Circuit G
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 room you are presented with a small infant. The examiner says, ‘Please examine the cardiovascular system of this 3-week-old baby girl and present your findings’.
CLINICAL SCENARIO
On general inspection you note that the baby is not dysmorphic and is pink and well perfused. There is an obvious left-sided scar. The child is not attached to any monitoring and has no clinical signs of respiratory distress, clubbing or cyanosis. Interestingly, the left hand appears cooler than the right and when you come to examine the brachial pulses the left appears weaker. The heart rate is 140 beats per minute. There is no hepatomegaly and the femoral pulses are palpable with no radiofemoral delay.
The left-sided scar runs from just below the nipple backwards and inferiorly to beneath and behind the armpit. There is also a 1 cm scar just inferior to its lower border. On auscultation a long systolic murmur, without a thrill, is heard throughout the precordium, radiating to the back. The first and second heart sounds are normal, as are the breath sounds.
What defect does the cardiovascular findings suggest and what bedside test would be important to request?
As you present your findings you notice she has fat and puffy feet. Is this of significance and what other findings may be present on the examination?
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 asked to examine the abdominal system of a 10-year-old boy.
CLINICAL SCENARIO
On initial inspection you note a pale boy who has a rounded face and patchy loss of hair to his scalp. His conjunctivae are pale but there is no evidence of scleral jaundice. His mouth is normal with no ulcers. On asking him to remove his T-shirt you notice that he has a pouch hanging around his neck into which is placed the end of a dual-lumen catheter (one red, one white) tunnelled to the right upper chest. There are a few petechiae across his chest. Respiratory and pulse rate are within the normal range for age.
What differentials will you have in mind at this point? What else will you specifically examine in addition to the abdomen?
His abdomen is mildly distended without scars or venous abnormality but he does have obvious striae. His liver edge is palpable three finger-breadths below the costal margin and the spleen palpable four finger-breadths below the costal margin. The rest of the examination is normal.
How will you present these findings to the examiner?
What bedside information would you request from the examiner?
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
A well Afro-Caribbean girl is seated cooperatively on a chair. You are told, ‘Please examine the eyes of this 6-year-old girl, who presented with morning vomiting’.
CLINICAL SCENARIO
On general inspection she is not dysmorphic. You examine in the following order:
• Acuity: Testing each eye individually (Snellen chart) – no defect.
• Visual fields: Testing each eye individually – no defect.
• Eye movements: You note that there is reduced lateral movement of the left eye. All other movements of both eyes are normal. The girl complains of diplopia on left lateral gaze. There is no nystagmus.
• Squint: You find that there is no tropia or phoria present.
• Pupils: The pupils are equal and reactive to light and accommodation.
• Fundoscopy: You find bilateral mild papilloedema (blurred disc margins and venous congestion) with no haemorrhage or exudates.
What nerve(s) are involved to give this pattern of external ophthalmoplegia?
What is the most likely cause of the vomiting?
What are the causes of the above condition in children?
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
The examiner tells you that this 7-year-old child has presented to his GP many times with a nocturnal cough. Could you examine his respiratory system to find out why?
CLINICAL SCENARIO
The child appears well grown and is breathing comfortably at rest. You ask him to remove his T-shirt and sit up on the couch. On general inspection you note that he has mild respiratory distress (intercostal recession) with a respiratory rate of 35 per minute. He appears to have prominent chest musculature and Harrison’s sulci bilaterally. He has no peripheral stigmata of respiratory disease, has a pulse rate of 90 beats per minute and is not centrally or peripherally cyanosed.
There is no palpable lymphadenopathy in the cervical or axillary regions. The chest has no scars. There is an apparent increased anteroposterior diameter when assessed from the side. You examine the front completely, followed by the back. There is bilateral equal expansion and resonant percussion note. There is a mild diffuse expiratory wheeze throughout the chest. There is no palpable liver edge.
What is the most likely diagnosis?
What part of the respiratory system examination should you offer to examine next?
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 invited to comment on the appearance of Crystal, a 6-year-old girl.
CLINICAL SCENARIO
Crystal is lying on the couch accompanied by her mother (who is wearing glasses and has multiple ‘skin tags’ apparent on her face). On general inspection Crystal has no striking abnormalities. You ask her to remove her vest and sit up for you. At this point you notice a number of brown pigmented patches with smooth outlines of variable size over her abdomen and chest.
You begin formal examination at the hands, moving up the arms to the axillae, which appear freckled. The face is not affected and there are no mucosal lesions in the mouth. The anterior and posterior aspects of the chest have multiple (> 5) pigmented patches present, with the largest measuring 10 x 15 cm approximately.
What is your current working diagnosis?
You present your findings so far to the examiner and explain that you wish to examine the child for associated features.
What systems will you now examine and how will you structure your examination?
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, the examiner asks you to assess the motor development of an infant the Child Development Centre have been following up.
CLINICAL SCENARIO
The infant is accompanied by her mother. On initial general inspection you find her to be looking around lying on her back. She is moving all four limbs, is able to reach out for bright toys, pass objects from hand to hand and to place them in her mouth. She turns to her mother’s voice but makes little noise and no words herself.
You ask the mother if you may examine her more closely. With permission you then formally test the motor development (gross and fine motor).
On pulling to sit there is reduced truncal tone and mildly reduced head control. She is unable to sit unsupported. When held vertically, she will put weight on both legs and bounce weakly. She will not support herself or hold on to the cot side for support. In ventral suspension you again note impaired head control (to 45°) and truncal hypotonia. On lying her down on her front the infant will push on her hands a limited amount. You move on to test the Moro reflex, which has been lost.
