Transcript The Clinical Exam

The Clinical Exam
The clinical exam
• Eligible if you pass two or more sections
of the written examination
• 4 short cases
• 1 long case
• 6 SCEs (structured clinical exams)
• Short and long on the first day
• SCEs on the second day
Paediatrics
• There will be a paediatric case
• No specific age limit
• Emphasis is on approach to the child and
communication with the child and the
parents
Extra cases
• Supplementary long or short may be
allocated if decision between mark 4 or 5
unable to be made
• Only in the event of exceptional
circumstance
• Two most senior examiners
• Occurs immediately afterwards or at end
of examination section dependent on
examiner availability
The Short Case
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Show case your patient
20 minutes with an examiner pair
5 minute break
20 minutes with another examiner pair
10 minute split with each patient is not
mandatory – examiner judgment required
to accommodate nature of cases.
• Each case introduced with a standardised
stem
What sort of cases will I see?
• Examiners try to give everyone cases
from
• – Cardiovascular
• – Neurological
• – Respiratory/GIT
• – One “other”
• A paeds case is usually included
somewhere
• Site organisers have final discretion in
choice and mix of cases
What could the “other” cases be?
• Hands (eg RhA)
• Leg ulcer
• Speech
• Pregnant patient
• Neck mass
• Parkinsons
• Higher mental functions
• Eye exam
Ian Rogers cases examined
• Pulmonary fibrosis with pulmonary HT
• – X retired from work 2 years ago b/c of
SOB, please examine his CVS
• • CCF with pacemaker and jaundice
• – X has been admitted for Mx of SOB,
please examine his CVS
• • VSD in a young child with Downs
• – X was born 3/52 prem, please examine
her CVS
• • Mitral regurgitation with sternotomy scar
Ian Rogers cases examined
• Child with L pulmonary hypoplasia and
diagphragmatic hernia
• – X has a congenital disorder involving his
chest, please remove his shirt & proceed as
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• • Asthma resolving in a child
• – X was admitted to hospital 2/7 ago with cough
and resp diff, please examine his resp
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• • Bronchiectasis and cleft lip repair
Ian Rogers cases examined
• Splenomegaly – 3cm tippable
• – X has a lump in his lower abdo, could
you please examine his abdomen
• • Lipoma in inguinal area
• – This man has a lump in the lower abdo,
could you please examine his abdomen
• • Chronic liver disease with infected
ascites
• – Please examine this ladies GIT system
but be very gentle as she is in some pain
Ian Rogers cases examined
• R LMN VII palsy post mastoidectomy
• – X has problems with his hearing, could you please
examine his cranial nerves
• • MS lower limb weakness, gait disorder and sensory
deficit
• – X has problems with her walking, could you please
examine her lower limbs
• neurologically
• • Addisons in an 8 year old child
• – X reports troublesome dizziness on standing, please
examine his CVS
• • Eyes – quinine toxicity
• – X has problems with her eyesight, could you please
examine her cranial nerves
• • Cellulitis leg with peripheral neuropathy
• – X has a sore right leg, could you please examine it
My cases
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70 yr old man with mixed valvular disease
25yr old female with enlarged thyroid
18month child with developmental delay
25yr old female normal 8 month
pregnancy
General tips on examining
• Be nice to your patient
• Don’t hurt your patient
• End of the bed assessment extremely
important
• Exposure first – include legs
• Practise practise practise
• Practise on patients you see in ED every
day
• Carry summaries from Talley and
O’Connor
How should you present your findings?
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Typically have 2-3 minutes to present
Examiners want to hear
– Likely diagnosis
– Details of important positives and
negatives
– Differentials
– Severity, aetiology, complications
– Summary (because we dont listen)
• Tell em what you are going to tell em
• Tell em
• Tell what you just told em
Should I talk while examining?
• This is entirely up to you
• Examiners are specifically told this
• Ian suggests talking as far as the
clavicles
• Experiment and work out what is best for
you
How are they marked?
• This is all about to change
• 2 examiner pairs will no longer confer to
generate a single mark
• A simple numerical formula will apply
• You will need to pass at least 2 of 4 cases
• You may be able to pass with a total
score of less than 20 out of 40
The Long Case – Wayne Hazell
• Giving a didactic talk on how to do a long
case is quite challenging!
