What is expected of a candidate in a short case. How to use your ten minutes effectively. The abdomen.

What is being tested in the ten minutes that you have for the short case in the FCPS 2 or other post-graduate exam?

Say the command from the examiner is: “Examine the abdomen and do any other relevant examination.” Or the command may be “This patient has had repeated blood transfusions. Examine the abdomen”.

You are being observed for : clinical methods: ability to pick up the most relevant or important finding: see your clinical judgement as to what you consider important enough to look for in the general physical exam or other systems. Since the time is short the examiner is also observing which portion of the abdominal examination you are willing to cut short to pick up a sign that will lead to the diagnosis and better management. Remember that a busy clinician has to choose what to look for without sacrificing the correct methodology. I am giving examples below of why a candidate is likely to perform poorly and how to avoid common mistakes.

  • A man in his sixties is lying on the examination couch. He is malnourished, his feet look swollen and he is pale. (The adjective describing him is pale. If you wish to use the word pallor then say he has pallor not he is pallor. Remember pale means lack of colour not yellow colouration). You have been asked to examine his abdomen “and relevant signs.” What will you do?  Do not expose him to mid-thigh and most important do not say that you are going to do so. This statement shows lack of maturity and lack of clinical courtesy.  If you can see the abdomen moving on respiration you may bend so your eyes at a level with the surface of the abdomen. There is no need to go to the foot end of the bed. This move wastes time and gains you no additional information. Remember your clinical methods have already been checked in the IMM (intermediate module), the application of appropriate methods is now being checked. Observe for an obvious lump or mass. With the permission of the patient and the examiner you may cover the lower abdomen and upper thighs with a sheet (not expose them) and request the patient to pull down his pajamas. Do this only if you are suspecting that the patient has an inguinal hernia. You can rule this out by simply asking him if he has a swelling in the groin or his private parts. It is best to leave this portion of your examination to the end of your ten minutes. Quickly palpate the abdomen, first superficially and then deep. Do the usual examination of the liver, spleen, kidneys. Do a fluid thrill if you see a distended abdomen and percussion for shifting dullness; remember to percuss back over the initial dullness otherwise you are just seeing if the area of aerated intestines has shifted. It is usually not necessary to listen to the bowel sounds unless you have been given a history of absolute constipation etc. If you find a small liver and spleen and both are soft, that means recent enlargement. Look for reaction in other parts of the lymphoid system i.e. examine the peripheral lymph nodes. Ask the examiner ” I would like to know if his hilar lymph nodes are enlarged on the chest X-ray or does he have an ultrasound of the abdominal lymph nodes?” If the examiner says those tests have not been done then say “I would like to get these tests done in my workup.” This way you are showing knowledge of where else the LN can be discovered and you will be guiding the discussion towards a disease in which lymphadenopathy occurs if that is what you want.
  • In the GPE please do not waste time checking for clubbing. Weigh the patient, look at his loose skin, check pulse BP and temperature, examine the lymph nodes and the thyroid. If the spleen is huge look for bruising. Anemia and jaundice should be checked. Note edema and look at the nails to confirm anemia and may be hypoalbuminemia. You will probably not have time for more. If you find anemia, jaundice and a hard spleen think of hemolytic anemia. If you find a shrunken liver, firm large spleen look for other signs of hepatic decompensation: prominent abdominal veins, note the direction of the flow; ensure you have picked up jaundice and ascites, palmar erythema, hepatic flap, spider naevi. Do not waste time looking for these if your diagnosis is going to be hemolytic anemia or myelocytic leukemia. It is important that you make a diagnosis as soon as you find some signs so that you can then do appropriate GPE examination.
  • One would imagine that it is next to impossible to fail in the examination of the abdomen but unfortunately that is what happens fairly often. The reasons are 1: overkill i.e. looking for too many unnecessary signs which are not required clinically so be careful, choose what you want to demonstrate with care. 2: inability to have a definite diagnosis or a sensible differential diagnosis at the end of the examination of the abdomen. 3: inability to interpret the signs i.e. is an enlarged liver part of a failing heart? If it is then look for signs of CCF. If the enlarged spleen is part of portal hypertension then have you looked for other signs to justify your diagnosis?
  • Immature approach to further investigations. Please do not say “I will do baseline investigations.” Every test is done for a specific reason. Some tests are done for almost every patient because the information obtained is useful in many situations. They are not routine. So what should you say? It is a good idea to say “I will do a {not go for) a blood picture to look for the level of hemoglobin which I expect to be low because I could detect anemia clinically. I will also look for leucopenia or leucocytosis and will note the platelet count. I will do an X-ray of the chest to look for hilar lymph nodes or a lesion that may be making the disease progression faster, an ultrasound of the abdomen to confirm my finding of an enlarged spleen or liver, the presence of ascites which can be missed in the early stages, I will check the blood sugar to exclude diabetes which may be a co-morbid disease as it is common, I will check the serum creatinine to establish renal function at the start of my treatment because drugs can adversely affect it.” Mention any other test but give a reason for doing it. Get the idea? Practice this technique with your colleagues in the ward. Mention specific or diagnostic tests. Find out how effective each test is at giving a definite diagnosis i.e. look up how often the test is false positive or false negative what other test you need to do to supplement the information you require. Sometimes we do a test because it is economical and we can screen out patients if it is negative. Then we need only do definitive expensive tests for the few who are likely to be positive for that disease.
  • Giving an uncommon diagnosis which does not occur in your part of the world or is rare anywhere in the world. Talk about rare diseases after you have exhausted the common possibilities and you really know your stuff and are sure you are getting passing marks. If you show wrong information of the rare disease you may fail even if you have performed well as there is negative marking so be careful.
  • Naming a group of diseases as a diagnosis instead of a definite disease. common diseases mentioned are: CLD, talk about cirrhosis and portal hypertension instead: COPD, talk about chronic bronchitis oe emphysema or bronchiectasis instead: talk about chronic myeloid leukemia instead of myeloproliferative disorder which is the name of a chapter in the textbook of medicine not a disease. You never admit a patient for the treatment of “myeloproliferative disorder”; you may admit a patient for the workup of a myeloproliferative disorder and you give him a definite diagnosis as soon as you get one.
  • Talking about treatment in broad headings instead of definite drugs. Like “I will give a beta blocker to reduce portal pressure”. Which beta blocker, in what dosage, for how long, how will you know that the pressure has been reduced in the portal system and what are the side effects to watch out for should be included in the right answer. Get the idea?

Published by

shaheenmoin

I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s