Mrcpch Tips

8/9/2019 Mrcpch Tips

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This document is intended to supplement literature on the MRCPCH clinical

examination available from the College, and is not intended to provide factual advice on

complete examination technique, nor what should necessarily be included as a routine

when carrying out examination or assessment of children in the MRCPCH Clinical.

Plenty of books already have been produced to give you this information, and it is

assumed that the reader is now competent in the physical examination of children.

It is more some ideas on what the examinerexpects of the candidate.......

The Standard.

Candidates should have reached the standard expected of a newly appointed Specialist

Registrar/ST4. The examiners will ask themselves. Would you be happy to have thiscandidate tomorrow as your new Specialist Registrar?

The marking

The marking for each station is as follows:

Clear Pass Pass Bare Fail Clear Fail Unacceptable

12 10 8 4 0

Overall pass mark for 10 stations is 100

All candidates scoring 96 -98 will have their marking papers reviewed by the Exams Board,

and some are upgraded to a pass. (see also appeals).


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The Circuit

22

2

5

22

/

/

/

/

2 4

&

6

10 5

3

&

1

The MRCPCH Clinical Examination circuit( total examination time 152 minutes, with 4 minutes

between stations)

stations 1&2 and 5-10 last 9 minutes

stations 3 and 4 last 22 minutes

there is a 4 minute gap between stations

each candidates will start at differentstation and then complete circuit

one examiner at each station

each candidate is seen by 9examiners

24 candidates / day

Communication

Skills 2

Clinical:

Cardiovascular 6

History taking and

Management Planning3 (red & blue)

(22 mins)

Clinical:

Abdo/other8

Clinical:

Neurological/Neurodisability 10

Clinical:

Respiratory/other 7Clinical:

Musculoskeletal/Other 9

Child

Development 1

Video Scenario

4 (red & blue)(22 mins)

History takingwith child andparent.

Identification ofkey issues, andmanagementplan

2 stations testingability to give anddiscuss informationwith a child, parent orcolleague

t clinical

videos, testingacute

assessment,diagnosis,initialmanagement

Short cases: testing clinical approach, examinationskills, and interpretation of clinical signs

(9 mins each)

Clinicalassessment ofdevelopment in

a young child(notpsychometrictesting) (9 mins)

The MRCPCH Clinical Examination circuit( total examination time 152 minutes, with 4 minutes between stations)

Minor amendments may be made to the proposed circuit.Order of stations may vary

Communication

Skills 5


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What to do if the fire alarm goes off (find an exam mentor and head for the exit . Donot talk to other candidates or the exam will be invalidated ).

Where the loos are, and where coffee can be found

The need to put your name and exam number on ALL your mark sheets

Identification of your candidate pair with whom you will navigate the circuit. You

will rotate through coupled stations through the exam circuit with this person. (see Fig1 above)

There will then be a walk around the circuit, to familiarise you with the layout. Not all

circuits are circular, but exam mentors should be on hand between stations to avoid you

arriving at the wrong station. Stations are numbered and labelled, and are normally identified

by the particular colour coded mark sheet visible on the door/entrance to the station.

As you arrive at each station you present the examiner with the station mark sheet for that

particular station. Make sure that in particular the correct mark sheet for Comms Station 2 orComms Station 5 ends up with the examiner.

General Circuit tips

Positive

Always be polite and introduce yourself to not only the examiner for that station, but also the

parent AND the child.

Be friendly towards the child and get down to his/her level, look at them directly and smile!

An unsure/ tired child is more likely to be won round. Find a toy or use a finger puppet if all

else fails.

Negative

Never be rough or abrupt/rude when examining if the patient objects take heed and

apologise. Significant upset to the patient will lead to an unacceptable mark for that station,

and an overall fail of the exam, and this could happen from:

Hurting the patient watch especially in abdomen, MSK, neurology Embarrassing the patient pulling up a tea shirt or taking off a bra without

permission in a pubertal girl

Other tips:

Dont forget to clean your hands with every clinical station and if possible make sure

that the examiner sees this.

Remember that there may be other doctors observing at the station. These may be

examiners in training or a senior examiner assessing the standard of examiner

marking.


