RRR — Development assessment

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Pubic hair in 3.5 yr old
  • Enuresis
  • Neonatal seizure – management

The Clinical station was carry on from our session on Tuesday. We covered the Developmental assessment of 3.5 yr old, History was taken on Tuesday. Dr D was in the hotseat and did a good examination. There are a few points ‘examiners’ mentioned. Do not waste time on repeating the same task – better to move on and come back.

Learning points are:

  • Choose the toys you will need
  • Check Environment for ‘artefact’ wheel chair, splints etc
  • One ‘tool’ as a time – remove from view before next
  • Opportunistic examination
  • Sit on floor at level of child.
  • Time management is very important
  • You instructions should be CLEAR & PRECISE.

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

Anil Garg

RRR — Development Station

Dear All

Thank you for joining the session today.

In RRR we discussed:

  • Delayed puberty
  • Iron Deficiency Anaemia
  • Recurrent vomiting

The Development was on request for members sitting the exam within the next few days. The scenario was a girl with features of Trisomy 21. Parental concerns were slow development as compared to her siblings. Task to take focused history – we could only cover this and not the verbalizing of the exam – which we will cover at our next session. Dr S took the hotseat and made a very good attempt at tackling the task. Details of symptoms were explored however important domains could not be covered due to time limitations.

We had a brief PowerPoint presentation by AG on ‘History in the Clinical Exam’. What emphasis is required for different stations you will be ‘taking history’.

Learning points are:

  • Developmental Concerns – Aetiology is implied – need identification.
  • Check what the child can do now.
  • Any regression?
  • Comorbidities & Medications
  • Social history
  • Impact on family members -how mother coping?
  • EHCP – Education – Health – Care Plan
  • Living Allowance: Disability, Mobility
  • Main Stream schooling – as far as possible

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

Anil Garg

RRR — Video Station … GBS

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Rickets
  • Meningitis in neonate
  • Increased Intra Cranial Pressure

The Clinical station was a Video station. The Clip showed a boy with history of hospital admission following a viral infection and with high stepping gait. Dr P was in the hotseat, while Dr S & Dr D wore the examiner hats. Dr P identified the clinical signs and formulated appropriate questions to ask and targeted examination. Examiners were able to add the missing links. Breathing difficulty vs respiratory support, muscle to and deep tendon reflexes.

The Learning Points are:

  • Develop a differential diagnosis – do NOT stick with ONLY one.
  • Take all the information provided in developing your DD
  • Investigations – it is reasonable to check specific results from medical records – this is something you will do in your clinic
  • Mention Investigations with expected results.
  • Hotseat has a seriously detrimental effect on the brain!!!
  • Be prepared – Practice – Practice – Practice.

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

Anil Garg

RRR — Video Station … Mucusy Newborn

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Failure of Resuscitation – causes & management
  • Bronchiolitis – Symptoms & Signs
  • Toddler Diarrhoea

The Video station was of a clip showing a newborn, noted to be ‘mucusy’ with mild respiratory distress noted at 2 hours, now ventilated, Xray was available. Dr D took the hotseat. A very good attempt was made at identifying the clues and asking relevant history and examination however some important cues were missed that were picked by other members. We had a very good discussion on physiology and further management.

The Learning points are:

  • See the video carefully – write what you have noted
  • Concentrate on other aspects of video (NOT what you have already)
  • Oesophageal atresia/tracheoesophageal fistula – was evident
  • Other important cues have to be also noted
  • VACTERAL association
  • Questions to ask – think of important condition – polyhydramnios
  • Airway management is First priority
  • While discussing Explain NORMAL before talking about ABNORMAL
  • Replogle tube: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Replogle_tube_management/

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

Anil Garg

RRR — Video Station: FTT 6/12 old

Dear All

Thank you for participating in the sessions today.

In RRR we discussed:

  • Checklist prior to transfer CHD child to Tertiary unit
  • Asthma therapy – complications
  • Acute Leukaemia – Symptoms & Signs

The Clinical station was a Video Scenario. 6 month old with Failure to thrive plus clues: tachypnoea, nasogastric tube in place. Dr A was in the Hotseat while Dr S and Dr R wore the examiner hat. Dr A was systematic and picked up some of the cues. Others also had difficulty with cues. They noticed there was some ‘thing’ but chose to ignore it. Discussion was wide ranging and covered a lot of ground.

