Circuit C
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
On entering the station you are presented with a girl approximately 9 years old. You are told, ‘A GP has referred this child because he thinks she has a heart murmur. What do you think?’.
CLINICAL SCENARIO
The girl is comfortable at rest. You commence your routine cardiovascular examination. There are no abnormalities until you commence auscultation of the precordium. You hear a systolic murmur at the lower left sternal edge but also, and if not louder, in the aortic and pulmonary areas. You are uncertain as to whether this is an ejection systolic or pansystolic murmur. You feel a thrill in the suprasternal notch. You find no evidence of heart failure and can find no scars.
Where must you examine in order to clinch your diagnosis?
If this is positive what else will you look at?
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 station you are given the instruction, ‘Please examine this 16-year-old boy’s abdominal system, paying close attention to his nutritional status. Why do you think he has a scar?’.
CLINICAL SCENARIO
The boy looks smaller than you would expect for his age and has a gaunt appearance. Peripheral examination potentially shows some wasting of the hands, his conjunctivae are pale but his mouth is free from ulcers. You note that his muscle bulk looks reduced and offer to test this. There is a large laparotomy scar across his stomach but apart from some mild tenderness in the left iliac fossa abdominal examination is unremarkable.
How do you test his muscle bulk?
What else will you ask for and examine?
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 station you are presented with an African girl approximately 10 years old with an obvious movement disorder. You are asked to comment on her appearance and the abnormal movements.
CLINICAL SCENARIO
The child appears agitated and has persistent jerking movements of her arms. They move in an uncoordinated fashion, obviously to the girl’s distress. She is unable to keep her hands held together. Occasionally she demonstrates some facial grimacing.
How will you approach your examination?
What important differentials should you be aware of?
You are told she was a normal child 3 months ago and there is no family history of metabolic or neurological disorder. What investigations would you consider?
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 you are presented with a child approximately 5 years old. You are asked to examine his respiratory system to discover why he is coughing so much.
CLINICAL SCENARIO
The child is sitting on his mother’s knee. You ask to move him to the examining couch but his mother is uncertain as to whether he will cooperate. You explain that you would like at least to try. As soon as he is lifted towards the bed he starts crying. You quickly ask the mother to sit him on her lap and explain to the examiner that it may be easier to examine the child while he is settled.
On inspection he has a respiratory rate of 35 but no obvious recession. He has no scars, does not look cyanosed or anaemic but does cough during the examination. At one point he produces some mucky sputum.
While sitting on his mother’s lap he lets you examine him. His chest is not overtly hyperexpanded and there is good air entry, apart from the right base which has reduced air entry with multiple crackles and creps. The percussion note at this point is equivocal. The left side of his chest sounds clear.
Of interest, he has a cannula in his left hand. There is no oxygen in the room. What else do you need to know to make your diagnosis?
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 presented with a child approximately 2 years old. You are asked to comment on any striking features and discuss how this might relate to the child’s anaemia.
CLINICAL SCENARIO
On general inspection the child is pale and looks small for his age. He is playing with a toy in his mother’s arms and you notice an abnormality to his right hand. On closer inspection he appears to have two thumbs but both are hypoplastic. The more proximal lacks a distal phalangeal segment and the distal is attached by only a small piece of skin (see Fig. 3).
What more do you want to examine in his upper limbs?
After presenting your findings, which other parts of the body will you examine?
Just before presenting your overall findings you notice some café-au-lait spots on the child’s chest. What could the diagnosis be?
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.
CLINICAL SCENARIO
A child about 5 years old is playing with a ball in the centre of the room. You notice immediately that he has hemifacial hypoplasia. His left eye, cheek and ear are deformed. His external auditory meatus is nearly entirely absent on the affected side, with his eye present but obstructed on the lateral aspect by overlying skin. His mandible is not well formed and causes his mouth to appear lopsided.
How do you assess his hearing?
Will the dysmorphism affect how you approach this case?
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.
SETTING
You are a specialist registrar working at a district general hospital which has a large number of medical students.
SCENARIO
It is the start of the new academic year and the next intake of paediatric medical students have just started their attachment. All the students are to undergo training in basic life support (airway, breathing and circulation) of an infant. You are to instruct Robert in how to manage a 2-year-old child who is not breathing and does not have a pulse. You may not complete the task in 9 minutes but you should teach in a systematic manner, ensuring Robert understands the tasks he must perform and that he performs them correctly. A mannequin with appropriate aids has been provided.
