Dear all

Thank you for participating in the session today.

In RRR we discussed:

• Limp in a 4 year old
• SVT – management
• Stridor – causes

We covered the Video station today. AG gave a PowerPoint presentations of What – How – Do’s & Don’ts for the station.

We were able to cover two video scenarios: a 12 year old a post viral high stepping gait and a 4 day old with Jaundice. Dr A & Dr K took the hotseats and Dr V & Dr S & Dr N were with the examiner hats.

The important Learning points are:

• Read the given information very carefully – each word is important
• Video watch FULL till END.
• Note signs demonstrated
• Develop a differential diagnosis of 2 or 3.
• Specific history ad examination points
• In management escalate to consultant other team
• You are not responsible to provide all care.

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:

• Stages of play
• Language – receptive / expressive
• MDT

The Development assessment task was to determine Developmental age of a 3.5 year old child with facies of trisomy 21. Dr V took the hotseat with Dr F in Examiner seat. Dr V completed the task well and in good time. Summary was discussed and input from all members discussed.

The Learning points are:

• There will not be child in the Development station – hence need to verbalize
• Age assessment – start with what is the expected maximum for age
• You can then move down or up depending on response
• Can he hop on one leg / ride a tricycle
• Can she make a tower of 9 cubes / draw a square
• This will give the upper age limit
• Have a template in your mind to follow
• Be systematic
• In history – always ask – How parents / carer coping?

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. 

We covered Development station – History and Assessment in a double session today to keep continuity.

In RRR we discussed:

• Developmental delay – causes: Prenatal, Perinatal, Postnatal…
• Management of Development delay
• Wilm’s Tumor

Development station is still  ‘Virtual’ and there is NO CHILD. You will have to verbalize the examination to Examiner.

The Development station – presentation was of a 4 year old whose mother was concerned about his ‘fine motor’ skills. Task was to take a focused history and then do a fine motor assessment.

Dr M was our Role Player, Dr K was in the hotseat. Dr K made a very good attempt at getting relevant history and still had about a minute left. The were a some facts that were missed: Development in domains other than Fine motor – that has to assessed and demonstrated. Co-morbidities, Family history, Who all are involved in child’s care are details important to obtain.

Check for Vision & Hearing tested and if any concerns.

Dr U was in the Hotseat for Assessment, Dr A & Dr T had the  examiner hats. Dr U completed the exam in due time and elicited most points. Summary to examiner needs to be practised.

The Learning points are:

• General Examination is part of Development examination also.
• Briefly look for general appearance, any splits, wheel chair, drugs etc.
• Sit comfortable across child – explain what you will be doing / expect child to do.
• Collect ‘Tools / Toys’ you will use.
• ONE TOOL AT A TIME – keep others out of field of vision.
• Mention Removing the ‘Tool’ after use – else it is present on the table!
• Start with Offering cube – check for Handedness.
• Crayon – check type of grasp – palmer or pincer.
• You will have to describe what you expect the child to do – examiner will confirm or refute.
• Permission to use scissors
• Can ‘ask parent’ to help is child is reluctant
• Make a temple for History and examination so as not to miss important aspects.

Dr Shishir has sent 3Cs & 3Bs to our WhatsApp group – do check – it will guide your examination.

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:

• Limp in 3 years old boy – Cong Hip Dislocation (- painful / painless screening)
• Neonatal seizures – management
• Ataxia 5 years old boy

History station was history from a 15 year old with Diabetes Type 1, with high HbA1c who has recently joined doctor’s ‘practice’. Dr S was in the hotseat and Dr s was a very able Role player, Dr T & Dr M had the examiner hats. Dr S made a good attempt at completing the task. He had ample time. There were some errors which were picked by examiners and other members.

