Circuit A
STATION 1
This station assesses your ability to elicit clinical signs:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
The examiner introduces you to Hannah, who is a 12-month-old girl. You are told that she spent the initial few months of her life in hospital and you are invited to examine her cardiovascular system.
CLINICAL SCENARIO
Hannah sits on her mother’s lap without any oxygen therapy and is not dyspnoeic at rest. You are surprised she is 12 months old as she looks small for her age. Her head appears narrow when viewed face on and a little long in the anteroposterior direction. You ask the mother to remove her T-shirt. As you approach Hannah she begins to cry. You attempt to console her with the small teddy bear attached to your stethoscope. This makes matters worse. You notice that she has multiple small scars on her hands and a small scar on the left side of her chest.
You do manage to feel strong peripheral pulses and there is no evidence of central cyanosis. Useful examination of the chest and precordium is impossible due to Hannah’s crying.
The examiner then asks you to comment on your findings thus far. What do you say?
STATION 2
This station assesses your ability to elicit clinical signs:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
On entering the room you are told, ‘This is Simon, who is a 16-year-old boy. Please examine his abdomen’.
CLINICAL SCENARIO
On inspection Simon is a thin boy and seems short for his age. He is pale and has a full and plethoric face. Despite his neck and shoulder blades having generous amounts of adipose tissue his extremities look wasted in comparison.
There are no peripheral stigmata of liver disease. He has three abdominal scars: two oblique scars in the left and right hypochondrium and one suprapubic scar. You also notice a small 2 cm scar close to his right clavicle. On palpation you find a left pelvic mass approximately 10 cm in length. It is non-tender, non-mobile and quite firm. He has no hepatosplenomegaly.
What do you think this pelvic mass is?
How do your clinical findings fit together?
STATION 3
This station assesses your ability to elicit clinical signs:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
The examiner says to you, ‘This is Abdi. He is 11 years old and was born in Somalia. He was first treated by the ENT surgeons 5 years ago and since then his mother has been concerned about his face. Please examine his fifth, seventh and eighth cranial nerves using the equipment provided’.
CLINICAL SCENARIO
Abdi sits happily with his mother. On the table next to Abdi there is a piece of cotton wool and a tuning fork. At first glance there is a mild asymmetry to his face. You find no abnormality when you use the cotton wool to assess the sensation of the ophthalmic, maxillary and mandibular branches of the fifth cranial nerve. When you ask Abdi to screw up his eyes, puff out his cheeks and smile there is obvious weakness of the muscles in the left side of his face. He is unable to move his forehead on the left side. You place a vibrating tuning fork on the centre of the Abdi’s head and ask him which side is louder. He tells you the left. You place the vibrating tuning fork next to his right ear and then place the base on the right mastoid process. He tells you it is louder when placed next to the ear. When repeated on the left side he tells you it is louder when placed on the bone, although you had difficulty finding the mastoid process due to scar tissue in this region.
Is there anything else you would like to examine?
How do you present your findings to the examiner?
STATION 4
This station assesses your ability to elicit clinical signs:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
On entering the room the examiner says to you, ‘This is Anthony, who is six. Have a look at his skin and then listen to his chest’.
CLINICAL SCENARIO
Anthony is an appropriate size for his age. On inspection of Anthony’s skin you see he has dry, erythematous patches of skin covering his trunk, face and the flexor surfaces of his limbs. There are excoriated areas with visible scratch marks.
He is comfortable at rest and there is no evidence of cyanosis. There is no recession or indrawing. He is not barrel chested. You commence your exam by having a look at his hands. You notice no clubbing. The examiner stops you at this point and tells you he asked you to listen to his chest.
Auscultation of the chest is normal with no wheeze. The expiratory phase is normal.
You present your findings as a child with atopic eczema and a normal chest examination.
You are asked if he has Harrison’s sulci. You are now concerned you are wrong but do not feel he has Harrison’s sulci and he definitely does not have any wheeze.
What do you say to the examiner?
You are asked to explain to his mother how to manage the skin complaint. How would you do this?
STATION 5
This station assesses your ability to elicit clinical signs:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
On entering the room you are told, ‘This is Nicola and her mother. Nicola is 7 years old. I’d like you to have a chat with her and ask her mum any questions you think may be important’.
