End of Posting Exam

Well, well, here's an excerpt of what Prof (M) Dr Oteh, my supervisor and also the head of department of Cardiology has to say for the end of posting exam, short case. I find it rather useful, so I hope I could share it with you guys:

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As you know, you will be examined on two short cases. The short cases can be CVS, Respiratory, Abdominal or CNS. Other systems including haematological, rheumatology, dermatology and endocrinology come under miscellaneous.

Though many will be apprehended by this interrogative style of exam, there is no other exam as specific as short cases. Number one, you definitely know what you are going to be asked, ie to examine a specific system and come with the correct finding, and hence diagnosis. The following are the possible instructions that you will hear from the examiners:

• Examine this patient's cardiovascular system
• Examine this patient's respiratory system
• Examine the abdominal system
• This patient came with left sided weakness. Do a neurological examination of the upper limbs
• Examine this patient's hands (usually rheumatoid!, but could be other, clubbing, or other arthropathy, less likely)
• Examine the neck (likely thyroid goitre - you must determine the 'thyroid status').

The following are common findings or cases that will be put in exam. But remember, cases are taken from the ward, therefore very much dependent on what kind of patients are in the ward. But for sure, renal dialysis, heart failure, asthma/COAD, CAP and stroke are common presentation, it is UNLIKELY that any exam will be devoid of those cases! Therefore you must know what to expect.

1. Know how to examine correctly. Not by theory, but you must show that you have done it one hundred times. If you are not too confident now, take one of your friends (same gender, of course, then you are sure of your intention...) and examine each other on each of the systems (CVS, Resp, CNS). Do it until you feel comfortable and confident. It is always easy to examine a normal subject, and one that you can repeat again and again - until you are happy yourself. So choose a good friend, not one that will always laugh at you!
   
   
2. Make a list of the common cases, and know what to expect. The following are not exhaustive:
   
   • CVS:
     
     • Cardiac failure - leg oedema (don't forget sacral), JVP (know how to assess correctly), ascites may be there too. Check for large pleural effusion
     • Valves - BEWARE: mediastinal scar, and also infraclavicular scar from pacemaker implantation. Check patient's pulse if in Afib (irregular, irregular). Learn to differentiate systolic and diastolic murmur. Honestly, you are less likely to be given a diastolic murmur of mitral stenosis. If there is aortic regurgitation (early diastolic) they may put the patient in exam. The usual, the most common one is either pan-systolic murmur of mitral regurgitation, or mid-systolic murmur of mitral valve prolapse. Occasionally VSD may be brought in, and the murmur is quite easy and you will suspect this in a young patient with left sternal pan-systolic murmur. Do not forget other findings too, like malar flush, central line etc.
     • 'Intermediate cases' - means not a very classic case eg. a patient with pacemaker and has atrial fibrillation, may be put in due to lack of cases.
     • In checking the pulse, complete everything - ie ensure the rhythm is regular or irregular - many candidates hesitate when prompted - that displays lack of confidence. This is a simple thing! Just keep your finger on the pulse for long enough - between 20-30 seconds.
     • Tips on murmurs - listen long enough at two areas - apex (mitral) and lower left sternal - most of the murmurs can be found there. At least 30 seconds, if you are unsure, or if you cannot hear anything on the first instance. Do not forget to check for radiation, for mitral - axilla, for aortic - neck.
       
       
   • Respiratory:
     
     • The common one is pleural effusion - be very fluent with the features then it will come handy. Others like consolidation due to pneumonia or malignancy (watch for clubbing). Then check for lymphadenopathy.
     • Others - if there is pulmonary fibrosis for sure they will put in. (do you know what are the features of pulmonary fibrosis?). Others are like empyema, lung abscess, bronchiectasis (usually clubbing with crepitations on lungs)
       
       
   • Abdominal:
     
     • Hepatomegaly, splenomegaly, hepato-splenomegaly and renal mass are the common cases. Beware! 'Abdominal' may actually be haematological, or renal depending on the findings. So be open minded. Obviously jaundice with hepatomegaly is abdominal (hepatic eg hepatitis, liver failure/cirrhosis), while hepato-splenomegaly or splenomegaly without features of chronic liver disease suggest haematological - in this case be prepared to discuss myeloproliferative or lymphoma as diagnosis.
     • If you find renal mass with fistula on the hand, then you should have clearly in mind what diagnosis you are dealing with. All in all - be fluent with differential diagnosis of each of:
       
       • Hepatomegaly
       • Splenomegaly
       • Hepato-splenomegaly
       • Other abdominal mass/renal (be prepared to discuss possibilities of diagnosis)
       • Ascites
     • Of note, abdominal examination is a one system in which examiner can assess whether you are gentle or rough with the patient. One thing, as I made comment last time, when examining for the liver and spleen, be sure you are pressing you tip of fingers/hand in during inspiration, watch if patient has any tenderness as well.
       
       
   • CNS:
     
     • This is quite vast, so you must be prepared. Do not be overwhelmed with whatever comes, as long as you know the right techniques, you will pass. Many students simply do not know or cannot perform correct CNS exam. You must be fluent with Cranial Nerves exam, Upper limb exam and lower limb exam - do practice this. Practice how to check for rigidity, how to perform correct tendon reflexes, Hoffman's sign, Babinski, Cerebellar.
       
       
   • Sound too overwhelming? I do not think so. You have undergone all that, and we had dealt with each system on a real patient. All you need is revise, and be fluent with the techniques.
     
     
3. Presenting the findings. This is an area where many fail to impress, pity, after performing a good clinical examination, your effort is wasted if you don't know how to present your finding. You also need to practice this. Practice in front of a friend - or in front of a mirror! for each case, eg practice presenting finding of a left upper limb UMNL for instance, or atrial fibrillation with MVP.
   
   When presenting:
   
   • Look at the examiners - both if there are two of them
   • Never look down or stare at patient, as if you have forgotten something
   • Present your finding as you have found them - no need to worry. A clear case is clear, a less clear one is as is, even to the examiner. If you have examined correctly, most likely your finding is correct - present them as is, even is one finding seems to contradict the other. As a yr 3, the examiner usually are willing to compromise, and correct you, or give second chance, so always listen to the hint...
   • Present the negative and positive findings - sometime negative finding is important, so you mention them, this is to convey to the examiner that you are looking for it, but have not detected it - as, in a rare case, may be the sign is there, and you have missed it - you will get a second chance. But if you did not mention at all, you may be in trouble.
     

Finally, I wish you the very best of luck in you exam. Calm down, take your time to prepare, no need to panic or worry - this will not change anything.

Prof Oteh

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