This idea has been long due and perhaps we all should work together to create database of clinical cases seen in membership exams. I have just recently finished my exam(dunno the result as yet), and the cases are still fresh in mind. I can outline cases which I have seen and may be helpful to you guys. I reckon by creating database, we can all simplify our approach to clinical exam. I am hopeful to get some respond from those who have gone thro the exam. I am still awaiting for my fate though i feel I have to start again. If we work together, difficult task will be easy. Majority of us working on our own.
Station
1) Long case - 13 y old Cystic fibrosis presented with long standing hx of knee pain for 2 yrs. Been on ibuprofen only. Socially, been unable to attend school 3 days per week. All investigation to date are normal. What do you think?
2) CVS - 15 y old boy with Poland Anomaly(absence of pectoralis muscles) with murmur and dextrocardia. He also have soft systolic murmur in aortic area.
3) Resp - 14 y old boy with long standing cough. No clubbing but leukonychia. Good subcutaneous fat distribution. No evidence of harrison sulci. What's the DDX?
4) Abdo - 8 y old boy with mild jaundice and splenomegaly..obviously he's caucasian? Think about DDX. Hereditary spherocytosis. What Rx, when remove spleen, associated problem( ie gallstone and aplastic crisis) discussed.
5)Other - 6 y old boy with multiple depigmented area, scar on knee. Examine skin and join. Hyperflexible joint. I think this is Erlers Danlos. What do you do with skin? Any advice to parents? What type of ED syndrome? How do you investigate?
6)Development - 18 month old. Assess all milestone. Easy pizzi!!
7) Emergency - I'll tell you next time!!
8) Communication 1 - Break bad news to mum of John 9/12 old with R hemiplegia and abnormal babinski. Advice on management.
9) Communication 2- 4 y old boy with nephrotic had 4 relapses. You r SpR at DGH. Gonna refer to nephrologist to start on cyclophosphamide. Give advice. Pls talk about use of steroid side effect including growth and cushing. Monitor closely urine for response of remission and side effects. Say this is best for your child. Negotiate and offer solution for social problem(dad disagree for Rx).
10)Neuro - Hemiplegic cerebral palsy with chorea movement!!
Answer
1) HPOA of knee. Maximize Rx for CF and only analgesic given for treatment of HPOA
2) Poland anomaly with situs inversus and aortic stenosis
3)Not sure the correct answer. I think it's asthma becoz - no clubbing and no evidence of loss of subcutaneous fat. Exam - normal apart from tachypnoea.Defend your answer. I would like to perform CXR and sweat test to outrule any other underlying lung problem.
4)Hereditary spherocytosis, esp caucasian!!!!
5)Examine skin and joint - scar with hyperflexible joint = Ehrlers Danlos. Avoid contact sports. Need to know manouvre for hyperlaxity joints!!!!
6)Normal 18 month age toddler. Be systematic when assessing toddler. Fine motor comes with vision. Hearing comes with language(expressive or receptive). Then, gross motor, social and play skills...
7)TBC next time
8&9)Communication - establish aim of discussion, then go with flow to discuss option with empathy. Show you care. Listen tentatively.Negotiate an agreed plan together. Emphasis management is aimed at your child, best interest of patient.
10)Demonstrate neuro xm- tone(clasp knife, rigidity), power, reflexes(hyper),gait,cood etc
Till next time...I shall continue on video scenario.
I am back again. Sadly, I failed in my clinic by 2 points(passing mark 100/120). I got only [snip]. It's a good start as all my cases, I seem to do well. Practice and do a lot of short cases. Even if not, you can still stand a chance to pass provided do some pre mock or pre rehearse case.
I did it when i was in my medical school. Dont be intimidated by other candidate, focus on your finding be thorough and confident. FYI, I failed in my communication and cardiovacular station, because i was too nervous to defend my finding. Be confident OK.
Now, my next attempt this time should be pre rehearse. I feel there is the need to improve the technique. I shall obviously line out cases which definite or common in exam scenario. There is light, dont be anxious or nervous. Focus on each station. Even if you dont do well you can still make it. I got super 12/12 in my video(full mark). Sorry not to boast but to encourage you guys to use all avenue and please talk during xm but not waffle!
I havent got in hand of the cases seen in the video. Yet, majority of the time it's about acute paediatric. The difficult part will be communication. It seems you will need to varies your approach with empathy. Be diplomatic and giving option. Dont use jargoan( I use nephrologist then describe as renal team). If u made mistakes, retract but explain what it is. Breaking bad news perhaps one of the worse. Offer solution, follow up and ways to help the family socially, medically and not forgotten financially.
Dear friend,
I think our weakness is language because we're english speaker as our mother tongue. Having said that concentrate on the questions asked. I feel if you all sit together, memorizing the questions, similar q's will come out again and again.
