Thank you for participating in the session today and making it so interactive. 

My apology for the information overload. We covered a lot of area and I trust it will sign post you to where to focus your effort and where to find the resources.

We discussed the approach to a ‘cardiac’ patient. General examination followed by systematic examination of the chest.We discussed normal physiology in a child and how the fetal transition to circulation occurs and the pressure changes associated with it. How do use pressure changes affect the flow of blood and give rise to murmurs. We then had a number of audio video clips depicting murmurs commonly encountered in children.
The learning points were:

• Better understanding of cardiac physiology.
• Recollection of murmurs.
• Continuous murmur of PDA vs Aortic stenosis + Aortic Regurgitation
• Diastolic murmurs clearer.
• Foetal circulation and effects after birth on murmurs.
• Brushed up schematic working of CVS examination.
• Encourage to say what you find
• Practice of how to ‘run’ your clinical examination.

Please add your comments or anything I have missed.
Anil Garg

Thank you for your participation in the sessions on clinical stations.

The new set up is different from before and is also new to us. We are trying to guide preparations to the best of our understanding of how the new setup will run and how  candidates will have to adapt their examination and presentation techniques to score maximum marks.

There have been two PowerPoint presentations on clinical station in general and more specifically for CVS station.

The learning points are:

• Look at the images provided very carefully for cues that you would have from seeing a child
• Practice talking through the examination
• Good presentation is essential
• Need to be very systematic so as not to miss a ‘sign’
• If you do NOT ask – examiner will not tell you
• Read basic physiology and management options
• CVS – murmurs are a weak point for all – need practice
• Be vary of two conflicting finds in your presentation
• Normal pulse with Aortic stenosis or with significant regurgitation
• Better not to comment – if not certain
• Investigations – Know what you will be looking for.

We will do a session on common murmurs that can be expected at next session.
Add your comments or any points I may have missed.

Anil Garg

We have just added a presentation on how to take a Good Focused History.

Common scenarios, what to avoid and Not to get into Communication station mode.

Focused History – Brief Guide

We discussed the management of coeliac disease in the first session. Dr S summarised her findings from previous session. The discussion on significance of a ‘negative’ coeliac screen tTg level in context of management of disease, likely complications, what regular monitoring will be required and role of biopsy.

Dr Siba gave valuable advice on Coeliac disease management:

• Serology is important and levels of tTg – IgA antibodies > X 10 are confirmatory evidence
• Serology levels of < X10 – need to be confirmed with a Biopsy
• Following a new diagnosis Screening of 1st degree relatives is required
• Pneumococcal vaccine is recommended as patient deemed ‘asplenic’.
• Advice parents to have a separate shelf / cupboard to keep ‘Gluten free’ food and utensils
• Sepeartae butter dish etc is recommended to avoid contamination

REMEMBER A PERSON HAS A DISEASE – HE IS NOT THE DISEASE.

I met Tobias, a case of Coeliac disease vs I met Tobias who has Coeliac disease.
Choose your words carefully.

Examiner has been listening to you taking history so DO NOT repeat it all.
Salient points which support your conclusion only – sound better and save you time for discussion.
In the second session we discussed Management of Crohn’s disease. Very well done by Dr M.
We also discussed how the new format virtual exam will affect our performance at various stations.
Learning points:

• Read clinical examination and practice speaking
• Need to mention what you will be looking for
• Passport / Bracelet for Steroid and other medications or disease process

Please watch the video as there was lot of information discussed that I have not been able to put here.
Add a point or any comments.
Anil Garg

We had our first sessions on Winter UK time – due to error on my part – the first session scheduled for 3:00-4:00 pm UK time – the invitation was sent for old time of 4:00-5:00 pm. My apology. Hopefully the error should not recur.

We also had 2 histories: One a Young person with Coeliac disease and the second a young person with Crohn’s disease. Anish and Ayo were is the role players and performed beautifully. The coeliac history was a bit hit and miss but the Crohn’s disease history was very well done. There is always room for improvement and we had formative suggestions from peers and Siba.

The learning points were:

• Introduction is important – be brief
• Give Role player time to respond: keep quiet for 5-10 seconds – do not interrupt.
• Active listening.
• Explore main complaint and also common associations.
• Chronic disease – if unexpectedly get worse – think of Compliance first.
• You may need to probe on compliance and not just a gradual acknowledgement
• Other disease process – workout a differential
• Social history is important.
• HEADSS – for young person is important – DONOT leave till very late.
• Remember you cannot ask about ‘everything’.
• If you finish early i.e. 9-10 minutes – likely you have missed out on an important aspect in history.
• Summarize.

