Structured physical examination from newborn to adolescent — formative SAQs

SAQ 1 — Age-adapted sequence and threat conversion (20 marks · 15 minutes)

A 9-month-old is brought with fever. The infant clings to the caregiver and has not been undressed. [15]

Questions

1. Outline preparation and examination sequence for the next 10 minutes, including what you leave until last and why. (8 marks) [15]
2. List four red-flag findings that would make you abandon the routine sequence for ABCDE. (4 marks) [15]
3. State how you would measure and interpret heart rate and respiratory rate in this infant. (4 marks) [1]
4. Tympanic membranes cannot be seen because of distress. Write one documentation line and one safety-net plan. (4 marks) [15]

Model answer

1. Sequence. Prepare with hand hygiene, introduction, warm setting and caregiver lap. Observe colour, interaction and work of breathing first. Count respiratory rate when as calm as possible and note conditions. Auscultate heart and lungs early. Examine the abdomen next. Fully undress for rash when feasible. Leave ears and throat until last if safe. Avoid forced restraint as the default. [15]

2. Red flags. Exhausting work of breathing or poor air entry; unresponsiveness or seizure; shock signs including mottling, weak pulses and prolonged CRT with altered interaction; airway threat; rapidly spreading purpura; collapse with severe dehydration. [15] [4] [3]

3. HR/RR. Count for an adequate interval; document sleep, cry and fever; interpret with age-banded evidence-based ranges and local paediatric charts; recheck outliers; do not use adult norms. [1]

4. Incomplete ENT. Document: “Tympanic membranes not visualised due to distress.” Plan comfort measures and timed re-examination; safety-net for worse breathing, poor intake, non-blanching rash or lethargy. [15]

SAQ 2 — Newborn screening manoeuvres (20 marks · 15 minutes)

You perform a predischarge newborn examination on a term infant at 36 hours of life. [10] [7]

Questions

1. Describe correct red-reflex technique and action if one reflex is white. (5 marks) [10]
2. Differentiate a soft hip click from a positive Ortolani finding and state the implication of a true positive Ortolani. (5 marks) [7] [8]
3. List bedside features that make a murmur more concerning than innocent. (5 marks) [12]
4. You find an unexplained bruise on a non-mobile 10-week-old. What examination and system actions follow? (5 marks) [11]

Model answer

1. Red reflex. Dim the room; use a direct ophthalmoscope; compare both eyes. A white, absent or markedly asymmetric reflex needs urgent ophthalmology pathway, not delayed routine review. [10]

2. Hips. A soft click is not a clunk of reduction. A true positive Ortolani indicates a dislocated hip that reduces and is a high-concern screening finding requiring evaluation and referral pathways rather than reassurance alone. [7] [8]

3. Concerning murmur. Cyanosis or symptoms; abnormal or unequal femoral pulses; thrill; diastolic component; harsh or loud quality; heart-failure signs; poor feeding or growth — arrange timely senior or cardiology review. [12]

4. Bruise. Perform a full skin examination; document objectively; use validated bruise-pattern concern as a trigger for evaluation; start the safeguarding pathway; do not discharge on a smiling infant alone. [11]