P. 1
Paed Osce checklist

Paed Osce checklist

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Published by: Nurfatehar Ramly on Jun 14, 2011
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10/22/2013

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Module I: Assessment of the Newborn
STEP/TASK (Some of the following steps/tasks should be performedsimultaneously.)CASESGetting Ready
1.Greet the mother and introduce yourself.2.Tell the mother what you are going to do, encourage her to ask questions and listen to what she wants to say.
HISTORY(Ask the following questions if data are not available on the mother’s/baby’srecord)Personal Information:
1.What is your name (mother’s name), address and phone number?
2.
Age of the mother during pregnancy?3.What is the name and sex of your baby?
Perinatal history1-Prenatal historyA-Maternal Obstetric History
1.How many times have you been pregnant (Gravida) and how manychildren have you got (Para)?2.How many living children do you have now?3.Do you have history of abortions/ still births/ neonatal deaths?4.Are causes of abortion or deaths known?5.Have you breastfed before?
B-Maternal Medical History:
1-
Do you suffer from diabetes, hypertension, edema, proteinuria or fits or other relevant diseases during the relevant pregnancy?2-Did you have any infectious diseases as herpes simplex hepatitis B, or TB?
3-
Ask mother for history of fever, rash, lymph nodes (neck nodules), jaundice, cough or other symptoms of trans-placental infections(Toxoplasmosis, CMV, or German measles)?4-Ask about history of medications?5-Ask about history of exposure to X rays or radioactive materials? (whatis the type of radioactive material?)
2-Natal
1.Duration of pregnancy.2.When was your baby born? (day and hour)3.Where was your baby born and who attended the birth?4.Did you have fever and/or foul smelling water (amniotic fluid) around
 
the time of delivery?5.When did your bag of water rupture? (more than 18 hours before the birth is premature rupture of membranes)
6.
Was the labour or birth difficult or complicated, Comment on:
Fetal distress?
Prolonged labour?
Caesarean section? (elective or selective)
Assisted delivery as Forceps or Ventose extraction?
Abnormal position and presentation?
Any other complication?
3-Postnatal1.
Did the baby cry immediately after delivery?
2.
Did s/he need resuscitation at birth?
3.
Did s/he need oxygen
4.
Did s/he need any NICU care?
5.
Did s/he look bluish (cyanosis)
6.
Ask about jaundice
7.
Did s/he bleed from any opening or below skin
8.
Ask about convulsions
EXAMINING THE NEWBORNA- Assessment of Overall Appearance/Well-Being :
1.Wash hands thoroughly with soap and water and dry with a clean drycloth or air dry. (alternatively you can use antiseptic gel)2.Place the baby on a clean warm surface or examine him/her in themother’s arms in a well lit environment.3.Weigh the baby.4-Gestational age assessment Full term or preterm from:
Measurements( Wt, length, OFC)
Physical findings (scalp hair, ear lobule, breast nodule, externalgenitalia, plantar creases)5-Neonatal reflexes (most important three): (Elicit each and know timeof disappearance of each)
Moro reflex
Grasp reflex
Suckling reflex6-Count the respiratory rate for one full minute7-Observe whether there is nasal flaring, grunting, retractions and/or chest indrawing.
8-
Assess and count the heart rate in a full minute using a stethoscope.
9-
Measure the temperature rectally with a personal thermometer.10-Observe abnormal colors (cyanosis, jaundice, or pallor)
2
 
11-Observe activity, movements and posture.12-Assess cry, level of alertness and muscle tone.13-Examine skin (noting any bruises, abrasions and hemangiomas).
B- Head, Face, Mouth, Eyes and Nose:
1.Examine head (for size, shape, fontanels, and abnormal scalp swellings).2.Examine face, (for abnormal facial features and movements).3.Examine mouth, (tongue, lips, gums, and palate).
4.
Examine eyes, (for corneal cloudiness, cataract, any swelling, redness,or pus draining from them.5.Perform Doll position6.Examine nose for signs of distress and patency
C- Heart, Chest, Abdomen and Cord, and External Genitalia
1.
Examine cardiovascular system, (HR, heart sounds, murmurs and pulses)2.Examine chest, (shape, gynaecomastia, respiratory movements,auscultation).
3.
Examine abdomen (distension, concavity or abdominal wall defects,assess the cord stump and count its vessels, palpation for organomegalyor masses, percussion for free peritoneal fluid and auscultation for intestinal sounds).
4.
Examine genitals noting ambiguity and look for patency of the anus.
5.
Assess size of penis and examine for descended testes.
D- Back and Limbs
1.Examine back, ( for any swellings, lesions, dimples, or hairy patches).
2.
Examine all limbs (movements and fractures).3.Is there Erb’s palsy (by Moro reflex).
4.
Assess hands and feet for Poly and / or Syndactyly5.Examine hip joints for limited abduction.6.Wash hands thoroughly with soap and water and dry them with a clean,dry cloth or air dry (or alternatively use antiseptic gel) .7.Document all your assessment appropriately.
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