This another sample from my other friend. Well well now in comm skill there is overlapping cases. Crohn's who refuse NG feeding is quite popular communication scenario. Therefore, forecasting(not to believe but to prepare similar scenario) may be a way ahead. Pre prepared scenario in communication skill very much wide.
I think it is difficult circumstances if u panic. However clinical experiences permitted may help you dealing with real life experience.
communication: 1, ability to deal with professional issue with a junior. 2, 15 yr old with crohns disease who is refusing n/g feeds ,discuss with her. 3, dermatomyositis and headache. history taking.
5. cardiology. pulmonary stenosis.
6 developmental assessment. speech.
7. respiratory. chronic lung disease, tracheostomy and o2 dependent.
8 .facial palsy.
9 .crouzon syndrome
What you need to remember
1)Introduce
2)Giving right info
3)Offer anybody to be around(ie father n mum together)if breaking bad news, and leave bleep
4)Using normal body langguage - eh, ummm, yeah
Not lecture style or dominated
5)Ask what do they know or what info
6)Agree on topic of discussion - whether u decide or they tell or in the q sheet
7)Then agree with plan of management, re emphasis or recap info/summary
8)If difficult, negotiate ur way with alternatives
9)Be calm in abusive and difficult scenario, apologetic if bad news, straight foward info, using pause if breaking bad news and emphatic
The best way to approach angry parents if u are breaking bad news(say child with NAI) - focus on importance of the child.
'I think u brought Jamie here to get it check. We have found that he had spiral fracture. We would like to do further investigation and further xray to determine the cause. I am sure you want to get to the bottom of the problem. '
Emphasis similar role and agreement, ie jamie interest rather that finding difference or argumentative or superiority.
. does not feel hungry, such as the child with cancer or liver disease
· is not able to eat or drink by mouth, such as the child with a broken jaw
· tires when feeding or eating, such as a premature baby
· is not able to chew and swallow well
· has a high need for calories, such as the child with cystic fibrosis, heart
disease, or lung disease
· is not able or not willing to take in enough calories by mouth to support
proper growth, such as “oral aversion”
Importantly in Crohn becoz of disease can be anywhere in the GI, maximizing calories for growth, administration of elemental diet(may not tolerated), sometimes children may have oral aversion needing SALT, and administration of drugs if needed in difficult child.
hi Fahi,
yes you have summarised the indications for NG feeding. other indications i could think of:
for cold saline lavage: in cases of haemetemesis.
in intestinal obstruction: for gastric aspiration, (presence of bile stain will help diagnose lower intestinal obstruction)
for tube feeding: in cases recovering from GBS , meningitis etc
Thanks sibalan for the addition! Great to have someone chatting now!
FYI, they may give clinical scenario on bloods ie lipid profile to discuss with medical students. I may be panicking seeing the result but try to be methodically. Once u read the instruction, try to think foward your points, what are going to say etc.
It may be a session of discussion, it may be a session of history taking. Having said that, you need to know your strength and not to exposed your weakness.
Medical student may ask - what is the meaning of high LDL. Then, it is difficult for u unless u have understanding of lipid Physiology
and disease related to it.
I mentioned couple of scenario
1) giving info like above or even procedure/consent
2) Risk management - dealing with collegue, angry parents etc, drug error
3) Breaking bad news
4)ethics
5) Education
It has been a while since I have been writing. The exam is just around the corner. I felt bit tired being on call and trying to read. It is exausting. I have no more holidays so I have to utilise and make time that I have in 24 hr. As long as it is not hazardous to my health that's OK.
Secondly, I have just finished Ramadhan. The celebration of Eid also sometimes can deviate you off the course. Studying, fasting and working especially being in the west, can be challenging. Yet, I have to keep in my mind, that this exam is easy and I need to practice a lot.
This is the final week. Just to add few things
1) Utilise medical students when they are around. You can empower them as you can put yourself into examiner's shoe. Then, you'll be able to see inorganization or inappropriate ckinical skills. I enjoy teaching students if they are well prepared. We had a bunch of unprepared(perhaps in old days I used to be like them)students. Though it gives u fresh revision, but it is not stimulating enough to get into membership level.
