What is expected from a candidate in the FCPS 2 long case.

You have half an hour to take a history and examine the patient. You have to make the most probable diagnosis, have a short list of differential diagnosis and a list of appropriate investigations that you would like to do. Be prepared to interpret a result because the examiner can show you an ECG, an X-ray or ultrasound report, a blood report or a CT scan. What is the purpose of this portion of the examination?

  • Can you ask the right questions to reach the diagnosis? Commonly made mistakes are that the candidate immediately takes the biodata, socio-economic history before asking “What is wrong with you” or what has brought you to the hospital”. Two things that are wrong with this technique of “getting this portion of the history out-of-the-way ” or “mukao” are the patient loses patience with you for being asked personal questions impersonally. He or she feels that they are being interrogated by the police for a crime. You fail to establish a rapport ot empathy with the patient who is then antagonistic to you through out the interview. Have you ever seen one of your consultant walk up to a patient and ask  “How old are you (often a tactless question), are you married? How many children do you have? How much income do you have? Are you educated? What work do you do? How many rooms does your house have? What food do you eat and is the water you drink clean?” All before asking “How are you? What medical problems do you have? Are you comfortable sitting up or prefer to lie down while I talk to you?” if you get the answers to your    questions and the patient then gets upset with you and declines to give you any more information you are stuck without a working diagnosis and no way are you going to pass the exam. I have had one candidate,  in one of the exams where I was an examiner ask all these questions plus a lot more as part of the systemic survey which were totally irrelevant and then proceed to make a diagnosis of COPD (chronic obstructive pulmonary disease) without once asking about cough or sputum production!!! Obviously he had been told the diagnosis before he came into the exam hall and did not have the intelligence to ask the right questions! Of course he failed. The surest way to fail is to find out the diagnosis before hand. You get a thought block and forget to ask the most obvious questions.
  • Focused questions. Once the patient tells you his/her most prominent complaint for example breathlessness and wheezing then ask focused questions and do not waste your time doing a “systemic survey” about CNS symptoms such as headaches and epilepsy or GI symptoms like heartburn, diarrhoea or constipation. After you have finished taking the history pertinent to the major complaints a quick ” Have you ever fainted when you are very breathless? or had a headache ? Are you bowel habits unchanged and do you have a good appetite? Is your weight increasing or decreasing and are you passing urine without a problem? Would you like to give me any other information about your illness?”  will get you relevant information you need with minimal wastage of time. Remember to ask the important questions first, then start the GPE and ask less important questions as you work. Try making the questions part of a conversation not an interrogation.
  • Completing your mental list of questions and doing a systemic survey. You do not have to ask every question that you were taught as a third year student. You did not know about presentation of disease, pattern recognition, the interpretation of common symptoms so you were give a long list of questions to ask. As you gained clinical knowledge you learnt to ask more relevant questions. Once you have made a diagnosis you can ask very focused questions. Once you have decided your patient has heart failure you do not have to ask about absolute constipation!!!
  • Picking on the wrong symptom or sign as the significant one. This sends you off on the wrong track altogether and you end up asking silly questions. Picking the right one is a matter of clinical experience and training. If you have not been going to ward clinics and have been sitting at home swatting books you are going to make this mistake. Also if instead of reading recommended textbooks of medicine like Kumar, Harrison’s, Davidson’s, Cecil and Loeb’s textbook of Medicine you are reading swat books or summaries written by a registrar who has probably not passed the FCPS exam himself then you are definitely going to make this mistake. There is no easy way to learn medicine so do not look for shortcuts. you can subscribe to Epocrates, the free portion is about prescriptions i.e. which medicine to prescribe for which disease and in what dose: you have to pay a subscription to get the diagnostics portion but it is worth it and not very expensive. An excellent medical database is Uptodate. This is updated every few months, It gives you the common symptoms, their prevalence and pathophysiology, D/D, complications and treatment. It will also give you information about recent research and trials. This is a bit expensive, a personal subscription for one year is around $400 but worth every penny. Several young doctors can chip in or get a students subscription. It is worth every penny you spend. Be careful. you may actually know more than the examiner!! The other place to learn how to take a history are the case studies in the BMJ (British Medical Journal) and NEJM (New England Journal of Medicine). The BMJ is free, has subject review, recent research, updates on latest treatment. and the NEJM if you register as a visitor will give you free access to journals which are more than 6 months old. There is Medicine International which is not a research journal but a “textbook” journal as it gives review of common diseases. The BJMH is another good one to read {British Journal of Hospital Medicine). Looking up these journals is well worth the time spent.
