Last week i had visited my friend in Portlaoise(one of the county in Eire) and we 've had lengthy discussion about exam structure in Ireland
. There is major differences in MRCPI and MRCPCH
. Among others are;
1) Traditional system - ie still have long case and short cases. You can get anything, he mentioned to me cases he seen was a child who presented with collapsed. Ddx neuro, metabolic, cardio(prolonged QT), drugs related. He was given ECG to interpret. You can be given CXR(miliary TB), CT scan of tumour or calcified brain tissue(from hypoparathyroidism therapy) etc
2)You can be lucky, ie getting simple cases or difficult seeing cases may be unknown to you. The principle will still be the same. May need to utter specific treatment, multidiciplinary approach etc. You may get simple diabetes but bombarded with difficult q's like using insulin pump, research in diabetes etc. Or difficult q's like Apert syndrome but parents revealed each and every intervention for the child, you may be lucky enough to pass.
3)Short cases seem to be similar. You may get 2-3 cases depended on times. You need mental strength to get thro this. i also remember, you will have to sit for written paper ie short essays and imaging the week before. So time is the factor that you will have to overcome to complete the exam.
I am in my home country again.Just spending time with family for calming effect. It is totally different problems when you are out with your community or society.Some may have political agenda,some are related to socioeconomic background. Well,I'm not here to discuss the reality of life,which someday you may have to think about, but to bring another topic....What have you seen in Paediatrics
.
I am pretty sure each of us has seen rare and exotic cases as part of our learning process.The cases can be rare,which you've not seen before,or common but can be looked into other side of the coins. Lemme give you some examples of mine;
Rare cases;
1)Term baby born by vaginal delivery without any complication.She was brought to SCBU(Special Care Baby Unit)for mild jaundice and lethargy. She was found tobe hypotonic with poor cramming
reflexes.She was mildly dysmorphic with downslanting palpebral fissure.No other abnormality found on physical exam.Bloods were normal apart from elevated T3/FT4. She finally got MRI which showed no pituitary(rare case of panhypopituitarism).BTW,initially we suspect Prader Willi but the genetic testing came back normal
2)Term baby again was brought by SHO for possible seizure examined on Day 3.Seizure was thought to be focal on R sided of the body. Subsequent Obs
also showed 2 focal seizures, baby was put on lorazepam with phenytoin and subsequently pyridoxine due to unresponsive and prolonged seizure activities.All bloods to outrule sepsis and metabolic causes came back normal. Baby had a scan and it showed L side infarction despite normal antenatal and perinatal period.No obvious maternal or infants risk profile(cause of venoocclusive problem).
3)I have seen even cases of 4 year oldwith ADEM following mild varicella, 5yold with acute cerebritis needing shunt following rotavirus infection, 35 weeker accidentally found by me with bilateral dysplastic kidney(I did renal function with intention to check electrolyte but end up to do urgent USS to outrule PUV due to elevated urea & creat), newborn Down syndrome with clicky hip which I have to reveal/breakbad news toparents but was found to have transient blastaemia or abnormal myeloparesis and 14y old with juvenile multiple sclerosis initially under the surgeon for head injury but MRI revealed abnormal signal onpart of the brain.
Common;
14y old presented with recurrent chicken pox,he's immunocompetent and has had 2 previous documented episodes in his life time.
Odd cases of spina bifida occulta seen in the west despite fortification of folic acids but missed cases of using low dose folic acid seen in maternal risk like those who've been on anti epileptic medications.
Some rare cases may be seen like Cockayne syndrome, Aicardi,Campomelic dysplasia,congenital enteropathy depended on only milk feeding, also been seen but these group may have poor prognostic outcome!
Have you seen many??
fahi
p/s -if u r enthusiastic enough,you can write case report n compile in ur logbook!!
However you may try to divert from your life as paediatrician or physician, you have to encounter numerous pressure in life. I do believe you will have to be all rounder, ie knowing what is basic and useful for the benefit of yourself. For eg knowing the system where you work, political situation in the country you lived in, cultural differences. In short, be competent in every opportunity so that you will not be depending to others.
I once dreamed my dream home to be dependent on normal energy source like solar to power my own house. Car can be hybrid even solar generated or perhaps in the future will be on recyclable source of plant fuel! Well may be this is too imaginative. Wait! I also dreamed that one day clone can only be focused only to organ(not human) to prevent rejection issues!
