands (by examination).

- Says his birthday (by examination).

Approach for Hearing and Speech assessment

Tools

Picture Book-Animals-Cup, colored Cubes- Doll- Rattle

(ABCD: Animals, Picture book, Cup, colored cubes, Doll, Rattle)

4 Steps:

1-Speak with him 2-Play with him

3-Ask the mother some Qs??? 4-Hearing assessment

1-Screening Qs???: I want to ask the mother if she has any concern about Ali hearing

2- Personal data: what is your name? My name is Taha, what is your name?

3-Picture book: dog and cat

4-Animals: dog, cat, hoarse

5-Cubes (colors): Yellow, Red, Blue (main color)

What is this color?

Where is the yellow?

Where is the same like this?

6- Task and preposition: put the cube in the cup

7- Sound imitation:

7- I want to ask the mother some Qs

When he wants to drink, how can he ask?

What can he say?

8-I want to assess hearing by:

Hearing distraction test (6 months to 1.5y)

Speech discrimination test throw McCormick toy test (2-4y)

‫تفاح‬ ‫ مفتاح‬- ‫طيارة‬ ‫ سيارة‬- ‫قطة بطة‬

Delayed speech: hearing problem,,,autism…learning disability..GDD

Different aspects of speech:

-Receptive: ‫ال يسمع اذا ال يتكلم‬

-Expressive: ‫مفيش كالم خالص‬

-Articulation: ‫كالم ملخبط‬

ASSESSMENT OF HEARING AND SPEECH

A) Ask the child about his name, age, sex, address and ask him to count from
1-10:

If he did not answer, tell that you want to ask the mother about any concerns
regarding his hearing.

B) Assess concentration and attention:

Give him a colored object and ask him to point to an object with the same color.

C) Assess picture recognition and selection: e.g. Ask him about the picture of the
duck: what is this? If he did not answer, tell him can you show me the picture of
the duck?.

D) Assess object recognition and selection: e.g. ask him about the horse: what is
this? If he did not answer, tell him can you show me the horse?

E) Assess imitation of sounds: e.g. show him a dog and ask him what is the sound
of this? If he did not answer I will ask him which animal has haw haw sound ?

F) Assess words together:

a) A single task: e.g. take the horse

b) Double task: e.g. take the horse and give it to your mother

c) Triple task: e.g. take the horse, put it behind your back and give it to your mother.

4-Social, play and cognition

Feeding (ask)

Toileting (ask)

Dressing (do)

Playing (do)

Tools:

Tools to do tea (boy)

Tools for cocking (girl)

Toy telephone (both)

Doll with hair and spoon (both)

Start by playing and dressing then ask about feeding and toileting

1-Pretend play: then take turn (‫)انت مرة وانا مرة‬

2-Pretend play (not done): doll: eating and hair combing (not done): Waves bye bye, pat-a-cake
and peek-a-boo

3-Dressing and undressing

ASSESSMENT OF SOCIAL MILESTONES

A) Feeding (by examination):

- Drinks from cup: 1 year.

- Uses cup and spoon: 1 1/2 year.

- Uses spoon and fork : 2 years.

- Uses spoon fork and knife: 3 years.

B) Play (by examination):

- Waves bye bye, pat-a-cake and peek-a-boo: 1 year

- Symbolic play e.g. feed a doll and explores environment: 1 1/2 year

- Solitary play and pretend (role) (imagination) play e.g. cooking tray or mobile talking: 2 years

- Parallel Play (interactive play evolving) and takes turn: 3 years.

- Share toys: 4 years

- Make believe play (you are mum and I am dad): 5 years

C) Care (by history only):

- Indicates need (not by crying) : 1 year

- Indicates toilet need: 1 1/2 year

- Dry by day: 2 years

- Uses toilet alone: 3 years

- Brushes teeth, wash and dry hands: 4 years

- Mostly dry by night: 5 years

D) Dressing ( by examination):
- Takes off shoes and socks: 1 1/2 years

- Helps in dressing: 2 years

- Able to undress: 3 years

- Dress with supervision: 4 years

- Completely dress without supervision: 5 years

5-Autistic child
The task may be fine motor----------Collect the tools

Start to speak with him: no response

I want to ask the mother if she has any concern about his hearing and vision

Start to play with him: cubes: no response, drawing: no response ‫شكرا يا ام على‬

Ok sir by observation I noticed that Ali has (Face?)

No stranger awareness-No eye to eye contact- No facial expression - No speech

He is playing with himself and I cannot engage with him in play, and he is not interesting with the
surroundings or interactive, and the mother has no concern about his vision or hearing so, I suspect that
Ali has autistic features and I want to ask the mother some Qs:

-Delayed speech

-Pointing (he is pointing or not)

-Toileting -Playing

-Behavior (dislike other, crowded places, hair cutting, washing)

-Repetitive movement or behavior

-Family history of autism

Any history of epilepsy (25% of autistic have epilepsy)

What will you do for him?

1-Formal hearing and visual assessment

2-Complete neurological and developmental examination

3-Refer him to the autistic specialist team for more evaluation and educational program

4-Psychosocial support for the child and his family

Q: Causes of autism?

General rules:
The examiner will give you the age

You must speak with the child: He is seeing and hearing or not?

He is wearing glasses or hearing aids or not?

He is dysmorphic with specific syndrome or not?

Do not rush: time is enough

During collecting the tools speak with him

Be systematic and smooth

Use one tool at a time

Encourage the child and be smiling (you are playing)

Set at the level of him and be on the left of him

Try 1st the if not cooperative another trial the if not use the mother for the task if still focused history after
permission from the examiner

Always assess vision before hearing

Non mobile child or infant (systematic approach)

1-General observation 4 points

2-Fine motor & vision 1st

Fix and follow (do not speak)

Reach for & grasp

Transfer & mouthing

Object permanence (follow fallen object)

Pincer grip

Pointing

Picture book: turn many pages or single page

3-Hearing and Speech:

Parents concern

Startle reflex

Any vocalization you are hearing

Babbling

Turn to the sound (rattle)

Respond to his name

Understand simple commands

Distraction test (need sitting without support &head control)

4-Social:

Interactive & smiling

Stranger awareness

Waves bye bye, clapping, pat-a-cake and peek-a-boo

5-Gross motor 180 degree maneuvers

Supine position: moving limbs, and rolling over

Pull to sit

Sitting with or without support

Standing (bearing WT or not

Hold up (vertical suspension) tone

Ventral suspension

Prone position

Crawling, rolling

Primitive reflexes

Parachute reflex: downward 6 m, forward 9 m