Critical bloodspot result before rural discharge — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar. Noah is 5 days old and looks well. The first dried bloodspot was unsatisfactory. The laboratory has now reported a critical elevated TSH. The family wants to leave for a town 2 hours away within the hour. You have 12 minutes with the family and 5 minutes for examiner discussion. [3] [17]

Information available on request

• Gestation 39+1, birth weight 3.3 kg, exclusive milk feeds, no antenatal concerns. [3]
• Examination: alert, normal tone, soft fontanelle, mild facial jaundice, feeding effectively. [3]
• No valid second card has been processed yet. [17]
• Family has one car and limited mobile reception at home. [17]
• If asked about other markers, the examiner may introduce a later galactosaemia concern branch. [10]

Tasks

1. Explain the unsatisfactory card and the critical TSH using screen-versus-diagnosis language. [14] [17]
2. Make a same-day plan for confirmatory thyroid testing and treatment pathway. [3]
3. Address rural logistics and name owners for open actions. [17]
4. Safety-net and teach-back. [17]

Marking anchors

Must-hit

• Does not delay critical TSH action because the infant looks well. [3]
• Treats unsatisfactory card as incomplete until a valid sample pathway is clear. [17]
• Uses screen-not-diagnosis language. [14]
• Creates a realistic rural return/transport plan with named ownership. [17]

Merit

• Explains brain-development rationale for CH urgency in plain language. [3]
• Anticipates contact-failure risk and secondary contact details. [17]
• If galactosaemia branch appears, stops galactose-containing feeds while confirming. [10]

Fail

• Sends the family home for a week with no confirmatory plan. [3]
• Declares lifelong disease on screening alone. [14]
• Leaves incomplete card without an owner. [17]