Examination Medicine: A Guide to Physician Training, 7th Edition

CHAPTER 15. The short case

You see, but you do not observe.

Sir Arthur Conan Doyle (1859–1930)

The short case is a test of the candidate’s ability to examine a patient smoothly, confidently and accurately. There is rarely the opportunity to go back and repeat the examination. It takes a long time to get used to being watched critically while examining. This is why it is important to practise short cases of every conceivable type so that the physical examination is performed automatically in the correct way. While proceeding, the candidate should be consciously synthesising the results, not trying to remember what to do next.

Written introductions (or stems) were introduced for the short cases in 2008. These have a standardised format, including the patient’s name and age, followed by a brief description of the patient’s symptoms, if there are any, and then a request to perform a particular examination. The stem is chosen by the examiners after they have assessed the patient. The written stem is given to the candidate or displayed on the door 1 or 2 minutes before the start of the case and is repeated verbally to the candidate when he or she enters the room. The idea is to give the candidate time to decide what to do. The possible trade-off is that the stems are becoming more subtle.

If the patient has no symptoms, the stem may state this. If the case is an obvious ‘spot diagnosis’, the stem may give the diagnosis and ask for an appropriate examination to assess the severity, activity or functional effect of the condition on the patient. For example: ‘Mrs Jones is a 60-year-old woman who has a long history of rheumatoid arthritis. Please make an assessment of the activity of the disease.’

If the stem contains specific instructions, these must be followed. For example, if asked to examine a patient’s gait, it is vital to get the patient to walk first. This may appear obvious, but many candidates have failed because they have not followed the examiners’ instructions. In the short case examination of a patient with bronchiectasis, the stem may be: ‘This man has a cough. Please examine him.’ The patient would have an obviously loose cough, typical of bronchiectasis. Candidates who ask the patient to cough would pass, but those who do not ask him to cough would more likely not pass. In reality, there is plenty of time, but you certainly do not want to run out of time before getting to the problem the examiners have raised.

The time allowed for each short case is 15 minutes. This means that time should be available for both examination and discussion. Patients are not really included just as quick ‘spot diagnosis’ cases alone, but if you do ‘spot the diagnosis’ it will be a golden opportunity to demonstrate systematically the associated signs in full. The examiners will expect a higher standard of examination when the diagnosis is fairly obvious.

With the previous marking system, a candidate could fail all the short cases and still pass the examination. This changed in 2013 so that everyone must pass at least one short case. The most common short cases are cardiovascular and neurological problems. We suggest that candidates aim to examine each short case proficiently within 8 minutes.

Remember that infectious diseases physicians are everywhere. Ask to wash or wipe your hands before going into the short case room (and do it). The examiners do not usually want you to wash them in the examination room because of the delay involved, but look around for somewhere to wash as you go out.

HINT

Wash your hands before and after examining! Some candidates keep a small bottle of hand gel in their bags so that they can be seen to wash their hands and are not delayed by having to search the room.

It is a good idea, when introduced to the patient, to step over and shake his or her hand firmly. This may endear you to the patient (and exclude dystrophia myotonica). Always position the patient properly (e.g. at 45° for the cardiovascular examination or flat for the abdominal examination) and make sure that he or she is appropriately undressed for the relevant examination.

It is always worthwhile taking a moment to stand back and look at the whole patient. This may prevent you from missing an obvious spot diagnosis, such as myxoedema, a thymectomy scar in a patient with muscle weakness (myasthenia), muscle fasciculations in motor neurone disease, a psoriatic rash in a patient with arthropathy or a Cushingoid appearance in a hypertension examination. Practice really does help improve ability to see clinical associations. A candidate will almost always fail the case if a major sign is missed. The examiners decide what signs they feel are most important, and in practice finding the majority of the agreed signs will result in a pass.

Do not ask the patient any questions about the diagnosis, but it is essential to say, ‘Let me know if this is uncomfortable or if I hurt you’, and, when examining the abdomen directly, to ask, ‘Are you tender anywhere?’ This is a test of bedside manner (and may give you a clue!). Always try to make the patient comfortable and avoid totally exposing the patient or exposing parts that are not being examined. Look at the patient’s face intermittently, particularly during the abdominal and hand examination, for signs that he or she is uncomfortable. It is distressing for the examiners to see from the patient’s face that he or she is in pain and that the candidate is unaware of this or is ignoring it.

