Circuit B
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 tells you, ‘This patient has recently changed practice areas and the GP is concerned about this 4-month-old child’s growth. Can you examine this child’s cardiovascular system to determine a cause for his poor weight gain?’.
CLINICAL SCENARIO
You are presented with a child who looks small for his age. He obviously has Down’s syndrome.
What cardiac defects would you predict this child may have?
The child is placid throughout the examination. On general inspection his lips are not cyanosed and you note dysmorphology consistent with Down’s syndrome. Examination of peripheral pulses reveals no delay or absence in any area. The pulse is 120–130.
On examination of the sternum you can see an obvious cardiac impulse. The apex can be felt just medial to the axillary line at the level of the fourth intercostal space. Both first and second heart sounds are present, although you suspect the second heart sound is louder than the first. There is a loud murmur without a thrill heard at the lower left sternal border. The chest is clear and a liver edge is just palpable below the left subcostal margin.
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
The examiner asks, ‘Can you introduce yourself to Sarah and make some general comments about her appearance?’.
CLINICAL SCENARIO
Sarah is a small preschool-appearing child who is able to say hello to you and tell you her name. She tells you she is 6 years old. You say to the examiner you would like to plot her height and weight on a growth chart as she appears small for age. You note a relatively large abdomen with some peripheral muscle wasting. You comment that she does not appear dysmorphic.
The examiner asks you to complete a full abdominal examination.
After a thorough examination of her hands, skin and eyes you can find no palmar erythema, clubbing, jaundice or spider naevi but do note some haematological dysfunction in the fact she has multiple bruises. These are not solely located on the shins but encompass the arms and thighs as well. They are of multiple colours and shades.
Her abdomen is protuberant but soft and non-tender. You feel an obviously enlarged liver (at least the width of your hand) but after a thorough exam cannot feel the spleen. You are surprised to find you are able to feel potential renal masses on both flanks. The liver is not tender to palpate.
Are there any other physical signs you wish to specifically wish to look at?
Are there any questions you wish to ask Sarah’s mother?
Is there a diagnosis which brings all these features 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
On entering the room the examiner says to you, ‘Please examine the back of this 6-month-old boy and then proceed to examine where else you feel necessary’.
CLINICAL SCENARIO
You are presented with a young infant who is lying on his back on an examining table. You introduce yourself to his mother and gain permission to examine the child’s back. Quickly, but obviously, you scan the child before turning him over. There is no obvious dysmorphism, the child is not grossly hypotonic and the hips are flexed. He is only wearing a nappy and smiles as you approach.
On turning him over there is an obvious large scar in the lumbosacral region. It is in the midline and looks at least a couple of months old.
Which areas of the body could you justify examining now?
You elect to examine the lower limbs. On close inspection he does not appear grossly wasted. There are no fasciculations and there is some intermittent kicking movement at the knee, although it doesn’t appear as coordinated as you would expect in a 6-month-old child. The hips are in a permanent flexed and abducted position. There is no hip extension. The knee is observed to extend but the foot is held in a position of dorsiflexion. You are unable to obtain ankle reflexes but feel happy you have obtained an adequate knee reflex. Babinski’s reflex is unequivocal but the child shows no facial response to the test. As you begin to test sensation the examiner asks you to present your findings so far.
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.
CLINICAL SCENARIO
You are presented with a teenage girl in her late teens who appears exceptionally tall (and too long for the couch!). She is comfortable at rest. On inspection of her hands, she has very long fingers. There is no central cyanosis.
On examination of her chest, she has an increased anteroposterior diameter and marked scoliosis. There is equal expansion but loss of the cardiac dullness on percussion. There are coarse inspiratory crackles at both bases and occasional wheeze. There is no hepatomegaly.
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
‘Please have a close look at Sarah’s face and neck. Her GP has noticed a subtle decrease in her height velocity.’
CLINICAL SCENARIO
You are presented with a girl who is approximately 5–7 years old. She has no overt dysmorphology. She engages with you and is able to answer questions about her age – ‘Seven’ – and where she goes to school. She has a normal voice. You comment to the examiner that you think she has a midline neck swelling.
How would you approach the examination of the neck?
Your examination reveals a diffusely enlarged firm thyroid swelling.
How would you confirm the swelling is an enlarged thyroid?
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
On walking into the room you are asked to assess the general development of Katie, who is 1 year old.
CLINICAL SCENARIO
Katie is sitting up in the middle of the room. She has been given a rattle to hold, which she bangs against the ground. She looks up at your approach and drops her rattle. You introduce yourself to her mother and gain permission to examine her. She picks up her rattle, which has fallen behind her. You commence your examination.
Gross motor: Although able to sit up without support, she is unable to stand. With her hands held there is an effort to pull up but she doesn’t yet have the strength in her legs. She will roll from front to back or back to front. Her general tone is good and there is no evidence of spasticity.