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Make sure that you undress the bits of the child fully that need to be examined. Too

often chest asymmetry is missed because a piece of clothing is not fully removed. The

same can apply to legs when examining gait. Clearly, the exception to this might have

to be the pubertal girl, but ask sensitively.

The issue of talking through the findings as you undertake a clinical examination

versus silently examining then summarising findings at the end is optional. Mostexaminers prefer the latter, and this is generally what I would advise. It gives more

time to communicate with the patient and mother verbally as the examination

proceeds, and explaining to the patient what you are doing and why and is better

practise. It also saves time and is less distracting for all if talking is kept to the end.

The examiners

The examiners have a busy time before each circuit. They have to examine and confirm

clinical findings on all the children used on their station (usually 3-4 children). Findings have

to be confirmed by examiner pairs (working on juxtaposed stations) who then have to

undertake two important functions for each patient:

Standard setting agreeing pass/fail or mark up/ mark down criteria on each patients

findings ( or essential facts etc in the case of Comms and History/ management

planning stations) between them.

Agreeing a standard lead in statement for each clinical station patient, so that all

candidates start with a level playing field.


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Tips for specific stations

Communication Stations (9 min x2)

Read the scenario outside the room. You should have about 3 minutes to do this. Try

to memorise the given name for the role player you will meet inside the room, and asmuch as possible background information given to you. There should be paper and

pencils to help writing details down helps most candidates. The information is

usually presented on a laminated sheet which can sometimes be taken into the room as

an aid memoir but leave it behind outside the room for the next candidate when you

leave!

Use a paper and pencil to illustrate any complex issue you are trying to get across to

the role player eg VUR in the renal system of a child with recurrent pyelonephritis.

This should always be available in the room, but take some in from outside to be sure.

Appear friendly and polite when you are introduced to the role player. Introduce

yourself. Sit in a sensible position not too close (dont touch/fondle the role player!)

and not too far away either. A table between you is a good idea if available.

Usually start by stating why you think you are here, and what the issue is that needs tobe addressed/discussed. Confirm with the role player that this is his/her

understanding.

Discuss the issue in small bites of information, and always pause between bites to

check understanding

Let the role player do some of the talking and listen. This is a communication station

NOT a lecture

If you dont know much about the issue tasked, say so, and advise where you might

be able to obtain the information. Dont make it up and bullshit. Erroneous

information will be marked down if dangerous information, severely so. Thepromise to send a leaflet about .... can be useful but only if it is realistic that there

will be one somewhere.

Try to leave sufficient time at the end (there will be a 2 minute to go bell) to

summarise the outcome of the discussion, and check that the role player is happy with

this information.

Common Comms Scenario Subjects:

Child protection issues

Drug errors

Immunisation issues

Teaching medical students

Dealing with a colleague who has problems


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History taking and management planning station (13 minutes with patient, 9 minutes

with examiner)

What the examiner is looking for:

Ability to take a focused history in 13 minutes

Candidates interactive enquiry skills

Empathy and sensitivity

Candidates interpretational, investigation and management skills

Approach:

Read the information on the laminated sheet prior to starting the station (3 minutes).

You are usually presented with a common paediatric problem often an OPD referral from a

GP. It could however be a child well known to the department with multiple issues if so

you should be asked to focus on one specific area.

With the patient & carer.

Take a FOCUSED history: concentrate on the task allotted.

Remember that these are real patients and parents, so they might have their own

agenda and ask questions which could side track you. If this happens, be firm but

pleasant and try to stick to the allotted task.

Dont treat this station like a Comms. station: you are not there to give explanations oroffer advice.

Remember to approach the child as well as the parent dont ignore the child, even ifan infant. Make sure that an older child has toys /games to keep him happy if you are

not engaging him directly.

Remember to ask about schooling/ social/ family issues and how the childs problem

may impinge on them.

Start thinking about management planning well before the 13 minutes are up (you will

be given a 2 minute warning of this), so that the issues that you target in on with more

searching questions will demonstrate that you have an understanding and can

prioritise.

With the examiner

Remember that the examiner has been sitting listening to you taking the history. If he

feels you have done a competent job, he is not going to waste time asking you to go

over all the details again. He will be concentrating on management planning.

Given the opportunity, it is best to summarise the presenting issues in 2 3 sentences.The examiner will usually at that point focus on either your knowledge of the

presenting problem, or the effects and implications that the problem might have on the

child or family.