CLINICAL SCENARIO
At first glance Nicola is a well-grown 7-year-old girl. Nicola talks throughout the examination with great enthusiasm about numerous subjects but with immaturity of content. You suspect she may have learning difficulty and have a good look for any dysmorphic features. She does not have Down’s syndrome and you note blue eyes and small teeth for her age, although her lips are quite full and she has a slightly rounded end to her nose. As she talks it is apparent that she has below average intellect for an average 7-year-old.
What would you like to ask mum?
You are then asked to listen to her heart. She has a central sternotomy scar with keloid scarring. There are no other scars. Her heart sounds are normal.
How do these findings fit together?
What do you think the diagnosis is?
What else would you like to ask mum to aid your diagnosis in light of the cardiac abnormality?
STATION 6
This station assesses your ability to assess specifically requested areas in a child with a developmental problem:
This is a 9-minute station of clinical interaction. You will have up to 4 minutes beforehand to prepare yourself. No additional information will be given or is necessary before commencing the station. When the bell sounds you will be invited into the examination room.
INTRODUCTION
‘This is Helen and her mother. Helen’s mum was concerned about her speech development compared to other children. Before asking mother any questions what do you think of Helen’s developmental age?’
CLINICAL SCENARIO
Helen is sitting at a table on your entrance to the room. She has been given some bricks to play with and she is currently hitting two of them together. She is suspicious of your arrival and looks between you and her mother. You introduce yourself to her mother and then to Helen. She says something incomprehensible to her mother, who smiles at her. You approach the table and ask her name. Although difficult to understand, there is a definite attempt at her name: ‘Eywen’. She then gets up and walks, with no difficulty, to a box of toys. She finds a crayon and starts scribbling in circular motions on a red book. You are not sure she should be doing this so you remove the book, at which point she clearly says ‘No’. Realising time will be of the essence you ask what colour the book is. She frowns and returns to the table. She starts making a tower of bricks with little difficulty. The examiner asks if there is anything you would like to ask her mother. Mother says she has little difficulty in understanding her but the nursery has raised concerns. She appreciates her speech can be difficult to understand. At this points Helen’s five-brick tower crashes to the ground.
How can you assess Helen further?
STATION 7
This station assesses your ability to communicate appropriate, factually correct information in an effective way within the emotional context of the clinical setting:
This is a 9-minute station consisting of spoken interaction. You will have up to 2 minutes before the start of the station to read this sheet and prepare yourself. You may make notes on the paper provided.
When the bell sounds you will be invited into the examination room. Please take this instruction sheet with you. The examiner will not ask questions during the 9 minutes but will warn you when you have approximately 2 minutes left.
You are not required to examine a patient.
The encounter should be focused on the task; you will be penalised for asking irrelevant questions or providing superfluous information. You will be marked on your ability to communicate, not the speed with which you convey information. You may not have time to complete the communication.
SCENARIO
You have reviewed Laura, a 3-year-old who has been admitted for the fifth time this year with acute asthma. You are informed by the GP that no repeat prescriptions have been picked up for Laura in the past 6 months and that Avril, her mother, is a heavy smoker.
STATION 8
This station assesses your ability to communicate appropriate, factually correct information in an effective way within the emotional context of the clinical setting:
This is a 9-minute station consisting of spoken interaction. You will have up to 2 minutes before the start of the station to read this sheet and prepare yourself. You may make notes on the paper provided.
When the bell sounds you will be invited into the examination room. Please take this instruction sheet with you. The examiner will not ask questions during the 9 minutes but will warn you when you have approximately 2 minutes left.
You are not required to examine a patient.
The encounter should be focused on the task; you will be penalised for asking irrelevant questions or providing superfluous information. You will be marked on your ability to communicate, not the speed with which you convey information. You may not have time to complete the communication.
SCENARIO
You are leading a teaching session for the unit’s medical students on examination of the newborn. You have been provided with a dislocated hip mannequin.
TASK
Instruct Craig, a fourth-year medical student, on the correct technique for the neonatal hip exam. You do not need to provide background epidemiological information about developmental dysplasia of the hip but if you have time you may check Craig’s understanding of what to do if an abnormal hip is discovered. The aim is for Craig to perform a professional, reproducible and effective hip examination on the mannequin in a role-play situation.
STATION 9
This station assesses your ability to take a focused history and explain to the parent your diagnosis or differential management plan:
This is a 22-minute station of spoken interaction. You will have up to 4 minutes beforehand to prepare yourself. The scenario is below. Be aware you should focus on the task given. You will be penalised for asking irrelevant questions or providing superfluous information. When the bell sounds you will be invited into the examination room. You will have 13 minutes with the patient (with a warning when you have 4 minutes left). You will then have a short period to reflect on the case while the patient leaves the room. You will then have 9 minutes with the examiner.