2)Use sparing partners. If u have somebody who'll sit with u, use them to practice and criticised. This works well if both of u symbiotically work to complement each other. My friend is attending a course in Dublin, she'll update me with some clinical skills which I felt deficient.
3) Examiner may trap u with - Are you sure? So instead of panicking, reorganize yourself to your findings in clinical examination. Dont be trapped to change your statement if your finding is correct.Be strong, give reason. If it's difficult, say so!
4)Practise in front of mirror or tape using recorder. It'll give u idea of ur bad habits. U may find your hand is fidgety, your eye rolling upward during questioning or interview/communication sessions. Improve you body language!
Revise until you can utter - diagnosis, investigation, management and complications. Brief is Ok but elaborate on the point. The other organization thought is when answering questions.
Example
Causes of hepatomegaly in this case is
1)Metabolic
2)Infection
3)Malignancy
4)Cardiac
5)Hematological
6)Others - Stills, etc
So try to give broad answer then say the most likely cause is......It doesnt matter whether you have forgotten 1-2 causes but definitely try to classify broadly and giving example!
One of important aspect that we used to ignore is social aspect in paediatric. We seem to be forgetful about this area. However, in holistic and thorough approach, this issue is key to many paediatric condition.
Example, schooling in Down syndrome, household pressure, peer relationship, financial constraints etc. The good example if asked, causes of failure to thrive:
1) Organic causes - include chronic illness(cardiac, renal,malignancy), endocrine, metabolic, syndromic, reduce intake, less absorption(malabsorptive condition), increase output(enteropathy), immune problem etc
2)Non organic - behavioural and social paeds(emotional, neglect etc)
Please remember social aspect as part of differential diagnosis or cause or even management in Paeds.
Sorry for being quiet for a while. Great news, I will be working in cardiology unit next. It is unexpected news coz I have yet to complete my membership but the interviewer seemed to be happy for me to take a competetive post. Anyhow, let's not get bog down with my personal life. Let's focus on couple of issuesin the exam.
1) Majority mx in paeds require one to mention about multidisciplinary approach. This is true in chronic and debilitating condition such as cerebral palsy, spina bifida, ex premee etc. So it is important as exam technique to bare in mind that a group of people involved in the mx of the patient. Even so, in circumstances of NAI(unexplained nature of injury) please mention social worker involvement and further investigations needed for the best interest of the child.
2) I have extensive discussion with few collegues in technique of communication. I have listed in previous posting what needed to be done. My strategy is simple - prepare early your points before entering in communication skills. There is a need to be-
i. Compassionate - Be gentle, say u undersatnd how difficult the condition
ii. Emphathy- Be good listener, give choices, use non verbal skills
iii. Provide alternatives - ie negotiate what u should be doing
eg tough scenarios
Consultant not happy no discharge letter done. SHO and Reg are called and Reg is asked to talk to SHO.
a. Dont put blame on collegue - single mistakes will lead to failure in this communication skills
b. Provide alternatives - OK say responsibility shpuld be taken together. What we need to formulate perhaps changing in rota to accomodate bleep free time or perhaps management week for SHO so that time can be allocated for dictation issues. We can also suggest the use of technologies like handheld device like in States but may be it is costly and need to be sorted out via the hospital
So negotiate your way through.
Another scenario - Child must NG.She is embarassed because being [bleep], doesnt look nice and wants nose pearcing
So discuss issue like what does she understand about her disease. Vital and important nutrition be administered because as any other chronic illness, nutrition is important factor. We dont wanna see u having growth stunted(important in girl). You MUST (say it because this is what instruction want) have it. What we can do about NG is we can insert it while u are not at school, that can be trained by nurses with mommy around. The special feeds can be given overnight. Equally important, I think it is also important about issue of [bleep] and image. You should try not to think about your appearance and try to ignore what people said. I think it is equally important that we treat your condition to prevent from relapsed.....