Remember that the main focus with the examiner is likely to be management

planning. Demonstrate your ability to prioritise and use a logical approach.


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Tips

Stick to a focused history, but this may include social/educational/family issues, as

these may be influenced by what is wrong with the child.

Engage with the child, not just the parent

Avoid giving advice and being drawn into discussion

Prioritise management planning as you are taking the history

Common Errors

Not focusing on the issues suggested

Turning the Station into a Comms station

Not having thought through the important issues related to management planningsoon enough to ask the relevant questions


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Development Station (9min)


A basic knowledge of the main developmental milestones gross motor, fine motor,

language and social.

An ordered approach to assessment

An ability to engage with the child

An ability to summarise the findings quickly, and show some understanding ofassessment and management planning for children with disability

Likely cases:

Any child with a developmental age of 6 months 5 years. (the child may be older but

delayed)

You are unlikely to see a severely autistic child, as they are difficult to assess.

Children with hemiplegias, ataxias, movement disorders and mild/ moderate cognitive delay

are common. You may be asked to assess a child who is cognitively and physically normal.

It is unlikely that you will be asked to carry out a global assessment on any child except an

infant (insufficient time). Usually you will be asked to carry out only one of:

Gross motor

Fine motor

Language/communication/social skills

Tips

Keep the child engaged and happy assessment will be difficult if the child becomes stroppy.

Sit an older child on a chair with a desk, and a younger one on mothers knee

Stick with one assessment tool/toy at a time and clear away and remove from the childs

vision when finished to avoid distraction before using another tool/toy.

Try to be systematic in approach and use of tools

Leave time in the last 2 minutes for summary and brief discussion about

findings/management planning: this is important to the examiner in assessing your mark.

Check with the examiner as to how much you can ask the childs mother about the childs

performance. This clearly may be a necessary approach in a tired/uncooperative child, and

sometimes in areas of assessment of language development. With an uncooperative child,

focused questions if agreed by the examiner, will gain you marks.


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Assessment Tools

Stick with the simple ones, and dont use ones that you dont understand. The College sends

the host examiner a list of assessment toys/tools which is far more than is necessary, and this

can easily lead to distraction for the child and muddle for you. Generally, avoid complex

shape boards and puzzles. I would suggest:

Fine Motor:

Small bricks for stacking/making a bridge or train or steps

Large bricks for stacking

Beads on a string

Soft pencils or crayons and plenty of paper

Childrens scissors

Gross Motor

Flat clean floor space (may have to be outside a small assessment room)

Large and small ball

Attractive coloured toy (to attract a child, but out of reach)

Steps

Rattle

Language

Picture books with simple everyday objects best 4 to a page

Coloured bricks or beads

Simple story books with lots of pictures for a child to describe and find objects, or

explain activities

Common errors

Too many toys/assessment tools on the table at once distracts child and creates

muddle

Unsystematic approach to the task jumping from one assessment tool to another Not focusing on the assessment task set

Being unsure as to how to undertake the assessment

Being unaware of standard milestones


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Musculoskeletal/Other (9min)

Note This station may NOT have a patient with a musculoskeletal disorder. Listen to

the examiners introduction.


An ability to carry out a basic pGALS# assessment (but only if the child seems to have a

musculoskeletal problem!) (you may only need to assess, or be asked to assess a specific

physical area such as lower limbs or spine)

o Child with muscle, joint or bone pain

o Unwell child with pyrexia

o Child with limp

o

Delay or regression of motor milestones

o The 'clumsy' child in the absence of neurological disease

An ordered and sympathetic (remember that the child may have painful joints)

approach to assessment

An ability to summarise the findings quickly, and show some understanding of

assessment and management planning for children with musculoskeletal disability

Likely cases:

Children with chronic joint disease (children with active inflamed joints unlikely to beseen, as repeat examination would be inappropriate.

Children with fixed contractures related to muscular or neurological disease

Children with evidence of systemic disease (eg SLE, dermatomyositis, psoriasis), but

without necessarily any evidence of joint involvement.

Tips:

Only use a pGALS assessment if the child clearly has musculoskeletal problems, or

you are asked to carry out this assessment Look carefully at the child for pointers to cutaneous or systemic disease, preferably

before assessing joints etc eg growth failure, altered posture, skin rashes etc.