Fine motor: If she drops her rattle she is able to pick it up (in either hand) with a palmar grasp.
Hearing/language: She responds to her mother’s voice by looking at her. You are not given time to do a formal distraction test. She makes noises but no distinguishable words.
Social: She smiles and shows little fear of you. When given a spoon she accidentally hits herself over the head with it.
General: She appears small for her age, and has the composition of an approximately 6-month-old child. There are no dysmorphic features but she does have a plagiocephalic skull and scars on her hands.
What do you say to the examiner?
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 will be talking to Mrs White, the mother of Hayley, a 3-week-old baby who has been found on Guthrie neonatal screening to have raised immune reactive trypsin and to be likely to have CF. She has been asked to come to the hospital for the results and further management to be explained.
TASK
Explain the results of the Guthrie test to Mrs White and the necessary next steps in management. You must sensitively respond to all of Mrs White’s questions and do not have to cover all areas in the time allocated.
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
The nurses have asked you to talk to the mother of James about discharge arrangements. He is due to go home tomorrow but you are expecting the delivery of premature triplets today and his space on the unit is needed.
BACKGROUND
James was born at 25 weeks’ gestation. He is now 39 weeks’ corrected gestation. He was ventilated for 2 weeks and required CPAP for a further month. He was out of oxygen by 34 weeks’ corrected gestation. He had a right-sided IVH. He had a PDA, which was successfully closed with indomethacin. He was investigated for sepsis on two occasions. James required NG feeds for a prolonged period but has now successfully established breast feeds and is gaining weight.
He is the only child of his parents. His father works away from home a lot.
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 that 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 specialist registrar working in a district general hospital. You receive the following letter from a GP and are seeing the family in an outpatient clinic:
Re: Sumira Mussuamba DOB 9/12/1996
Sumira is an 8-year-old asylum seeker from Somalia who has been in the UK for 8 months with her mother and siblings. Sumira’s father died during the conflict in Somalia.
I think Sumira had febrile convulsions as an infant and there is a family history of febrile convulsions.
Since moving to the UK Sumira has begun to have convulsions. They begin on the left side and become generalised. She is unresponsive and her eyes roll. She has been to A&E on one occasion but did not stay overnight.
Please could you see this child, who has recently joined my practice, for further management of her fits? I have commenced sodium valproate 400 mg bd.
COMMENTS ON STATION 1
DIAGNOSIS: DOWN’S SYNDROME WITH AVSD
Children with Down’s syndrome are commonly utilised in exams as they may have multiple pathologies but are gifted with an extremely pleasant temperament. It is a syndrome you should know inside out and back to front.
This station is testing your ability to combine clinical findings from a variety of sources. You must be able to utilise your clinical skills to detect a murmur and provide the differentials: ventriculoseptal defect (VSD) or atrioventricular septal defect (AVSD). As the murmur is at the lower left sternal edge it is unlikely to be PS or AS. Realising this child has Down’s syndrome then makes AVSD the most likely diagnosis because it is the most common cardiac defect in Down’s syndrome.
The apex was near the mid-axillary line and therefore this child has cardiomegaly.
The second heart sound is louder, indicating a degree of pulmonary hypertension.
The absence of a thrill makes an AVSD more likely (although if the VSD is severe the thrill may be absent and an AVSD may have a thrill).
No mention of a diastolic murmur but a diastolic flow murmur may well be present at the apex of lower left sternal edge.
The examiner will then further expect you to realise that not only must this lesion be repaired but also that Down’s children have an increased risk of pulmonary hypertension so will have an earlier surgical intervention. You may pass this station for a correct description of the presenting feature but what will gain you the vital clear pass marks is the ability to apply your findings to this particular clinical scenario.
Immediate investigations are an ECG (biventricular hypertrophy) and CXR to assess the degree of cardiomegaly with an ECHO to define the extent of the anatomical defect. An ECHO can also estimate the pressure in the right ventricle (by calculating the Doppler measure pressure difference between the right and left ventricle and knowing the systemic pressure). However, evidence of severe pulmonary hypertension will require cardiac catheterisation to quantify the degree of pulmonary vascular resistance.
Treatment will involve diuretics but only surgery will be curative.
CLASSIC FEATURES IN DOWN’S SYNDROME
Newborn
| Head | Hands | Heart |
|---|---|---|
| Flat occiput | Fifth finger | AVSD |
| Epicanthic folds | Absence of middle phalanx | VSD |
| Brushfield’s spots in iris | Single crease | PDA |
| Protruding tongue | Distal axial triradius | Tetralogy of Fallot |
| Small ears | Broad appearance Hyperextensible | Increased risk of pulmonary vascular disease |
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