We continued with our theme of Abdomen and discussed a 4 yr child with recurrent abdominal pain. He looked very well. He had a transverse scar in upper abdomen approx 12 – 15 cm across with a circular 3 cm diameter scar and number of spikey scars along the linear scar. No organomegaly.
Interesting –   discussion. Trying to have a succinct coherent presentation took combined effort. Diagnosis was Surgery for intestinal obstruction in early infancy due to volvulus. Circular scar was by a local healer branding the child.
Learning points were:

• give presentation under: Inspection, palpation, percussion – if, auscultation
• narrow down differential diagnosis to 3 most likely – at times not possible
• Investigations with expected results to help narrow done the Differential diagnosis
• Surgical scars are likely to have surgical DD but think of Constipation.
• Do not go to Coeliac disease – if no other clues
• Missing signs attracts lesser penalty than making up a sign.
• If REALLY in doubt – then mention your dilemma.
• If your examination technique was GOOD – examiner will take that into account

If there are any more points that I may have missed – please add them

Anil Garg

We continued on the theme of Abdomen as was suggested. First there was a powerpoint presentation of important Do’s & Don’t’s. How to score marks in all the domains you will be tested at this station. 4 domain and 8 marks for the station – Communication gets 25% of the marks!

The scenario was of a 15 year old who came for annual FU. Well built, scars in abdomen – periumblical and RIL with a firm mass 15 X 15 cm.
Good discussion – Renal transplant.
Learning point:

• Revise scars you can encounter
• Check for scars when child sitting at edge of bed – walk around to look
• Presentation – keep it basic to begin with – esclate as per questioning
• Differential diagnosis – support with findings
• Sleek examination
• Beaware of what else you will like to check – here BP, hernial sites

Please go on site to add any more comments I may have missed.
Anil Garg

We discussed a 8 years old child with nausea, weight loss and pruritis. Differential diagnosis was Chronic liver disease with portal hypertension secondary to — possible aetiology.
Learning points:

• Group the aetiological causes into broad categories
• Infective, Drugs, Metabolic, Autoimmune, Cardiac etc
• Similarly arrange thought process to discuss investigations
• Very fine details are not required – can / should seen advice from Specialist Hepatic unit.

Another point we discussed was – the next Examination date is not certain and may be delayed. I would like you all to continue with your preparations and lose ground on the time you have worked so hard.

To avoid a gap and you dropping from the sessions – I have offered to add 2 sessions to 4 session subscription i.e. 6 instead of 4, till a date for the examination is published by RCPCH.

It is hard to pick up after a break and make up lost ground.

Do continue to practice and send me suggestions on how to improve your learning experience.

Anil Garg

We discussed Video station of the exam in open session for Eid celebrations.

PowerPoint presentation on format of the station and what to expect. Advice in how to prepare from getting the information outside the room, observing signs, supporting differential diagnosis with your observations and planning through investigations and early management.

Video was on a newborn with VACTRL association. Good discussion by few participants who stepped up to take the HOT seat.

There were some technical issues with background sound with active microphones.

I hope it was useful and helped your preparations for the exam.

Do leave your comments & I look forward to meeting you in future sessions.

Anil Garg

Video was of a term looking, 3 day old neonate notes to have signs of significant Hypotonia requiring tube feeding and under phototherapy. No obvious respiratory distress.

The signs demonstrated were picked up – baby was hypotonic – but important to mention each sign when describing your findings – supporting observation of hypotonia: frog like posture, complete head lag, rag doll ‘tone’ slipping through grip on holding under the arms / axilla.

Important o frame history question appropriately so as to help your differential diagnosis and same for targeted examination.

Learning point:

• Ask question – very specific – ideally a closed question.
• Differential diagnosis: BROAD brush to begin with – gives scope to expand
• MORE important – gives wriggle room in case your only diagnosis is not correct
• Investigations – again – start with basics – say what you EXPECT to find.
• How they will guide your differential
• Have a reasonable idea of the management plan.

It was the first session in our current cycle after communications. Video was of a 18 month old with signs suggestive of possible Kawasaki disease.

