The Clinical Exam

1. The Clinical Exam

2. 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

3. 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

4. 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

5. The Short Case • 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

6. 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

7. What could the “other” cases be? • Hands (eg RhA) • Leg ulcer • Speech • Pregnant patient • Neck mass • Parkinsons • Higher mental functions • Eye exam

8. 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

9. 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 • approp • • Asthma resolving in a child • – X was admitted to hospital 2/7 ago with cough and resp diff, please examine his resp • system • • Bronchiectasis and cleft lip repair

10. 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

11. 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

12. My cases • 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

13. 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

14. How should you present your findings? • 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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.

22. 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

23. 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!

24. 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”?

25. 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

26. 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.

27. 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

28. 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

29. 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?

30. Opening with the patient • Introduction • Thankyou

31. 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!

32. 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?

33. 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.

34. Opening statements • 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.

35. Opening statement • 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”

36. Presenting history • The most important part of the presentation • • Relevant Part history • • Relevant negatives and positivies

37. 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

38. Nice touches • 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

39. Examination • 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

40. 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

41. 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.

42. 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.

43. 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.