Examination Medicine: A Guide to Physician Training (71 page)

4. 
Strategy for treating lipids in view of his intolerance to statins.

Second examiner

1. 
How is he managing at home? Does he have problems with depression?

Does he drink too much? What would you say to him about this?

2. 
Management of valvular disease. Which is more significant lesion?

COMMENTS

1. 
This man appeared well and might have been included in the exam because of his two malignancies, but the more significant unresolved problem was his recurrent productive cough. This is an excellent topic for discussion and it is likely the examiners would be keen to pursue this problem. You would also want to talk about diabetes management and cancer surveillance.

CASE 7

Mr RD is a 66-year-old retired public servant.

Problem list provided to examiners

1. 
Antibody deficiency.

2. 
Chronic wound right thigh, previous necrotising fasciitis.

3. 
Type 2 diabetes.

4. 
Ischaemic heart disease.

5. 
Hypertension.

6. 
Hypercholesterolaemia.

7. 
Obstructive sleep apnoea.

8. 
Gastro-oesophageal reflux.

9. 
Hypothyroidism.

10. 
Opioid dependence.

11. 
Subacute bowel obstruction.

12. 
Inflammatory bowel disease, procto-colectomy 1998.

His gut problems began in 1996 with bloody diarrhoea and a diagnosis of inflammatory bowel disease.

Biopsies were more suggestive of Crohn’s colitis and he was treated for a few years with steroids and azathioprine. He was intolerant of sulphasalazine.

Biological agents were not available at that time and poor control of his symptoms led to a proctocolectomy and the need for an ileostomy drainage bag. He had further surgery with relocation of his stoma in 2006 because of a parastomal infection.

There were recurrent admissions to hospital with subacute bowel obstruction. Opioid dependency developed at this stage.

In 2009 he had further surgery to relieve adhesions, which was largely successful.

His stoma works continuously and he empties it three times a day.

He does not know how much small bowel was resected.

His appetite has been poor since the wound problems and he has lost 20 kg. He takes Ensure supplements.

Two years ago he had surgical removal of two skin lesions on his right thigh. The wound broke down and numerous further operations were performed. The wound was complicated by necrotising fasciitis. Various organisms, including
e.coli spp
, were cultured. He has a photographic record of the wound, which he was keen to show. An immunoglobulin deficiency was diagnosed after investigations for failure of his wound to heal. He has intermittent human IV immunoglobin infusions.

He had two myocardial infarctions in 1997 and then a stent to the right coronary artery in 1998. He describes recurrent episodes of what he called ‘unstable angina’ requiring admission to hospital and narcotic analgesics in 2010, but an angiogram showed his stent was patent and there was no obstructive disease. His chest pain was atypical and not associated with ECG changes.

There was a history of hyperlipidaemia and hypertension, currently treated with artorvastatin 10 mg and he is not currently on anti-hypertensives. He has not smoked for 18 years.

He takes clopidogrel rather than aspirin because of gastro-intestinal side-effects associated with aspirin.

Type 2 diabetes was diagnosed in 1999. He measures his BSL ‘randomly’; results are between 4.5 and 9 mmol/L and he does not know his HbA1C.

He has regular eye checks and has no nerve problems.

Metformin was associated with diarrhoea and he takes glimepiride. This dose has been reduced because of episodes of hypoglycaemia. He believes his renal function is normal.

He has had a diagnosis of obstructive sleep apnoea; this appears to be mild and is not being treated.

He lives at home with his wife who is well. His son died 3 years ago from complications of type 1 diabetes. He has no particular financial worries. He drives and is moderately physically active. He uses morphine on a daily basis for thigh pain.

Examination

1. 
He appeared well nourished.

2. 
Blood pressure 130/80 mmHg, pulse 65/minute and regular. No signs of heart failure.

3. 
The thigh wound was almost healed, except for small area at the lower margin.

4. 
The stoma appeared satisfactory and the abdominal examination was otherwise normal.

5. 
There was no peripheral neuropathy.

Discussion

First examiner

1. 
History and management of IBD, including malabsorption and nutrition.

2. 
Ischaemic heart disease.

3. 
Candidates could be asked to speculate on the original cause of the thigh wound. Remember pyoderma gangrenosum and necrobiosis diabeticorum. Discussion about the slow healing should consider his antibody deficiencies as well as his Crohn’s disease. The recurrent infection with bowel organisms and curious photographic record of the wound might make you think about a factitious cause.

4. 
While discussing the management of his IBD, also consider investigation of possible malabsorption, e.g. vitamin B
₁₂
deficiency and tests for this, e.g. blood count, serum albumin, folate and B
₁₂
levels, vitamin D.

Second examiner

1. 
Possible ischaemic heart disease would lead to a standard spiel about risk factor control. But don’t take the patient’s assertion that he had experienced recent acute coronary syndromes at face value. Make sure you ask about the characteristics of the symptoms. Think, is the diagnosis was incompatible with the angiography findings? What about the influence of the opioid dependence on the symptoms?

2. 
You may be keen to wheel out your usual diabetes presentation, but you may not be allowed to by the examiners.

3. 
There may only be time for a brief discussion of the opioid problem with the usual discussion about referral to the pain management clinic.

COMMENTS

This complicated patient could provide good candidates with an opportunity to look beyond what they were told to achieve a high mark. Never blindly believe the history – look for evidence to support your diagnoses, and always consider a different diagnosis in every long case (and in clinical practice).

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!).