The Learning points are:

• Develop a template for History and all other stations
• Divide time into 4 /5 bits – make bullet points
• Think of 2-3 differentials as cause for presentation
• Use provided information to open up the discussion
• Start with greetings and Open questions – let role player speak
• This will help get RP’s agenda and not negotiate Your agenda / diagnosis
• Use Close questions towards end to complete the information
• Chronic disease with given diagnosis – explore social issues
• Do NOT slip into Communication mode and waste your time
• Practice acknowledging and ‘Parking’ RP’s queries effectively
• Practice, Practice, Practice with in your groups

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:

• Hypothyroidism in 12 year old
• Recurrent infections in 6 years old
• Primary & Secondary survey following RTA

History station was of a 12 year old girl with two recent episodes of fainting and falling at school. Dr K was our Role Player as young person’s father, Dr S was in the hotseat while Dr F & Dr V had examiner hats. Dr S took a comprehensive history with in the time limit. She parked RP’s Query very well avoiding falling into Communication mode. Very brief – 4 -5  sentences summary at 9 minutes warning  helps take stock of what you have covered so far and what further needs to be explored.

The Learning Points are:

• Have & Follow your template: Do not forget Social history
• Have a Differential diagnosis 2-3 and work accordingly
• Keep your language SIMPLE
• Time management is a MUST
• Clarify ‘identity’ of RP at introductions – patient / parent
• Paraphrase given information to open discussion
• ‘Tell me more ….’ sounds easier than ‘Elaborate’ .. both mean same
• Let RP speak – you can use Leading questions
• Check ‘How RP is coping / is being affected?’
• At 9 minutes – a brief summary helps take stock of situation
• Explore ‘hidden’ agenda – usually some point is likely
• HEADS – ask Role player – if required – do not ignore being ‘shy’

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

Anil Garg

Dear All

Thank you for attending the session today. 

We completed History in Clinical exam – how it is used and tested across all stations and how it is different at each station and how you have to tackle at each station. You can see the presentation online.

History station was focussed history from a parent of 11 years old boy with Coeliac disease. Dr U was in the hotseat, Dr A was a very able Role Player as father of Jon and Dr S & Dr S had examiner hats. Dr U made a good attempt at getting the information required – spread over 2 sessions – hence there was an element of disjointedness. 

There are few Learning points:

• Social issues can come up in with Chronic diseases – be aware
• Introduction – remember you are Not ‘Baby doctor’ – if dealing with an older child
• Be just a Paediatrician or a doctor on Call of in the clinic
• Let the Role player speak without interrupting – they will not talk for more than 2 mins!
• Make not of points they are mentioning – tackle them in order of importance
• If ‘all is well’ – look for some hidden cause – dig deeper and you will get to know
• Do not go into dietary details – if all is said to be well
• If a review is needed – ask as specialist i.e. dietician in this case
• Do not slip into communication mode – you will be wasting your time unnecessarily
• PARK the query – acknowledge the query – DO NOT ignore
• Do not introduce new worries – if not required
• Use your template as guide so as not to miss important aspects
• Offer Written management plans as part of your management strategy

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 double session today.

In RRR we discussed:

• Brain tumors – symptoms & signs
• Preterm / Sick infant stabilisation / care
• Kawasaki disease

We covered 3 clinical stations today:

• Other – Eyes examination: Hotseat – Dr A
• Abdomen: Hotseat – Dr A
• MSK: Hotseat – Dr A

Our examiners were: Dr A, Dr M, Dr K, Dr F & Dr V.

The Learning points are:

• Eye Exam – check if uses Specyacles. Test acuity with corrective glasses if needed
• Check vision in EACH eye individually
• Do not need to check vision on a chart – use book, pictures, clock in the room
• Aids – Acuity – Movements – Visual fields – Fundoscopy
• Abdomen – know scars and their significance
• Kidney transplant – normally in RIF
• If you feel a mass – do not ignore it – trust your skills
• Percuss to get information on “how solid”
• MSK – confirm – if not made claer
• Screening 3 questions – ask following seeking permission
• Pain, ability to go up and down stairs, dressing self and eating with ‘fork & knife’
• In India – unlikely to use F&K – ask can feed self independently
• Start with upper limbs – and progress smoothly.
• Need to check hands as if with JRA
• The examination can be finished in 5 mins with practice
• 1 min for ‘nerves’ a if a local joint exam is needed
• Develop templates for each, share and practice

Next week we will start History and Managment station.