Add any other points or comments.
Anil Garg

Thank you for participating in today’s session.

We made a change to the intended program by swapping new history scenario to continuing the discussion on asthma. I made the choice because asthma is a very common topic in the exam and then come your way in history and management, communication, clinical and even video stations. We presented the summary as it would be to an examiner.

The discussion was conducted with Dr Aloke and highlighted the different aspects management could proceed during the discussion.

The learning points are:

• Update yourself with NICE guidelines on Asthma Management in children.
• Tests that can be done in the clinic to evaluate condition and progress: PEFR.
• FeNO – a new monitoring test available and used at certain centres but will be rolled out.
• Spacer devices available – how to choose most appropriate for ‘your child’.
• Aerochamber vs Spacer.
• Be able to describe how to use an inhaler device
• Differential diagnosis: GORD, Post nasal drip – allergic rhinitis, Cystic fibrosis, IgA deficiency
• BTS guidelines on treatment: SBA, ICS, LABA, Montelukast agonist, Oral steroids, Theophylline.

Add any points I may have missed or to add any comments.
Anil Garg

You can access the guidelines from:

• https://bnfc.nice.org.uk/treatment-summary/asthma-acute.html&nbsp;

• https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/AOP_FeNo-testing-asthma-diagnosis.pdf
• https://respiratoryacademy.co.uk/module-1/how-do-you-know-if-the-spirometry-test-meets-the-quality-standard/ 

Thank you for participating in the session.

We discussed a 10 year old boy with asthma who was causing concern to parents. We had Dr Urmila role play.
I emphasised the basic nut &n bolts of a History station and how it differs from a Communication station – though there are a lot of similarities in both and a significant marks can be acquired by good communication skills. We completed the history part of the station.

The main learning points are:

• Read the Information sheet carefully.
• Each line and ‘word’ has significance and had been deliberately chosen.
• The cues from there should guide to formulate a differential diagnosis.
• Prepare your questions related to the DD.
• Be systematic in your information gathering.
• Ask screening questions for relevant diagnosis.
• Role player will not give information unless you ask.

Add any further points or comments.
Anil Garg

Thank you for participating in the session today and making it so interesting.  In the video today we saw a two hour old baby, dysmorphic looking who was being ventilated and had evidence of his oesophageal atresia would tracheo-oesophageal fistula, bilateral abnormal ears, vertebral anomalies . The clinical observation of the child was good and noted by all but review of the chest x-ray was less convincing and required some prompting.
The learning points:

• Common thing first – ABC.
• Observe the video carefully, 3 times – FOCUS of different aspects – DO NOT fixate on the same thing
• Be systematic in your summarizing
• Oesophageal atresia – blind upper end needs – Reprigol suction catheter.
• Air below diaphragm is an important sign – MENTION it.
• Listen to question carefully – what 3 things will you do next….
• Inform your Consultant before discussing with other teams.

If I have missed and point – add or leave a comment.
Anil Garg

Thank you for your participation in the session and making it interesting and useful. Dr Urmila and Dr Siba were with us and gave very valuable feedback.

We saw video clip of a 14 year old with weight loss, dehydration, acidotic breathing, confusion. Differential diagnosis.

It was good to note all the signs were picked up, good differential diagnosis was made and appropriate questions to differentiate the DD. Discussion was on Diabetic ketoacidosis.

Learning points:

• Look up the current guideline
• Know Diabetes inside out as it can come in H&M, Clinical, Communication or Video station.
• Observe the video carefully
• Summarize well and in order
• Do not make up signs or history points
• Read all Hypo / Hyper scenarios and Shock – ready for discussion.
• Link to latest Diabetes guidelines.

Vist www.mrcpchonline.org to add and points I may have missed or any comments.

Anil Garg

Thank you for participating in the session today and making it so interesting and interactive. We discussed at three day old baby who was floppy. The signs were picked up by son but as a collective all signs were picked up inappropriate differential diagnosis was formulated. 

We needed some guidance on how to formulate the question to ask for history and what specific examinations may be carried out to help you narrow down the differential diagnosis. 

The learning points were:

• Watch video carefully
• Work out the possible differential diagnosis
• Frame questions carefully.
• Be precise and specific to information required. Closed questions are best here.
• Finds should be phrased with minimum words and try avoid long descriptions if possible
• Speak with Consultant, your own and Tertiary specialist as required.
• You are not expected to know everything!
• While working out differential, think of a specific test for the condition.

Please add points or comments at http://www.mrcpchonline.org.
Anil Garg