Circuit H
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 asked to examine a 4-month-old infant who has been referred to you because a murmur was heard at a routine health check.
CLINICAL SCENARIO
The infant looks small for his age but is pink and well perfused. You ask the mother to undress the child carefully and then perform a full cardiovascular examination.
The child lacks substantial muscle bulk but you find good peripheral pulses, heart rate of 140/min, with no cyanosis. The child’s respiratory rate is 50. There are no scars on the chest, and the mediastinum is not displaced. A long systolic murmur is heard loudest at the lower left sternal edge and radiates throughout the precordium but not to the back. There is a palpable thrill at the lower left sternal edge but no heave.
What further examination features would you wish to elicit at this point?
What additional information would you request at the end of the examination?
What investigation would you primarily request and what lesion do you expect to find?
INTRODUCTION
On entering the room you are asked to perform an abdominal examination on the 1-month-old child who recently presented to a paediatric ambulatory clinic.
CLINICAL SCENARIO
The infant is alert and active. It is clear from initial inspection that the child is jaundiced. There are no peripheral stigmata of abdominal disease. The pulse is 130/min and the CRT is less than 2 seconds. The infant has yellow sclera and has no pallor. The respiration is comfortable and there are no scars or skin abnormalities visible on the chest.
The abdomen is distended asymmetrically, with the right side more prominent. There are no scars or distended veins. The abdomen is soft and nontender. You find a palpable liver three finger-breadths below the right costal margin. There is no other organomegaly or masses. Bowel sounds are present. There are normal male genitalia. There is no lymphadenopathy. A dirty nappy is next to the patient.
What is the most important diagnosis to exclude?
What further information do you request to supplement your examination?
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
The girl is sitting down next to her mother. She looks well and is the appropriate size for her age. She tells you she is able to walk without assistance. She has her lower limbs sufficiently exposed and is able to get up from the chair without any problem. There is no obvious wasting or deformity to her legs. You ask her to walk to the end of the room and then to walk back. No abnormality is apparent. You ask her to walk on her tiptoes, on the sides of her feet and on her heels, all of which she is able to begin to do but with difficulty. She stumbles on a few occasions. You ask her to stand upright, feet together, and find she is stable; however, when Romberg’s test is performed it is found to be positive.
The examiner asks you what you would like to examine next.
You move on to examine her lower limb neurology. Tone and power in both legs are normal. You elicit knee jerks but have great difficulty in obtaining an ankle reflex response. You are not sure whether this is your technique or a positive clinical sign. You continue on to examine sensation, which appears intact. Joint position sense, however, appears to be absent bilaterally in the big toes and ankles. You suddenly remember you haven’t examined coordination or the plantar response but the examiner stops you due to time restraint.
How would you present your findings and what additional information would you request from the examiner to supplement the examination?
What would you expect to find on testing vibration?
You are not asked for a diagnosis, but what would you be considering?
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 asks you to examine a 5-year-old child who presented to the ward with a cough.
CLINICAL SCENARIO
The child looks well, with no sign of respiratory distress. He is not requiring oxygen and can respond to questions in full sentences.
You note on general inspection that he has bilateral hearing aids, has a vertical linear scar in his top lip and has a portacath on the left side of the chest. You enter into your routine respiratory examination and find that he is clubbed but has no peripheral or central cyanosis. His pulse is 100/min and his respiratory rate is 25/min. He has no other external facial abnormalities and on oral examination you note that the hard and soft palate are also scarred.
On chest inspection you note the portacath on the left and a healed scar on the right side from a presumed previous port. There are no other scars. The chest expands equally and has a resonant percussion note throughout. There are coarse diffuse breath sounds bilaterally on auscultation but no focal crepitations or bronchial breathing. You examine for a liver edge and it is not palpable.
What clinical sign may be present on deeper examination of the mouth?
How will you present this information to the examiner?
What further aspects of the clinical examination are required?
What additional bedside tests would you perform?
Can you demonstrate to the examiner how to check for clubbing?
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 the examiner instructs you to examine a system of your choice in the child in front of you.
A school-age Caucasian boy is seated next to his mother. He is wearing glasses. You note that he has a marked pearly pink acneiform rash over his nose and cheeks.
CLINICAL SCENARIO
You inform the examiner that you would like to examine his skin for other lesions associated with the condition.
In his hands you note periungual fibromas on a couple of his fingers. The chest reveals a number of smooth-bordered hypomelanotic patches. You also note a number of pigmented café au lait patches.
The examiner agrees with your findings and asks if you would like to examine any other systems. What physical findings would you wish to elicit to show your understanding of the condition?
The examiner asks you if there are any questions you wish to ask the mother. How would you respond and what would you ask?
