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?

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?

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?

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?

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?

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.

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.

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.

INFORMATION

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

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.

DIAGNOSIS: VENTRICULOSEPTAL DEFECT

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!

DIAGNOSIS: HEREDITARY SPHEROCYTOSIS

Contrary to popular belief in the hot, stuffy and brightly lit exam room, it is not always easy to pick up peripheral signs of abdominal disease. When one of the authors mentioned he was unable to detect evidence of anaemia in his patient, her mother immediately said, ‘I know, I have never seen her cheeks look so rosy!’. The examiner admitted the patient looked neither jaundiced nor anaemic despite the diagnosis and the candidate was spared the blushes of admitting he had made up signs he thought should have been there.

The mother has had her gallstones removed (also having hereditary spherocytosis!).

CAN YOU

Explain a new diagnosis of hereditary spherocytosis to a family who are unfamiliar with the condition?

DIAGNOSIS: CEREBRAL PALSY

There is no excuse for not knowing your neurological exam inside out. The difficulty for some candidates is that, despite knowing how to perform the ‘perfect’ exam, the application and interpretation of the results are still difficult. You are also faced with the problem of guessing what the examiner would like you to do. It is very easy to get distracted from your examination routine because you are concerned about getting the whole answer.

For example, the candidate in our scenario notices the microcephaly and wants to examine the patient’s eyes. The examiner, having demonstrated a spastic gait, is annoyed as he feels he has given a clue to examine the lower limbs. He informs the candidate of this, so they go on to look at the legs. While examining the lower limbs, the examiner then becomes annoyed by the thoroughness of the candidate. Having demonstrated a microcephalic child with a spastic gait he feels you should quickly demonstrate just the increased tone and brisk reflexes. He says, ‘If you’re not quick you won’t have time to look at the eyes’ – which the candidate was stopped from doing in the first place!

It is probably easier to examine peripherally rather than centrally when you are under pressure. Therefore examine the legs first, giving yourself time to collect your thoughts. Don’t be distracted by neurological signs in isolation, i.e. the eye signs must be taken with the microcephaly and spasticity.

As your head doesn’t tend to shrink, it is likely an insult has occurred early in life.

In the neurological exam you must always be thinking:

Learn a good definition of cerebral palsy and know some causes (although in this case you can only give a differential).

REMINDER

A functional assessment should reveal what a child can do. Therefore if asked to perform this specific instruction, in the appropriately aged child, ask:

A quick way to uncover/ascertain a multidisciplinary approach is via the ‘POSH’ questionnaire:

DIAGNOSIS: PREVIOUS PNEUMONIA LEADING TO BRONCHIECTASIS (UNABLE TO DETERMINE THIS FROM INFORMATION GIVEN)

A frustrating element of the exam is sometimes there not being an ‘answer’. Many children are diagnostic dilemmas and have had multiple investigations, many treatments and thousands of membership candidates prodding and poking them. It is easy to convince yourself a sign must be there. To misquote the Jedi Master Yoda: ‘Maybe not. A clinical sign or no clinical sign. There is no maybe.’

Producing a list of possible investigations is of no benefit if you don’t know why you are doing that test.

The differential diagnosis of chronic cough amongst all ages:

It is vital in the respiratory case that an effort is made to assess the presence of clubbing, as you can see from the above table that the differential diagnosis is radically changed.

This child was not clubbed and his chest wall was not overtly hyper- expanded. You are told the cystic fibrosis screen was negative. Further history reveals he had a severe pneumonia a couple of years ago which has left him with permanent lung damage and some evidence of evolving bronchiectasis. Repeated chest infections have been a problem and while you were examining his hands you note a paucity of veins for his age (explaining the need for definitive access).

DIAGNOSIS: NEUROFIBROMATOSIS

Unlike Station 4, when the answer might not be obtainable from the examination findings alone, it may be just you who doesn’t have a clue! In this scenario the candidate recognised the large right leg and remembered something about hemihypertrophy and renal masses (suggesting an ultrasound when asked about investigations). He was asked what else he would examine and drew a blank. The examiner then demonstrated the large ipsilateral arm and an even more obvious unilateral tongue enlargement. The candidate had no idea and left deflated and confused, only noticing the café au lait spots as he left the room. Subsequently he passed the station probably just for picking up the original sign. Until you get the mark sheet you do not know how you have performed!

REMINDER

CAN YOU …

List causes of café au lait spots?

DIAGNOSIS: ISOLATED SPEECH DELAY

Candidates commonly forget that specific elements will be asked for. In this case only speech and language are being assessed, so the child copying a circle will not gain you marks. However, if told to draw a circle this shows a certain level of language appreciation and at least the ability to hear. But if the child is barely three (may not be able to draw a circle) then this is an unfair request. Therefore you need not only to know your developmental milestones inside out, but you must also be precise about the area they are testing and know how to apply them consistently.

Unless directed otherwise, it is entirely reasonable to ask the mother her child’s level of functioning. ‘Can your child hear and see?’ will save 9 minutes of embarrassment.

Asking the child to place certain objects inside a cup or take them out of a box assesses understanding and requires only a small level of gross motor functioning.

If you have a visual memory the College-recommended Child Development: An Illustrated Guide is very useful.

REMINDER

The McCormick Speech Discrimination Test uses 14 paired words which should be recognisable by children from the age of approximately 2 years old. A set of toys are placed in front of the child, and the child is asked to name them all (the toy is removed if not identified correctly). The examiner covers his mouth and asks the child to show him or her one of the toys. The ideal level is 40 dB but in the exam situation you are merely demonstrating the principle.

Examples

NUTRITIONAL HINTS

Already you can see that there is a massive amount to cover in the 13 minutes available. The examiner will be looking for the candidate who is able to cover a large amount of ground quickly but without rushing. They will need to highlight points which require immediate input, at the same time elucidating factors which will need long-term management. Experience in CF (and other chronic disease) clinics will be invaluable in getting an overview of the complex needs of these patients. As stated previously, you must be observed by senior staff taking histories as it is something you will have rarely done since being a student.