Dr HR has said .. Yesterday session was very good.

Only conflict was how examiner take my question about sign shown in video?For example clubbing was seen and if i ask clubbing is there or not ?Examiner may say failed to pick up sign.

The conflict is Consuming your time unnecessarily. My suggestion is you can say “Can I confirm Clubbing I noted in the image” Examiner will say “Yes” – of you are correct. This will not take more than a few seconds.

Another example There was No dysmorphic features but if i ask is there any dysmorphic features or not?Examiner may take it on another way that i didn’t pick up that face is normal or he may take to off track by asking what abnormal features are u looking for(Dysmorphic features too is big list!!).

Again – mention – “I would like to confirm – Child looks Normal and has NO dysmorphic features” Examiner: Yes / NO.

3rdly There was pansystolic murmur in video and if i ask which type of murmur than Examiner may take it as candidate dont recognise common murmur and asking non essential generic questions.
So how to ask when some signs already shown in video or photo as clue is dilema still.That question should not throw off track or giving wrong image like candidate failed to identify given sign.

You CANNOT ask which type of murmur. You should only ask for location and maximal intensity and radiation – if appropriate. Murmur characteristics will be presented in the discussion along with other information gathered.

Please note the above are my suggestions only and reflect what I would expect from a candidate. Examiners do vary to a degree as you might have noticed in our sessions.

Look forward to your comments and questions

Anil Garg

Thank you for participating in the session today. It was a first for us all.

We practised verbalizing the 4-6 minutes of actual clinical examination.

It was hard work. Dr S and Dr V took the hot seat and performed will, considering it was the first time. Others also had a ‘go’. Talking through different parts of the full exam: General physical observation, Palpation and Auscultation. As a group we know it all.

Learning points are:

• Picturize the whole situation
• Have a working differential from initial information and cues
• Introduction, Hand hygiene, Permission.
• Ask about pain from ‘role player’ / examiner
• Describe what you want to check and get information on
• Be careful of describing your examination technique
• Right sequence of proceeding and specific questions
• Practice Binary questions – a sign is present or Not
• Do not beat around the bush
• Summarize in a few sentences – remember Examiner has given you the ‘findings’.
• Practice, Practice, Practice to cover the whole in 5 minutes.

add a comment or any points I may have missed.
Video of the sessions will be available.

Anil Garg

Thank you for participating in the session today and making it so interactive. 

My apology for the information overload. We covered a lot of area and I trust it will sign post you to where to focus your effort and where to find the resources.

We discussed the approach to a ‘cardiac’ patient. General examination followed by systematic examination of the chest.We discussed normal physiology in a child and how the fetal transition to circulation occurs and the pressure changes associated with it. How do use pressure changes affect the flow of blood and give rise to murmurs. We then had a number of audio video clips depicting murmurs commonly encountered in children.
The learning points were:

• Better understanding of cardiac physiology.
• Recollection of murmurs.
• Continuous murmur of PDA vs Aortic stenosis + Aortic Regurgitation
• Diastolic murmurs clearer.
• Foetal circulation and effects after birth on murmurs.
• Brushed up schematic working of CVS examination.
• Encourage to say what you find
• Practice of how to ‘run’ your clinical examination.

Please add your comments or anything I have missed.
Anil Garg

Thank you for your participation in the sessions on clinical stations.

The new set up is different from before and is also new to us. We are trying to guide preparations to the best of our understanding of how the new setup will run and how  candidates will have to adapt their examination and presentation techniques to score maximum marks.

There have been two PowerPoint presentations on clinical station in general and more specifically for CVS station.

The learning points are:

• Look at the images provided very carefully for cues that you would have from seeing a child
• Practice talking through the examination
• Good presentation is essential
• Need to be very systematic so as not to miss a ‘sign’
• If you do NOT ask – examiner will not tell you
• Read basic physiology and management options
• CVS – murmurs are a weak point for all – need practice
• Be vary of two conflicting finds in your presentation
• Normal pulse with Aortic stenosis or with significant regurgitation
• Better not to comment – if not certain
• Investigations – Know what you will be looking for.

We will do a session on common murmurs that can be expected at next session.
Add your comments or any points I may have missed.

Anil Garg

We have just added a presentation on how to take a Good Focused History.

Common scenarios, what to avoid and Not to get into Communication station mode.

Focused History – Brief Guide

We discussed the management of coeliac disease in the first session. Dr S summarised her findings from previous session. The discussion on significance of a ‘negative’ coeliac screen tTg level in context of management of disease, likely complications, what regular monitoring will be required and role of biopsy.

Dr Siba gave valuable advice on Coeliac disease management:

• Serology is important and levels of tTg – IgA antibodies > X 10 are confirmatory evidence
• Serology levels of < X10 – need to be confirmed with a Biopsy
• Following a new diagnosis Screening of 1st degree relatives is required
• Pneumococcal vaccine is recommended as patient deemed ‘asplenic’.
• Advice parents to have a separate shelf / cupboard to keep ‘Gluten free’ food and utensils
• Sepeartae butter dish etc is recommended to avoid contamination

REMEMBER A PERSON HAS A DISEASE – HE IS NOT THE DISEASE.