The examiners do ask the candidate to take the patient’s blood pressure as part of the cardiovascular examination. In the past the measurement was often provided when the candidate asked, ‘Do you want me to take the blood pressure?’ or said, ‘I would now normally take the blood pressure’. This is not as simple as it sounds and many candidates can have considerable difficulty with this. In practice examinations some have looked shocked when told to go ahead and do what they had just offered to do; others struggled with an unfamiliar sphygmomanometer, while others looked as though they did not really know how to measure blood pressure.

HINT

Practise taking the blood pressure accurately under exam type conditions, and be prepared to do so in your case.

Candidates often worry about the need to look for radio-femoral delay when they are asked to do a cardiovascular case. This is not necessary unless the introduction mentioned hypertension (or you find hypertension when taking the blood pressure!).

Remember that you are, in fact, demonstrating the signs (particularly in the case of a neurological short case) to the examiners. It is important to perform each manoeuvre accurately and deliberately. Be seen to be smooth and confident, as if you have done the examination a thousand times before. Also try to be confident of each sign before moving on to another area (e.g. on finding an abdominal mass, concentrate on excluding the various possibilities and coming to a firm conclusion), and do not worry too much about the time it takes. Practice will facilitate formation of conclusions accurately and quickly.

Very occasionally, the examiners will pull a candidate away in the middle of an examination. This is why it is important to synthesise the data as you go. Do not get flustered by this – it usually means that enough of the examination has been completed for you to have discovered the important signs. Examiners no longer require the interpretation of a particular sign in isolation (e.g. the collapsing carotid pulse in aortic regurgitation or the double apex beat in hypertrophic cardiomyopathy).

Usually there is no interruption until the examination is almost finished. We suggest that candidates keep on examining until told to stop, and then list all the other things they would like to have done and why (e.g. urine analysis, rectal examination).

Before presenting the findings, listen closely to the examiners’ instructions. Candidates will often be asked: ‘What did you find?’ at which point they are expected to describe the relevant signs first and then comment on possible causes. Sometimes candidates will be asked: ‘What is your diagnosis?’, at which point they are expected to give a diagnosis or differential diagnosis first and then list the signs supporting the contention.

HINT

Formulate your diagnosis and differential diagnosis based on the individual in front of you.

Using a formulaic presentation of your findings might give you more time to think, but can be intensely irritating for the examiner if this is the fourth time they have heard ‘Mr Smith is an elderly man lying comfortably in bed’. And especially if the patient is no older than the examiners and is obviously breathless and not comfortable.

One useful method of presentation is to first repeat the examiners’ introduction briefly, then give the relevant findings, followed by the provisional diagnosis. For example: ‘I was asked to examine Mr Jones, a 60-year-old man who has had problems with dyspnoea. On examination of his cardiovascular system, I found …’ When describing the signs it is probably easiest to present them in the order they were looked for (e.g. for the cardiovascular system – pulse rate, then blood pressure, then jugular venous pressure). It is important to state all the positive signs and the important negative ones. Be definite about each sign mentioned or do not mention the sign at all. There is no place for expressions such as ‘slightly asymmetrical’ or ‘minor’.

HINT

In neurological examinations, don’t rush to undertake sensory testing which is often frustrating and less reliable. Leave the sensory examination to the end if at all possible.

Alternatively, you may talk as you go. This is not always acceptable to the examiners, and we recommend such an approach only in special cases in adult medicine, because the processing of information is usually more difficult for candidates (see Ch 16).

Confidence is critical to success in the short cases. Do not lose confidence if you make a minor error, just continue – the examiners may not even have noticed.

