Passing Clinical Examinations

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Passing Clinical Examinations

BACKGROUND

Clinical examinations come in all shapes and sizes. Most medical students focus on their licensing or ‘final’ exams, doctors in training on exams testing further skills, such as the MRCP, or those that provide specialist status, such as the Boards in the United States.

The examiners in all these examinations have the same objective: to test the candidates’ competence in areas that are important in clinical practice. In devising the examination format, the examiners are aware that:

• the situation is artificial

• the test should be consistent and fair

• many candidates will ‘learn for the exam’.

Thus, examiners continually amend the format of the examination so that it is more valid, more reliable and more closely aligned to clinical practice. Currently the trend is away from ‘spot diagnosis’ to an observation of limited focused clinical examination. This aims to replicate what happens clinically, and to encourage candidates to learn the skills they will need in practice.

These examinations have differing formats but almost all include a requirement for the candidate to perform the following stages:

• Stage 1: Examine a patient neurologically, observed by an examiner.1 The examiner will be looking for a systematic, appropriate and thorough neurological examination, using reliable examination technique. They will also observe for communication skills, including rapport with the patient, professional manner and treating the patient with appropriate consideration and empathy. In other words, ‘what you do’.

• Stage 2: Describe the findings, coming to some sort of conclusion.1 The examiner will be looking for a correct identification of abnormal physical signs, an appropriate interpretation of these abnormalities, and a reasonable synthesis of the findings and suggested diagnoses and differential diagnosis. In other words, ‘what you find’ and ‘what it means’. Interpreting the signs depends on getting the signs right and this will depend on having done the examination properly—so stage 2 depends on stage 1.

• Stage 3: Discuss the further investigation or management of the patient’s problem.1 The examiner will discuss aspects of further investigation and management. This tests the candidate’s knowledge relating to this particular clinical problem. This is not the focus of the clinical part of the examination, as this knowledge is often tested using other examination formats. Discussing these elements further depends on having an appropriate diagnosis or differential diagnosis—so stage 3 depends on stage 2, which depends on stage 1 (Fig. 29.1).

Figure 29.1 Three steps to success

Most candidates run into problems with stages 1 and 2, and may not get to stage 3. The examiners may try to help, with prompting or leading questions (let them).

The best way to pass the exam is to be competent. This is why this chapter is at the end of the book. So, if you turned straight to this section, go right back to the beginning of the book (unless it’s an emergency²).

WHAT TO DO

Consider each stage of the examination in turn.

Stage 1: Examine a patient neurologically, observed by an examiner

You are not meant to reach a stunning diagnosis but to demonstrate that your examination is:

• systematic

• practised

• reliable

• appropriate

• thorough

• professional.

The difficulties arise because:

• you are unable to undertake a systematic, practised, reliable, appropriate and thorough examination

• time is limited

• you are anxious (especially if the first point is true).

The solution is to sort out the first point; when competent at examination, you will use time more efficiently and become confident.

Systematic, practised and reliable

This book is set out to allow you to develop a systematic approach to clinical examination using reliable methods.

To develop a system you can rely on, you need to practise. Professional golfers practise hitting the ball thousands of times on the driving range so when under pressure in competition they know just what to do. Neurological examination is just the same. What you need to do has been described throughout the book; the more you do it and the quicker you become, the less you are concerned about what you should do next and the more confident you are in your findings being normal or abnormal. Generally speaking, you will also look slicker.

Practising with someone watching you can help this further—preferably someone more experienced, but colleagues can also help. Think about ‘demonstrating’ physical signs so that your spectator will also see any abnormalities you find. You can learn by watching— anyone; you often learn as much watching someone having difficulties doing something as watching an expert. You will also be less anxious in the exam if you are used to being watched.

Appropriate and thorough

In some clinical examinations you are asked to do only a partial examination and are usually provided with only a limited history: for example, ‘Please examine this man, who has had progressive difficulty walking over the last year.’ This is not as artificial as it seems. In clinical practice most patients will have one problem that will be the focus of the neurological examination and the rest of the neurological examination is effectively a screening examination. You should therefore be able to work out what is ‘appropriate’ in the context of the exam (Table 29.1). It is useful to think of ‘appropriate’ in this context as ‘what is needed to solve the clinical problem’.

