Circuit D

Circuit D



STATION 1


This station assesses your ability to elicit clinical signs:



• CVS



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 boy approximately 8 years old. You are told, ‘Please examine Jonathan’s cardiovascular system and present your findings’.



CLINICAL SCENARIO


The child looks well. Peripheral examination is normal. The only positive examination findings are an obvious thrill at the lower left sternal edge and a harsh systolic murmur heard throughout the precordium but loudest at the lower left sternal edge.


What do you say to the examiner?



STATION 2


This station assesses your ability to elicit clinical signs:



• Abdo/Other



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 4 years old. You are told, ‘Please examine Sally’s abdominal system and then present your findings’.



CLINICAL SCENARIO


The Caucasian child looks well. She is not obviously anaemic and you cannot convince yourself whether she is jaundiced or not. Her abdomen is soft and non-tender. Her spleen is palpable to three finger-breadths and you cannot feel a liver. There is no other obvious clinical sign present.


What do you say to the examiner?


Why does her mother have a scar in her right hypochondrium?



STATION 3


This station assesses your ability to elicit clinical signs:



• Neurological



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 2- to 3-year-old girl. She is obviously microcephalic and developmentally delayed. The examiner invites you to comment on her appearance.



CLINICAL SCENARIO


You note her microcephaly and comment that her gaze seems deconjugate. The child is then asked to walk across the room and back. At this point you notice she is wearing ankle supports (ankle-foot orthoses: AFOs). Both her hips and knees are flexed and the weight of her body seems to be balanced on her toes. In order to move forwards she rotates her body to one side to bring forward her leading foot. The examiner asks you what you would like to examine next.


What do you say and what will you be looking for?



STATION 4


This station assesses your ability to elicit clinical signs:



• Respiratory/Other



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 boy approximately 12 years old who is sitting upright on a couch without his top on. There is a semicircular scar above the left nipple. He breathes easily with a normal respiratory rate. You are asked to examine his respiratory system.



CLINICAL SCENARIO


Clinical examination is unremarkable although you are unsure as to whether he is hyperexpanded or not. You mention this to the examiner, who asks you how you would confirm this.


He then tells you the child has been suffering from persistent chest infections for some time now.


What must you examine his hands for?


What investigations would you like to do?



STATION 5


This station assesses your ability to elicit clinical signs:



• Other



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 an adolescent girl. She looks well. The examiner informs you she has had multiple falls recently and her mother is worried she has become clumsy when she walks. Please assess this child.


How will you commence your examination?



CLINICAL SCENARIO


You examine her gait and it is entirely normal. You can find no problems with her balance and her lower limbs have normal tone, power and reflexes. You are perplexed until you notice that her left leg appears larger than her right.


How will you proceed?



STATION 6


This station assesses your ability to assess specifically requested areas in a child with a developmental problem:



• Development



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


You are informed that the child you are to assess is 3 years old. You are asked to examine her speech and language development.


How do you proceed?



CLINICAL SCENARIO


Her mother tells you that she only uses two to three words maximum and apart from ‘no’ the other words are unrecognisable.


The examiner would like you to demonstrate that she truly understands specific tasks requested of her.



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:



• Communication One



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 in paediatrics working in a district hospital.



SCENARIO


Your SHO has seen a 6-month-old child whom you suspect may have meningitis. You wish to perform a lumbar puncture before commencing antibiotics. Please explain this procedure to the child’s mother. She is aware of why the lumbar puncture must take place and you need not take any further history.



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:



• Communication Two



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 neonatal registrar for a tertiary neonatal unit.



SCENARIO


You have just completed a neonatal ward round. You spent some time discussing Robert, an ex-24-week preterm infant who is now 27 weeks corrected. He has had a stormy course and is still ventilated. However, his respiratory condition is improving and it is hoped he will be put onto CPAP soon. He has recently started feeds, having been on a course of TPN. He has avoided any septic complications but unfortunately has biventricular grade 4 haemorrhages on ultrasound scan. A medical student, Tanya, asks why the team are still treating Robert, as she has heard this kind of haemorrhage always leads to cerebral palsy and isn’t this unfair?


Tanya is on an attachment to the unit and is well known to you. A prolonged introduction is unnecessary. She is also familiar with Robert’s history so you need only focus on the relevant issues to answer her question.



STATION 9


This station assesses your ability to take a focused history and explain to the parent your diagnosis or differential management plan:



• History-taking and Management planning



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 paediatric SpR working in a general outpatient clinic in a district general hospital, where you have received the following letter:



Dear Doctor


Re: Monique 7 years


Thank you for seeing Monique, whose family have recently returned from France, where they have been living for the past 7 years. Monique’s mother is English and tells me she has been diagnosed with cystic fibrosis. She was managed by a medical team in France but a transfer letter they had written has been lost. Her mother has kindly listed some of the medications she is on but I am not familiar with all of them. I feel Monique needs some more specialist management and was hoping you could make a detailed referral to the closest tertiary centre.


Your help is appreciated.


PS. Monique is on the 2nd centile for weight and 9th for height.


Take a history from Monique and her mother, for whom you have no background history. Discuss your referral and management plan with the examiner. You do not need to explain your plan to Monique’s mother.



COMMENTS ON STATION 1



DIAGNOSIS: VENTRICULOSEPTAL DEFECT




‘I have examined Jonathan, who is a well-looking boy, and I would like to plot his height and weight on a growth chart. There is no evidence of cardiorespiratory distress and positive findings are a thrill at the left sternal edge with a grade 4 pansystolic murmur loudest in this region. This is a VSD and I note there is no evidence of heart failure.’


With ventriculoseptal defects being the most common congenital cardiac anomaly, these (one would hope) will be the murmurs you are likely to hear. The VSD is a must-know station. You must be able to diagnose this with confidence. For some candidates this will mean hunting high and low for a cardiology clinic or attending a specific course. The advantage of assured diagnosis is not only in the confidence it will give you in the exam but also the examiner will find it much easier to test you. Easy marks are subsequently gained for knowing investigations, antibiotic prophylaxis and indications for surgery. These cannot be asked if you are still deliberating as to whether it is aortic stenosis!









Tips
Exam A loud second heart sound suggests pulmonary hypertension (from a large shunt) until proven otherwise Feel the suprasternal notch (a thrill there means AS, or rarely PS) A thrill means the murmur must be grade 4:

1. Soft and heard with difficulty


2. Soft but easily heard


3. Loud but without thrill


4. Loud and associated with thrill


5. Loud, with thrill but stethoscope must be in contact with chest wall


6. Audible without the use of a stethoscope

Related posts:

  1. Circuit F
  2. Circuit H
  3. Circuit B
  4. Circuit A

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Feb 14, 2017 | Posted by in PEDIATRICS | Comments Off on Circuit D

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