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SHORT CASES IN CLINICAL EXAMS OF INTERNAL MEDICINE: (For PACES, Arab Board, FRACP, FCPS, MD and Other National Board Examinations)Wanis Hamad Ibrahim FRCP (Edin) FRCP (Glasg) FRCP (Ire) FCCP (USA) Senior Consultant Physician Department of Medicine Hamad General Hospital Associate Professor Department of Clinical Medicine Weill-Cornell Medical College Doha, Qatar Foreword RA Malik
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Short Cases in Clinical Exams of Internal Medicine
First Edition: 2017
Printed atDedicated to
My mother, Mubaraka Al-Darrat for her sacrifice and constant support throughout my lifeForeword
Forewarned, forearmed; to be prepared is half the victory.
–Miguel de Cervantes
Medicine is both an art and a science. Scientific knowledge creates the foundation and the art of deduction and application enables the discerning clinician to arrive at the correct diagnosis enabling appropriate management.
Nowhere is the practice of Medicine challenged so acutely as it is in the examinations in Internal Medicine. The candidate is expected to undertake a thorough and systematic physical examination, identify the pertinent physical signs, create a sensible differential diagnosis, apply clinical knowledge and present their findings in a clear, structured and professional manner. However, when the pass rate is below 50% for the Practical Assessment of Clinical Examination Skills (PACES) examination, preparation is the key. In the words of my old mentor Professor JD Ward (Ex-Vice President of the Royal College of Physicians), preparation and daily practice is key to success in the Membership of the Royal College of Physicians (MRCP).
I believe that Dr Wanis Hamad Ibrahim has created a comprehensive book from the examiner's perspective, and incorporated a unique conversational style, which recreates the conditions encountered in the examination. The material covered is comprehensive and up-to-date, and builds on a wealth of experience, which guides you through what to expect in the examination, and how to examine proficiently, and present your findings in a professional and competent manner.
Professor of Medicine
Weill-Cornell Medical College, Doha, Qatar
Central Manchester University Teaching Hospitals and
University of Manchester
Clinical examinations are considered in many countries as an integral part in the assessment of a doctor's clinical competence. To candidates, they represent a major hurdle during their training. There is significant anxiety and stress associated with the preparation of these examinations that peak on the day of the examination. Internationally, there is significant variation in the way these examinations are conducted. Two types of clinical short cases examinations are currently conducted at national and international levels. In the traditional unstandardized examination, a candidate is typically examined by two examiners on all short cases. The more standardized form of examination requires two examiners (who mark independently) at each station. The former examinations have a considerable number of disadvantages including inconsistency in marking and judgment between examiners (hawk versus dove), gender, personality and ethnic biases. Furthermore, many national and some international boards appoint clinical examiners without prior training which results in further variability and inconsistency in marking. Nevertheless, the key factor for passing clinical examinations remains the candidate's preparation for the examination. Going for a clinical examination is like going to a battle. Irrespective of clinical experience, preparation and practice are the key to passing clinical examinations. You can hear about cardiologists, who fail cardiac cases; gastroenterologists, who fail abdominal cases; or neurologists, who fail neurology cases in clinical examinations because they have not prepared well. Preparation for these clinical examinations requires in addition to attainment of broad medical knowledge, acquisition of the required clinical skills of physical examination, and mastering the art and discipline of presenting findings, and case discussion in a clear systematic manner. Several crucial steps prepare the candidate for their short cases. Whilst many candidates feel confident in their clinical skills and techniques, stress in the real examination will expose significant skill and knowledge gaps. It is essential therefore that day-by-day short-case practice should become second nature to all candidates preparing for their clinical examinations. The best way of attaining this is by frequent bedside assessment and teaching of a motivated group of candidates by a registrar or a consultant (preferably who has been through the examination hurdle). The exam-oriented consultant supervision and comments during the wardround, and mock examinations are also helpful. Revision courses may help to familiarize candidates with the common examination cases and examination methods but alone are never sufficient to pass clinical examinations. Parallel to mastering proper examination skills is a good grasp of medical knowledge related to the common examination cases. Reading the medical textbooks without considering commonly encountered cases in the examination is virtually guaranteed with failure. The examiners are assessing knowledge and clinical acumen, and the latter cannot be derived from the textbook. Candidates should also focus on reading books that are dedicated to help candidates pass their clinical examinations. These books familiarize candidates with the most common cases encountered in examinations. Many candidates believe that currently, there are not enough books that meet this purpose. Hence, many of these books are large medical textbooks that are detailed and extremely wordy, but lack focus and include detailed theoretical information that is useful in written rather than clinical examinations. The examiners are looking for common sense clinical answers, not the latest theories on the molecular basis of disease. As an international clinical examiner, the primary organizer and host examiner for different clinical board examinations, I endorse the view that candidates need concise information to help them systematically examine cases, quickly identify the abnormality, and derive the correct diagnosis. In this book, I have put tremendous effort into including all possible questions that my examiner colleagues have asked or may ask in the examinations. In order to provide the candidate with a model answer in the examination, I have provided a typical conversation between an examiner and a candidate where the examiner asks, and the candidate provides the expected answer. This may also put the reader of the book in a more interactive atmosphere rather than reading a large text with the bottomline information lost in the details. Being a previous candidate for undergraduate clinical examinations, I realized how candidate's working memory is negatively affected by the exam-provoked stress. Candidates, for example, can easily forget a simple list of causes of a disease. Considering this, I have included some mnemonics in various pages to help recall some long lists. Each case or system in this book is preceded by how to examine to help candidates focus on important physical signs related to that case. Common mistakes or pitfalls committed by candidates and various examiner's instructions that have been observed in real examinations are also clearly addressed at the beginning of each case. Particular attention has been paid to the up-to-date management of each case, which is a common question in clinical examinations. Finally, I have gathered all my experience as a clinical examiner, organizer and educator in the book to help doctors feel confident when proceeding to their clinical examinations.