Table 29.1

Some common clinical problems seen in examinations

Clinical problem	Focused examination	Common syndromes
Walking difficulties	GaitMotor system; tone, power; reflexesSensationCoordinationConsider: fast repeating movements; eyemovements; speech	Cerebellar syndromeAkinetic rigid syndromeSpastic paraparesis (with or without sensory signs)Peripheral neuropathy
Numb hands and feet and loss of dexterity	GaitMotor system; tone, power; reflexesSensationCoordination	Spastic tetraparesis with sensory signsPeripheral neuropathy
Weakness in arms and legs	GaitMotor system; tone, power; reflexesSensationCoordination	Spastic tetraparesis with or without sensory signsMixed upper and lower motor neurone syndromePeripheral neuropathy
Speech difficulties	SpeechFaceMouth	DysarthriaDysphoniaAphasia (less likely)
Double vision	Eye movements	Cranial nerve lesion VI, III or IVMyasthenia gravisThyroid eye disease
Visual problems	AcuityFieldsFundiPossibly eye movements	Optic atrophyHomonymous hemianopia Bitemporalhemianopia

A systematic examination that is appropriate will inevitably be thorough; that is, it will cover all the necessary parts of the examination. It does not have to be obsessional or fussy to be thorough; indeed, this would waste valuable time.

Professional

Be polite, courteous and considerate—as you should be with all patients (and colleagues!).

COMMON MISTAKES

• Not thinking. Remember you are trying to solve a clinical problem.

• Rushing into the examination and not looking at the whole patient. You may fail to observe simple things like pes cavus or scars. If you are examining the eyes of a patient in a wheelchair, it is likely the eye problem has something to do with the mobility problem—a helpful clue.

• Worrying about the ritual of the examination. Remember, neurological examination is a tool to help you test how the nervous system is functioning and in what way it is not functioning. It is not a dance.

• Forgetting what you have found. It is useful to summarise your findings in your head as you go along; this helps ensure you are thorough, as you should recognise any gaps that need filling.

• Getting bogged down with sensory testing. This commonly happens if you start by testing light touch, and test proximally to distally. To avoid this, test vibration sense, then proprioception, then pinprick and temperature. Start testing distally and work proximally (see Chapters 21 and 22).

• Finding signs that are not there. If there is something you are not sure about, examine it again. Generally it is worse to find something that is not there than to miss something that is. Remember, it is perfectly reasonable to be asked to examine a patient with no neurological abnormalities. (There may be clues in the history: ‘Please examine this man, who has intermittent walking problems’ (my italics).)

• Forgetting what you would do in the real world. If, for example, you found that sensory testing was not adequate because of time, say so. ‘Sensory testing was limited by time and I would be keen to repeat it.’ However, generally, patients will have been selected so that an adequate assessment can be undertaken in the time available.

• Examining the left eye with the ophthalmoscope and eliciting the left ankle reflex are particularly difficult and need practice to perfect—so examiners watch you do these with great interest!

Stage 2: Describe your findings, coming to some sort of conclusion

The examiners will have watched you examine the patient and will have a reasonable idea of what you have found (demonstrated). They will ask you to describe your findings or conclusions—remember to answer the question they ask. How you answer will also depend on the level of the exam you are taking. There are three approaches:

1. To describe the physical signs systematically (A), using the conventional order, summarising them (B), then coming to a synthesis of the signs (C) and suggested differential diagnoses (D)—as in Boxes 29.1 and 29.2. This is long-winded, but allows you to describe the physical signs and your reasoning. This approach is generally restricted to final medical student examinations.

Box 29.1 SYNTHESISING YOUR FINDINGS AND ANSWERING QUESTIONS ON DIAGNOSIS

Example 1 (a relatively complicated case)

Different approaches (see text) describing a patient after a limited examination of the legs of a ‘patient with leg weakness’. He looks as if he is aged between 40 and 50.

