Dear All

Thank you for joining the sessions today.

We started our summer semester. We discussed New – Old Clinical examination. How the Clinical exam has moved from ‘Old standard’ to Covid modification moving on to Fully virtual to gradual face to face, with no children to now children at all Clinical stations except Development station. We still need skills acquired during Covid virtual phase of Universal and Dependent cues.

We use these in our Interactive Zoom Sessions guide your practice and help you develop your own rhythm for each station by taking the Hotseat and examiner seats – all are observers and give their observations.

In RRR we discussed:

• Non Epileptic Seizures – types
• Cong Adrenal Hyperplasia
• Paracetamol poisoning: effects and prognosis

The Clinical station described a 2 year whose parents are worried about his walking. Video gave cues that will be available during examination you should observe during the 6 minutes. Dr A took the hotseat and Dr L & Dr P had the examiner hats. Dr A made a good attempt at conducting the examination but here was confusion on the technique. Dr P gave a very good description of how to proceed during this station. He gave a mnemonic: D-W-A-R-F-S – I will request him to send the full version in our WhatsApp group.

Dr Shishir monitored the Clinical examination and gave another important mnemonic: A-F-P-M-D-S-S. I will request him also to give details of his thinking process helping us not forget.

The Learning points are:

• Structured Examination technique is a MUST
• Observation will get you 70-80% of information
• Age appropriate examination
• Cannot examine a toddler and a teenager the same way.
• Do Not upset the child.
• Move away if you note Child is getting upset.
• ‘The child was uncooperative’ – NO
• I could not get the child to do …..’ sounds better.
• Parents will like you more for your thoughtfulness – also in regular practice.
• Write your own ‘Performa of how’ for each station / system.
• Mnemonics – are an important part to keep our practice smooth.

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Please follow the following link if you would like to join us.

1 June 2023

18:00 – 19:00 hrs, British Summer Time (UK time)

Anil Garg is inviting you to a scheduled Zoom meeting.

Topic: Anil Garg’s Zoom Meeting
Time: Jun 1, 2023 06:00 PM London

Join Zoom Meeting
https://us02web.zoom.us/j/2191937091?pwd=a0tvc1cyeVVmOExXa1pIc3RvOHZjZz09

Meeting ID: 219 193 7091
Passcode: Spring

http://www.mrcpchonline.org

Dear All

Thank you for participating in the session today.

Dr P joined us today and gave us a flavour of the recent exam in Singapore. How it feels after the exam starts and how we work on our reflexes. Her main mantra is to Practice – Practice & Practice. Reading books and new material is not going to be helpful. Our daily clinical practice is going to come to our help and guide through the exam. Thank you Dr P.

The Clinical scenario was History of a 12 year old, with coeliac disease whose mother was worried about sending him on a 3 days school trip. Dr N took the hotseat and made attempt at gathering details of the history. He finished with more than 3 minutes to spare. There were points missed as the spare time signified and other members help fill in some of the missing gaps.

The Learning points are;

• Do not forget introductions – Communication skills important
• Build rapport
• Be Fluent and confident
• Check of Role Player’s concerns
• Explore details – it is important to gather information
• Note Information difference between History & Communication
• Do not park every query / concern RP mentions
• Do not take short cuts and cover all essential points in history
• Co-morbidities – check
• Do not assume RP’s wishes or agenda – ASK
• If important illness in mentioned – explore some details
• RP -will not give the information unless you ask.

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Dear All

Thank you for participating in the session today.

In RRR we discussed:

• Biliary atresia – diagnosis & treatment
• Prematurity – complication / problems
• Care after cardiac surgery

Our H&M scenario was of a 3 week old baby presenting with poor feeding, weight loss and Sr Na: 113 mmol/l. Dr P was a very able and good Role player, he was non demanding, not quite like a RP to be expected in exam. Dr L took the hotseat with Dr A having the  examiner hat. Dr Shishir gave expert advice. Dr L took a very good history with good introduction and parking query but ran short of time. Too much time was spend on exploring the feeding history at cost of other important facets.

