The Short Case

What is the short case?

• The candidate is given approximately 8-12 mins to examine a body system or anatomical area
• No history is taken
• Verbal communication is only allowed to get the patient to follow a set of instructions or if the patient's speech is being formally tested
• Following the examination the candidate must give a 3-5 minute summary of
  1. The examination findings
  2. The likely differential diagnosis based on the finding
  3. The probable causes and severity of the condition
  4. General discussion related to the above
• A smooth and confident technique reassures the examiner that you have a systematic manner of examining the patient and eliciting signs and defining the findings
• A gentle, kind and friendly manner indicates that you are an experienced and professional clinician.

Why is the short case so weird and stressful.…

• No rapport established with the patient (usually a history ‘breaks the ice’ before physically touching the patient)
• The patient may need to be involved in a lot of physical tasks rather than just answering some questions
• There are no initial clues about the likely diagnosis (problem formulation based purely on signs)
• It’s an artificial method of assessment (usually the diagnosis comes from the history and the examination findings confirm the hypothesis)
• The assessment is very brief
• You don’t have a lot of time to ‘think’ about the problem.

How to make the short case less weird and stressful…..

• Rehearse the examination until it is smooth and polished.  In the lead up to the exam get in the habit of using a disciplined and orderly technique on all the patients that you see.
• If you can do most things automatically (e.g. do the examination, and provide instructions) then you have more time to ‘think on your feet’
• Show the examiner that you are already thinking ahead. Don’t stop/start the routine as if you are thinking about what to do or say next.
• Don’t start the exam until the patient is in the best position or standard position you are accustomed to e.g. sitting 45 degrees, lying flat, sitting over bed with hands on a pillow (occasionally it will be impossible to do this – let the examiner at the end how this limited the assessment and your preferred method)
• Have all your equipment ready before you start the exam. Don’t fumble and search for items in your pockets and bag as you go along.
• Anticipate that you may not be required to elicit some signs i.e. vital signs, corneal reflex, fundoscopy, PR, gait in a spinal patient e.g. While you are examining the hands announce to  the examiner ‘I am going to measure the BP next.....If no response then immediately proceed.   Don’t finish looking at the hands, then look at the arm, stall for a few seconds in a perplexed fashion then ask if you can take the BP
• Pre-empt the next phase of the exam e.g. reach for your tongue depressor and torch just before you move from cranial nerve V and VII to IX and X
• Have a standard strategy for how you respond to an abnormal sign e.g. murmur > radiation and dynamic manoeuvres, III n palsy > exclude concurrent IV n palsy, ascites > ask examiner to help you to do fluid thrill
• It is generally impossible to conduct the whole thing in silence without any comment. An intermittent friendly comment helps break the ice and reduce the awkwardness of the situation. Even a ‘take a deep breath, good work, thank you’ is helpful.  After a gruelling neurological exam you might apologise 'that was a little workout wasn't it?'
• Be nice to the patient ‘I would like to have a look at your abdomen, tell me if I cause you any discomfort’….
• Let the patient know what you are going to do next…I will like to look at your hands…I will like to a closer look at your neck…I am just going to press on your tummy….Can I look at your eyes…I would like to test the strength in your arms…Can I just check your co-ordination…I am going to test the feeling in your legs…I would like to look at how you walk….
• Remember the neurological examination has a lot of talking and requires patient co-operation – have a set of pre-rehearsed clear and ambiguous instructions so you aren’t struggling to get the patient to understand or comply (also have alternative instructions if the first ones don’t work) e.g. 'I would let to test your reflexes one more time.  Now I am going to ask you to clasp you fingers like this <demonstrate to patient> and pull.  We will practise this together once more time <repeat manoeuvre>.  Now relax again. I a moment I am going to ask you to please repeat this movement.  Now, 'pull' <immediately test reflexes>.  That's good.  Thank you'
• Don’t be afraid to ask the examiner to assist your with certain manoeuvres 'would you mind helping me.....' e.g. sit the patient up, stand by assistance for gait testing, check for fluid thrill.
• If you see a large collection of abnormal signs but having trouble dissecting them – don’t slog away silently trying to unravel them without making an initial comment e.g. ‘it seems there are a quite few things going on there, I might need to spend a bit more time on this part of the examination, ‘sounds like you have more than one murmur going on there, I am going to try a few more things to sort this out’, ‘you seem to have more than one problem with your eye movements, can I try these tests’. This reassures the examiner that you know what the issue is and not making random gestures to delineate the problem.
• Some parts of the exam e.g. testing power can be quite exhausting.  Don't forget to let the frail patient take a breather if they look like they are tiring.
• If a patient can’t achieve a task, just say ‘looks like you are having difficulty/struggling with that...let’s try this…’. Don’t get thrown off by things not ‘working out’. Smoothly proceed to the next task. The fact the patient is struggling or frustrated can be a diagnostic clue and definitely worth mentioning in the formulation.
• Don't be frustrated that there are not a lot signs to find.  The absence of signs can be just as important as the presence of signs e.g. 'I was asked to examine Mrs. X respiratory system, it was notable that she was not attached to pulse oximetry, appeared comfortable, in no respiratory distress, not cyanotic and not on supplemental oxygen.'

