Dear All

Thank you for participating in the session.

Dr A gave us an update on her experience fo the recent exam a few days ago. We then had:

RRR:

• Friedreich ataxia
• Delayed puberty
• Acute Liver Failure

Clinical station: a 11 year old girl presents for FU. She is small, has distended abdomen and a longitudinal scar to the right of midline. Dr L took the hotseat while Dr S & Dr N had the examiner hats. Dr Shishir conducted the station. Dr L did a full abdominal examination, including general physical exam. The only point to improve was time.

The Learning points are:

• Write points of examination on a A4 sheet
• Practice regularly so it becomes a ‘reflex’.
• Summary – give your impression or diagnosis or DD first
• Then support your opinion with +ve & -ve findings.
• Think and put all points together – clinical reasonong.

Please visit http://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.

Dr S joined us to share her experience of the recent exam. She felt the exam was straight forward and there was enough time at each station to complete the examination at clinical stations and tasks at other station. Children in UK get very good supportive care hence it is difficult at times to identify a lesion e.g. spastic diplegia with minimal signs due to good physio & occupational therapy support.

Clinical station was a 8 year old admitted previous evening with breathing difficulty – to do a respiratory system examination. Dr Shishir was the examiner. Dr S took the hotseat. He made a very good attempt at the clinical exam. There were some parts missed and Dr N took the hotseat for another attempt. Working diagnosis of the case was: Asthma exacerbation. Other members gave their input on how to complete the examination. Summary needs to be brief and ‘post graduate’.

The Learning points are:

• Have a differential diagnosis
• Systematic, fluent examination
• General physical examination is essential at every station.
• Review growth – check centiles
• Respiratory system includes ‘Upper airway’ nose, pharynx, larynx
• Check for polyps – look up the nose – show and mention. Rhinitis.
• Look at skin for eczema – as a cue for asthma.
• Respiratory effort and respiratory rate.
• Give your ‘diagnosis’ / impression first then mention supporting findings.
• Not the other way round when you list findings first.
• Management of Asthma: Stepwise’ and as per BTS guidelines
• Inform consultant in case of deterioration
• Arrange for support from ICU / anaesthetic colleagues

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

Anil Garg

Dear All

Thank you for joining in the session today

4 members have exams in the next few days hence we altered our time line and had a Q&A session on what is expected at various stations, what to do at the exam, how to brush up on last minute preparations to present your best to impress the examiners. Dr Sonia and Dr Shishir gave their advice based on their comparatively recent successful experience of the examination. We then practised a clinical Station: 7 year old Michael, comes for OP review, he had cardiac surgery when 1 yr old. Task was to do a CVS examination. DR S got the Hotseat while DR S, Dr A & Dr P had the examiner hats. Dr S completed a good CVS examination requiring more than 6 minutes. Examiners fed back on the fine details and Dr S presented summary and discussion well.

The Practice and Learning points are:

• Systematic examination – fluent
• Structured approach
• Observation surroundings – Inspection – Palpation – (percussion) – Auscultation
• BP – ask towards end when summarising
• Do not read on evening before the exam
• You will be working at ‘Spinal level’ in the exam.
• Remain Calm & keep your wits about you.
• ‘Reboot’ after each station
• Do not carry the ‘baggage’ to next station.

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

Anil Garg

Dear All

Thank you for participating in the session today.

In RRR we discussed:

• Failure to Thrive: causes & Investigation
• Asthma: management of Acute severe attack
• Increased Intra Cranial Pressure: symptoms & signs

AG gave a Power Point presentation on approach to Neurology station, Dos, Don’ts and systematic examination.

The clinical station was neurology – Parents of 4 year old concerned about his walking. Task – to examine Lower Limbs. This was to build up on previous session. Dr P was in the hotseat with Dr S & Dr A had the examiner hats. Dr P made a very good attempt, was systematic and proceeded well but ran short of time and also used jargon in communication with child. Examiners and others made good observations and gave appropriate comments. Dr Shishir gave valuable tips on the examination process.

The Learning points are:

• Time management is VITAL
• Select tasks in Neurology exam – you cannot do everything
• Use cues when provided
• Keep Commands / instructions to child SIMPLE
• Upper Limbs – remember Cerebellar ‘functions.
• Failure to Thrive: Non Organic & Non organic causes
• Practice – Practice – Practice

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

Anil Garg

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