INFORMATION
You are the SpR in a general paediatric clinic. You receive the following letter from a local orthopaedic consultant. Please take a relevant history from the patient, Tamsin, and her mother:
Thank you for seeing Tamsin. She is a 13-year-old girl with a long history of juvenile idiopathic arthritis. I have performed a number of operations on her and most recently an osteotomy of her left hip. This operation was 3 months ago and I understand she is still not back at school. I would be grateful if you could offer your expertise in smoothing her return to education.
After taking a history the examiner asks you:
COMMENTS ON STATION 1
DIAGNOSIS: PERSISTENT DUCTUS ARTERIOSUS
Every candidate has a fear that they will have little positive (or negative) to say to the examiner because they have been unable to examine the child properly. Even worse, they have examined the child properly and still have nothing to say! There are numerous learning points to remember in this type of station and if you remember a few you should always be able to give a professional answer.
1 APPROACH
As we all know from clinical practice, children of this age can be difficult to examine. They are often clingy and may have stranger anxiety. While examining centres try hard to enrol cooperative children they often get tired or can be unpredictable. It is this random nature that makes children so endearing to paediatricians. You should be comfortable with some distraction techniques for children from 6 months to 5 years. Here are some classics:
Ask mother to show the child a colourful book while you listen to their chest.
Tap a wooden tongue depressor on the desk to attract attention.
Ask the child if you can guess what they had for breakfast by listening to their abdomen (and chest) with your stethoscope.
Start listening to teddy’s heart, lungs, abdomen, etc., or mother’s arm, leg, etc., so the child feels more comfortable.
If you say, ‘May I listen to your heart?’ and the child says ‘No’ then you have dug a large hole for yourself. ‘I am going to …’ should avoid this catastrophe.
Always try to smile and appear unthreatening, despite the stress you are under. Children are unfortunately good at picking up on this. Never carry on regardless if a child becomes very distressed as this will in turn distress the examiner! If a child becomes uncooperative they will often direct you with an alternative plan. Remember there is a tick box in the exam for acknowledging an uncooperative child.
2 OBSERVATION
Before you begin your hands-on exam ask ‘mum’ to remove any clothing. It will be impossible to pass a station if you miss a scar and you cannot claim you have thoroughly looked unless the chest is exposed.
With a child of this age observation is absolutely vital as it should give you enough information to make a sensible list of possible diagnoses. In the above scenario we need to simply stand back and take a look for a minute.
We note that she sits without oxygen and is not cyanosed or dyspnoeic.
We look more carefully and notice she is small for her age, has plagiocephaly and on inspection of the dorsum of her hands has multiple scars, presumably from previous venepuncture.
As mum distracts her and removes her T-shirt you carefully inspect her chest and both axillae. Now you can see a healed left lateral thoracotomy incision. She has had surgery for either:
• pulmonary artery (PA) banding;
• a Blalock-Taussig (BT) shunt;
• persistent ductus arteriosus (PDA); or
In the absence of a central sternotomy scar she has not had a BT shunt as she is pink. Remember, a BT shunt is a palliative procedure and will not reverse the cause of the cyanosis. PA banding is used to prepare the vessels for a Fontan procedure but again will not correct the cyanosis until a more definitive repair has been performed. This leaves (given that this is a cardiac station) only a PDA or coarctation repair as possibilities. We know her pulses are normal, although if the coarctation has been repaired then obviously you will be able to feel the femoral pulse. In this situation, if a classical repair has been used then the left radial pulse should be weak. Balloon dilatation of the coarctation is unlikely to show any discernible difference. So theoretically the child may have had an aortic coarctation or a PDA but we know she shows signs of being premature. Therefore, if Hannah became very distressed and uncooperative you would be able to say to the examiner:
‘Hannah is a 12-month-old girl. She is not attached to any monitoring or supplementary oxygen. On inspection she is pink in air with no respiratory distress. I note she has plagiocephaly and her hands show scars consistent with multiple venepuncture. She appears small for her age but I would like to plot her on a growth chart. On examination of the precordium Hannah has a left lateral thoracotomy scar. I was unable to proceed further with my examination but this acyanotic child has features of prematurity and a left lateral thoracotomy scar which would make a repaired persistent ductus arteriosus the most likely diagnosis.’
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