Examination Medicine: A Guide to Physician Training by Nicholas J. Talley, Simon O’connor Read Free Book Online Page B
Authors: Nicholas J. Talley, Simon O’connor
avoid taking a long trip to the examination city on the morning of or the night before the test.
----
1 Diagnosis? See p. 324 ( Fig 10.6 ) for an answer.
2 The examiners are Simon O’Connor, holding the patella hammer, and Nick Talley observing intently.
CHAPTER 4
The long case
In what manner are the examiners elected? Are they elected by the profession or any part of the profession whose interests are equal to those of the whole and are they responsible to the profession at large for their conduct?
Neither the one nor the other.
Lancet 1824; i:20
When the examiners discuss a long case with a candidate they are expecting to find out how the candidate would manage the patient and his or her problems. They want to know whether the candidate has a practical grasp of what is required in consultant practice. Candidates are expected to have a mature and sensible approach to the patient and his or her problems. It may help to picture yourself as the physician taking over the care of a new patient. Practising long cases trains candidates to be better clinicians.
Careful allocation of time with the patient in the long case is vital. The exact proportions will depend on the case itself, but, as a rough guide, spend 25 minutes on the history-taking, 15 minutes on the examination and the rest of the time preparing discussion and reviewing vital facts with the patient. Remember though, that you can continue to ask the patient questions as these occur to you while you are examining. Nothing is more important than ensuring you leave enough time to put your thoughts in order.
Candidates favour many different systems for recording long-case details (as an aid to memory or aide memoire ). There are two we recommend: one is to use a pad that can be held comfortably in the hand and the pages turned unobtrusively. Most candidates now use a large card folder, one side of which is used for the history and the other for the examination findings; a second card (if necessary) is used for relevant investigations, management and short lists of facts you may wish to mention. Obviously, numbering each side is important, so as not to mix up the order of presentation. These cards are usually provided to candidates who want them at the examination site. Mixing up thecards can be a disaster. One candidate was sitting, preparing to enter the examination room, when the side door opened and a puff of wind blew the cards out of her hands. She was then ushered straight into the examination room with the cards in random order. She began the long case badly and failed.
Candidates who do not want to rewrite the whole long-case presentation before facing the examiners (time is often a problem) may find it helpful to number the paragraphs with a red pen in the order in which they wish to present the story.
Many examination centres provide manila folders. These are large enough for candidates to be able to write out one whole long case on one folder. They do, however, seem to lead to a lot of turning backwards and forwards and folding and unfolding as candidates search to find where something was written. Practise with whatever method you choose so that it works smoothly.
The history-taking and physical examination
Once you have said, ‘How do you do?’ to the patient at the beginning of the long case, we suggest initially following the steps outlined below. Remember though that there is no single right way to conduct any part of the exam. This book is meant only to provide a framework upon which candidates can work out what suits them best. These steps may help you rapidly ascertain the patient’s major problems so that you can direct further questioning more easily.
1. Explain to the patient that this is a very important examination. Gain the patient’s interest and support. This is a test of bedside manner.
2. Ask the patient what is wrong. If he or she asks, ‘Am I allowed to tell you?’, look confident and firm and say, ‘Yes, of course’.
----
1 Diagnosis? See p. 324 ( Fig 10.6 ) for an answer.
2 The examiners are Simon O’Connor, holding the patella hammer, and Nick Talley observing intently.
CHAPTER 4
The long case
In what manner are the examiners elected? Are they elected by the profession or any part of the profession whose interests are equal to those of the whole and are they responsible to the profession at large for their conduct?
Neither the one nor the other.
Lancet 1824; i:20
When the examiners discuss a long case with a candidate they are expecting to find out how the candidate would manage the patient and his or her problems. They want to know whether the candidate has a practical grasp of what is required in consultant practice. Candidates are expected to have a mature and sensible approach to the patient and his or her problems. It may help to picture yourself as the physician taking over the care of a new patient. Practising long cases trains candidates to be better clinicians.
Careful allocation of time with the patient in the long case is vital. The exact proportions will depend on the case itself, but, as a rough guide, spend 25 minutes on the history-taking, 15 minutes on the examination and the rest of the time preparing discussion and reviewing vital facts with the patient. Remember though, that you can continue to ask the patient questions as these occur to you while you are examining. Nothing is more important than ensuring you leave enough time to put your thoughts in order.
Candidates favour many different systems for recording long-case details (as an aid to memory or aide memoire ). There are two we recommend: one is to use a pad that can be held comfortably in the hand and the pages turned unobtrusively. Most candidates now use a large card folder, one side of which is used for the history and the other for the examination findings; a second card (if necessary) is used for relevant investigations, management and short lists of facts you may wish to mention. Obviously, numbering each side is important, so as not to mix up the order of presentation. These cards are usually provided to candidates who want them at the examination site. Mixing up thecards can be a disaster. One candidate was sitting, preparing to enter the examination room, when the side door opened and a puff of wind blew the cards out of her hands. She was then ushered straight into the examination room with the cards in random order. She began the long case badly and failed.
Candidates who do not want to rewrite the whole long-case presentation before facing the examiners (time is often a problem) may find it helpful to number the paragraphs with a red pen in the order in which they wish to present the story.
Many examination centres provide manila folders. These are large enough for candidates to be able to write out one whole long case on one folder. They do, however, seem to lead to a lot of turning backwards and forwards and folding and unfolding as candidates search to find where something was written. Practise with whatever method you choose so that it works smoothly.
The history-taking and physical examination
Once you have said, ‘How do you do?’ to the patient at the beginning of the long case, we suggest initially following the steps outlined below. Remember though that there is no single right way to conduct any part of the exam. This book is meant only to provide a framework upon which candidates can work out what suits them best. These steps may help you rapidly ascertain the patient’s major problems so that you can direct further questioning more easily.
1. Explain to the patient that this is a very important examination. Gain the patient’s interest and support. This is a test of bedside manner.
2. Ask the patient what is wrong. If he or she asks, ‘Am I allowed to tell you?’, look confident and firm and say, ‘Yes, of course’.
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