(A) (Signs) The patient was unable to walk. The tone in the right leg was increased, with spasticity at the knee and clonus at the right ankle. The tone in the left leg was normal. There was pyramidal weakness in the right leg, hip flexion grade 2, hip extension grade 2, knee extension grade 3, flexion grade 2, foot dorsiflexion grade 1 and plantar flexion grade 3. The power in the left leg was normal. The tendon reflexes in the right leg were pathologically brisk with an extensor right plantar; the left-sided reflexes were normal with a flexor plantar. There was loss of vibration sense in the right leg to the anterior superior iliac spine, loss of joint position sense in the toes, and reduced proprioception at the knee. The left-sided vibration sense and joint position sense were normal. Pinprick and temperature were lost in the left leg to a sensory level at the costal margin. These modalities were normal in the right leg. Coordination was not tested on the right because of weakness; on the left it appeared normal.

(B) (Summary of signs) The combination of a right-sided upper motor neurone lesion at or above L1, and a right-sided posterior column sensory loss with a left-sided spinothalamic sensory loss and a sensory level at T8 indicate.

(D) The differential diagnosis is of a spinal lesion at or above T8 (anatomical diagnosis). This could result from external compression or trauma to the spinal cord or an intrinsic lesion within the cord (pathological diagnosis). External compression most commonly occurs from disc disease, spondylosis or tumours,* most commonly bony secondaries, though also meningiomas or neurofibromas. Intrinsic lesions are most commonly due to demyelination, either myelitis or related to multiple sclerosis;* more rarely, vascular lesions such as cord infarcts can produce this problem (though typically they produce anterior cord syndromes) or very rarely intrinsic spinal cord tumours.

^*See ‘N.B. Euphemisms’ in text.

Box 29.2 SYNTHESISING YOUR FINDINGS AND ANSWERING QUESTIONS ON DIAGNOSIS

Example 2 (a relatively straightforward case)

Different approaches (see text) describing a patient after a limited examination of a ‘patient with walking difficulties’.

(A) (Signs) His gait is abnormal. He is slightly stooped; his gait is narrow-based with small steps. His right arm is slightly flexed and does not swing. His facial expression is reduced. He has a rest tremor in his right hand. He has cogwheel rigidity in the right arm and leg. Power is full. The reflexes are slightly increased on the right. The plantars are flexor. Sensation is normal. There is moderate right-sided bradykinesia, evident on fast repeating movements of hand and foot. Coordination is accurate, though slow on the right.

(B) (Summary of signs) This man has a parkinsonian gait and a right-sided rest tremor, with cogwheel rigidity and bradykinesia.

(D) (Differential diagnosis) The most common cause of an asymmetrical akinetic rigid syndrome is idiopathic Parkinson’s disease. Other differential diagnoses to consider are drug-induced parkinsonism (which is usually symmetrical), or rare extrapyramidal diseases such as multisystem atrophy, diffuse Lewy body disease, progressive supranuclear palsy (or, in a young patient, Wilson’s disease).

2. To summarise the relevant abnormal signs (B), a synthesis of the signs (C) and suggested differential diagnosis (D)—as in Boxes 29.1 and 29.2. This is more succinct and gives the opportunity to discuss and clarify signs before coming to a synthesis. If these are not quite right, the examiner may wish to prompt you towards the correct interpretation.

3. To propose a synthesis of the signs (C), with or without reference to abnormal signs (± B), and discuss a differential diagnosis (D)—as in Boxes 29.1 and 29.2. However, if signs or synthesis are incorrect, it is more difficult for the examiner to prompt with questions.

Approach 2 is probably the correct strategy in postgraduate examinations if no specific question is asked.

It is worthwhile practising each of these approaches when you see patients and actually to say them out loud—preferably to a more senior colleague; a contemporary will also be able to offer advice. If no one else is there, do it anyway, to practise putting your thoughts into words.

When coming to a synthesis, describe the anatomical or syndromic diagnosis first. Then offer a differential diagnosis of potential causes. You can classify potential causes according to their pathological process rather than specific diseases. Start with common causes; if you suggest a rare cause you might want to tell the examiners you appreciate that it is rare. The examiners are interested in your clinical reasoning, so part of the test is to see how you approach the differential diagnosis.