The scenario is that Robert finds this child in the hospital car park. He is not in danger and is able to send for help. He must provide basic life support until the paediatric crash team arrive.
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
Stephanie, a 5-year-old girl, was involved in a high-impact road traffic
accident and has been on your unit for 8 days. She has suffered severe brain injury and is making no respiratory or neurological effort. A brain stem death test is to be performed by the consultant shortly after a long discussion with the parents. Stephanie’s brother, Mark, who is 18, has been asking questions about the test and what it means. Her parents have asked for a doctor to speak to him as they feel too traumatised. The consultant asks you to speak to Mark.
BACKGROUND
Stephanie was a previously healthy girl who was hit by a car while crossing the road. Mark has only just arrived on the unit, having had to return from holiday. He is about to go to university to study law. He is unsure what brain stem death is and why the doctors can’t leave her on the ventilator until her head is better and she wakes up. He is obviously extremely upset at not having been able to come home earlier.
Please sensitively discuss with Mark why you are performing a brain stem death test and what this might involve. You do not need to talk about Stephanie’s management previously. The brain stem will show brain stem death. There will be no chance of recovery.
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 a specialist registrar working in an outpatient clinic in a general district hospital. You receive the following letter from a GP:
Thank you for seeing Steven, a type one diabetic who has been under my care for a number of years although I have only intermittently seen him since his last appointment at the diabetic clinic last year. Worryingly he was recently admitted in DKA with a poor record of his sugars in the preceding days. His mother has become concerned with his behaviour and is wondering whether his poor control recently is due to a change in his diabetes.
I would be very grateful for your help managing Steve’s recent change in control.
BACKGROUND
Steven was diagnosed 6 years ago and has been on regular subcutaneous insulin since. His control has generally been very good and his last HbA1c measured at the diabetic review clinic last year was 6.5%.
Take a history from Steven and his mother and present your management plan to the examiner.
COMMENTS ON STATION 1
DIAGNOSIS: AORTIC STENOSIS
It would be nice if every child seen in the cardiovascular station has obvious signs and symptoms – but they don’t. You may have a child with an unusual congenital heart defect whose abnormality is impossible to determine on clinical examination. So it is important to know what to rule out if your child has a murmur of indeterminate origin.
In this case you know the child has a systolic murmur without the presence of previous surgery or heart failure. What could this be?
As the child is not cyanosed, and there are no scars, this child does not have an uncorrected cyanotic heart condition (tetralogy of Fallot, pulmonary atresia without a ventricular septal defect, etc.). Ventricular septal defect is a fair guess in a well child, although it is unusual to have a defect which isn’t loudest at the lower left sternal edge. How do you rule out potentially more sinister defects? Pulmonary stenosis classically presents with an ejection systolic murmur maximal at the left sternal edge with an ejection click and split second heart sound. If all patients presented classically I think the exam would be a lot more fun! Fortunately aortic stenosis has a sign which cannot be present with other anomalies: a carotid thrill. The textbooks tell you a suprasternal thrill but pulmonary stenosis may also produce this. If a thrill is felt in the carotid region (and it is obvious, I promise!) then the murmur must be due to aortic stenosis. If you don’t feel a thrill you are not much better off, as it could still be aortic stenosis, and all the other differentials! But it is an important negative.
If you ascertain the presence of a thrill then you should start feeling comfortable as there are a number of other features to start looking for, all relatively easy to learn.
Did you remember to ask the examiner to check peripheral pulses and perform a blood pressure?
REMINDERS
Turner’s syndrome (full details can be found on p. 184) 5X (although mosaicism possible)
Cardiac disorders are the cause of increased mortality in this syndrome
Aortic coarctation most common cardiac defect
Dental malocclusion increased, so prophylaxis vital
Predisposition to keloid scar formation (child may have cardiac surgical scars)
Indication for using growth hormone (and consider using steroid to increase final height).
| Aortic stenosis | Tips |
|---|---|
| Exam | Apex beat (do you always examine this?) may be displaced |
| Suprasternal and carotid thrill | |
| Systolic murmur in aortic region and left sternal edge | |
| Have you felt for peripheral pulses? (Associated with coarctation) | |
| The slow rising pulse is a very difficult sign to elicit | |
| Have you listened to the back? (Not always helpful but there shouldn’t be radiation, unlike in coarctation) | |
| A budding cardiology professor may pick up the diastolic murmur of aortic incompetence, which is more likely to occur post-surgery | |
| Investigation | ECG normal in the well child but may show signs of left ventricular hypertrophy:
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