Thank you for attending and making today’s session so lively and interesting.

We discussed a scenario in which a 21 day old baby presented with lethargy, poor feeding and weight loss. Serum Na: 110 mmol/l. Ankita was the role player and Anurag took the hot seat. The history and communication were appropriate. Consanguinity needs to be confirmed if there is suggestion of a recessive condition.

The differential diagnosis could be done better and appropriate management can only be correct if our differential diagnosis is on track.

Learning points:

• In a neonate with lethargy and poor feeding NEVER forget sepsis
• Differential diagnosis should be most likely first
• If results or information suggests a life threatening condition – MANAGE that first
• In this child sepsis and hyponatremia have to be priority in treatment
• Frequency of medications – can make an educated guess and ask for confirmation.
• Is it drug x – Hydrocortisone and other – Fludrocortisone
• Role player is likely to clarify even if they have not given the name on drugs first
• Investigations to support or rule out your differential
• Discuss with your consultant

If there are points I have missed or comments you wish to add.
Anil Garg

Misbah had shared with me the information college had given regarding changes to the new exam.

It is reassuring to learn that there will be no change to the history and management, communication and video stations of the exam.

Changes are to the clinical stations and the development station.

There will be three clinical stations instead of four. They will be two short clinical stations and one extended clinical station.

The extended clinical station will have a scenario given followed by time for history and examination. The examination will be virtual hands-free.

It will be very important for the candidate to practice vocalising what they have been doing intuitively and in autopilot since they qualified.

This would be followed as before with summarising, differential diagnosis and management planning.

The development station will be on similar skeleton framework and the candidate would be expected to describe how they would be conducting the developmental assessment.

The rest of summarising the evaluation of differential diagnosis of developmental age and the discussion will be as before.

Any change causes anxiety but if we stand back and look at the new format it is more of old then off new. You will be expected to do differently only for a very short portion of the particular station and this will improve with practice till the actual date.

We agreed to:

• Read Hutchison’s Clinical methods for systemic examinations.
• Write out bullet points of one system each
• Positive and negative signs to identify in a given scenario
• We will share & practice
• Wait for RCPCH details on the clinical station
• Start on our rolling Course systematic template from 1 September.

We practised skills so we could do them in our sleep – NOW we need to learn to talk in our sleep!

add a comment or any point I may have missed.
Anil Garg

Thank you for participating in the session today and making it so interesting. We saw a video clip of a 12-year-old boy with Acute Lymphatic Leukaemia on treatment. He had the normal side effects of chemotherapy and a central venous access and get across to me with a peg.

The venous access devices and Peg gastrostomy are not commonly seen in overseas centres and hospitals and it was interesting to discuss them in detail and also go over the indications. We discussed the complications and what questions to ask if faced with such a video.

Learning points:

• Look up venous access in children in different clinical conditions.
• Commonest cause of loss or hair / bald – in children is Chemotherapy for malignancy.
• Febrile neurtopenia is a common complication and needs urgent management.
• Check the warning signs of infection with central lines.
• Intraosseous access in resuscitation scenarios – do not forget.

Add anything I may have missed or add your comments and suggestions.

Comment / Observation
Anil Garg

We discussed communication with parents of a baby, who surprised the midwife when she noted, ambiguous genitalia. The situation was further complicated by father not being there at the start of the session and joining halfway through. The scenario was done professionally and clearly.

It was good to note that the parents were congratulated even though there was an obvious concern that required discussion. We should not sound like doctors of doom and gloom will only bring bad news.
The learning points were:

• In breaking bad news do not beat around the bush – say it followed by TIME to let it sink in.
• Ask if the parents have seen the child and if not offered to see the child together with them to show the point of concern.
• Remember imagination is worse than actual in such circumstances.

• Do NOT assign a gender to the newborn
• Ambiguous – mention what it means and how it correlate to observations in the child
• Give some idea of the possible causes and what you need to monitor in the immediate future
• Chemical balance – allows a baby to develop normally into a boy or a girl
• Imbalance in the levels of chemicals / hormones can lead to changes we note here.
• Do NOT assign gender & if need to give a Neutral Name.
• Do not forget 30 second rule EVEN when rattled!

We will have a ‘Discussion’ a clinical case in our next session.

Add a comment or a point I may have missed.

Anil Garg

Commnets

Thank you for participating in the session today double a little thin on the ground Covid duties are having a toll on our attendance. Take all the safety precautions & Stay safe.

We discussed a communication scenario of discussing with parents of four-year-old who has been seen for being clumsy and clinical examination suggests he may have Duchenne muscular dystrophy. This scenario was fairly straightforward but it is important not to assume a diagnosis as the final when describing to parents on the first consultation unless specifically mentioned.

Learning points:

• Introduction and normal interactive behaviour with rapport.
• Do not give the ‘Diagnosis’ as a definitive – if you are only suspecting.
• Describe the signs parents can identify with and put in context with your thinking
• Child is ‘likely to have …XYZ’ because of these and we need to confirm by investigations.
• Keep quiet for 4-5 seconds for the information to sink in.
• Let Role player respond with their ’emotion’ question’ and then reply to their queries.
• Be ‘optimistic’ and not a Doom and Gloom doctor / colleague.
• Avoid being technical – said all the time but under stress we all ‘regress’.
• Keep it simple – basic grass root level information to start with.
• Contact Us

Add a comment or anything else I may have missed.
Anil Garg

We discussed video clip showing seven-year-old boy with history of being clumsy and falling. Findings on the video clip showed a normal gait but unsteady when walking on heel. Calf muscles looked prominent and Gower’s signs was positive.

There was some confusion as to what specific history points should be asked. Examination was less controversial and included looking at the tongue, reflexes and spine.

The differential diagnosis was fairly straight forward but we had a discussion whether the findings could be possibly consistent with poliomyelitis.

Learning points:

• If the diagnosis is very clear then you need not make a long differential diagnosis list
• Support your diagnosis with findings in history and clinical signs
• Do not be ‘locked’ into your diagnosis – have a second option if asked.
• When asking for what would you like to examine: inquire specific finding
• Neurological case – Do NOT forget 5 Ss.

Add any point I may have missed or to add a comment.

Contact Us
Anil Garg

We discussed video clip of a six week old baby with moderate to severe respiratory distress. This was evidenced by child being increased work of breathing, sleepy, head bobbing, tachypnoea with oxygen via nasal prongs maintaining a satisfactory oxygen saturation. The findings were picked up by all, question of relevant history and examination. Impending Respiratory failure.

However investigations were coloured by personal experience – i.e. RSV identifications was not done due to ‘financial’ constraints in the working units.

Learning points:

• Practice medicine in an ‘ideal’ world as if ‘all was available’.
• If an important ‘facet’ is missing – mention it – and in an ‘ideal situation’ you will do it.
• Reasonable to check FiO2 – if not clear – as that will affect your management decision.
• Continue to relate to Video clip signs – do not move to ‘theory’ realm.
• Watch the Complete Video as sequence of events will determine management options
• Presentation skill is essential in conveying your thoughts effectively

Please add any points I have missed or to add a comment.
Anil Garg