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

RRR — Clinical Station — Neurology: Lower Limbs exam

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Coeliac disease – diagnosis & management
  • Brain tumour – SOL – Symptoms & Signs
  • Hirschsprung’s presentation

The Clinical station was 12 year old presenting for review – for Neurology  examination of Lower Limbs. AG discussed Neurology examination – Lower limbs, Upper limbs including the important General Examination. Dr D took the hotseat and made a good attempt of examination but ran out of time. Others gave useful suggestions on what was in the clinical video clues given.

The Learning points are:

  • Systematic approach is VITAL
  • Examination technique should be smooth flowing
  • Inspection / Observation – Palpation / Tone – Percussion / Reflexes – Auscultation prn
  • 5 Ss – Shoes / Scars / Spine / Shunt / Squint
  • summarize well – keep diagnosis / differential in mind
  • Managment – top few options

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

Video recording of the session will be available in 24-48 hours.

Anil Garg

RRR — Clinical Station: Other / Neurology

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Hydrocephalus
  • Staph & Streptococcal infections
  • Fragile X syndrome

The Clinical station was on a 2 year old presenting with maternal concerns regarding his walking. He demonstrated a large looking head, scar in cervical spine area and with no other obvious abnormal clinical signs. Dr A took the hotseat and Dr AR took a second shot at the clinical examination. Lot of signs were picked up & some missed. The picked up signs were not summarised and discussed.

The Learning points are:

  • Complete systematic examination is a MUST
  • It should seem you have examined hundreds of children
  • You should be fluent in you technique.
  • Growth centiles – check in the beginning.
  • Expose the parts to examine.
  • Inspections needs to be thorough.
  • Do not skip at this stage.
  • You may ask for a Chaperone if appropriate.
  • Engage child and if needed Ask mother to help
  • In ‘Neurology’ examination – 5 Ss Not to be missed
  • Shoes – Spine – Scars – Squint – Shunt

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

Anil Garg

RRR — Clinical Examination : Other

Dear All

Thank you for participating in the session.

In RRR we discussed:

  • Hyperthyroidism in 13 year old
  • Acute Liver Failure
  • Developmental Regression in 2 year old

The Clinical Station was to examine a young person with a neck swelling. Dr A took the hot seat and made a very good attempt at the examination and discussion. There were very good suggestions from examiners regarding thinking more broadly and conducting relevant ‘examinations’. Midline neck swelling is likely to be a ‘Thyroid swelling’ unless it is proved otherwise.

Learning points are:

  • Have a differential diagnosis
  • In Thyroid swelling – beside the neck findings – consider
  • Voice changes
  • Eye signs
  • Muscle weakness – proximal myopathy
  • Tremors
  • Deep tendon Reflexes
  • Systematic and orderly examination technique
  • Ht & Wt centile are appropriate in all situations

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

Anil Garg

RRR — Clinical Station

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Oedematous 4 year old
  • Ambiguous genitalia – new-born
  • Central cyanosis – new-born

AG gave a Power Point presentation discussing the Clinical stations in the exam from 2023. The exams are expected to move to Face to Face with children. This is a major move from Online exams during the Covid pandemic. We then had question answers on specific aspects of the clinical stations.

The Learning points are:

  • Develop a differential diagnosis of 3 early
  • Structured format of your examination technique
  • Explain what you will be doing – avoid Pain – stop.
  • Opportunistic examination with infants and young children
  • General examination is essential at ALL stations
  • Ht & Wt Centiles – not actual cm & kg
  • Consider asking for Parent’s help
  • Consider Chaperone with older children
  • ‘What will I see if the ‘dress’ was not removed’ –

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

Anil Garg

RRR — History & Management — Seizure

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Anorexia nervosa
  • Coeliac disease
  • Altered sensorium – 9 yr old

The H&M was a review of a 7 year old with an afebrile seizure when on holiday abroad. Referred by GP for review. Dr Shisher was moderator. Dr S was in the hotseat. Dr A very able Role Player. Dr D & Dr S wore the examiner hats. Dr S, good introduction and took very good history and covered most of the important details. A few points were lacking and highlighted by the examiner.