You test fine motor control initially with a single bright red brick, which she takes in a full palmar grasp and transfers from hand to hand. A second brick is introduced, which she takes in her other hand and then bangs the bricks together. She is not able to scribble with a crayon, build blocks into a tower of three or put pieces into a simple jigsaw.
What is the developmental age of this child in the area of gross motor development?
What is the developmental age of this child in the area of fine motor development?
What additional developmental reflexes could you describe or test in this child?
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
Dean (12 years old) has been brought for review in clinic following a recent admission. Your task is to discuss with Dean and his mother the need for a regular inhaled steroid for control of his asthma. You should also confirm the family’s understanding of the management plan for an acute exacerbation.
BACKGROUND
Dean was recently admitted for 5 days to the children’s ward with a severe acute exacerbation of his asthma. Over the preceding 12 hours he had been using his salbutamol inhaler every 20 minutes at home with no improvement. In the emergency department he had required oxygen, salbutamol and ipratropium nebulisers, i.v. salbutamol and i.v. hydrocortisone in order to see improvement.
He had been discharged home with a short course of oral prednisolone and, as required, inhaled salbutamol by spacer. His mother had refused to start him on inhaled steroid at discharge but was happy to come to an outpatient appointment to discuss the options.
Dean was a normal term delivery and has a normal developmental history. He has no other medical problems and takes no other medication. He lives with his mother (a heavy smoker) and sister, both of whom suffer with eczema. He has a significant persistent night-time cough and daytime wheeze with exercise.
Do not take any further history.
You will not be asked any questions by the examiner, but you must be prepared to answer any questions from the patient or his mother. You may not discuss all the possible information in the time appointed but will be expected to cover individual areas in sufficient detail.
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 presented with Donna, a 21-year-old in her first pregnancy, now at 24 weeks’ gestation. She was admitted through the emergency department with lower abdominal cramps and vaginal fluid loss. She has been assessed by the obstetrician and given steroid as he feels she is at risk of pre-term delivery.
You have been asked to discuss with Donna and her partner Jamie the resuscitation and stabilisation of the baby if it is born at 24 weeks.
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 SpR in a paediatric outpatient clinic at a district general hospital. You have received the following referral letter from a GP:
I would be grateful if you could see this 5-year-old boy in your outpatient clinic with regard to his episodes of loss of consciousness. He has developed these episodes over the preceding 4 months and has been seen in the local emergency department on one occasion following an occurrence at school. A 12-lead ECG, BP, FBC, glucose and U&Es at this time were normal.
He was born by NVD at term and has shown normal development to date. He has no other past medical history and takes no medication. He has one elder sister (8 years), who was diagnosed with febrile convulsions at age 3 years and has had no further problems.
He has recently moved to a new school and his parents feel he has settled in well.
I wonder if he may have a seizure disorder or cardiac dysrhythmia.
You are to take a targeted history from James (5 years) and his parents (John and Mary) with regard to these episodes of ‘loss of consciousness’ and formulate a management plan. You are not expected to examine the child.
COMMENTS ON STATION 1
DIAGNOSIS: REPAIR OF AORTIC COARCTATION; TURNER’S SYNDROME
A thorough knowledge of cardiovascular defects, their management and their sequelae is vital for the exam. It is important that you know what the common scars look like – reading about a lateral thoracotomy scar is not the same as having seen one. In this case the small secondary scar is probably from a chest drain.
It is important to let the examiner know that you would measure a four- limb BP in addition to plotting the length, weight and head circumference on the appropriate chart. An ECG, CXR and echocardiogram are essential firstline investigations of a significant murmur with no innocent features.
This child has had a repair of aortic coarctation; the pedal oedema is important as it suggests an underlying diagnosis of Turner’s syndrome. It is not a feature of cardiac failure in this circumstance. Karyotyping of a blood sample will be diagnostic in the majority of cases.
The clinical features of Turner’s syndrome (congenital lymphoedema, short stature and gonadal dysgenesis) can be divided into neonatal, childhood and adolescent findings. You should become familiar with Turner’s syndrome as the children are generally well but require prolonged follow-up. Extensive detail is provided here as this same child could be used for the communication skills stations – ‘Explain to this child’s parents what a diagnosis of Turner’s syndrome means?’ – or as a history-taking/ management-planning scenario.
| Age | Clinical findings |
|---|---|
| Neonatal | Dorsal oedema of hands and feet |
| Redundant nuchal skin folds (secondary to in utero cystic hygromas) | |
| Low birth weight and reduced length | |
| 17-45% cardiac lesion (bicuspid aortic valve, coarctation of aorta, aortic stenosis, hypoplastic left heart) | |
| Developmental dysplasia of the hip (DDH) more common | |
| Childhood | Short stature (proportional) |
| 10% developmental delay | |
| Facial abnormalities (epicanthic folds, small mandible, prominent ears, high palate) | |
| Webbed neck | |
| Low posterior hairline | |
| Prominent ‘shield’ chest | |
| Widely spaced nipples | |
| Cubitum valgum | |
| Hyperconvex fingernails | |
| Grommits for ‘glue ear’ common | |
| Teenage | Failed onset of pubertal development (10% have breast enlargement) |
| Progressively more prominent pigmented naevi | |
| 30% renal abnormalities | |
| 70% impairment of non-verbal perceptual motor and visuospatial skills | |
| 15-30% hypothyroid | |
| Scoliosis, lordosis and kyphosis more common |
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