N.B. Euphemisms: If the discussion occurs while the patient is there, you will be expected to use euphemisms for diagnoses you discuss that are potentially alarming for the patient (especially if they have something else). Examples include: demyelination for multiple sclerosis; anterior horn cell disease for amyotrophic lateral sclerosis (motor neurone disease); neoplasia for cancer.

COMMON MISTAKES

• You fail to answer the question asked. This often involves answering a similar but different question. This is popular with politicians in interviews, but unpopular with examiners.

• When asked about causes of problems, you jump to rare and unlikely pathological diagnoses. Avoid this by starting with an anatomical or syndromic diagnosis and then suggest pathologies, starting with common diseases and then moving on to rarer problems.

• You panic. Sometimes (well, quite often) people get so flustered in exams that they do not do as well as they should. You can avoid this by practising both neurological examination and being in a stressful situation. Presenting cases at clinical meetings or simply asking questions in meetings or lectures provides useful practice in articulating your thoughts under stress.

TIP

Here is a helpful way to learn neurology. If you have not seen a patient with a particular disease, then turn the textbook descriptions into descriptions of imaginary patients with appropriate physical signs. This not only helps you remember and recognise the conditions but also helps you practise putting it into words. You can do this anywhere, in the bath or on the bus (though best not say it out loud then!).

Some common or important conditions you might want to practise on are:

• multiple sclerosis

• amyotrophic lateral sclerosis (motor neurone disease)

• cervical radiculomyelopathy

• hereditary motor and sensory neuropathy

• dominant hemisphere middle cerebral artery stroke

• lateral medullary syndrome

• Brown–Séquard syndrome (Box 29.1)

• myotonic dystrophy

• Parkinson’s disease (Box 29.2).

Stage 3: Discuss the further investigation or management of the patient’s problem

This part of the clinical exam primarily aims to test whether you are sensible and have good ‘clinical sense’, and does not depend on a wealth of knowledge (though this will help). Knowledge is tested more extensively in other parts of your exams.

Remember that this examination is trying to replicate real clinical practice—so do what you would do in real life. If you have only had a limited history and been able to do a partial neurological examination, you would normally take a full history and complete examination. Suggest this, but indicate what particular aspects you would focus on; for example, in a patient with a neuropathy you might suggest that you would be interested in general medical history, drug or toxin exposure, alcohol intake and detailed family history.

If you are asked about other investigations, indicate how you would use the investigations to solve the clinical problem—why would you do each test? Remember the tests are there to help you—how would they help you?

When suggesting investigations, generally start with the simple ones. However, if there is a specific complicated test that would solve the problem, that is the one to do (e.g. genetic testing is the best way to confirm the diagnosis of myotonic dystrophy).

Discussing management in the very limited time available is easiest if you have a mental framework to help you. Almost all management plans can be divided into:

• management of the underlying disease process

• specific symptom treatment

• general management, including long-term strategy.

Boxes 29.3 and 29.4 give some examples of how to use this approach.

COMMON MISTAKES

• Failing to provide any framework for management and just listing names of drugs.

• Not considering non-medical areas of management: for example, nursing, physiotherapy and occupational therapy, or wider social issues.

Box 29.3 ANSWERING QUESTIONS ON INVESTIGATION AND MANAGEMENT OF THE PATIENT IN BOX 29.1

Question: How would you investigate and manage this patient?

I would first review the history, in particular the speed of onset of his current problems, and seek evidence of previous neurological episodes or other significant medical problems, particularly any history of malignancy. I would ask about bladder and bowel involvement. A full examination might provide other clues, either of general medical problems or evidence of other neurological lesions. Simple investigations such as blood count, looking for anaemia, prostate-specific antigen or liver function tests and chest X-ray, as directed by the history, may be helpful, but the crucial investigation is spinal imaging to determine the nature and level of the spinal lesion. MRI is the preferred technique, which should image the spine at and above T8. This is going to determine the further investigation and management and needs to be done urgently. (Management of the underlying disease process). If cord compression is found, then urgent referral for neurosurgery is needed. If not, MRI of the brain, CSF examination and evoked potentials may be needed. Demyelination could be treated with steroids. (Specific symptom management) Pain control may be needed and bladder involvement may necessitate catheterisation. (General management) As the patient is immobile, prophylaxis against venous thrombosis, pressure area management and physiotherapy will all be needed. The longer-term management will depend on the cause of his spinal cord syndrome and the potential scope for recovery. Rehabilitation, including physiotherapy and occupational therapy, will be important to minimise his disability. N.B. In a younger patient, demyelination or benign tumours would be more likely; in an older patient, malignancy or degenerative changes would be more likely. Adjust your comments accordingly.

