Developmental examination

All doctors working with children should have good knowledge of normal developmental milestones, as early diagnosis of developmental problems and appropriate intervention is desirable to improve the outcome. Candidates should be able to identify key warning signals and know the practical relevance of the milestones. ‘Developmental assessment’ is the comprehensive evaluation of a child’s physical, intellectual, language, emotional, and social development, and is an area where most candidates lack competence and confidence. It should be distinguished from ‘developmental screening’, which is a brief, formal, standardized evaluation for the early identification of children at risk of a developmental disorder. In the developmental assessment station, a candidate can be assessed in different ways: a developmental history with the parent and child; assessment of specific developmental domains (such as gross motor skills, fine motor skills, speech, language skills, etc.); or global assessment of an infant or older child. Occasionally, the candidate might be asked to just ‘observe the child’s play’ and comment on the development. The candidate should anticipate and be prepared for these scenarios. In the exam, a detailed assessment of development is impossible, as it is complicated and time consuming. Ideally, observations of the child should take place with several people in varied settings, which is not feasible in the exam. However, useful assessment of a child’s development can be easily performed as part of routine examination. The main purpose of the developmental assessment in the exam is to identify the child’s strengths and weaknesses, the developmental problem, and, if possible, the cause of the problem. The candidate is expected to give an approximate developmental age at the end of the assessment. Before we continue, it is important to understand the commonly used terminology. A child is said to have ‘developmental delay’ when he or she shows a significant lag (more than two standard deviations) in acquiring milestones in one or more domains. Global developmental delay is defined as a delay in two or more developmental domains. ‘Developmental deviance’ occurs when a child develops milestones outside or apparently ahead of the typical acquisition sequence. ‘Developmental regression’ is the loss of previously acquired milestones. Children develop skills in various areas, also called developmental domains: gross motor, speech and language, fine motor, cognitive, personal–social, and emotional.

Examination of the cerebellar system

Although many books include cerebellar examination as part of the motor examination, it is discussed separately here in view of its importance. As children with cerebellar diseases are not often seen in routine clinical practice, candidates tend to neglect this system in their preparation and so find it difficult in the exam. Assessment involves examination of the gait and coordination, which tests both cerebellar midline and hemispheric function (tables 10.1 and 10.2). In the exam, you may pass through a station asking you to examine either the cerebellar system or the gait alone. If such an instruction is given, be clear what you need to focus on. Key competence skills required in the cerebellar examination are given in table 10.3. These steps are repeated for every system to reiterate their importance and to help you recollect the initial approach of any clinical examination. Also refer to chapter 4. • On entering the examination room, adhere to infection control measures by washing your hands or decontaminating with alcohol rub. • Introduce yourself both to the parents and the child. • Ask the name and age of the child, if not already told by the examiner. • Speak slowly and clearly with a smile on your face. • Explain what the examination involves and obtain consent. • Establish rapport with the child and parents. • Expose adequately while ensuring their privacy. • Positioning: to examine the older child, they may sit on the edge of the bed or on a chair when they are not acutely ill. It is preferable to examine the younger child on their parent’s lap rather than on a couch, which can cause much apprehension. The aim of the visual survey is to capture every available clue, which should help you to arrive at the correct diagnosis. • Look at the child and try to estimate the approximate age. • Always consider whether the findings combine to form a recognizable clinical syndrome. Common syndromes with cerebellar involvement include ataxia telangiectasia, Dandy–Walker cyst, Chiari malformation, and Friedreich’s ataxia.