The Learning points are:

• Systematic approach to history is essential
• Note main bullet points in outside 4 mins with Differential
• Divide your time accordingly
• Open and Closed questions
• Do Not spend too much time – move on to next bullet point
• Come back to check more details if time permits
• Remember 80% info gets 80% marks – No history get 0% marks
• Social history, How carer is coping is essential 
• Family history
• Education & Support available – check
• Empathy
• Summarize at 9 mins

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Dear All

Thank you for participating in the session.

In RRR we discussed:

• Encopresis & soiling
• SCID / HIV – 10 month old
• Sudden onset paraplegia 15/12 old

AG presented and discussed History in the Clinical exam with a PowerPoint presentation. How History in the Clinical exam is a little like the various forms of cricket games: 5 days test / 50 over OD / T 20. All need same skill set but players have to choose and play differently in each format. The Do’s & Don’ts of the exam.

Learning points of the session:

• Structured approach to history
• Have a differential diagnosis in 3 mins to work through
• Communication is assessed here also – 4 marks
• Rapport, Empathy
• How is ‘RP coping?
• Open and closed questions
• Age appropriate questions
• HEADSS for teenagers
• Acknowledge RP’s concerns
• PARK concerns and do NOT get into Communication mode
• Explore cues given by RP – do not ignore
• Immunocompromised – Check for h/o Chickenpox

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Wish safe travel and sterling performance to our memebes who will be in the true ‘hotseats’ in the next few days.

Anil Garg

Dear All

Thank you for participating in the session today.

In RRR we discussed:

• Stridor – Floppy larynx – DD
• UTI prevention advice
• Bruising legs & arms – HSP DD

The Clinical station was History and Managment. Dr A had the Role player hat of a 15 year old young lady with diabetes feeling tired and unwell. Dr P took the Hotseat with Dr A & Dr P with Examiner hats. All others were also asked to prepare for the station with points they will ask. Dr P had a very good attempt and got most of the history. The observations were that there was more reliance on Closed questions than open questions that led to certain information not being unearthed. Role player also felt as it the interrogation was a session with school teacher!

The Learning points are:

• Prepare a differential diagnosis / cause list in 4 mins ‘outside’
• This will give you frame work for your history
• Follow up on cues from Role player – Do Not ignore
• Empathy
• Open ended questions in the earlier part
• ‘How are you coping?’
• Closed questions will usually be necessary to complete
• Menstrual history in ‘eligible’ age group
• HEADS – do not forget

Shishir gave invaluable tip for Development station:

• 3 Cs: Cubes – Crayon – Cutting
• 3 Bs: Book – Board (puzzle) – Beads

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Thank you for participating in the session today.

In RRR we discussed:

• Haematuria – aetiology
• Inflammatory Bowel Disease – Crohn’s Disease
• Child abuse – fractures in immobile infant

The clinical station was assessment of Developmental age of a 3.5 year old child. Do remember at the next diet there will not be a child at the Development station. It is similar to a Virtual station with Examiner being the ‘child’ and you will need to get Dependent cues from them. Role player will be there to get history from. Dr A was in the Hotseat with Dr A and Dr P had the examiner hat. Dr A made a good attempt at assessment. It became apparent Virtual station is more difficult to work through when child is not present. Dr t moved to the hotseat and made a better attempt at the task.

It is important to summarize your assessment – Do NOT just narrate what you have gathered from the examiner instead start with if the development is appropriate or delayed – one domain or more than one – Age – and then give your supporting evidence.

The Learning points are:

• Systematic approach to your examination technique
• General observation at the start – what is the child with and what is he/she doing?
• Directions to ‘child’ have to be clear and simple
• One tool at a time – mention removing it after ‘done’
• Practice Verbalising the assessment examination
• Finish in 7 minutes
• Remember Non Accidental / Unexplained Injury

Please visit www.mrcpchonline.org to add your comments or points I may have missed

Anil Garg

Dear All

Thank you for participating in the session today.