I met Tobias, a case of Coeliac disease vs I met Tobias who has Coeliac disease.
Choose your words carefully.

Examiner has been listening to you taking history so DO NOT repeat it all.
Salient points which support your conclusion only – sound better and save you time for discussion.
In the second session we discussed Management of Crohn’s disease. Very well done by Dr M.
We also discussed how the new format virtual exam will affect our performance at various stations.
Learning points:

• Read clinical examination and practice speaking
• Need to mention what you will be looking for
• Passport / Bracelet for Steroid and other medications or disease process

Please watch the video as there was lot of information discussed that I have not been able to put here.
Add a point or any comments.
Anil Garg

We had our first sessions on Winter UK time – due to error on my part – the first session scheduled for 3:00-4:00 pm UK time – the invitation was sent for old time of 4:00-5:00 pm. My apology. Hopefully the error should not recur.

We also had 2 histories: One a Young person with Coeliac disease and the second a young person with Crohn’s disease. Anish and Ayo were is the role players and performed beautifully. The coeliac history was a bit hit and miss but the Crohn’s disease history was very well done. There is always room for improvement and we had formative suggestions from peers and Siba.

The learning points were:

• Introduction is important – be brief
• Give Role player time to respond: keep quiet for 5-10 seconds – do not interrupt.
• Active listening.
• Explore main complaint and also common associations.
• Chronic disease – if unexpectedly get worse – think of Compliance first.
• You may need to probe on compliance and not just a gradual acknowledgement
• Other disease process – workout a differential
• Social history is important.
• HEADSS – for young person is important – DONOT leave till very late.
• Remember you cannot ask about ‘everything’.
• If you finish early i.e. 9-10 minutes – likely you have missed out on an important aspect in history.
• Summarize.

Add any other points or comments.
Anil Garg

MRCPCH C

Thank you for participating in today’s session.

We made a change to the intended program by swapping new history scenario to continuing the discussion on asthma. I made the choice because asthma is a very common topic in the exam and then come your way in history and management, communication, clinical and even video stations. We presented the summary as it would be to an examiner.

The discussion was conducted with Dr Aloke and highlighted the different aspects management could proceed during the discussion.

The learning points are:

• Update yourself with NICE guidelines on Asthma Management in children.
• Tests that can be done in the clinic to evaluate condition and progress: PEFR.
• FeNO – a new monitoring test available and used at certain centres but will be rolled out.
• Spacer devices available – how to choose most appropriate for ‘your child’.
• Aerochamber vs Spacer.
• Be able to describe how to use an inhaler device
• Differential diagnosis: GORD, Post nasal drip – allergic rhinitis, Cystic fibrosis, IgA deficiency
• BTS guidelines on treatment: SBA, ICS, LABA, Montelukast agonist, Oral steroids, Theophylline.

Add any points I may have missed or to add any comments.
Anil Garg

MRCPCH Clinicals Onlineworking together to reach your goalwww.mrcpchonline.org

You can access the guidelines from:

• https://bnfc.nice.org.uk/treatment-summary/asthma-acute.html&nbsp;

• https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/AOP_FeNo-testing-asthma-diagnosis.pdf
• https://respiratoryacademy.co.uk/module-1/how-do-you-know-if-the-spirometry-test-meets-the-quality-standard/ 

Thank you for participating in the session.

We discussed a 10 year old boy with asthma who was causing concern to parents. We had Dr Urmila role play.
I emphasised the basic nut &n bolts of a History station and how it differs from a Communication station – though there are a lot of similarities in both and a significant marks can be acquired by good communication skills. We completed the history part of the station.

The main learning points are:

• Read the Information sheet carefully.
• Each line and ‘word’ has significance and had been deliberately chosen.
• The cues from there should guide to formulate a differential diagnosis.
• Prepare your questions related to the DD.
• Be systematic in your information gathering.
• Ask screening questions for relevant diagnosis.
• Role player will not give information unless you ask.

Add any further points or comments.
Anil Garg

Thank you for participating in the session today and making it so interesting.  In the video today we saw a two hour old baby, dysmorphic looking who was being ventilated and had evidence of his oesophageal atresia would tracheo-oesophageal fistula, bilateral abnormal ears, vertebral anomalies . The clinical observation of the child was good and noted by all but review of the chest x-ray was less convincing and required some prompting.
The learning points:

• Common thing first – ABC.
• Observe the video carefully, 3 times – FOCUS of different aspects – DO NOT fixate on the same thing
• Be systematic in your summarizing
• Oesophageal atresia – blind upper end needs – Reprigol suction catheter.
• Air below diaphragm is an important sign – MENTION it.
• Listen to question carefully – what 3 things will you do next….
• Inform your Consultant before discussing with other teams.

If I have missed and point – add or leave a comment.
Anil Garg