All the clinical features elicited in the video clip were picked up.

Difficulty was in formulating a differential diagnosis and what specific examination may you wish to do i.e. get the findings of – Do not say ‘vital signs’ as that is very unlikely to help you narrow down your differential.

In this case looking for lymphadenopathy, joints and possible oral mucosa for koplick’s or strawberry tongue would have been appropriate.

Management was discussed and important to co-relate it to the clinical signs that have been identified.

• Learning point:
• Formulate a DD supported by the clinical signs.
• Work out appropriate investigations – again related to your DD – NOT random general.
• Can get baseline investigations if you expect them to get worse.
• Need to be quick and try and lead the viva questions if you can
• add your comments and questions.

Dear sir       

today’s class was an eye opener for approaching a task which on first instance looked clueless but with establishing rapport and getting the role player in comfort zone and asking few questions and addressing his concerns made it doable..

I have a query sir in general …my mock task was to explain duct dependent lesion to father…and after initial greetings I asked the father whether he wants to have anybody else with him..the examiner interrupted and said nobody else is allowed and you are supposed to know it…

although it didn’t cost me nor it was mentioned in feedback… I would like to know if I can use such phrase???       With regards…….

Please give your opinion on how it should be approached?

A lot were confused about lack of a well defined task but to address ‘Role player / parents’ concerns following a brief clinical history of preterm baby with reflux.

Such scenarios are not uncommon and when you deal with parents in your clinical practice you do not always clearly know what the ‘Task’ will be when you meet a parent.
You explore with the parent their concerns, encourage them to come out with all they are worried about – this will not take more than 2 minutes or 3 at the maximum. You can then paraphrase the concerns and confirm that is what is worrying them – like Freda did – and then the task becomes very easy.
You need to be guided by the Role player and after the concerns are defined – you can take over the ‘talking’ but in 30 sec bites and checking understanding and engagement in the discussion.
Use silence effectively – if YOU keep silent – Role Player will speak – give them PLENTY of time to speak. If you intervene too early or after the first concern – you will MISS the boat – so to speak.
Learning points from today:

• Know common equipments in use – apnoea monitor / alarm – & their functions
• Not to assume information – SIDS was not on the radar – so don’t bring it up
• Summarise at 6 minutes – acknowledge if you note RP is still NOT satisfied / upset
• Offer remedial solutions in the next 2.5 minutes or their other information. Admission for observation – CAN be a solution.
• Do NOT panic.

Fo any more points that I may have missed please add them in your comments.

Misbah role played very well and it was interesting to note her ‘response’ to 2 different candidates approach to the same ‘task’. One felt she was very difficult while the other found it easy and smooth going.

Before you give your ‘information – bad news’ – ask RP / parent what do they know of the situation – then elaborate filling details – this is much gentler. Also use silence after giving the news of 10 secs for RP to come back with their queries.

Learning points:

• Read the task carefully and think of options needing consideration
• Use ‘simple’ language BUT do not make is ‘baby childish’.
• Fracture of a bone is a fracture – Do NOT beat around the bush – Do NOT waste your time.

• Try and NOT to get involved with answering for other speciality e.g. Obstetrics in birth related issues
• Save your time for Paediatric related issues of the scenario
• Summarise.

Video recording of session available to view if you missed the session.

Please leave your comments

Comparing two task was important and useful to understand why reading the information provided is VERY relevant.

Communication scenario:
Today we discussed scenario on giving information to parents of a new born. Both had congenital malformations – TGA and Oesophageal atresia with fistula.

There was a little difference in the information provided. One – diagnosis was suspect and other – diagnosis was confirmed.

Good attempt and almost meet standard performance.

Learning points:

• Read ALL the information provided very carefully
• Ask parents their concern before giving details you have thought of.
• Keep the description simple. Escalate if Role Player indicates
• Check for understanding
• Speak in 30 Sec bites.
• Use silence effectively by keeping quiet.
• Be lead by the parent / role player.
• Summaries effectively.

Practice practice practice.