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Newborn Baby Assessment (NIPE) | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the patient including your name and role
3 Confirm the patient's name and date of birth
4 Briefly explain what the examination will involve using patient-friendly language
5 Gain consent to proceed with the examination
6 Adequately expose the child for the assessment
Encourage the parent(s) to ask questions during the check and to participate where
7
appropriate
History
Take a brief history of the pregnancy and the delivery (e.g. mechanism of delivery,
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complications)
Weight
9 Measure the infant’s weight and plot on a weight chart
General inspection
10 Inspect the infant for clinical signs suggestive of pathology (e.g. pallor, cyanosis, jaundice)
Tone
Assess tone by gently moving the newborn's limbs passively and observing the newborn
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when they're picked up
Head
12 Measure the infant's head circumference and record it in the baby's notes
13 Inspect the shape of the head and note any abnormalities
14 Palpate the anterior fontanelle: note if it feels flat (normal), sunken or bulging (abnormal)
Skin
Inspect the skin for colour abnormalities (e.g. pallor, jaundice), bruising/ lacerations and
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birthmarks
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Face
16 Inspect the face for dysmorphic features, asymmetry, trauma and nasal abnormalities
Eyes
17 Inspect the eyes for abnormalities (position, shape, erythema, discharge)
18 Assess the fundal reflex in each eye
Ears
Inspect the pinna: note any asymmetry, skin tags, pits or the presence of accessory
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auricles
Mouth and palate
20 Look for clefts of the hard or soft palate and inspect the tongue for ankyloglossia
Neck and clavicles
21 Inspect the neck for abnormalities (shortened length, lumps, clavicular fracture)
Upper limbs
Inspect the upper limbs for abnormalities (e.g. asymmetry, missing fingers, single palmar
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crease)
23 Palpate and compare the brachial pulse in each upper limb
Chest
Inspect the chest for abnormalities and assess the infant’s respiratory rate and work of
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breathing
25 Auscultate the lungs
26 Auscultate the heart
27 Assess pulse oximetry
Abdomen
28 Inspect the abdomen for abnormalities (e.g. distension, hernias, cord stump infection)
29 Palpate the abdomen to assess for organomegaly
Genitalia
Inspect the genitalia and note any abnormalities (position of the urethral meatus,
30
testicular swelling, absent testicle, fused labia)
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Lower limbs
Inspect the lower limbs for abnormalities (e.g. asymmetry, oedema, ankle deformities,
31
missing digits)
32 Assess tone in both lower limbs
33 Assess movement in both lower limbs
34 Assess the range of knee joint movement
35 Palpate and compare femoral pulses
36 Perform Barlow’s test
37 Perform Ortolani’s test
Back and spine
38 Inspect the back and spine for abnormalities (e.g. scoliosis, hair tufts, naevi, sacral pits)
Anus
39 Inspect the anus for patency
Reflexes
40 Assess a selection of newborn reflexes (e.g. palmar grasp, rooting reflex, Moro reflex)
To complete the examination...
41 Explain to the parent(s) that the examination is now finished and offer to dress the baby
Share the results of the assessment with the parents, explaining the reason for any
42
referrals you feel are required
43 Check if the parents have any further questions
44 Thank the parents for their time
45 Dispose of PPE appropriately and wash your hands
46 Summarise your findings
47 Document your findings and suggest further investigations/referrals
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Paediatric Abdominal Examination | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the parents and the child, including your name and role
3 Confirm the child's name and date of birth
4 Briefly explain what the examination will involve using patient-friendly language
5 Gain consent from the parents/carers and/or child before proceeding
General inspection
Observe the child in their environment (e.g. waiting room, hospital bed) and take note of
6
their appearance and behaviour
Hands
7 Inspect the hands for clinical signs relevant to the gastrointestinal system
8 Palpate the radial pulse, assessing the heart rate and rhythm (femoral pulse in babies)
Face
Inspect the face and eyes for signs relevant to the gastrointestinal system (e.g. scleral
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icterus, oedema, pallor)
Inspect the mouth and throat for signs relevant to the gastrointestinal system (e.g.
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glossitis, angular stomatitis, aphthous ulceration)
Neck
Palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s
11
node on the left for evidence of lymphadenopathy
Close inspection of the abdomen
12 Inspect the child's abdomen for signs suggestive of gastrointestinal pathology
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Examining the abdomen
13 Perform light palpation of the nine abdominal regions
14 Perform deep palpation of the nine abdominal regions
15 Perform liver palpation and percussion
16 Perform splenic palpation and percussion
17 Ballot the kidneys
18 Assess for shifting dullness
19 Auscultate bowel sounds
Genital examination
20 Consider genital examination if relevant
Rectal examination
21 Inspect the rectum if relevant (e.g. imperforate anus, anal skin tags)
Lower limbs
22 Inspect for pedal oedema
To complete the examination...