Box 29.4 ANSWERING QUESTIONS ON INVESTIGATION AND MANAGEMENT OF THE PATIENT IN BOX 29.2

Question: How would you investigate and manage this patient?

I would first review the history, to determine the onset of the problem, any possible associated problem (for example, urinary symptoms, symptoms of postural hypotension or memory problems) and to find out how the patient is affected in everyday activities, as this will guide management. Examination might provide other useful clues; memory problems are associated with diffuse Lewy body disease, a supranuclear palsy with progressive supranuclear palsy (PSP). The diagnosis of Parkinson’s disease is primarily a clinical diagnosis and further investigations are usually not needed. In younger patients, copper studies could be considered to rule out Wilson’s disease. Management of Parkinson’s disease is symptomatic as there is currently no treatment established to alter the underlying disease process (management of underlying disease process). Treatment is therefore directed at the patient’s symptoms and aims to minimise his disability. Initially, milder drugs can be tried: for example, selegiline. If this patient is right-handed, it is likely that he would need to go on to the next stage, when either a dopamine agonist, such as ropinirole or pramipexole, or L-dopa, in combination with a dopa decarboxylase inhibitor, can be added, titrating the dose according to symptomatic benefit (symptom management). The overall strategy in the management of Parkinson’s disease is to minimise the impact of the disease using as little medication as possible, to minimise adverse effects (though as much as is needed). The patient needs to understand his illness to participate in the decisions over management and thus needs to be given appropriate information. Physiotherapy and occupational therapy are helpful in maintaining function and independence. Surgery can be used later in the disease in some patients (general management including long-term strategy).

LEARNING NEUROLOGICAL EXAMINATION IN A CRISIS

Hopefully very few readers will need this section, having learnt neurological examination through their training. Many students and junior doctors become anxious as they approach exams; however, they are usually a good deal more proficient than they think they are. Most can make great strides with only a little help, usually in organising their thoughts. If students get themselves into this predicament, it is often through a reluctance to practise something they feel incompetent doing.

However, sometimes people do find themselves in a fix. Proper preparation is not possible as the exam is next week. If so, this is what you need to do:

• Find one or more friends to act as examination partners to learn with you.

• Buy two (or more) copies of this book.

• Give one to each friend and read it from cover to cover (one evening).

• Practise examination of a normal subject (a willing patient or another friend), being watched by your partner, who can criticise what you are doing. Watch your partner and comment on his examination.

• Initially, practise examining by using only limited chapters, with the book to guide you. Start with elements of the examination that have a high chance of being needed in the exam:

– The eyes: Chapters 7–10.

– Other cranial nerves: Chapters 5, 6, 11–14.

– The motor system: Chapters 4, 15–20.

– Limb sensation: Chapters 21, 22.

– Coordination and abnormal movements: Chapters 23, 24.

– Speech: Chapter 2.

• Take it in turns to examine and to watch and advise until you are all confident with each chapter. Then practise conducting a standard examination (Chapter 28).

• Particularly practise examining the eyes (especially left eye ophthalmoscopy) and the limbs, and concentrate on developing a system of motor examination.

• Read the book again.

Having become familiar with the methods, now try to see as many patients with neurological problems as possible, again observing each other. After each examination, summarise the physical signs, come to a synthesis and differential diagnosis, and discuss the investigation and management with your examination partner, or even better with a more experienced doctor, if you can find one.

Patients are almost always keen to help. Patients with long-standing neurological problems will often be expert at being examined and are often particularly helpful.

When not seeing patients, practise describing the physical findings of imaginary patients with classical diseases and discuss their investigation and management with your examination partner.

¹ These are the three elements on the examiner’s mark sheet for the neurological part of PACES in MRCP.

² See last part of this section: Learning neurological examination in a crisis.