I sat once for irish exam, but lots of the q are basic science. The english one seems to be more enjoyable because it covers many aspects of paediatric. First plan, what q may come out. Some exam it has many metabolic cases, another time haematology cases etc. Common thing will definitely come out. For me, you have to improve in the area where you can increase the mark ie neurology. If you are well rehearsed in cardiovascular, I am not saying not focused too much, focused accordingly because your mark may be increased slightly. If you are not good in neonatology, give a good cover so that if prev xm you got 25%, you can increase your mark to 90%.
I dont have any magic advice. Do a lot of questions and plan it before the exam. You may get together with couple of candidates whose gonna sit for exam, download question from onexamination dot com. Share the online pay and get you to the new system of BOF, EMQ and MCQ.
Use daily clinical round to ask for questions, use available time to practice and strengthen your memory about Paediatrics
. Discuss but not too prolonged. Best of luck!!
All the cases presented are correct. Case 3 respiratory, I diagnosed the child as asthmatic, however I emphasis the need to investigate for cystic fibrosis. Definitely, you'll get CF as one of the case if u sit abroad!!
Now, video station...hmm which I got 12/12
1) Scalded skin - Rx with IV antibiotic and analgesic
2) Hypoparathyroidism - showed Chovestek Sign
3)Periorbital cellulitis- 1st action to give IV antbiotic
4) Whooping cough
5)Cong heart disease - give prostaglandin and mechanical ventilation
6)ITP rash
7)Radiological - DDH of L hip
8) Boy presented with lump(not sure where), next step... to perform biopsy
OK, I better pen off. I shall talk about next exam in 2 weeks time.
I am the first 11 morning session who took the exam today(26/6/07 in London). First, may I wish good luck to everyone who attempted this time. I wish I am lucky enough to pass this time. I hope, God can help me to complete my exam as I am preparing to go home from the 'west'.
Been here long enough to suffer hardship, changes of weather and people. Anyhow, my intention to write onece again to reveal the questions that I have seen today. This time, I have answered all smoothly. I am not trying to be overconfideent but my performance are far better than before.
OK let's go to the cases
1) Neuro - 4 y old Asian presented with hx of falling. She has tip toe gait. Tendon contracture. No clonus but remark plantar reflex. Tone 4/5. A bit uncooperative. Broad base gait. What's the dx?
Ans- Diplegic CP - categorised in spastic type
What hx - check perinatal, postntal and antenatal hx. How do u treat - physio, baclofen n botox. Dont forget surgical intervention as well.
2) GI - 3 y old with stoma bag. Born 36 week gestation.Distended abdo, but no organomegaly. Child is not dysmorphic. What's ur differential?
Ans - Ileostomy bag. Differentiate between colostomy and ileostomy - outpouching mucosa, RIF and content of stoma. What's the underlying Pathology
- my diff dx - Hirchsprung, anal atresia. I didnt mention NEC though he's big now. I did mention about investigation for blockage etc
3) CVS - 4 y old with murmur.
Ans - She has acynotic heart disease with significant ESM radiating to the neck. Palpable thrills in precordium and neck area. Dx aortic stenosis
4) Dev - 3.5 y old Asian child with dysmorphism.
Ans - She got Down with global develomental delay. A bit uncooperative in task though demonstrating developmental delay in all aspects
5)Others - Just examine this 12 y old.
Ans - I got stuck and panic for a while. She has very subtle dysmorphism. I realize on general inspection, she has broad thumb. Gosh Rubeinsten Taybi!!.Mention about mental retardation. I didnt find any exciting on physical exaam
6)Resp - 7 month old known Tracheo oesophageal fistula.
Ans - Thriving, has R thoracotomy scar. Marked transmitted sounds. What's the cause? My diff GOR, dysmotility because of TOF, aspiration. Investigation, initially putting white bore NG, then do X ray. Definite test Ba swallow. Talk about type of TOF, may present with FTT and cough per se. I got on well in this section.
7) Long hx - shoot, the examiner is intimidating! 15 y old referred by GP with hypertension.
Ans - No other sx apart mild headache and some wgt loss. BP just 120 - 130/80. He's 60 kg. I mention that just borderline, perhaps anxiety. Mum has HTN , diet controlled. He has 2 step sis, but being [bleep] at school. He's on concerta for ADHD but fairly high achiever.
Talk cause of HTN
Primary(essential) and secondary - to kidney, CVS, endocrine, malignancy(phaeo)
8) Communication 1 - Discuss with SHO - management, outcome and complications of extreme prematurity (23+2 gest)
9) Communication 2 - Discuss with med student about baby born of ambigous genitalia. Give ddx, management and outcome.
10) Obviously video this time is fairly tough. I'll list down the subtopic only
- Staph skin - Rx with fluclox and benzylpen
-Baby with laryngeal problem presented with stridor & recession- admit for Obs
. Not needing O2
-Child with CP and in status. Needing high O2. Poor gases.- Intubate and ventilate
- Rash in front the body - not sure ? dermatitis artefacta/ NAI
- Child with R facial nerve palsy - give artificial tears
-Child not moving L arm presented 2X. No swelling. Sagging L shoulder. No ternderness or Erbs- ? clavicular #
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