A short differential diagnosis is usually expected, even if the diagnosis is obvious. For example, a patient with fasciculation, plus upper and lower motor neurone signs in the legs and no sensory loss almost certainly has motor neurone disease, but a non-metastatic manifestation of carcinoma must be considered. Always mention common diseases before rare ones and always consider the patient’s age and sex. Never reel off any old list; the differential diagnosis must be tailored to the particular patient. Sometimes patients will have signs of two different problems. This should not be ignored. For example, a patient with proximal muscle weakness as a result of polymyositis may have unrelated Dupuytren’s contractures.

After presentation of the signs, a few minutes or more are set aside for discussion. The examiners are not encouraged to take the candidate back for a second look at a sign, as this can be extremely unsettling for the candidate and perhaps not fair. However, this does happen occasionally and it is best to think of it as a genuine second chance.

HINT

A redirect represents a genuine second chance – grab hold of the opportunity. There are no tricks in the examination.

From the examiners’ point of view, the candidate who is completely wrong presents a problem. This can occur because he or she has not read the stem properly; for example, when a request to examine the lower cranial nerves leads a candidate to begin to test visual acuity. Sometimes the examination depends on a spot diagnosis. For example, for an obvious acromegalic patient the stem might be: ‘This man has noticed some changes in his hands. Have a look at his face, examine the hands and go on from there.’ The risk here is that the acromegaly is not recognised and the candidate decides the diagnosis is, say, rheumatoid arthritis. The examination and discussion will then have nothing to do with what the examiners had expected and prepared for.

If the candidate’s mistake is recognised early on, the examiners may attempt to redirect the examination. This can be surprisingly difficult. Some candidates persist in continuing the way they began, despite strong hints or even direction from the examiners. This is presumably because they think an attempt is being made to trick them. This never happens.

HINT

If your diagnosis is completely incorrect, a good discussion won’t usually help you.

Sometimes the examination seems to be going well and then the candidate comes out with a completely wrong diagnosis. This makes the examiners’ prepared discussion unuseable. In this case the examiner will likely attempt to continue the discussion along the lines the candidate has begun. For example, the candidate appears to have examined a patient with small muscle wasting of the hands satisfactorily, but then, against all the evidence, decides the problem is rheumatoid arthritis. The examiners may ask what was found that led to the diagnosis and were there any alternative possibilities, but if no alternatives can be extracted from the candidate they will allow a discussion of rheumatoid arthritis.

This problem usually occurs when a candidate has decided on a diagnosis before looking at the patient. Deciding that the stem was, ‘“examine the hands”, therefore this must be rheumatoid’, must be avoided.

If a candidate has done well in a case and there are a few minutes left for extra questions, the score can only improve. Relevant X-rays or an ECG may be shown to the candidate. Some diagnostic and therapeutic aspects may be discussed in the short case.

HINT

If you have done well, in the last few minutes of discussion your score can only go up, not down. So don’t worry if the depth becomes overwhelming – press on talking about the issues in a mature, sensible fashion!

One examiner will introduce the patient and repeat the stem. This is likely to be the lead examiner. In many cases that examiner will conduct the discussion. There may or may not be an opportunity for the other examiner to ask some questions at the end. This may be a sign that the first one has run out of questions. This doesn’t really tell you whether things are going very well or very badly.

The College has moved away from the traditional ‘spot’ short case (e.g. acromegaly) and now concentrates more on ‘realistic’ cases (e.g. heart murmurs, abdominal masses). However, all types still crop up and candidates must try to prepare for most possibilities. It is also true that the more straightforward the case, the higher the standard of examination that will be expected, and vice versa. Trick cases are deliberately avoided.

The value of some traditional clinical signs is now being questioned as evidence-based approaches to clinical examination help establish the validity and utility of signs. There is much work still to be done in this area, but an understanding of the value of signs is increasingly important. A tactful approach may be needed with the examiners to prevent any resentment at the candidate’s failing to look for a traditional sign that is a particular favourite of theirs.

Six golden rules for the short cases

1. Do everything properly when you examine the patient – never take short cuts.

2. Think and synthesise as you examine the patient – be alert.

3. Never make up signs and never ignore signs because they don’t fit neatly together.

4. Always be sure of your facts when presenting – it’s better to say that you don’t know than to guess.

5. Always show consideration for the patient and never cause the patient pain.

6. Wash your hands before and after the case.