The principles of physical examination

Examination of the child combines science with art; developing competence in paediatric examination requires both knowledge of the correct technique and hours of hard work and practise. Lack of either will make the examination technique incomplete or inadequate. Perhaps the greatest difficulty an inexperienced doctor faces is to gain the confidence and trust of the child and their carers, while creating an impression of grounded self-confidence. In the examination, one should carry oneself well. This means you should be a good listener, be interested, cheerful, respectful, warm, caring, friendly, empathic, competent, and diplomatic. It is imperative to listen actively to the child and their carers and be as natural as possible—just as you would be with your friend’s child or indeed your own. The examination begins the moment you enter the room. It is essential to understand that the general approach to the physical examination of the child will be different from that of an adult and will vary according to the age of the child. As the child’s cooperation cannot be guarantied, you should remember that it is impossible always to use a set protocol while examining the child. We have listed the essential steps of examination in a particular order so that all areas are covered, but the candidate needs to adapt the examination sequence according to the needs of the child and the situation. As a general rule, anything that will inevitably be uncomfortable or unpleasant for the child (e.g. otoscopy or rectal examination) should be the ‘last act’ of the examination. A common mistake made by nervous candidates is to talk too fast; this is a trait that will always be more exaggerated under the stress of the exam. Pausing at the end of each sentence is an effective way of slowing down. Ensuring that each word is pronounced completely will also lessen the pace of your speech. Talking slowly and clearly with a smile on your face will help to hide nervousness. In this book and the accompanying videos, examinations are performed in a systematic manner. These steps provide a useful framework. Although there can be some flexibility, following the steps listed here will improve your technique.

Focused history taking

Focused history taking is a vital part of the MRCPCH clinical exam; candidates are expected to grasp the key issues and formulate an effective management plan. This station requires candidates to be efficient, purposeful, and well-directed in their approach. The candidate is expected to obtain and present the key facts in the history and suggest an appropriate management plan. The examiner sits in the room as an observer while the candidate takes the history. This gives the examiner ample opportunity to assess the candidate’s communication skills, general approach, and knowledge of the condition. Only 13 minutes are allowed with the patient in the presence of the examiner. In the subsequent 9 minutes, the candidate will present and discuss the history. Problem-oriented history and management is the most effective way of approaching this station. The objectives of obtaining a focused paediatric history are: • to establish and maintain rapport with the child and parents • to obtain an overview of the child’s previous and current health issues • to establish the psychological, family, and social context of a child’s illness • to reach a correct diagnosis (or form a differential diagnosis) • to plan an appropriate management strategy. Although the principles of history taking in children are similar to those used for adults, there are important differences in the scheme and the details. The paediatric case history is potentially more difficult to elicit and is influenced by the age of the child. For each age group, you will have to adapt your style. The primary historian may be the child or another person, usually the parent. The consultation itself is triadic, involving the child, their family (or caregiver), and the doctor. Always keep in mind the principles of communication (discussed in chapter 2) and use an empathic approach while taking the history. Although in most cases the parents give the history, the child must also be encouraged to speak. In young children who have limited speech, you must take the history through the parents or the carers. In teenagers, there is a difficult line to tread between giving the child complete autonomy and allowing the parent to be the main historian.

Examination of the abdomen

The examination of the abdomen is one of the easier cases in the clinical exam. It is, however, easy for candidates to fail this station if they cannot elicit the appropriate physical findings. As always, listen carefully to the examiner’s instructions. You may be asked to examine either the gastrointestinal system or only the abdomen; they are not the same. Occasionally, you may be instructed to palpate the abdomen and beginning at the hands in such situations will annoy the examiner. While giving instructions to the child, you must use simple language that can be easily understood. The examination of the abdomen is best done in correlation with the available medical history, as it often gives major clues. It helps to have a systematic approach to presenting your findings, which should be practised thoroughly. However, the examination process itself can be performed in a different sequence depending on the age of the child and their degree of cooperation. Key competence skills required in the examination of the abdomen are given in table 7.1. Abdominal cases commonly encountered in the MRCPCH Clinical Exam are listed in table 7.2. These are repeated in every system to reiterate their importance and to help you recollect the initial approach of any clinical exam. Also refer to chapter 4. • On entering the examination room, demonstrate your adherence to infection control measures by washing your hands or decontaminating them using alcohol rub. • Introduce yourself both to the parents and the child. • Talk slowly and clearly with a smile on your face. • Establish rapport with the child and parents (remember that ignoring the child can have negative consequences!). • Ensure privacy: to expose the abdomen adequately, the child should be undressed to the waist. Be careful when exposing older children and adolescents, with whom limited exposure should be practised. Cover the lower part of the body with a bed sheet, to avoid accidental exposure. • Positioning: initial inspection may be done in the standing position. Growth, nutrition, hernias, and abdominal distension are best evaluated in this position.