• Usually a process best dealt with by
experiential learning
• Expert appraisal, reflection and repetition
are central to the development of good
skills in this area
Opinions of Wayne Hazell
• The content of this talk are my opinions
only
• Many other opinions are valid
• These opinions presented here are not
necessarily ACEM policy
Long Case format
• 35 minutes with the patient
• • Relevant equipment should be present
in the room
• • 5 minutes outside of the room prior to
meeting with the examiners
• • 20 minutes with the examiners
Source of long cases
• Usually “hot” cases but occasionally
patients may be luke-warm or even cold
• What’s special about the long case?
• Some examiners believe the long case is
the mode of examination most resembling
ourclinical practice. Some examiners thus
take great note of the long case marks
when acandidate is being discussed.
What’s special about the long case?
• You only have one attempt at the long
case. If you fail the case, you fail the
section.
What’s special about the long case?
• One long case gives the same sectional
score and weight as:
• 8 VAQs
• 8 SAQ’s
• 6 SCE’s
• 4 shorts
What’s special about the long case?
• Two examiners only will determine your
sectional score
• Therefore you don’t want to leave the
examiners with any doubt!
• What’s special about the long case?
• The examiners will only be able to
compare your performance with a few of
your colleagues.
• Therefore you don’t want to leave the
examiners with any doubt!
Why do candidates have difficulty?
• As well as similarities; there are
differences between the long case and
what we do on theshop floor
• Multiple factors but does this contribute:
“cutting corners consistently [because of
thepressures in ED] leading to the
erosion of some basic historical and
examination skills required for the long
case”?
How many long cases?
• You should aim to meet the following objectives
• • Self confidence and clarity in your long case
note taking strategy
• • Self confidence and clarity in your long case
timing strategy
• • Self confidence and clarity in your long case
presentation ability and strategy
• • Verification of the above from external sources
• • First case: uni-dimensional, moderate number
of signs.
• • Second case: multidimensional, moderate
number of signs.
• • Third case: multidimensional, multiple signs
The poor historian
• You must have developed an approach to
the poor historian just in case.
• • Excuses and more excuses for a poor
history is usually not taken well but a well
• documented abnormal mini-mental state
examination and /or neurological
examination
• look very professional.
Additional preparation
• Medical record rounds
• • Drug chart rounds
• • References: Talley and O’Connor
common long cases
• • Systems review revision
• • “Ask about” revision
• • Relevant negatives and positives
revision
Timing with the patient
• No longer than 15 minutes just on history.
• • At the 15 minute mark or earlier start
examining the patient. You can continue
to take the history while you examine if
needed.
• • Stop at 30 minutes and collect our
thoughts and make your notes.
Concentrate particularly
• on relevant negatives and positives. Have
you missed anything?? If so go back and
ask or re-examine
5 mins prior
• Consolidate your opening and closing
statements.
• • Visualise your approach to presentation
• • Where are you going to go? Where are
your strengths?
• • Where might the examiners go? Are
there any investigations or results that
may come intoplay?
Opening with the patient
• Introduction
• Thankyou
Opening with the patient
• I don’t mean to be rude but I will need to
progress and gather information quickly
as this is
• a very important examination for me.
• • I may need to interrupt you at times.
• • You are allowed to tell me anything that
you know!
Questions applicable to the patient
• Do you know your diagnosis?
• • Do you know the tests you have had and their
results?
• • What did the doctors do for you
• • Do you know what the doctors have planned
for you? Investigations and management?
• • What have the doctors found when they have
examined your heart before? Etc
• • Do you have a list of your medications?
• • Do you have a list of your medical problems?
Presentation – opening statement
• Management Vs a
Diagnostic/Investigative problem.
• • Relevant background can come into the
opening statement.
• • Paint the “big picture” with the “big
details” in one to three lines.
Opening statements
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The layers of Mrs Green
Opening statement 1
• I would like to present Mrs Green who presented with cough and shortness of
breath for
investigation.
Opening statement 2
• I would like to present Mrs Green.
• Mrs Green presented with cough and shortness of breath for investigation on a
background
history of active SLE.
Opening statement 3
• Mrs Green is a 60 year old lady who presents the interesting management
problem of
pneumonia in a patient with SLE.
Opening statement 4
• Mrs Green is a 60 year old lady who lives alone independently. She presented
to the
emergency department with the challenging management problem of respiratory
failure
secondary to pneumonia. Interestingly this presentation was further complicated
by her
long standing pulmonary fibrosis, secondary to SLE, which had required
treatment with
immunosuppressant agents.