Well, for now, you have to live in reality. Reality been dogmatic by certain way of life.Being a physician needs life long stamina. From houseman, to SHO, to registrar, to senior registrar/associate specialist, to consultant, to assoc prof ultimately professor. It doesnt stop there, you still have to climb the ladder becoming head of dept, dean of medical school, chancellor etc.
My point here is that you need perseverence and steadiness in your ambition. Am I talking rubbish? It doesnt matter, the moment you start doing something, there will be other jobs need completion. In this era(esp in my home country), it is reasearch driven. Papers though small, case report version may account for higher recognition. Therefore, all doctor will have to involve in research at some stage. Research can be simple and asking simple questions and how to go about.
For example
1) Is there any non invasive method for urine collection in non toilet trained apart from what is currently recommended?
2)Why varicella vaccine wane with time? What hypothesis leading to waning of immunity status?
There are many q's that you can ask yourself to think, to find solution and answer. I think we have encountered interesting cases but how we are going about, critically thinking to improve the research. When you are young you are energised with ideas, free of family and cultural distraction, and hardworking to complete the task. Time is precious, therefore use it carefully and correctly.
Sorry for being so dormant. I didnt make it in the last exam. Oh well I might just have to start all over again. My weakness remains the communication skills. Sometimes it's good not to be too confident, coz u will fall in a trap of becoming overconfident. My life as usual like normal. I started bz job in cardiology,hence time is so minute. I gotta find space for my revision. Workload being in tertiary centre is immense. Therefore, dividing time and keep the motivation up is essential.
You have ups and downs in life but oh what the hell, life goes on. Dont be intimidated with past performance. Think positive, I may not be fully ready to take higher responsibility. With knowledge then comes responsibility and dedication. At least I still have the chance!
I am planning for part 1 Irish as part 1 UK is useless to be exempted in Irish exam. In scenario where opportunity is there, you just have to grab what it comes. I think even if try to be ready, u never would be. Anyhow, I shall start my discussion again. For now, Peace be upon you!
Just wanna update memory q's in MRCPCH
written just today
Paper 1
1) Photo- thanatophoric dwarfism
2)15 y with acute confusion, felt warm. Exam NAD. Temp 37.5C.CRP 6, NH3 80, WCC 7.5.
Cause possible - meningitis or substance abuse
3)Baby had pH study. Hx of arching post feeds. important info - pH <4 during the sleep
4)Photo - Child with port wine stain. Important assoc -glaucoma. Other possibility - seizure but child is well from the hx
5)Scenario - 10 y old with diabetes
a. temp 39, BM 4.7, sore throat and fever 39.6C.
answer - check infection screen n give abx
b. Drowsy BM 1.6 - give glucagon
c.Drowsy. BM 26. Temp 35C - give bolus saline and check infection and give abx.
Other alternative - give insulin 0.05u/kg but I still believe immediate rx will be the above b4 starting insulin.
6)14 y old pubertal delay. Mum also had menarche at 14 y. Breast T2, Pubic T1. No abnormality on physical exam.
Dx - Constitutional delay
7)Photo - molluscum contagiosum
Advice - no intervention needed
8)Child with CF. Black tarry stool. Blood low Hb, plt, MCV. Distended abdo
Ans - bleeding 2 to portal HTN(liver disease). Hb low can also be assoc with Fe def anaemia
9)3 y old with prolonged bleeding time 7 min and high APTT
Ans - von Willebrand disease
10)Pt with IDDM. High HbA1c 12.Lost wgt, no lipo heperthropy. No family or school problem. High sugar. Know DM
with pos anti islet cell ab. What happen to her
Ans - Poor compliance
11)Scenario
Med for each medical condition
Tuberous sclerosis with seizure/spasm - vigabatrin
Status epilepticus - IV lorazepam
Myoclonic jerk - valproate
12)Photo - Eczema herpeticum on foot
13) Photo - Ulcer on foot - Hereditary sensory and motor neuropathy
14)Floppy baby born needing intubation, bag and ask
Ans _ Myotonic dystrophy
15)Child presenting with unexplained bruiselso had lymphadenopathy. FBC, coag normal. What other investigation needed?
16)Pedigree chart
Suggestive X linked dominant eg vit D resistant ricket. No father to son transmission
17)3/52 presented with temp, grunting
Suspect G-ve sepsis
18)3/7 old baby with hypoglycaemia. Exam - microphallus.
