The short case

Published on 21/03/2015 by admin

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Chapter 3 The short case

The short-case section of any postgraduate examination covers a number of systems (typically cardiovascular, respiratory, abdomen, neurological), and different countries’ learned colleges vary in their approach. In Australia, the individual FRACP short case tends to have a lead-in that is fairly broad, for example ‘Examine the gait’, and a comprehensive examination is expected. Each short-case examination lasts 15 minutes.

On the day of the examination, in Australia, there are four short cases, two in the morning cycle and two in the afternoon cycle, and the candidate is examined by four sets of examiners. For each short case, the candidate is given 15 minutes with the patient. The candidate is supplied with a written introduction on a card, posted outside the door of the examination room, outlining a short history and indicating the system(s) to be examined, such as ‘Ian is a 7 year old boy who has had increasing trouble climbing stairs over the last 6 months. Please examine his gait’. The candidate has 2 minutes to read this introduction before meeting the patient. The same introduction is used for all candidates. The candidate should perform a relevant physical examination; the examiners are interested in the method of examination, and appropriate interpretation of signs elicited. Practice is the key to success.

In the UK, the individual MRCPCH short cases tend to have a lead-in that is more directed, so a more focused examination is in order: the examiner may say ‘Listen to the heart’, and that is what the candidate must do—not pick up the hands, take the pulse and look for clubbing, but get the stethoscope and listen. The short cases here are deliberately set out in the ‘comprehensive’ approach; it is easy to adapt the relevant portion of the examination to whichever lead-in the examiner gives. A short case tests the candidate’s ability to examine a child with the ease and accuracy of a consultant paediatrician, rather than a paediatric registrar, although the examiners are judging the candidate at his or her expected level of training.

A short-case examination should be sufficiently comprehensive for the lead-in given, but directed. It should be confidently performed, quick enough to be within the confines of examination timing, and above all conducted kindly and with consideration for the patient and the parent.

The emphasis is as much on the method of physical examination as on the interpretation of the signs elicited. Remember that the examiners are judging you as a (future) peer. Thus a high standard is mandatory.

Proficiency in short cases, even more so than in long cases, is dependent upon months of practice, preferably on a daily basis, perfecting a coherent approach to every possible clinical problem likely to be presented. Several examination problems, such as short stature or precocious puberty, require a great deal of clinical material to be covered in 15 minutes, so a well prepared routine is essential. This book gives an outline of an approach to most of the commonly seen short-case topics.

For several of the short cases outlined, there is an accompanying diagram that visually supplements the content of the text. The author found it easier to remember a diagram than a long list written on a card.

The time allotted to the short-case section varies between countries. Irrespective of the time allocated, it is usual that at least four systems are assessed. Often, the examiners will instruct that you may either talk as you proceed, or examine in silence and summarise at the completion of the examination. Most candidates prefer the former method, as it allows the examiners to see, and hear, how you think, and should a questionable finding be noted, the examiners may guide you at that point.

It is crucial to read carefully the written introduction to the case, which is provided before the candidate meets the patient, to get into the correct frame of mind and plan the appropriate approach. The introduction gives clear instructions as to the approach required. Several points here need emphasising. The introduction has been carefully formulated by the examiners, to be concise and realistic and fairly neutral, without obvious directed diagnostic clues. Do what the introduction instructs. If the request is to perform an abdominal examination, do not start with the hands—start with the abdomen.

In any short case, it is always worthwhile spending at least 20–30 seconds standing back and getting an overall impression of the patient; otherwise, signs such as chest or limb asymmetry, or a recognisable pattern of dysmorphism, may well be overlooked.

It helps to visualise yourself as a consultant before you commence any short case. It may be useful to imagine you are a locum paediatrician, being asked for a second opinion on any child you see. One sign of being stuck in ‘registrar mode’ is prefacing every potential action with ‘I’d like to’. Do not say ‘I would now like to look at …’—just do it! You do not see one consultant asking another’s permission to proceed during each step of an examination.