Opening statement
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Name
• Age
• Social situation
• Diagnosis
• Management problem: I know the diagnosis
• Emergency problem: respiratory failure
• Relevant Past History: SLE and pulmonary
fibrosis
• • Contributing factors/ risk factors:
immunosuppression
• • Generates examiners attention via
“challenging” & “interestingly”
Presenting history
• The most important part of the
presentation
• • Relevant Part history
• • Relevant negatives and positivies
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Presenting problem
• Active problem/s that are relevant to the presenting problem
• Active problems that are not relevant to the presenting problem: note these may be relevant
to ADL’s/ functioning.
• Non –active problems: too be listed only
Family history
• Usually brief
• If relevant this will be brought up to the presenting problem section
Medications
• Generic names
• Reference to condition used for
• Part of the medication list can be brought up
Allergies
• Easy to forget
Systems review
• Usually nothing to say if have done relevant negatives and positives properly
Social
SSS-HIP SAFE-T
• Stressors
• Sexual
• Smokes
• Home alone?
• Independence
• Psychological impact
• Safety features at home
• ADL’s –who & what support these?
• Finances
• ETOH
• Transport
Nice touches
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Type of presentation to hospital
• Date of presentation
• Current GP
• Currents Specialist
• Current ward
Nice touches
• Psychological impact of disease
Nice touches
• Emphasis sections via speech patterns/ eye
contact
• • Emphasise your areas of strength and hope
the examiners take the hint
Examination
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General appearance
• Vital signs
• System of most relevance first
• Present this like a short case
• Present related features of other systems
• Present other positive findings
Mrs Green
• Appearance
• Vital signs
• Respiratory short case with relevant + and –
• Cardiovascular system presented particularly with relevant right heart strain signs + or • Features of SLE elsewhere with relevant positives and negatives to show knowledge of
SLE
• Positive finding in other systems
Concluding statement
• How does this differ from an opening statement?
• Often similar for a management problem.
• Often different for a diagnostic or investigative problem
Mrs Green: concluding statement
• In conclusion; Mrs Green is now recovering from her pneumonia and respiratory failure.
Present ongoing management issues for her include the optimal management of her SLE
and pulmonary fibrosis; as well as addressing her lack of social supports. ……… If I was
managing Mrs Green when she first presented ……………
Time of presentation
• Will vary with complexity
• Straight forward cases should not be unnecessarily long
• Aim to talk for 10-12 minutes
• If you are interesting and on the right track examiners are unlikely to interrupt before this
time
Post presentation
• Keep talking until stopped by the examiners.
• • Dictate your terms for as long as possible
• • What would you do if this patient came into the
ED when they first presented?
• • What further investigations would you do for a
diagnostic problem?
• • What are the ongoing management issues
now and how would you handle them?
• • You could request to see an investigation
ECG, CXR etc.
• Conclusion: You can be in the drivers seat if you
are well-prepared
The SCE examination
• Structured Clinical Examinations (SCEs):
• SCEs test some of the elements tested in the 3
written sections of the exam but more closely
mirror realistic, evolving clinical situations.
• They have the advantage of allowing both
examiner and candidate to qualify, challenge
and expand an answer given in an interactive
manner.
• Communication skills are a component of the
SCE format.
• The broad subject matter of the SCEs is
reflected in the matrix published in the Training
and Examination Handbook.
• Features of well constructed SCEs include:
• A clear rationale for the SCE with regards to the
subject tested and questions asked which stands
irrespective of any visual props (such as radiographs
or ECGs) which may be used in the SCE (this means
that a prop alone is not sufficient reason to design a
SCE) .
• Avoidance of twists, traps or red herrings in the SCE
that well prepared candidates cannot be realistically
expected to predict or respond appropriately to.
• Avoidance of unnecessarily long passages of new
information given to the candidate during the SCE.
Typically, candidates cannot take in more than 2
sentences of new information.
• Numerical data (eg test results) should be provided in
written form and ample time allowed for interpretation.
• Double barrelled questions should be avoided.
• Selection of clinical images and test results (including
ECGs) for the SCE should be made with the view that
some discussion may be possible and offers an
advantage over VAQ format.
• More difficult or complex questions (eg “Discuss
questions”) need ample time allowance.
• Simple or straightforward questions may be made
more challenging by expecting a high level (consultant
level) answer.
• The requirement for candidates to be given a prompt
for some questions should be anticipated and planned
for (eg when there are mandatory requirements for the
answer to a particular question).
• When appropriate the SCE can be designed so that
the first question is given to the candidate outside the
SCE room before questioning begins.