RRR — Communication – Breaking Bad News

Dear All

Thank you participating in the session.

In RRR we discussed:

  • Recurrent wheeze in 4.5 yr old
  • Nephrotic syndrome
  • Stridor in 2.5 yr old.

The Communication scenario was addressing concerns of parents of a 4 hour old baby noted to be dusky with possible diagnosis of heart disease. Dr D took the hotseat while Dr S was concerned Role player. Dr D conducted herself very well even with an upset father. Other colleagues gave relevant comments.

The Learning points are:

  • Communication is about RP’s agenda – NOT yours.
  • Follow Shishir’s 2 min rule and speak with 30 sec AG’s rule
  • Check RP’s understanding of what is ‘going on?’
  • Examine the child with parents to discuss abnormal cues
  • Much better than drawing on a piece of paper in most circumstance
  • BE reassuring – I have managed similar conditions before
  • “With treatment child should be fine.”
  • Read the scenario very carefully
  • Focus on the task
  • Develop a differential on initial information and think broadly.
  • Do NOT apologize too many times – seems odd when you are the observer.
  • What is going on is NOT your fault or doing
  • You do feel for the ‘parent’ and hence feel Sorry / empathic for them.
  • Work in small groups and practice, practice & Practice

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

Anil Garg

RRR —- Communication Scenario: NAS

Dear All

Thank you for participating in the session. Dr MF & Dr SS were in the drivers seat with Dr AG & Dr ST as keen observers.

In UK it is traditionally believed that passing the MRCPCH exam is easier than passing the Driving Test. Dr ST has done us proud in achieving both is first attempt – Congratulations Dr ST.

In the RRR we discussed:

  • Kawasaki Disease
  • Constipation in 2 year old
  • UTI – investigations in a 2 year old

Communication scenario was discussion with a Medical student about a baby with Neonatal Abstinence. Dr M was an excellent Role Player with Dr A taking the hotseat and making a good attempt at dealing with the issues. We discussed what and how to address certain points and then Dr S had an opportunity to practice the same scenario. There were very relevant observations from most present.

The Learning points are:

  • Shishir’s Rule of 2 minutes to organise your thoughts
  • AG rule of 30 seconds to avoid monologue
  • Be technically correct: ‘baby in womb is not connected to mother’s circulation by umbilical cord’
  • Explain in simple terms – be specific do NOT beat around the bush
  • What causes ‘abstinence?’ – discontinuation of drugs – nothing else.
  • Investigations – know for WHAT – do not just give a list.
  • Think laterally also – recreational drug addiction – HIV / Hep B etc
  • What to do in case parents REFUSE permission for treatment.
  • Be mindful of what you say – there can be a disconnect between your ‘Thoughts & Speech!”
  • You get marked for your SPEECH and not your thoughts.
  • Practice regularly – watching others makes one feel ‘safe’
  • Hotseat and exams – nerves take over and one is liable to be confused.

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

Anil Garg

RRR — Video Station: 6 yr old with a rash

Dear All

Thank you for participating in the session this week. Dr Sumit was our moderator – I would like to thank him for his help an support. Due to technical reasons we could not record the session on Tuesday.

In RRR we discussed:

  • Intra Ventricular Haemorrhage in a neonate
  • Turner’s syndrome
  • Worsening respiratory distress in 10 month old.

The video station demonstrated a boy of 6 years with a wide spread rash. Dr D took the hot seat and picked up the clinical signs. The questions asked were good and examination findings could be clarified more explicitly. Discussion was good.