Examination of the cardiovascular system

All candidates taking the MRCPCH clinical examination will be expected to show competency in carrying out the cardiovascular examination. It is important to listen carefully to the examiner’s instructions and follow them. You may be asked only to auscultate the heart. If the examiner gives such an instruction, simply follow it! … You are advised to buy a good paediatric stethoscope, as it can reduce the difficulty in identifying cardiac sounds. The diaphragm of the stethoscope is designed to amplify high-pitched sounds; the bell does not amplify sound but transmits low-pitched sounds better than the diaphragm. The bell should be placed lightly against the skin, while the diaphragm should be placed firmly on the skin for ideal sound amplification and transmission. It is possible to make the bell act like a diaphragm by placing it firmly against the skin…. Examination of the cardiovascular system is best done in correlation with the available medical history, as this often gives major clues. It is helpful to have a systematic approach to presenting the findings, which of course should be practised thoroughly. However, the examination itself can be performed in a different sequence depending on the age of the child and their degree of cooperation. Key competence skills required in the cardiovascular examination are given in table 5.1. Cardiovascular cases commonly encountered in the MRCPCH Clinical Exam are listed in table 5.2. These steps are repeated in every system to reiterate their importance and to help you recollect the initial approach for any clinical exam. Also, refer to chapter 4. • On entering the examination room, demonstrate strict adherence to infection control measures by washing your hands or using alcohol rub. • Introduce yourself both to the parents and the child. • Talk slowly and clearly with a smile on your face. • Establish rapport with the child and parents. • Undress the child to the waist to allow proper examination. Expose adequately while ensuring their privacy. • Positioning: it is easier to examine older children while they sit on the edge of the bed, or on a chair when they are not acutely ill.

Examination of the child with short stature

Assessment of a child with short stature is one of the commonest endocrinology cases seen in the exam. It is important to remember that short stature is not a disease by itself and is an impairment of linear growth. The term ‘short stature’ is restricted to height-related issues above 2 years of age, in contrast to ‘faltering growth’ which focuses on weight-related issues in those less than 2 years. Short stature is a height which is less than the third percentile for age on the growth chart derived from local data. Other definitions of impaired linear growth are height significantly below genetic potentials (−2 standard deviations below midparental height), abnormally slow growth velocity, and downwardly crossing percentile channels in a child older than 18 months. To determine the normalcy of stature, one needs a relevant history and serial height measurements over time documented on a growth chart. In the exam, the examiner may provide the context of the case and the child’s growth chart. In the United Kingdom, the most widely used charts include the one published by the Child Growth Foundation 1996/1, and the UK–WHO growth charts published by the Royal College of Paediatrics and Child Health using the World Health Organization standards (figure 13.1). Be familiar with the use of the different charts and remember to use growth charts appropriate for sex and underlying disease (Down’s syndrome, Turner’s syndrome). The causes of short stature are given in table 13.1 and features of common conditions causing short stature in table 13.2. Possible conditions seen in a child with short stature commonly encountered in the MRCPCH Clinical Exam are listed in table 13.3. You may be asked to assess the child’s growth or assess the child with short stature. Such an assessment is appropriate only after taking into account the history and physical examination findings. However, in the clinical exam, you will not be allowed to take a history and have to evaluate the child based on the clues available at the bedside and examination findings.