This book is intended for candidates preparing for all clinical examinations using the short-case format such as MRCP (UK and Ire)—PACES, Arab Board, Arabian Gulf Boards, FCPS (Pakistan), MD (India), FRACP (Australia) and other national clinical examinations. Medical students may also find the book useful.
Wanis Hamad IbrahimAcknowledgments
I am indebted to the following colleagues from Hamad Medical Corporation, Doha, Qatar, for their great assistance and providing some photographic materials included in this book: Dr Amjad Mahboob from Internal Medicine Section; Drs Ahmad Shihab, Dirik Deleu, Suha Makki, Faisal Ibrahim and Yasser Osman from Neurology Section; Drs Fiaz Alam, Samar Al-Emadi, Izzat Khanjar, Abdul-Razzakh Poil, Salah Mahdi and Mohammed Hamoudeh from Rheumatology Section; Drs Dhabia Al-Mohannadi and Mohsen Eledrisi from Endocrine Section; Dr Salah Elbadri from Cardiology Section; and Drs Mohammed Mousa and Fatima Almansouri from Ophthalmology Section. My special thanks to Professor RA Malik for his invaluable suggestions and continuous support during the preparation of this book.How to Present your Findings to the Examiners?
In addition to the proper technique of physical examination and identification of the correct findings, the way that candidates present their findings to the examiners will affect the overall examiner’s impression about the performance of the candidates and the final short case mark. Many candidates of high standard can fail the examinations simply because they cannot convey the correct findings and diagnosis to the examiners. Presenting your ideas to listeners is an art in itself; and, therefore, candidates should practice repeatedly presenting their clinical findings to their peers or senior colleagues. The common two scenarios after a candidate completes physical examination of a patient are that either he/she is confident about the diagnosis or he/she identified the findings but is not confident about the exact diagnosis (in the latter scenario, the candidates has 2 or 3 possible differential diagnoses). If the former scenario is applicable and the candidate is confident about the diagnosis (for example, the candidate found a pansystolic murmur of maximal intensity at the mitral area radiating to the axilla suggestive of mitral regurgitation), then the candidate should tell the diagnosis first and then refer to the findings. For example, the examiner asks what your diagnosis is. The typical answer should be: ‘Well, this pleasant gentleman has features to suggest mitral regurgitation as evidenced by muffled first heart sound, a pansystolic murmur of grade 3 of 5 heard best at the mitral area radiating to the axilla’. There are no signs of heart failure or infective endocarditis and I would like to request echocardiography to confirm my findings and assess the severity of the valve lesion. A candidate who is confident about combined aortic valve disease (stenosis and regurgitation) can provide the following answer: ‘Well, this pleasant lady has features to suggest combined aortic stenosis and regurgitation as evidenced by an ejection systolic murmur heard best in the aortic area grade 3 of 5 radiating to the neck as well as an early diastolic murmur at the aortic area. The patient seems to be in heart failure as I could hear bilateral crackles over the lung bases. The predominant valvular lesion seems to be aortic regurgitation as the pulse is collapsing and, I could find peripheral signs of aortic regurgitation.
Alternatively, the candidate may have established some findings but he/she is not confident regarding the diagnosis. In other words, he/she is confused as the findings could fit more than one diagnosis. In that scenario, I suggest that the candidate should present his/her findings first, and then suggest a diagnosis and justify or defend his/her thinking. Example of this, a candidate found a harsh systolic murmur over the base (aortic area), but could also hear a loud murmur over the mitral area, and is not confident whether it is aortic stenosis or mitral regurgitation. The typical candidate answer will be: ‘Well, I examined this pleasant lady who has a holosystolic murmur that is best heard over the aortic area; however, I could also hear the same murmur with the same intensity over the tricuspid and mitral area. Although the murmur is heard loudly over the mitral area it does not radiate to the axilla and I could hear radiation of the murmur in the neck. This makes aortic stenosis the most likely diagnosis in my mind; however, coexistent mitral regurgitation needs to be ruled out by echocardiography. The patient is not in heart failure and there are no signs of infective endocarditis’. In the second scenario, the examiners usually ask questions that can lead the candidate to the correct diagnosis. Now think what will be the candidate mark, if he/she stated that the diagnosis was aortic stenosis and stopped, and it turned to be mitral regurgitation or vice versa. The second important point candidates need to consider when presenting their findings is to show extreme respect to the patient. A male patient should always be referred to as pleasant gentleman and a female patient as pleasant lady. Although each candidate is given a mark before the next candidate is examined, the examination is a competition between candidates and examiners, will usually compare your performance to other candidates. A candidate who starts his answer by: ‘Well, I examined this pleasant gentleman/lady….’ is definitely considered more courteous to the one who starts by: ‘This patient or this old woman, etc.’ Candidates in clinical examinations are usually under tremendous anxiety and stress, and a simple question by the examiner might be interpreted by the anxious candidate as a trick or trap. Always think simple and in case, you have a doubt as to what the examiner means by the question, do not just give any answer, simply request the examiner politely to repeat or rephrase the question.