Learning points are:

  • Concentrate on different ‘parts’ of video clip
  • Do NOT reconfirm what you have noted already
  • This will help in NOT missing subtle signs
  • If in doubt ASK. Mark / scar …. Examiner should clarify
  • Develop a differential diagnosis
  • Think of SIMPLE diagnosis
  • History questions should be based on your DD.
  • Examination has to be SPECIFIC – virtually Yes/No answer
  • Management is Broadbased
  • It includes OTHER measures beside Pharmacological drugs

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

Anil Garg

RRR — Video Station

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Biliary atresia
  • Choanal atresia
  • Enuresis in 5 year old

We discussed Video station today. AG gave a PowerPoint presentation on the details of the Video station with Dos & Don’ts. Video clip showed a 6 month old with distended abdomen, a transverse scar in upper abdomen, left hydrocele and pale white stools. Dr S took the hot seat while Dr D & Dr S wore the examiner hat. There was some confusion in identifying the clinical signs in the video. We had a good discussion on what should be done in a situation when you are not sure of the signs you ‘see’.

Learning points:

  • Do Not shy away from asking a question to examiner
  • Clinical sign – Clarify your doubt – if not sure – ASK the examiner
  • Examiner will normally clarify a specific point.
  • Do not ask – What can I see? Is that line a scar or mark for measurement?
  • Develop a differential diagnosis of 2-3 on evidence noted.
  • In management – discuss the ‘child’ in front of you
  • Do NOT give generic management as in the books
  • Be age specific in management discussion
  • Refer to your consultant and tertiary units for advice
  • Do NOT be prejudiced by previous experience of similar video

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

Anil Garg

RRR — Communication Scenario – Audit

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • 1 day old baby – hypotonic, poor handling
  • MCUG – describe to mother
  • Inflammatory Bowel Disease

The clinical station covered was a Communication scenario on request of Dr A, who also was our Role Player. Dr S & Dr N had the examiner hats. FY2 wishes to discuss her audit project – to discuss and manage her concerns. Dr A took the hotseat. He made a very good attempt but there were some valid points noted by the ‘Examiners’. 

The Learning points are:

  • Communication skill is essential to pass the exam.
  • Read the task carefully.
  • You should follow Role Player’s agenda and NOT your!
  • Let Role player speak uninterrupted after opening introductions.
  • Summarize briefly – 3-4 sentences – at 6 minutes.
  • You have to be ACCURATE with MEDICAL FACTS
  • Listen to Role Player for cues – vital
  • Briefly describe Normal before describing Abnormality.
  • Investigation – say with expected results.

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

Anil Garg

RRR — Clinical Station: Respiratory sys examination

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Preterm 30 wks – expected complicartions
  • Precocious puberty
  • Acute heamolytic anaemia

The Clinical station was examination of Respiratory system of a 8 years old with h/o increasing shortness of breath over past 3-4 days. Dr S took the hotseat while Dr A & Dr S wore the examiner hats. Dr S attempted the examination systematically but there were some points noted by the examiner: ward regarding pain, growth parameters, Clubbing, scars on chest wall.

The learning points are:

  • Consider a differential even diagnosis seems obvious
  • Ask of pain and reassure will stop if uncomfortable
  • General examination is mandatory at ALL stations
  • Systematic examination – Expose / ask
  • Inspection – Palpation – Percussion – Auscultation
  • It is fine to check for scars in General examination
  • Growth parameters
  • In summary – give your diagnosis then support with signs
  • Asthma is a common diagnosis – easy hence need better ‘performance’
  • Do NOT narrate your finds and keep your diagnosis for the end.
  • 3-4 questions on management

We move to a Communication scenario next on popular demand.

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

Anil Garg

RRR — Clinical Station – CVS

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Short stature – investigations
  • Recurrent abdominal pain
  • Prem: distended abdomen & vomiting

The Clinical Station scenario was on a 6 year old with cardiac surgery at 2 yrs for ‘Routine’ review in OP. Task to do a CVS examination. Dr A took the hotseat with Dr S & Dr D having the examiner hat. Dr A did a good CVS examination but there were a few points missed and more important the time of 6 minutes was not adequate – it took almost 11 minutes. Examiners made good suggestion.

Learning points:

  • Keeping to time is a MUST.
  • Examination technique HAS to be Fluid and systematic
  • Practice completing a system exam in 5 minutes.
  • Discussion with examiner: give your impression i.e. diagnosis
  • Do not necessarily narrate your findings
  • Support diagnosis with+ve & -ve finding
  • General Examination is part of EVERY station

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

Anil Garg

RRR — Clinical Station — MSK exam

Dear All

Thank you for participating in the session.

In RRR we discussed:

  • Shock – causes and management
  • Paracetamol Overdose
  • Seizures – 2 year old

Clinical station was 5 year old who presents with parental concerns regarding walking. Task was to do a MSK examination. Dr A took the hot heat and made a very comprehensive attempt running a little short on time. Walking concerns as presenting problem – Neurology examination and MSK examination are different though both have certain common strands to examine. Do not get confused.

Learning points are:

  • Clarify task if not sure
  • You will not be marked down for clarifying
  • If you follow the wrong stream – you will definitely lose marks
  • MSK normally means full pGALS with initial function questions
  • Neuro – power / tone / reflexes

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

Anil Garg