Enough about scenarios
3) I also learnt by discussion in hx taking it is not merely taking specific hx. Trying to teased out differential is one aspect by psychosocial components is an important one. Lets take my ADHD case
He presented with high BP so GP referred to you.
Hx need to include
i)symptoms of high BP - ie headache, palpitation, blurring vision etc
ii)Teased out differential - Fhx hypertension, on steroid, hx UTI(scarring and VUR), drugs(ADHD on concerta XL), malignancy like wgt loss etc
iii)Psychosocial aspects - Family life, school, financial effect, sibling etc
iv)Background problem - ADHD on his lifestyle. Medications, how much, how long, any other side effects etc
Check BP. A lot of measurement have centile chart. For eg BP for age, peak flow, Turner chart etc Aware of using centile chart though you are aware that BP can be estimated systolic component as 80 + age....
OK. I still have some more but I'll pen off for now. I have cases which my friend attended PAST test in Hillingdon. My other friend attented SMART course. It does matter, it'll give u the gist of xm.
Be prepared
Be confident
Polish ur techniques
Have methodical approach on communication, XM, hx
Practice, practice,practice until it looks like u have done thousand times - ie smooth xm
1) 3 y old with cyanosis, clubbing. Had mid sternotomy scar and L thoracotomy. She has 2 murmur. Indicate complex heart with shunt/drum like murmur(hollow). If clubbing present with 2 scars mentioned n cyanosis, palliative intervention is unsuccessful!!!
2)4 y old with clubbing has 2 similar scars(as above ie midline sternotomy + R thoracotomy). Child not in distress. If shunt closed, no murmur heard. The fact he's acyanotic means corrective surgery is working( BT shunt). Sometimes residual murmur can be heard. Majority of these double surgery cases, u can bet 9/10 will be Fallot!
3)10 y old with liver transplant scar. Think about Allagiles - dysmorphic, abnormal vertebrae, xanthoma,post embryotoxon
4)12 y old caucasian with jaundice and have spleen.
Dx Here spherocytosis
5)African boy with splenomegaly. Think about haematological ie sickle cell. Problem related including VOC, aplastic, salmonella osteomyelitis, stroke, susceptibility to encapsulated organism
6)Gait exam - must have sitting posture, standing, walking, then running. Other manouvre - tip toe, fog, stand one foot, heel toe
7) Hemiplegic gait. Unable to do fog test
8)Eye exam - pale optic disc. Dx Retinitis pigmentosa
9)Long case
a) Marfan with joint pain
b)Relapsed leukaemia - ocular relapsed
c)Boy with development delay - have asthma and severe eczema
d)Girl with Chr 18 deletion. Developing seizure
e) Rhetts with 1/52 hx stop eating. Mx should include epilepsy and behavioural modification. Admit to hosp for feeding and control seizure
f)CF - hx emphasis on growth and nutrition
10) Noonan with difficulties feeding. Have PEG and shield chest. Also have murmur eg pulmunory stenosis
11)William syndrome with cocktail party
12)Assess 2.5 y old with fine motor. Casting(throwing things) etc
13)Gross motor of normal child
14)Communication
a)25/40 weeker baby born. Talk to mum about prognosis
b)Child not for resus. Give firm advice but also choice for parents
c)Muslim family with LCAD and have to take pork milk formula. Discuss religion area, respect to family's decision.
d)Jehovah witness, baby born with APH. Say clearly baby will need bloods but respect her decision.
I racing with times. Sorry all cases I have to be short. In front of me, I have communication workshop from the above course.
1)7/12 old brought with bruises unexplained. Look after by child minder and daddy.Not on child protection Register.
-explained about NAI, non accusotory approach, action for child safety, inform cons on call, other test(skeletal survey, eye xm etc),inform social services
2)Discuss with SHO who failed to attend deliveries when called
- stress importance team working, clinical guideline, GMC document(pt care), support available, risk management session
3)10 y old with bruising and lethargy. Bloods showed pancytopaenia.
-follow proceduce of breaking bad news
-mx plan
4)Child presented with relapsed nephrotic syndrome
-calm when answering, clear mx, eevidence based info, not make promises, speak to consultant
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