Examination of the central nervous system

Due to the complexity of the diseases and the number of tests involved, examination of the central nervous system (CNS) is relatively difficult in the exam setting. Candidates should realize that an attempt to carry out every aspect of the physical examination of the CNS will take too long and is obviously impractical. Appropriate signs need to be elicited quickly to identify the existence of a lesion, its anatomical localization, and likely pathology. Hence, the examination of this system requires plenty of practise and a polished technique. In the exam, you may be asked to examine, for example, just the motor system, or the upper or the lower limb, rather than an examination of the whole central nervous system. Prepare yourself for a screening examination, which will uncover most signs in a relatively short time. Remember, a detailed assessment of complex disorders is never a part of the MRCPCH Clinical Exam. In this chapter, some areas have been explored extensively, keeping in mind the possibility of a ‘small area’ being examined. As the focus is mainly on examination technique and not theoretical aspects, basic neuroanatomy which has not been dealt with here should be read about elsewhere. Key competence skills required in the neurological examination are given in table 8.1. Neurological assessment begins with the first contact with the child, that is the moment you enter the room. It is necessary to have a predetermined, systematic order of examination so that important signs are not overlooked. However, you should be ready to adapt the examination technique, depending on the child’s age and the level of cooperation (e.g. compliant teenager, difficult toddler). Candidates should realize that a great deal can be learned by inspection before touching the child. Integration of observations with specific findings gathered during the neurological examination will fetch much credit. Candidates are often not expected to reach a diagnosis in a short case. They are expected to define the deficit, decide on the anatomical level, if possible, and then consider the likely causes. Abnormalities commonly seen in the exam include cerebral palsy, hemiplegia, quadriplegia, diplegia, primary myopathy, and hereditary motor sensory neuropathies. It is productive to have a pattern recognition approach to neurological disorders.

Examination of the respiratory system

The examination of the respiratory system causes much anxiety among candidates, as many feel the findings are difficult to elicit, particularly in a small child. Just like other systems, having a structured approach makes identification and interpretation of the findings easy. It is important to practise the proper examination technique repeatedly, as this is the best way to improve the skills that are essential to obtain accurate findings. However, the examination itself can be performed in a different sequence depending on the age and the degree cooperation of the child. The examination of the respiratory system is best done in correlation with the available medical history. First, assimilate the available history, which will give an idea of the expected findings and subsequent diagnosis. At the end of the examination, it is important to describe significant findings (table 6.1) with reference to specific surface locations, as shown in figure 6.1. Key competence skills required in examination of the respiratory system are given in table 6.2. These steps are repeated in every system to reiterate their importance and to help you recollect the initial approach of any clinical exam. Also refer to chapter 4. • On entering the examination room, demonstrate your strict adherence to infection control measures by washing your hands or by using alcohol rub. • Introduce yourself both to the parents and the child. • Talk slowly and clearly with a smile on your face. • Establish rapport with the child and parents. • Expose the chest adequately while ensuring their privacy. • Positioning the patient: the child should be undressed appropriately to the waist to allow proper examination. It may be easier to examine an older child when they sit on the edge of the bed, or on a chair. It is preferable to examine younger children on their parent’s lap rather than on a couch separated from the parents, as this can cause much anxiety. Removing a toddler or an infant from his or her parent will most probably yield a screaming child in whom eliciting any physical findings will be virtually impossible.

Examination of the skin and skin appendages

Examination of the skin can provide information about cutaneous or systemic diseases. As always, examination of the skin is best performed in correlation with the available medical history. Even if the examination is conducted in a different order, you should have a systematic method of presenting the findings. Examination comprises inspection and palpation of skin and skin appendages (hair, nails, teeth, and mucous membranes) and is performed in one of two scenarios. 1. The skin may be sequentially examined alongside the examination of other systems (e.g. neurocutaneous syndromes, which are disorders with neurological features, characteristics lesions on the skin, and tumours in different parts of the body) (table 14.1). 2. A dedicated examination of the skin may need to be carried out when it is the suspected primary involved organ and includes evaluation of the hair, nails, teeth, and mucous membranes of the mouth and genitalia. Key competence skills required in examination of the skin are given in table 14.2. Some of the clinical features of common paediatric dermatoses are given in table 14.3. These steps are repeated in every system to reiterate their importance and to help you recollect the initial approach of any clinical exam. Also refer to chapter 4. • On entering the examination room, demonstrate strict adherence to infection control measures by washing your hands or by using alcohol rub. • Introduce yourself both to the parents and the child. • Talk slowly and clearly with a smile on your face. • Establish rapport with the child and parents. • Expose adequately while ensuring their privacy. • Positioning: the patient must be undressed adequately to carry out a complete examination. Inadequate skin exposure with the cloth pushed to one side or lifted momentarily often casts shadows on the skin and is not conducive for proper examination. Infants and very young children should be undressed completely. The younger child is examined preferably on the parent’s lap. Older children can lie down except for the examination of back, which can be examined in the sitting position.