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
You are instructed to talk the examiner through your developmental assessment of this 3-year-old girl. The child is accompanied by her mother and you note that she is in a pushchair with specific modifications for positional support. You make the following observations:
• Gross motor: You see spontaneous movements of all four limbs but with apparent spasticity bilaterally. She has poor head control. You ask her mother regarding her ability to roll, sit or stand and find that she will do none of them.
• Fine motor and vision: She does not reach for objects. She will hold toys placed in her hand but does not transfer them. There is no demonstrable pincer grip, though she has lost the grasp reflex. You note that she has bilateral coloboma of the iris. You test her ability to fix on your face and follow it to 90 or 180°. You do the same with a red toy and in both situations note that she is unable to follow. She appears to have a wandering gaze.
• Speech, language and hearing: You ask if the child has any language – noises, coos, babbles, words. The mother explains that she simply makes screams or non-specific noise. You ask if the child has had a hearing test and whether she seems to respond to noises by startling or quietening to her mother’s voice.
What tests do you know for hearing and vision at different ages that may be appropriate for a child with this level of developmental delay?
• Social, emotional and behaviour: You are unable to elicit any smiles or laughter and ask the mother if there have been any such actions noted by her. You note that the child is still in a nappy. The mother tells you she is fed orally but is fully dependent for toileting, though will cry when ‘dirty’.
What is the developmental age of this child in each of the areas of development?
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 are to inform the mother of James that he has had two surface swabs positive for MRSA which were taken on his arrival at your unit. You should advise her of the management plan. James is to be nursed in isolation and receive topical treatment for the MRSA. He was previously in an SCBU bay with five other babies.
BACKGROUND INFORMATION
James was born at 38/40 gestation by elective LSCS with a birth weight of 3.7 kg. He is his mother’s first baby. At the 20/40 antenatal scan he was found to have gastroschisis. He was delivered at the tertiary centre and operated on shortly after birth. He has recovered well and was transferred over to your hospital (his local DGH) for establishment of breast-feeding on day 14. His scar is healing well and he is now on full enteral feeds. He is still awaiting the results of his chromosome analysis.
His mother is a 34-year-old history teacher.
How will you introduce the topic of MRSA?
If the mother reacts aggressively, how will you calm her?
The mother has heard of the ‘killer bug’. How do you address this?
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 to give the results of the investigations, formulate a management plan and convey this to David’s mother.
BACKGROUND INFORMATION
David is 19 months old. He was seen 4 weeks ago in the paediatric admissions unit. He had presented with a history of tasting a small amount of peanut butter and within 10 minutes having developed a blotchy, raised erythematous itchy reaction over his whole body. He had become wheezy at this time, though this resolved with no specific treatment. He received paracetamol only.
His subsequent examination and developmental assessment were normal.
He has a family history of atopy, with his father suffering from asthma and his mother suffering from hay fever.
He had the following investigations:
• RAST to peanut 200 IU (negative to other nuts and milk)
• Skin test to peanut ++++ (negative to other nuts and milk).
What management plan would you recommend and would you prescribe the adrenaline (epinephrine) pen device (EpiPen)?
What additional follow-up would you arrange?
How could you check that the mother has understood your instructions?
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.
SCENARIO
You are to see Clare, an 8-year-old girl with Rett’s syndrome.
Your task is to take a focused history regarding Clare’s diet and recent problem of poor weight gain and formulate a management plan.
COMMENTS ON STATION 1
DIAGNOSIS: VENTRICULAR SEPTAL DEFECT REQUIRING MEDICAL/SURGICAL INTERVENTION
It is important when performing the cardiovascular exam to be thinking of what your findings imply as you go. The fact that the child is pink suggests that there is an acyanotic cardiac lesion. However, the evidence of poor growth and distress indicates the lesion is compromising. This child has a ventricular septal defect and must be examined for signs of failure. In this case it would be important to examine the abdomen for a palpable liver edge (and if present decide if it is pulsatile/smooth and determine the liver span by percussion) and then check that the femoral pulses are present. As the child has a thrill the murmur must be at least grade 4.
This child will need referral to a paediatric cardiologist for input in regard to diuretics, ACE inhibitors and surgical closure of the defect. Do not forget to comment on the child’s nutritional status – feeding will be an issue and the child will need calorie supplementation and potentially nasogastric feeds.
At the end of all cardiological examinations it is useful to state what you would go on to do and be prepared to do it. The following are general but not specific:
1. Measure the blood pressure.
2. Plot the weight, length and head circumference on the appropriate chart.
3. Dipstick the urine (for haematuria associated with endocarditis).
An ECG would be useful in determining any electrical abnormality and may help narrow the differentials. You should by now have a well-structured approach to the childhood ECG. It may be complicated by age, congenital heart defects and conduction defects, but a few simple steps can help you locate the abnormalities and look for evidence of developing complications. The two key features to comment on are:
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