The Learning points are:

  • IVH – ventricular index, neurosurgical opinion
  • SIADH – restrict maintenance fluids in ‘Respiratory’ conditions
  • Observe carefully – try and focus on ‘different’ aspects of video
  • Write them down, do not get engrossed in what you have already noted
  • Think of a differential – most obvious first – try not to limit to ONLY one
  • If a diagnosis stands out – mention that first
  • Wrong order WILL make you lose marks
  • Eczema herpeticum – uncommon but is a common exam scenario
  • Secondary bacterial infection – Staph – is common hence treat
  • Indications for acyclovir & avoiding contact following chickenpox
  • Dr Shishir has circulated current guidelines – look them up
  • Keep reading and practicing management of ACUTE CONTIONS
  • All Hypos – Hypers – Status xyz
  • Management: KNOW broad interventions – NEED NOT go into minute details
  • Time management is important

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

Anil Garg

RRR — Development – Fine Motor Assessment

Dear All

Thank you for joining the sessions today.

Dr S joined us from Kuwait today and offered specific and practical advice – having been in the RCPCH hotseat not so long ago.

Dr S advised to use: C-C-C-B-B-B in assessment.

In RRR we discussed:

  • Problem Oriented History of a child at Development station
  • Signs of spasticity & treatment options
  • Support for 5 year old with difficulty of walking

the Clinical station we covered Development – Fine Motor Assessment. We saw a Fine motor assessment being demonstrated by a colleague. Dr A took the hotseat and made a very good attempt at assessment. There were issues on better summary and presentation methods. All the participants contributed to the discussion.

The Learning points are:

  • Essential to have a systematic approach
  • General observation is part of EVERY station
  • Time is tight – practice to complete in scheduled time
  • Choose Toys appropriately
  • ONE TOY / TOOL AT A TIME. REMOVE AFTER USING.
  • If you finish EARLY – likely you have MISSED some time.
  • Vision & Hearing – need to be confirmed
  • Hand preference EARLIER than expected needs to be ‘Reported’
  • MDT: Know composition and WHAT each member does.
  • Crayon – Colour matching – Cutting – Blocks – Books – Beads.

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

Anil Garg

RRR — Development – Basics, What to and What Not to …..

Dear All

Thank you for participating in the session yesterday. Apology I could not send you update after the session.

Dr MF joined from Pakistan and gave specific and valuable ‘nuggets’.

In RRR we discussed:

  • Speech & Language mile stones of 3 yr old
  • MDT for 18/12 old with hemiplegia: who all in it?
  • Education plan a 3 yr old child with Down’s syndrome

The Development we carried on from last session. AG presented how to and nuts and bolts & basics of Development station:

  • History – what information to get: aetiology / family effects
  • Summary – how to do a good job?
  • Development assessment
  • Discussion with examiner

We did not have a hotseat session but there was good group discussion.

The Learning points are:

  • Need clarity of thought
  • Speech has Receptive & Expressive components
  • “Paraphrase question and then answer – give you time and easier
  • Be systematic & organised during the whole station
  • 2-3 screening questions for each domain
  • Cannot ask details of domain you have to assess
  • EHCP & SENCO – new acronyms – look them up
  • Each case is different – do not just do a tick box exercise
  • Summarize properly – do not just repeat what you have just done
  • Give your OPINION – with supporting evidence

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

Anil Garg

RRR — Development Station

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Cerebral palsy: What is and classification
  • GMFCS – levels
  • Burns in 1 year old – Accidental or non-accidental – history & exam

The clinical station was on Development. 4 year old presents with parental concerns of non being able to manage & do as they expect. Dr I was a very able role player, Dr A took the hot seat for history and Dr K took the hotseat for Developmental assessment. Dr A took a very comprehensive history covering all aspects important and presented it very succulently. Perhaps a little less time on gross motor and more on speech and vision may have earned some brownie points. Dr K attempted the assessment and made a good effort. There were a number of things we could improve and hence will discuss and demonstrate on Thursday.

Learning points:

  • our grey cells have some unexpected functions on the hotseat
  • practice does improve our control over our grey cells
  • Focused history is asked for hence you will NOT be able to cover EVERYTHING
  • Aetiology, social functioning & social support are important facets
  • 10 minutes is a short time but adequate to get relevant details
  • Have 2-3 screening questions for each domain
  • Check for HEARING & VISION
  • Else if child does not respond to your question – you will not know why?
  • Listen to the question Examiner asks – respond to the query
  • Questions asked for in history – Do Not start talking about examination

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

Anil Garg

NEW OLD Clinical Examination: Nuts & Bolts

Dear All

Thank you for participating in the session today.