Learning points:

  • Address the Role Player by name – not ‘Mum’ or ‘Dad’.
  • Avoid Medical jargon
  • Use the information provided carefully but take as accepted
  • Work out a differential diagnosis to explore
  • Seizures come from two sources: Brain or Heart
  • Read and refresh all medical emergencies
  • Summarize at 9 minutes – brief
  • This will highlight what you may need to ask or elaborate further
  • Do not lose your calm
  • Practice will keep ‘Brain connected’ during ‘hotseat / Exam’

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

Anil Garg

RRR — History & Management

Dear all

Thank you for participating in the session.

In RRR we discussed:

  • Kawaski disease
  • Autism – main features
  • Asthma management follow OP review

The History station was of a 21 days old neonate presenting with lethargy, poor feeding and failure to gain weight. Dr A took the hotseat, Dr P was the Role Player and Dr R & Dr A wore the examiner hat. Dr A made a very good attempt with good introduction, allowing RP to put her concerns across and getting the details. In discussion there were some lapse due to the pressure of being in the hotseat.

The Learning points are:

  • Be careful of your Communication skills & words used
  • Acute management is very important
  • Revise ALL Hypos.., Hypers.., Status.. conditions
  • Have them on your finger tips
  • Even with an obvious diagnosis – explore other options briefly
  • 9:4 minutes go very quickly – hence time management is vital
  • Summary at 9 mins needs to be very brief
  • Antibiotics for neonate – do not forget

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

Anil Garg

RRR — History & Management: Tachycardia

Dear All

Thank you for participating in the session today.

In RRR we discussed:

  • Chronic diarrhoea with Failure to Thrive
  • Haemolytic Uraemic Syndrome (HUS)
  • Necrotising Entro-Colitis (NEC)

The History was of a 12 year old presenting for annual review for her Tachycardia with breakthrough symptoms in past few months. Dr A took the Hotseat, Dr A was a very able Role Player as mother and in Double role of being Young person. Dr P was with Examiner hat and Dr Shishir was our host today – he was moderator. Dr A had a very good attempt but there were some gaps in the information gathered due to extensive information gathering in other areas costing him time. Some of the gaps in information was picked up others.

The Learning points are:

  • Paraphrase the information provided to begin and build on it.
  • Do not go very deep in establishing the given diagnosis
  • Recent worsening – 3-6 months – need to explore
  • “What do you do to feel better?” is a good question.
  • More important to gather information regarding treatment
  • Compliance. Other Drugs – recreational.
  • Failure of treatment can be due besides not taking is ‘out growing’
  • Drug level is a very good way to confirm compliance
  • Other relevant conditions: Thyrotoxicosis, Anxiety etc
  • Do not get into Communication Mode
  • Acknowledge questions and Park as appropriate
  • Be careful of your Language – ‘Kid’ is not appropriate for a child
  • Do NOT forget the various other facets of history.
  • Make a note of points to ask in the 4 minutes while reading information provided
  • Do not beat around the bush and repeat same questions.

Please visit www.mrcpchonline.org 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:

  • Short stature
  • Asthma management
  • Henoch Schönlein Disease

The main session was changed to a Video station as Dr P, our RP, was busy at work hence we changed to Video station scenario. The video clip was of a 2 day old new born, with evidence of seizure activity, oxygen via headbox and virtually no movement of left arm. Dr D opted for the hotseat. Dr P picked all the relevant clinical clues and asked appropriate questions coming up with good differential diagnosis. It is important to remember ANTIBIOTICS for an unwell neonate as Sepsis can never be ruled out and ignoring it can lead to death.

The Learning points are:

  • Watch the video very carefully
  • Try and focus on different aspects to one you have noted during first view
  • Differential diagnosis: mention most common FIRST
  • Structure your answer – in broad categories first as far as possible.
  • Examiner may ask details on one of them
  • Sepsis – never forget as a possible cause
  • Communication with parents is important
  • DOCUMENTATION – mention you will write down in the notes – definite mark
  • Law states: If NOT written – assumed it is NOT done. Medicolegal catch
  • The last point you should adopt in your Clinical practice – if not so already

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

Anil Garg