Ans - CAH
19)3 y old with stridor. Given steroid. Sitting anxiously on dad's lap. SpO2 88%.O2 given
Ans - call anaes & open airway like jaw thrust
20)14 y with sore throat. Lyphocytosis on bloods
Check EBV status
21)Audiology test - Severe sensoryneural hearing loss on 1 ear
22)9 y old with hx of Rolandic seizure. CXR LLL consolidation. Bloods - low Ig
Ans- Give Ig infusion
23)8y old with polyuria and polydipsia. Had water deprivation test showed wgt loss responding to DDAVP.
What other investigation needed?
Ans - MRI head
24)Phot - child with rash( appear after fever episode) Roseola infantum
25)2 y old with stridor. Started on dexamethasone. Review, persistent stridor
Give further dexamethasone
26)7/12 with diarrhoea and vomiting. Developed purpuric rash hematuria. Low Hb and high urea.
Dx HUS
27)5y afro carribean with 3rd pneumococcal mningitis. Developed hemiplegia. No abn on repeat LP after 7 days treatment. What is the cause of hemiplegia?
Cerebral infarct vs subdural effusion
28)4/12 oral thrush, spelenomegaly. CXR - haziness. Normal WCC.
Dx PCP (pneumocystis) - give co-trimoxazole & steroid
29)10y girl hx blunt trauma on abdoDeveloped anuric, K 8. High creatinine
Rx - Hemodialysis & neb salbutamol
Peritoneal contraindicated becoz trauma abdo
30)Baby presented with irritability. High red cell in CSF. what investigation needed
CT brain
31)photo - xanthomata
32)Child labelled as chesty for weeks. Bloods lymphocytosis
I passed again to go for my next clinic. I have ample time now and must prepare well to get through. As I said, you must put confidence that you gonna pass and put the trust to God to help you. Pre-preparation is a must, visualised what cases will pop up etc etc.
I believe, one course should be enough if you concentrate well on the technique!I dont believe many course or many books can help. Try on one or two books as reference then make additional notes based on multi questions on the 'exercise' books. I have been to one and apply to it thoroughly. My weakness now is for communication station. I may go for that course to improve on my technique.
I heard a story of a Japanese came here to the west, stayed only 6 months in London to learn about child rehab experience, is able to open the biggest centre in Japan.
Similar to us, one course should make useful for your life time. Your reading should be , perhaps once, and be used again and again and again! Hope that is useful. Thanks again for reply and support.
Firstly, lemme wish 'a very good luck' to whoever whose gonna sit the exam on the 26th of this month. It has been a long battle for you all and keep faith, with good luck and examiner, I hope the exam would be as easy as watching telly!
I just wanna add a few thing only in cases that you might seen in cardiology. Everybody is afraid of murmur, in fact cardiology may not be only be congenital heart problem. Yes obviously, the chunk of cardiac xm will be related to heart, but long case may not be. Examples of case;
1) Cardiac problem - pink vs blue
Pink cong heart heart - fairly easy if it is straight foward ie PDA murmur, aortic stenosis. It can be staus post balloon valvoplasty of any valve. Watch for association, ie Down - Complete AV septal defect, may have assoc AV regurg after that, Cri Du Chat a/w ASD, Hurler a/w Dilated cardiomyopathy etc
Whereas blue heart , unlikely you get uncorrected TOF or TGA or tricuspid atresia or DORV. It will be a stable child with midline sternotomy scar ie secondary to either palliative(for eg BT, Mee, Glenn, Daymus Kane,Fontan, Kawashima shunt) vs corrective (AV canal defect, Ross procedure, valvular replacement). So in general, if you see sick baby, they gonna have some palliative shunt for univentricular heart( RV hypoplasia vs left hypoplastic heart syndrome).
Bigger child may have had Fontan completion (TCPC - Total cavo pulmunory connection with fenestration). Hence following BT shunt at few days old, to Glenn at couple months age to Fontan at 3-4 yr of age.
Beware of post op complications - ie arrythmia, common one would be JET(junctional ectopic tachycardia), bleeding, wound infection, chylothorax, thrombus(commonly seen because they use neck veins in Glenn), pericardial effusion, renal failure, brain infarct etc
There are also different procedure like norwood in HLHS, hybrid procedure where advantage rise from not using anti coagulatin or anti platelet(post Glenn n Fontant they use aspirin or warfarin).
I think that's few guide of cardiology that I can give! Hope that's useful
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