23 Explain to the child and parents that the examination is now finished
24 Ensure the child is re-dressed after the examination
25 Thank the child and parents for their time
26 Explain your findings to the parents
27 Ask if the parents and child (if appropriate) have any questions
28 Dispose of PPE appropriately and wash your hands
29 Summarise your findings to the examiner
Suggest further assessments and investigations (e.g. vital signs, nutritional assessment,
30
urinalysis)
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Paediatric Cardiovascular Examination | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the parents and the child, including your name and role
3 Confirm the child's name and date of birth
4 Briefly explain what the examination will involve using patient-friendly language
5 Gain consent from the parents/carers and/or child before proceeding
General inspection
Observe the child in their environment (e.g. waiting room, hospital bed) and take note of
6
their appearance and behaviour
Hands
7 Inspect the hands for clinical signs relevant to the cardiovascular system
8 Assess and compare the temperature of the hands
9 Assess capillary refill time (CRT)
Pulses and blood pressure
10 Palpate the radial pulse, assessing the heart rate and rhythm
11 Assess for radio-radial delay
12 Assess for a collapsing pulse
Jugular venous pressure (JVP)
13 Measure the JVP with the patient positioned correctly
Face
Inspect the face and eyes for signs relevant to the cardiovascular system (e.g.
14
conjunctival pallor, xanthelasma)
Inspect the mouth for signs relevant to the cardiovascular system (e.g. central cyanosis,
15
angular stomatitis, high-arched palate)
Close inspection of the chest
16 Inspect for scars, chest wall deformities and pulsations
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Palpation
17 Palpate the abdomen to assess for hepatomegaly
18 Palpate the apex beat and assess position
19 Assess for a parasternal heave
20 Assess for thrills
Auscultation
Auscultate the mitral, tricuspid, pulmonary and aortic valve with the diaphragm of the
21
stethoscope
22 Repeat auscultation of all 4 valves using the bell of the stethoscope
23 Auscultate the lung fields on the anterior and posterior aspect of the chest
Final steps
24 Assess for evidence of pedal or sacral oedema
To complete the examination...
25 Explain to the child and parents that the examination is now finished
26 Ensure the child is re-dressed after the examination
27 Thank the child and parents for their time
28 Explain your findings to the parents
29 Ask if the parents and child (if appropriate) have any questions
30 Dispose of PPE appropriately and wash your hands
31 Summarise your findings to the examiner
Suggest further assessments and investigations (e.g. abdominal examination, respiratory
32
examination, vital signs, ECG)
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Paediatric Neurological Examination | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the parents and the child, including your name and role
3 Confirm the child's name and date of birth
4 Briefly explain what the examination will involve using patient-friendly language
5 Gain consent from the parents/carers and/or child before proceeding
General inspection
Observe the child in their environment (e.g. waiting room, hospital bed) and take note of
6 their appearance and behaviour. Watch them during play to assess their attention span,
motor coordination and problem-solving abilities.
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Cranial nerves
7 CN I: Assess olfaction (in older children)
8 CN II: Assess visual acuity
9 CN II: Assess visual fields
10 CN II: Assess direct and consensual pupillary reflexes
11 CN II: Perform fundoscopy including assessment of the fundal reflex
12 CN III, IV, VI: Assess extraocular eye movements
13 CN V: Assess facial sensation
14 CN V: Assess mouth opening against resistance
CN VII: Inspect the face for asymmetry and ask the child to perform various facial
15
expressions if possible
CN VIII: Perform a gross assessment of hearing and assess vestibular function by
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observation (e.g. poor head control, truncal unsteadiness, ataxia)
17 CN IX, X: Observe the child drinking or eating
18 CN IX, X: Inspect the soft palate including the uvula for asymmetry
CN XI: Ask the child to shrug their shoulders and turn their neck against resistance (older
19
children)
20 CN XII: Inspect the tongue for fasciculations and ask the child to protrude their tongue
Upper and lower limb examination
Inspect the upper and lower limbs for abnormalities (e.g. asymmetry, wasting, abnormal
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movements, abnormal posture)
22 Observe gait
23 Assess upper and lower limb tone as appropriate
24 Assess upper and lower limb power as appropriate
25 Assess upper and lower limb reflexes as appropriate
26 Assess upper and lower limb sensation as appropriate
Cerebellar examination
27 Perform focused assessment of cerebellar function (e.g. co-ordination)
Cognitive assessment
Assess current developmental milestones (e.g. speech) or perform age-appropriate
28
cognitive tests (e.g. MMSPE)
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To complete the examination...