Dont hurt the child ask if it hurts before manipulating a joint or you may score an

unacceptable

Avoid doing a pGALS# assessment in a ritualistic manner it is too easy to focus onthe order of the examination , and miss the clinical abnormalities that you are trying to

demonstrate.

Undress the child sufficiently to carry out a full examination


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Useful reference:

# pGALS an evidence based MSK screening examination for children with a demonstration

performed on a normal child. Available through the RCPCH website as a DVD, or go tohttp://www.arc.org.uk/artinfo/medpubs/6965/6965.asp

or supplementary handout http://www.arc.org.uk/artinfo/medpubs/6535/6535.asp
http://www.arc.org.uk/artinfo/medpubs/6965/6965.asphttp://www.arc.org.uk/artinfo/medpubs/6965/6965.asphttp://www.arc.org.uk/artinfo/medpubs/6535/6535.asphttp://www.arc.org.uk/artinfo/medpubs/6535/6535.asphttp://www.arc.org.uk/artinfo/medpubs/6535/6535.asphttp://www.arc.org.uk/artinfo/medpubs/6965/6965.asp


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Neurology (9 min)


Ability to carry out a comprehensive but focused neurological assessment.

Ordered and sympathetic to the assessment (remember that the child may have

significant cognitive or neuromuscular disability)

Ability to use neurological assessment tools properly (eg ophthalmoscope, tendon

hammer, tuning fork etc)

Ability to properly interpret neurological signs and use them as a pointer to a

diagnosis

Ability to summarise the findings quickly, and show some understanding of

assessment and management planning for children with neurological disability.

Likely cases

Immobile or uncooperative children that are difficult o examine are unlikely to be used.

Children with diplegias, hemiplegias, ataxias, tremors, muscular dystrophies and myotonias

children who are mature enough to be likely to be cooperative, with chronic stable signs, and

usually at least part mobile.

Typical lead in: This child has been referred by his GP because of a gait disorder could

you please assess this and comment...

Tips:

Listen to the instructions from the examiner carefully you are likely to be requested

to carry out a focused examination either focused on the relevant clinical findings

related to an apparent disability, or a limited but comprehensive assessment of, say,

cranial nerves or lower limbs.

Look carefully at the child for pointers to neurocutaneous or genetic syndromes or

systemic disease, preferably before focusing on the neurological examination.

Dont upset the child when examining sensation, or checking a plantar (Babinski)

response or you may score an unacceptable, and use appropriate tools (NOT a

previously used needle or the sharp bottom end of a tendon hammer)

Practice the use of neurological assessment tools it doesnt create a good impression

using too small a tendon hammer and tapping rather than swinging it.

Ask to use of an assistant if necessary perhaps the childs mother to help with eye

covering when assessing for squints/amblyopia etc

It may be useful to carry out a pGALS assessment (see MSK station)


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Common errors

Unsystematic approach to the task jumping from one area of assessment to another.

Not focusing on the assessment task set

Being unsure as to how to undertake the assessment

Distressing the child by asking him/her to do things clearly impossible because ofhis/her level of disability.

Poor use of assessment tools


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Respiratory (9 min)


Ability to carry out a systematic and thorough respiratory assessment and recognise

clinical signs Ability to use respiratory assessment tools properly (eg stethoscope, peak flow meter)

Ability to properly interpret respiratory signs and use them as a pointer to a diagnosis

Ability to summarise the findings quickly, and show some understanding of

assessment and management planning for children with neurological disability.

Likely cases

Children with chronic rather than acute physical signs. Acute empyema or acute asthma is

therefore unlikely here (but can be seen in the video station). In the UK a child with Cystic

Fibrosis is likely and the diagnosis is often a giveaway if a portacath and gastrostomy isseen! Other commonly seen patients will be ex prems with chronic lung disease. It is often

difficult for centres to obtain cooperative children with long standing respiratory signs so

dont be too surprised if the child you are examining does not have clinical respiratory signs

or the station may be used as an other, so listen carefully to the examiners lead in

statement.

Typical lead in: This child has been referred by his GP because of a chronic cough could

you please carry out an assessment and comment...