How to begin (the general inspection)

This initial interaction will help relax you, the patient and the examiner:  It is a critical point of the short case.  It should appear deliberate and purposeful (even if it is only for a brief period of time).  

1. Hello, my name is Dr. X, before I examine you (or your child) closely I would like to take a general look at you or look at your breathing.
2. Stand back in a relaxed but studied approach – hand on chin, head cocked to one side like Sherlock Holmes investigating a crime scene. Move you head/eyes in deliberate way from head to torso. Step around or behind the bed as necessary, look deliberately at oxygen flow rates, infusions, sputum pots walking aids and other visual clues.
3. Good, now I would like to have a closer look, ‘May I have both of your hands’…..

Make a brief statement (but don’t prattle on) if there is a startling clue on initial inspection (otherwise proceed quickly to the examination) e.g.

Point to a visual cue e.g. set of calipers and say ‘I presume these belong to you’'
"Mmm, I notice your face looks a bit flushed or your lips look a little dusky’"
Oh, that’s an interesting sound, it seems to be coming from your heart. I would like to listen to than in a moment..
’‘You look like you are a little out of breath, Is it OK for me to examine you"
’‘My you seem to be covered with quite a few bruises"
"That tremor must be really bothering you.’‘
"Looks like you are having some trouble with your breathing’"

Make your commentary in a rhetorical way rather actually expecting the patient to answer

This reassures the examiner that your general inspection is already giving you important information and you are confident with your signs. It is also a good icebreaker with the patients, builds rapport and makes it easier to progress….

Further examination (after the hands)

Examples:

Key into major symptoms

It is worth briefly commenting about a clearly obvious sign then proceed quietly through the rest of the examination"….that’s an interesting clicking coming from your chest...I will to need to listen carefully""….that liver certainly feels enlarged….I will like to feel a bit more closely, tell me if it becomes uncomfortable""…..looks like you have a bit of squint….I will need to have a better look at your eyes….""…..those joints look at bit swollen/sore…. I will like to examine them a little more closely, tell me if it becomes uncomfortable"

Questions about style

• Some candidates find in certain situation that narrating (all or some) of the positive physical findings during the examination is helpful.  This is more of a question of style.  Whatever method is chosen, it should appear logical and well integrated into the process.  If it causes the examination to appear fragmented or confusing then a review of the process is required.  Usually a few carefully chosen comments on key signs is adequate to let the examiners know what you are thinking.
• When eliciting signs be aware of where the examiners are standing so that you are not obscuring positive findings.  Make eye contact with the examiner to catch their attention to an abnormal finding e.g. clonus, shifting dullness
• When asked to formulate the case, be prepared to immediately respond.  Remember what was asked of you.  'I was asked to see Mr. Jones and examine his knee.  He was lying comfortably in bed with a notable fixed flexion deformity'