We concluded our Spring course and reviewed what we have covered together.

  • Rapid Random Review: 70
  • Interactive Zoom Sessions: 24
  • Hotseat: 25
  • Blogs with details: 24
  • Learning points: 110
  • One to One Sessions: 10

AG discussed the NEW OLD MRCPCH Clinical exam.

Clinical exam has come round 360 degrees disrupted due to Covid. The Clinical exam was ‘suspended’ for a period followed by FULLY virtual exam. Face to Face exam without children was next and now the exam has reverted to how it was intended to be – FACE TO FACE WITH CHILDREN.

There is one lasting change in the exam and that is in the DEVELOPMENT STATION. It has now changed to a 22 minutes station. It now has two components: History and Development assessment. It is scenario based with candidate required to get appropriate focused history to elicit aetiology, functioning and support followed by development assessment of a domain. Discussion with the examiner is the final interaction on the station.

Questions on what to read:

  • NICE guidelines
  • Know all ‘Hypos’, ‘Hypers & Status … conditions you know.
  • The above will cover almost all emergencies.
  • Note difference in emphasis in history at various stations.

We will start the Summer course with Development station on suggestions by all.

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

Anil Garg

RRR — Video Station …. Respiratory distress

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Jaundice in newborn
  • Bilateral hydronephrosis @ 20 Week antenatal scan
  • Enuresis in 6 year old

The Video station was of a clip a 16 month old presenting with respiratory distress and a CXR showing loops of intestine in Right hemithorax. Dr P was in the Hotseat and Dr K & Dr P had the examiner hat. Dr P picked up all the clinical signs, had appropriate history questions, examination and good management plan. The examiners made valid comments. Dr MF joined us as faculty and made good advice on approach and how to focus on the task.

Learning points are:

  • Be focussed while watching the video clip.
  • Develop a differential
  • Trust your eyes – give weight to your observation
  • Do NOT try to manipulate and box findings into your ‘diagnosis’.
  • Be flexible and ready to change following your observations.
  • Congenital abnormalities can present out of neonatal period.

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

Anil Garg

RRR — Video station : Newborn with Head swelling

Dear All

Thank you for attending the session today.

In RRR we discussed:

  • Haemophilia
  • Chickenpox
  • Respiratory Distress Syndrome – Term newborn

The Video station today was on a new born whose mother was concerned about shape of his head by day 4. DR A was in the hotseat. He picked up the clinical signs. Ad A took over and framed the questions appropriately.

There are some learning points are:

  • Develop a differential diagnosis – from initial information and definitely after watching the video.
  • DD will direct you to correct questions & examination
  • Cephalhematoma / Caput / subgaleal haeamorrhage
  • Follow the time line of these ‘condition’
  • Neonate – ask about feeding, birth & current weight
  • Chickenpox – complications & effect in immunocompromised
  • RDS in term – important to think of common conditions first

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

Anil Garg

RRR — History & Management …

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Hypoglycaemia in a 2 year old
  • Rapid onset Flaccid paralysis on Lower Limbs – causes
  • Hearing loss

The History and Management station was of a 16 year with Diabetes presenting general malaise & with HbA1C: 10.5 mmol & a positive Coeliac screen. Dr I took the hotseat and Dr D was in the Role player mode. Dr I covered almost all in relevant history but there were some points that could have been explored better. Comments from the group were appropriate however most failed to take full note of the initial information provided.

Learning points:

  • ALL the information given in introduction is IMPORTANT
  • DO NOT OVERLOOK and do not ignore
  • Be systematic in your history
  • Drug / medication history is very important
  • Try and get details and spend some time on it
  • Chronic conditions with an acute ‘twist’ – try and find relevant history
  • Summary – do not repeat all you have gathered as Examiner has also been listening
  • Your diagnosis / impression with +ve & -ve supporting facts

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

Anil Garg