In RRR we discussed:

• Acute Renal Failure – definition & causes
• Sarcoma – diagnosis & management
• Hoarseness in a 4 year old

In our Clinical session we continued with Development station / scenario from Tuesday. Dr P gave history summary. Dr K took the Hotseat for Assessment of NH, 4 year old. He made a good attempt but there were a few points that could be improved: Rapport with child and General observation. Dr A took the second attempt and improved on managing the assessment. He overlooked a fact – one tool at a time and complete one tool before moving on to next. His summary was good.

The Learning points are:

• There will not be children at this station at this diet
• Examiner will be your ‘Role Player’ giving dependent cues.
• General observation is ESSENTIAL for Development station too.
• Introductions same as in other stations
• Rapport building with ‘child’ with few easy ice breakers
• Observe child’s: ‘Aids’, Posture, initial Interaction, Eye contact
• CLEAR instructions – targeted – child can understand
• Fine motor: Start with ‘handedness’. 
• Select your Tools: Cubes, Paper & Crayon, Book, Beads etc
• Use ONE TOOL at a time.
• Check the task till he cannot demonstrate – Upper functional age limit.
• Remove it from vision once finished with it.
• be Systematic – do not move forward and back
• Summarize with your Assessment of skill level and not list

Dr Shishir joined us and gave vital tips on Developemnt and Communication.

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Dear All

Thank you for particpating in the session today.

In RRR we discussed:

• Iron Deficiney Anaemia: management
• Hearing loss in 6 year old
• Abdominal malignancy: Symptoms & signs

The Clinical Station was to examine the Lower Limbs and any other relavant examination in a 12 year old girl. She had features of Left hemipresis. Dr K took the hotseat and made the first attempt at the station. Dr K ran out of his 6 minutes. Dr A came to the hotseat next and completed the exam in a structured way though with a little guidance. Comments from all were relevant.

The Learning points are:

• Structured fluent examination is essential
• Inspection of surroundings and ‘child’ is next
• Get down to level of child & kneel to get your eyes at correct level
• 5 Ss are essential in a neurology station:
  • SHOES – give important clues
  • Spine
  • Scars
  • Shunt
  • Squint
• Observe the ‘Whole’ child and not just the legs
• Compare one side with the other
• When offered to ask question to get to aetiology
• “When did parents first concerned of problem?’
• This will guide to time where to explore for more details
• Keep questions – simple.

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg

Dear All

Thank you for participating in the session today.

In Rapid Random Review we discussed:

• Presentations of severe illness in Children
• Chickenpox – complications
• Liver Failure: Management of child

The Clinical station was examination of 14 years old, Rachael who has come for a routine FU. Task is the examine her Respiratory system. Dr P took the Hotseat with Dr A, Dr L & Dr A taking the examiner hat. Dr P conducted a systematic Respiratory examination with a General physical examination to start with. Most of the clinical signs were noted but some significant findings were not noted. Parts of respiratory system was also missed due to time limitation and not lack of knowledge. Examiners picked up the missed findings. We then had a discussion on findings foloowed by summary and presentation to examiner.

The Learning points are:

• Read the Statement VERY CAREFULLY
• Names: have a good idea of girl’s & Boys name. Should give idea of gender
• Getting gender wrong is virtually a fatal mistake. If not sure – ask & clarify.
• Systematic examination is essential – practice so you can finish in due time
•  Do not jump to conclusions
• If condifient of diagnosis – give that first in summarizing and then support with findings
• Narrating list of findings over 35-50 secs is a waste of your time
• Chickenpox is a common condition – read specially in Immunocompromised.

Please visit www.mrcpchonline.org to add your comments or points I may have missed.

Anil Garg