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

We practised Communication scenario – 7 day old cyanosed baby, diagnosed with CHD on this admission. Seen the video of the case and discussed management with examiner previously. Today it was to speak with the neonate’s parents.

MF was in the hot seat and the task was completed with excellence. Only a couple of minor points could be identified that could be improved.

Take a pause of a few seconds – up to 5 – 10 after breaking bad news – let the information sink in. Generally you can wait for the Role player to come back and ask a question. Describe the abnormality / pathology in simple words and then offer to draw a diagram – if the Role Player so indicates. Summarise at 6-7 minutes leave and open question after – “Is there anything else you wish to ask / discuss?”

Learning points:

• Be systematic in approach
• Use ‘Pause / Silence’ as a powerful tool in your discussion
• 30 second rule – check for understanding / acknowledgement
• How is the baby? – Be honest, brief but optimistic – “Stable now and has responded to our immediate treatment’.
• Future management after further query from Role player – if appropriate.
• Remember Name of RP & Child – try and not confuse.

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

Thank you for attending the session today and to Ankita for taking the hot seat.

We discussed a 14-year-old with history of tachycardia since the age of four years on treatment and no worse for the past four months. She saw a specialist and was advised an operation and has been concerned and has come to see you for her routine visit. The history was taken well. It’s important to remember HEADSS + menstural – for a teenage Female.

Important to know of common conditions and treatment of supraventricular tachycardia.

Learning points:

• Remember it is focused history hand do not wander too wide.
• Take the clues from the information given – you need not second guess the diagnosis
• Generally with chronic conditions – some triggers in previous 4-6 months
• Teenage history: HEADSS essential
• Summarize at 9 minutes before carrying on.
• Be empathic – EVEN is a history station.

Add comments or anything I may have missed.

Anil Garg

We discussed a seven day old baby who was sent in by the midwife for poor feeding.

The clinical signs were: central cyanosis, peripheral shutdown, normal respiration with no evidence of distress and CXR showing pulmonary plethora. The signs were picked up and appropriate history was asked for an examination findings confirmed.

There was some discussion on the management regarding being prepared for known side-effects of common medications.

Learning points:

• Examiners are ‘looking for’ patient safety first and a registrar who is ‘safe’.
• Inform Consultant first before discussing outside your ‘unit’ if situation permits else tell them as soon after.
• CXR – describe in a systematic manner. Less likely to miss important findings.
• Differential diagnosis: Respiratory or Cardiac – then it is easier.

Add your comment or anything I may have missed.

One of the participants mentioned was informed that next diet clinical exam in UK will be all online. I have no way of knowing but  keep checking RCPCH website for updates. If So – it will be like we have been practicing.

Anil Garg

We discussed a young person – 15 year old with Type 1 diabetes for 8 years. Presenting with weight loss, abdominal pain and HBAIc 11.5 gm. RP by MF. SH took the hot seat and elicited a  good history with very good communication skills, giving enough time for RP to respond and provide relevant information. Other observers chipped in with more details of social history, more exacting details of treatment.

Learning points:

• Do not forget to build rapport – ice breaker to start
• Phrase questions carefully and try to ask one at a time.
• Check why young person has come alone – may get clue to family dynamics
• Insulin – check dose iu, frequency, site, compliance
• Diet is important but do not get bogged down with detailed carbohydrate count
• Ask for information – DO Not assume.
• Good HEADSS screening
• Parents should be first line of support in management.

If I have missed any other points please add your comments.
Anil Garg

We discussed approach to History station and how to manage your time.
Plus a video station – 1 year old with trisomy 21, Jaundice, umbilical hernia and distended umbilical veins.
Learning points:

• History station have a ‘plan’ while reading the scenario.
• Prepare ‘mental’ consultation for first 2 -3 minutes
• Be ready to change your plan on response from patient / role player
• ‘How are you coping?’ Very important and should be asked early after presenting complaints.
• HEADSS for teenage history.
• Social history – after presenting signs & symptom details – do not leave till end.
• Summarize and then leave an open question.
• Park any major queries but do NOT ignore them.

Leave a comment or to add anything I may have missed.
Anil Garg