  • Spending too much time on the history. Take the history in 7 minutes. If you spend more than 10 minutes on the history then a) you are spending too much time asking unnecessary questions b) you have not managed to pick up the diagnosis. You are not going to have time to finish the examination and will probably miss some important finding like a raised BP or anemia or peripheral neuropathy.
  • Not being able to interpret the findings. The worst findings are the cardiac signs. Most candidates have no idea what the sign they say is present means. A tapping apex beat in aortic stenosis for example: a tapping apex beat means a poorly felt ill sustained apex beat as the left ventricle has not had much exercise like a teenager who sits in front of a computer all day and cannot produce a strong punch if he has to hit someone. A tap occurs in mitral stenosis because in a stenosed valve the pressure is on the left atrium, the left ventricle only gets a small amount of blood which it can easily pump into the aorta and the ventricle does not get much exercise. If the left atrium is enlarged and there is pulmonary hypertension expect to find a right ventricular heave and may be a double apex beat: the left atrial contraction followed by a left ventricular tap. So just do not say “a tapping apex” and then not be able to explain it. Just call it a normal apex beat’; that is a safer bet, at least you will not fail immediately. Remember if there is atrial fibrillation then on auscultation there cannot be a presytolic accentuation of the mid-diastolic murmur. The presytolic accentuation is caused by the contraction of the left atrium. In AF the atrium is fibrillating it cannot contract properly!!! Do not call a pansystolic murmur TR if you cannot find signs of advanced heart failure like a grossly misplaced apex beat which will remain even after diuretic therapy, a pulsating liver and a raised JVP.  Do not comment on the first or second heart sounds in a “pansystolic murmur”. By definition this murmur drowns out both heart sounds. If you can hear the heart sounds then call it a long systolic not a holosystolic murmur. Please do remember to mention the 3rd and 4th heart sounds if only to say that they are absent. Remember that mitral stenosis develops 10-15 years after developing rheumatic fever though in Pakistan because of lack of access to medical care it may develop in 3-5 years that is why we see it in children.
  • Do not get carried away by one sign and forget to look for other unrelated findings. In a recent FCPS 2 exam a patient was placed in the shortcase. The command was “Perform th GPE and do the relevant examination”. The patient had thickening of the skin under the nails in the hands and feet covered with thick white dry skin. There were inflammatory plaques on the dorsum of the fingers of the hands. All 5 candidates diagnosed psoriasis. They missed the fact that there were no lesions on the skin of the trunk or axilla or the dorsum of the hands or feet, they missed Groton;s plaques on the fingers. The “relevant” examination expected of them was the strength of the proximal muscles. The next day the same case was kept in the short case and the command this time was do the motor examination of the lower limb and relevant exam. It was expected that the candidates would pick up the severe proximal weakness in the hips and thighs, check the shoulders and look at the skin lesions, They all diagnosed psoriasis again. The unfortunate man was a young soldier who had come in with severe weakness: he had to ask a colleague to help him get up from a squatting toilet, could not put his arms above his head to put on a shirt nor carry his rifle. He was not bothered  about the hyperkeratosis below the nails of his feet and hands. He had classic Polymyositis/dermatomyositis with marked proximal muscle weakness and Gotron’s nodes. Subungual hyperkeratosis is a feature of PM/DM. There were no psoriatric lesions on his body or scalp. He was anti Ro/ssa and antisynthetase positive and his muscle enzymes were markedly raised. The subungual hyperkeratosis had every body flummoxed. Even the candidate who got this patient as a long case missed it and diagnosed guess what? Psoriasis

So folks think about all this, read the right journals, data bases and book. Do not take short cuts. Spend your weeks preparing for the exam by going to the ward and taking histories and examining patients and making your most likely diagnoses.

 

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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.

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