Tips:

Listen to the instructions from the examiner carefully you may be requested to carry

out a focused examination rather than a complete respiratory examination

Remember that a complete respiratory examination includes the nares and pharynx.

Always auscultate directly on to the skin not through clothing, unless you are

dealing with a pubertal girl if so always respect her privacy and ask first.

The value of undertaking vocal fremitus(VF) and vocal resonance(VR) examination

in a child is questionable unless there are signs of diminished air entry or dullness on

percussion (and even then they are not very useful in younger children). The examineris likely to see these as a waste of time better spent on discussion at the end. It

would however be advisable to comment that you are NOT undertaking VF & VR

because there are no clinical signs detectable to indicate that they should be done.

Examination should always include respiratory expansion, percussion and full

auscultation.

Remember to mention the need for pulse oximetry and peak flow measurement as

being part of the examination if indicated.

Common errors



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Being too slow in undertaking the assessment

Not spotting clinical signs. It is easy to go through the ritual of looking at chestexpansion, tracheal deviation etc and be so fixed on what to examine next that you

miss the signs.

Not undressing the child sufficiently to properly examine the chest.

Useful referrence

Chris OCallaghan, DM, PhD, and Wendy Stannard, MBChB, MRCPCH. Leicester, UK:

OCB Media, 2001; CD-ROM CHESTOctober 2002 vol. 122 no. 4 1502


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Cardiology (9 min)



An ability to engage with the child An ability to summarise the findings quickly, and show some understanding of

assessment and management of children with cardiovascular problems

Likely cases

Children without complex heart disease, but with clear cut findings are commonest VSD, PS

etc. You may see a child with complex cyanotic heart disease, but often these have been

operated upon, so the examiner will not usually be looking for a diagnosis (usually difficult

without an echo) but for you to list your findings, and suggest likely possibilities.

Tips:

Listen to the instructions from the examiner carefully you may be asked to carry outa focused rather than complete cardiovascular examination, which would be expected

to include a full systemic inspection and examination of the chest bases etc

Try to keep the child happy if tired or fractious it may be necessary to auscultate

early on but if so explain why you are doing this to the examiner. Remember to use both bell and diaphragm during ausculatation, and to examine the

child in different positions and auscultate the back for radiation of pulmonary

murmurs.

Remember to palpate for thrills with loud murmurs, as well as for apical pulsation,and timing of murmurs.

Remember to check femoral and radial pulses, and character

Look for evidence of a medical syndrome this may give a clue to the underlying

cardiovascular problem (eg Williams or Downs Syndromes)

Common errors


Being too slow in undertaking the assessment

Not spotting clinical signs, and finding signs that dont exist

Incomplete assessment


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Abdomen/other (9 min)

Note: Children with long standing clinical abdominal findings are hard to come by for

some hosts in the UK. This station may therefore have children without abdominal

findings, and you may be asked to examine and interpret something else.



An ability to engage with the child

An ability to examine gently and thoroughly, without causing discomfort

An ability to summarise the findings quickly, and show some understanding of

assessment and management of children with various abdominal findings which may

indicate a longstanding systemic disease.

Likely cases

Children with chronic haematological problems resulting in splenomegally are now much

rarer in the UK but still seen in some areas. Chronic liver disease children, and children with

hepatic and renal transplants are often used as fall back cases. Clearly children with

malignant abdominal tumours are very unlikely to be included in the exam, and sometimes

the child presented may have no clinical findings at all or maybe a gastrostomy. The

examiner can still ask you to fully examine such a child and mark you on technique and later

discussion.

Tips:

Listen to the instructions from the examiner carefully you may not be examining theabdomen at all!

Look carefully at the child for pointers to systemic disease (eg growth failure,

dysmorphism, liver failure signs.

Dont upset the child by being rough. The examiner will be looking carefully for this.

It is acceptable not to percuss for shifting free fluid if there is no distension, butalways percuss any enlarged palpable organs fully, and measure size with a tape

measure rather than FB.


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Video Station (22 min)

The main purpose of the video station is to provide a means of assessing acute paediatric

problems that would be unlikely to be available for clinical stations that have to be plannedweeks in advance. A CD rom video mock exam was available from the College for a time but

is no longer available. The format is that there are a number of clinical video clips which each

have a number of questions, which once submitted cannot be changed.

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