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:

• Empathy – we talk of it – how?
• Cyanotic Heart Disease – 5Ts
• Ethics: 5 pillars

The clinical station was Neurology Examination of Lower Limbs of a 12 yr old girt with left hemiplegia but extensive physio and occupational support hence difficult signs. Obvious limb discrepancies. Dr V took the Hotseat with Dr U and Dr S with examiner hats. Dr V made a good attempt at the station but took far too long on the initial examination and ran short of time. Examiners picked up the clues and gave useful suggestions.

The Learning points are:

• Have a differential diagnosis – do NOT go with one diagnosis only to start with
• Systematic examination has to be sleek – as if you have done it 100s of times
• Expose the relevant part – ask patient and parent to help
• Kneel down to observe Gait & examine leg bulk, scars
• If is DOUBT – MSK or Neuro examination – ASK examiner – Clarify
• Check power in Groups of muscles acting on a joint: flexors – Extensors

5Ss for Observation at Clinical Neuro Station:

Observe / Comment on:

While standing: check for 5 Ss…

•Squint – Look at eyes … side •coloboma  •colour

•Shunt

•Spine  –Scoliosis / kyphosis

•Scars – Legs / Spine – Tendon release

•Shoes• Extra support: Asymmetrical wear & tear

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. Results declared yesterday of the recent exam again made us really PROUD. 8 of our members became Members of RCPCH and sadly one member was unable to satisfy the examiners on the day.

In RRR we discussed:

• UTI investigations
• Infantile spasms
• Paracetamol Overdose

The Clinical station was Respiratory system examination of a 14 year old young person attending OPD for a routine Follow Up. Signs were of growth failure, porta-cath, clubbing, and an Insulin pump. Dr V took the hotseat while Dr T and Dr A had the Examiner hats. Dr V attempted the station and collected some of the clinical signs but ran short of time. The Examiners picked the clues missed.

The Learning points are:

• Systematic and sleek examination is required
• You need to finish the examination in 5 minutes
• Seek permission and explain what you will be doing and expect from child / young person
• PAIN – check for pain / discomfort – reassure will stop if needed
• General examination is PART of every station – spend 30 secs.
• Expose the part after introductions and your task
• Mention all you see – even if you are Not sure what it may be.
• Adolescent: check for Puberty and history if appropriate
• Look up porta-cath and other options for prolonged venous access.

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:

• Urine sample – collection
• Inflammatory Bowel Disease: Ulcerative Colitis / Crohn’s
• Atopic eczema

The Clinical station was CVS examination of a 6 year old attending for a routine FU. Operated at 2 years. In a stroller. Dr S took the Hotseat with DR K & Dr F having the examiner hats. Dr S made a good attempt at describing the examination. General examination was covered with systemic examination running short of time, with extra time the examination could not be completed. Examiners noted the positives and missed technique and signs.

The Learning points are:

• Read Introductory statement VERY carefully. 
• Note any ‘abnormal’ or out of place features presented.
• Structured examination technique is a MUST.
• Inspection – Palpation – Percussion – Auscultation
• Fundamentals – do NOT forget.
• General examination with surroundings.
• Ask for Weight & Height Centiles and NOT Kgs & Cms.
• Follow your template for examination – write one & share
• Be confident of your examination and findings
• Do not manipulate signs to fit what you think is the diagnosis.
•  Summarize with your ‘impression / diagnosis’ do not just narrate what you have found.
• Practice to finish Systemic examination in 5 minutes.
• Write out template for each station and share them in Group

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

Anil Garg