However, do not overstep the boundaries of confidence. Do not argue with the examiners under any circumstances. Very rarely you may be right, but you may fail and be thought arrogant. If you become angry with an uncooperative child, you may fail; if you inadvertently hurt a child, such as in a joint examination, you may well fail. If you do not follow the instructions of the provided introduction, you will fail; as one examiner was heard to say (in a mock exam, thankfully): ‘Answer the bloody question!’

At the completion of your examination, you may mention further areas that you would examine next, should time permit, and then present a succinct summary of your findings with the most likely diagnosis, followed by a logically presented differential diagnosis. The differential diagnosis need not be exhaustive. In particular, it should never be a rote-learnt list for a certain type of case, but it should be relevant only to the particular child you have just examined. Be careful that the first diseases you mention are not inappropriate suggestions. For example, an infant with jaundice and a Kasai scar on the abdomen should not be given a diagnosis of metabolic liver disease as the most likely possibility. So, beware of ‘automatic list’ responses.

Should you see a particularly confusing patient, and you are quite unable to work out their signs, do not bluff. It would be appropriate to admit that you find the signs confusing, but approach this methodically and logically. For example, if a child has a large array of heart murmurs, and the underlying diagnosis is completely unclear, it may be sensible to say, ‘This child has complex congenital heart disease, but I am uncertain as to the exact anatomical diagnosis. However, taking each murmur individually …’, and proceed to give a differential diagnosis for each murmur, mentioning that an electrocardiogram and a chest X-ray may clarify the diagnostic possibilities. You do not have to get the diagnosis absolutely correct to pass. Conversely, getting the diagnosis correct does not equal passing: if a child has an obvious aortic stenosis, missing neck auscultation for murmur radiation, and giving no thought to assessing the severity of the lesion, will not help you to pass.

Many candidates over the years have had acting lessons and training in elocution to improve their presentation. For many, overcoming mumbling is a major hurdle. A successful solution for some candidates has been to videotape their performance, and then replay this to see how they would appear to the examiners.

An important point in presentation is correct coinage. Do not use terms such as ‘I think there perhaps might be a little bit of asymmetry of the chest’; either there is asymmetry, or there is not. Similarly ‘perhaps a tinge cyanosed’ is not an appropriate description. You should try to eliminate words of uncertainty from your vocabulary.

As well as avoiding the ‘I think perhaps’ syndrome, you need to consciously tighten up your description of the patient’s signs: for example, ‘acyanotic’ is far preferable to ‘pink’, and ‘paucity of spontaneous lower limb movement’ is preferable to the ‘legs aren’t moving quite as much as I’d expect them to’. Use the correct medical terminology every time; avoid all colloquialisms.

Do be aware that the examiners themselves have examined the children on the morning of the examination, without the aid of the child’s notes and with a similar introduction to the one that the candidates receive. This means that they too have examined the child ‘blind’, and thus any conflicting or questionable findings can be noted so as to maximise the suitability of the case, and assess whether the lead-in is appropriate.

The most useful form of practice is to be critically assessed by a consultant, and optimally one who is an examiner. Being examined by an advanced trainee who has recently passed is also very beneficial. The most easily accessible form of practice is, of course, with your fellow candidates.

It makes sense to practise at a number of different hospitals and to be exposed to as many different examiners as possible, so as not to become accustomed to one particular pattern of criticism and questioning.

The criteria used to assess performance in the short case have five headings (assessment domains): approach to patient, examination technique, examination accuracy, interpretation of physical findings and discussion of investigations. One of the examiners will have already examined the patient ‘cold’, before the first candidate, without seeing any prepared notes, such that the circumstances are as close as possible to those the candidate will experience; the examiners know how easy (or otherwise) the child may be to examine, and whether any particular signs are difficult to elicit. The examiners then spend some time reviewing the notes, and a prepared short-case summary sheet, which lists the written introduction (stem), the diagnosis and the examiners’ agreed signs. Remember, all examiners will have undergone a calibration session in the weeks before the examination, to ensure consistency and fairness.

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