29 Explain to the child and parents that the examination is now finished
30 Ensure the child is re-dressed after the examination
31 Thank the child and parents for their time
32 Explain your findings to the parents
33 Ask if the parents and child (if appropriate) have any questions
34 Dispose of PPE appropriately and wash your hands
35 Summarise your findings to the examiner
36 Suggest further assessments and investigations (e.g. skin assessment, neuroimaging)
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Paediatric Respiratory Examination | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the parents and the child, including your name and role
3 Confirm the child's name and date of birth
4 Briefly explain what the examination will involve using patient-friendly language
5 Gain consent from the parents/carers and/or child before proceeding
General inspection
Observe the child in their environment (e.g. waiting room, hospital bed) and take note of
6
their appearance and behaviour
Hands
7 Inspect the hands for clinical signs relevant to the respiratory system
8 Palpate the radial pulse, assessing the heart rate and rhythm (femoral pulse in babies)
Face
Inspect the face and eyes for signs relevant to the respiratory system (e.g. nasal flaring,
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conjunctival pallor)
Inspect the mouth and throat for signs relevant to the respiratory system (e.g. central
10
cyanosis, cleft palate, tonsillar hypertrophy)
Tracheal position
11 Inspect the position of the trachea
Close inspection of the chest
12 Inspect for scars, chest wall deformities and asymmetry of chest wall movement
Assess the child's respiratory rate for 60 seconds to calculate the number of breaths per
13
minute
Palpation of the chest
14 Palpate the apex beat and assess its position
15 Assess chest expansion
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Percussion of the chest
16 Percuss the chest wall, comparing side to side as you go
Auscultation
Auscultate the lungs on each side of the anterior chest at each location to allow for direct
17
comparison
18 Assess vocal resonance if appropriate (i.e. if child old enough to follow instructions)
Lymph nodes
19 Inspect and then palpate the major lymph node chains of the neck
Posterior chest assessment
Assess the posterior chest including inspection, chest expansion, percussion, vocal
20
resonance and auscultation
Final steps
21 Assess for evidence of pedal or sacral oedema
To complete the examination...
22 Explain to the child and parents that the examination is now finished
23 Ensure the child is re-dressed after the examination
24 Thank the child and parents for their time
25 Explain your findings to the parents
26 Ask if the parents and child (if appropriate) have any questions
27 Dispose of PPE appropriately and wash your hands
28 Summarise your findings to the examiner
Suggest further assessments and investigations (e.g. vital signs, cardiovascular
29
examination, peak expiratory flow rate)
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pGALS Examination | OSCE Checklist
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Introduction
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the child and parents including your name and role
3 Confirm the child's name and date of birth
4 Briefly explain what the examination will involve using child-friendly language
5 Gain consent to proceed with the examination
6 Adequately expose the child
7 Position the child standing
Screening questions
8 Do you have any pain or stiffness in your muscles, joints or back?
9 Do you have any difficulty getting yourself dressed without any help?
10 Do you have any problem going up and down stairs?
Inspection
Perform a brief general inspection of the child, looking for clinical signs suggestive of
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underlying pathology
12 Inspect the child from the front
13 Inspect the child from the side
14 Inspect the child from behind
Gait
15 Observe the child's gait (including heel and tiptoe walking)
16 Assess the child's footwear
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Arms
17 Ask the child to put their hands behind their head and point their elbows out to the side
Ask the child to hold their hands out in front of them, with their palms facing
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down and fingers outstretched
19 Inspect the dorsum of the hands
20 Ask the child to turn their hands over (supination)
21 Inspect the thenar and hypothenar eminences for muscle wasting
22 Ask the child to make a fist
23 Assess precision grip
24 Ask the child to put their hands together palm to palm
25 Ask the child to put their hands together back to back
26 Ask the child to reach upwards
Ask the child to look upwards (assessing cervical extension - can also perform this in the
27
spine section)
28 Perform MCP squeeze
Legs
29 Assess active knee flexion and extension
30 Perform passive knee flexion
31 Perform passive knee extension
32 Perform passive internal rotation of the hip
33 Perform MTP squeeze
34 Perform patellar tap
Spine
35 Assess cervical lateral flexion
36 Assess lumbar flexion
Temporomandibular joint
37 Assess TMJ function
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To complete the examination...
38 Explain to the child that the examination is now finished
39 Thank the child for their time
40 Dispose of PPE appropriately and wash your hands
41 Summarise your findings
Suggest further assessments and investigations (e.g. focused examination of joints
42
suspected of having pathology, further imaging)
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