Circuit F
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 5-year-old child. You are told to examine his cardiovascular system.
CLINICAL SCENARIO
The young boy looks well. Peripheral examination is normal. Auscultation of the precordium reveals a soft systolic murmur at the upper left sternal edge. There are no scars, no thrills or heaves or radiation of the murmur. You note that the murmur disappears on changes of position.
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.
CLINICAL SCENARIO
There is a well-nourished but small-for-age infant lying at rest on the bed. He is fully clothed but his head appears slightly jaundiced. You mention this to the examiner but bear in mind he has some dysmorphic features you cannot definitely identify.
The examiner asks you to look at his abdomen, but not palpate it. There is a scar in the right hypochondrium.
You tell the examiner you are suspicious of biliary atresia as there is evidence of an operation: presumably a Kasai procedure has been performed.
Instead of congratulating you on your clinical skills the examiner says, ‘Bedside diagnosis already? Well then, can you listen to the child’s precor- dium and tell me what you find?’.
You listen to the child’s heart, wondering why, as this is an abdominal station, and are surprised to hear a murmur in the pulmonary area.
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.
CLINICAL SCENARIO
On inspection you notice that Jasmine has a tired expression, bilateral ptosis and is only in early puberty. Her proximal muscles, in particular, appear wasted but there is no fasciculation. Her tone appears normal, as do her reflexes. She is able to lift her arm up to shake your hand but her grip is weak. You proceed to test repetitive movement by asking her to imitate you making opening/closing movements of your hands. On repeated testing of her power you find she can lift her forearm from the bed but not against resistance.
What is the power grade (MRC) of her arm?
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 6 months old. You are asked to examine Simon’s respiratory system.
CLINICAL SCENARIO
You notice a plump but small-for-age child receiving oxygen via nasal cannulae. The child is plagiocephalic. His chest is hyperexpanded with normal vesicular breath sounds on examination. You note a small scar over the left lateral chest.
How will you present your findings and conclusion to the examiner?
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
You are asked to examine the eyes of a 13-year-old boy. His mother and sister are also in the room. His sister is in a wheelchair.
CLINICAL SCENARIO
On initial inspection you notice he is not dysmorphic, does not have ptosis or obvious ophthalmoplegia. You note he has brown eyes but no KayserFleischer rings. He has normal acuity, pupils, visual fields, fundi and eye movements. You are then asked to compare his eyes to those of his sister and finally to look closely at his eyes in the light – you note blue sclerae.
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 entering the room you see a bench containing a range of development assessment tools. You are asked to assess the speech and language of Matthew, a young boy of pre-school age.
CLINICAL SCENARIO
You introduce yourself to the mother and child. The child is sat at the foot of his mother and playing with a Thomas the Tank engine. He is about 3–4 years of age. He does not respond to your introduction. You attempt to engage him in conversation but get minimal response from the child and certainly no eye contact. He appears absorbed in his play. You ask the mother to engage with him. You notice he responds to his mother, although he continues to have his back turned. After repeated requests he eventually turns around.
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
It is the day after a bank holiday weekend and the ward pharmacist informs you that a drug error has been made. Steven, 13, who is meant to be receiving weekly methotrexate for arthritis, has instead received a daily dose over the bank holiday weekend. Steven’s mother is waiting in the parents’ room and is aware a drug error has been made. She is understandably upset over the potential consequences.
You must counsel Steven and his mother about the drug error and discuss what will be done about it.
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 have been asked to counsel and advise the mother of Peter, a 2-week-old infant. Peter’s Guthrie test had indicated congenital hypothyroidism and subsequent blood tests have confirmed this. You must explain the diagnosis, and discuss the potential problems and treatment options. The diagnosis is not in doubt and no further blood tests are needed.
BACKGROUND
Peter’s hypothyroidism was picked up by the normal screening process. Unfortunately, when he was brought to the unit for confirmation bloods there was a communication error between the SHO and the mother, who was told the results were normal (a patient with a similar surname had normal electrolyte results). When the consultant was told the result was normal he immediately asked for blood tests to be repeated as the child looked clinically hypothyroid. You have heard at a previous morning handover that the mother had been upset about the process.
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 in a district general hospital. You receive the following letter from a GP:
I would be grateful if you would see this young girl regarding constipation. I have previously prescribed laxatives but her mother has found that these have not helped. I would be grateful for your assistance, especially as Constance is now soiling and her mother is keen to solve this issue before she starts full-time primary school.
Take a thorough history from Constance’s mother and explain your management plan to her.
COMMENTS ON STATION 1
DIAGNOSIS: INNOCENT MURMUR
‘Jason is a well-grown boy and I would like to confirm this by plotting his height and weight on a growth chart. I note a soft, short systolic murmur grade 2/6 in the left upper sternal edge, which disappears on lying down, does not radiate and is not associated with a thrill or heave. Peripheral pulses are present. This is likely to be an innocent murmur.’
On auscultating a murmur it is important to describe it adequately such that you describe all the features heard and lead neatly to the final diagnosis. This includes commenting on the location, radiation, grade and duration within the cardiac cycle. The classification of grades is found on page 111.
Innocent murmurs are common in general paediatric practice and therefore you should be prepared to have this diagnosis in your differential. Be aware of the different types of innocent murmurs, e.g. pulmonary flow murmur, venous hum and Still’s murmur, and also the key features of ‘normal murmurs’. If there is any suspicion then a murmur should always be investigated, by ECG, chest X-ray and – the gold standard – an echocardiogram.
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