|Year : 2013 | Volume
| Issue : 2 | Page : 119-121
Cracking clinical cases
Vivek Pravin Dave1, Tarjani Dave2
1 Consultant Retina Services, Ocular Oncology and Facial Aesthetics Services, Netra Mandir, Eye Institute, Mumbai, Maharashtra, India
2 Consultant Oculoplasty, Ocular Oncology and Facial Aesthetics Services, Netra Mandir, Eye Institute, Mumbai, Maharashtra, India
|Date of Submission||03-Mar-2013|
|Date of Acceptance||20-Mar-2013|
|Date of Web Publication||20-May-2013|
Source of Support: None, Conflict of Interest: None
Clinical examinations section is a whole different ball game as compared to theory examinations. Often most students find it rather easy to score in a theory examination, but when it comes to a clinical case examination it seems a tough cookie to crack. In this article, we would like to share a few tips and some dos and don'ts with respect to taking a clinical examination successfully.
Keywords: Clinical cases, practical exams, practical tips, viva voce
|How to cite this article:|
Dave VP, Dave T. Cracking clinical cases. J Clin Ophthalmol Res 2013;1:119-21
Clinical cases section is for a majority of candidates, the most stressful part of the entire examination experience. Unlike theory which tests more of your memory than your thinking, clinical cases present the reverse scenario at the spur of the moment. Ensuring a good performance in your cases not only elevates your scoring graph but also gives you the confidence of being able to make correct clinical judgments. Nevertheless, taking a good clinical case examination is no rocket science. It's an amalgam of strong clinical basic skills, awareness about the exam pattern you will face, self-confidence, and common sense. Herein, we will consider a few points of importance, which would help you prepare better for the clinical cases.
| Strengthen basics early|| |
The importance of early mastering of clinical skills cannot be over emphasized and it is imperative that you are well versed with the entire gamut of the clinical examination skills before you enter the examination hall. This is possible only if you have examined patients meticulously day in and day out during your residency without short cuts. Practice every basic clinical examination skill so well during residency that your entire comprehensive examination becomes a reflex. This is crucial on two fronts. Firstly, the examination stress often causes thought blocks, which can lead to valuable time being lost. Secondly, depending on your roll call or some unforeseen situation, you may end up getting less time than others. Adequate practice will ensure that you don't miss out on any clinical finding and note down everything in time.
Get into the habit of developing an active thought process right from day one of residency. Cultivate the art of noting clinical findings and corroborating them with each other to reach differential diagnosis or a definitive diagnosis rather than jumping to one diagnosis. This will help you if you face a case in the exam, which you have not seen before. If you note all findings correctly and keep thinking, your theory knowledge will automatically guide you to the differential diagnosis. The examination is not meant to see whether you can diagnose what is mentioned on the patient's case sheet. It is meant to test whether you can pick up clinical findings, take a good history, and put the pieces together to come to a logical differential diagnosis. The right way of reaching the wrong diagnosis may pass you while the wrong way of reaching the right diagnosis may cause failure.
Nowadays, there is a huge trend of having optometrists in the patient care system, wherein they cover history taking, vision recording, refraction and sometimes also pressure recording and gonioscopy. This fact if overlooked by the resident can suddenly have him holding the retinoscope in the exam and not knowing what to do with it!!!. To avoid such unpleasant scenarios remember that in the exam, there won't be an optometrist and its every resident for himself. Hence ensure that you practice those skills periodically and prevent any surprises. It would take a real benevolent examiner to spare you if you can't record vision and refraction correctly.
Know what you are in for - Horses for courses
The post-graduate programs that you would be pursuing would vary from MD/MS, DNB, DOMS or FRCS. Each of these formats would have a different approach. The approach would also vary depending on where your exam center would be and who the examiners are. It's extremely important to know what kind of cases you would expect, what would be the time limit, what are the facilities at your expected center and the overall pattern of the examination. For e.g., in a DNB exam with four cases, you are likely to get only 15 min/case whereas in a MD/MS set up you may even get up to ½ h. As against this, in FRCS you may not need to take the entire case but the examiner would be observing you from close quarters performing the clinical task that he asks you to. Hence, the mental preparation and practice has to be different based on each exam. It's worthwhile contacting senior peers who have experienced the same format of examination and taking valuable tips from them. You can also find "past candidate experiences" online. , Though it's not a good idea to be judgmental about a center or a format based on the past candidate experiences, it nevertheless can be a guideline to help you brace up for the exam. Often a new center with unfamiliar surroundings in a different city can be an added stress factor. So make sure you have visited the center once before your exam in order to familiarize yourself with the place and also to ensure the way and in what time you can reach it.
Before the exams, it's very common to get stuck up reading theory from examination oriented books. However, remember that the next day you will have to speak out and demonstrate. So for about a week or so before the exam, it's a good idea to sit in groups of 1 or 3 (but not more) and discuss out the clinical cases. A fun and effective way would be to conduct mock viva and the clinical exams between each other. This will make you speak out and give you valuable practice to form answers impromptu. This will also give you realization that it's easy to feel that I know the answer, but to actually phrase your answer can sometimes be difficult and hence requires practice.
Make sure you reach the exam center well on time to avoid stress. Reaching late can make you miss some important exam day instructions, put the organizers into inconvenience and sometimes can put the examiners off. Dress formal be well-groomed and carry all your lenses and instruments (including color pencils to draw corneal and retinal diagrams). Though almost all centers will provide you with instruments, why use an unfamiliar one on the day it matters the most. Once a case is allotted, judge the working principle according to the facilities. For example, if you notice that there is a single slit lamp among say 10 candidates who have started taking a case roughly 10 min later everyone would have finished history and the basic examination and may now require the slit lamp causing crowding at the slit lamp. One way to avoid this is to take vision of the patient and record your slit lamp findings first. You can then come back and complete the history. Make sure that you note key points down on the supplement paper provided along with your roll number. Although it's not necessary that the examiners will ask you to submit this, it may help you to revise the points in your mind while you wait for your call. While waiting for your roll to be called revise the case in your mind and present it to yourself mentally. This will avoid facing a loss of words in front of the examiner and ensure you have a head start answering. Often it's about a start in front of the examiner, which sets the tone for the rest of the viva. Well begun is half carried out.
Always remember to ask the name and the occupation of the patient, a simple thing which tests the doctor-patient relationship. Greet the examiner with a smile, maintain eye contact, don't fidget and maintain a positive body language. If asked to demonstrate on the patient, make sure you explain the patient what you are going to do. Remember the examiner is observing. When asked questions like "what investigations will you perform?" don't start with phrases like "we can do this investigation" or "one can do this investigation." Start with "I will request so and so investigations." If asked for example, "what is the lesion on the left macula?" say "It is a drusen" rather than "I think it is a drusen." If there is a difference of opinion remember the golden rule that "the examiner is always right." Never argue with the examiner. Be assertive not aggressive. If you do not know the answer to a question say "I do not know" rather than beating around the bush and wasting the examiners and as a result "your" time. Avoid general answers and speak to the point restricting your self to what is asked.
The primary complaint
A small but often missed point is that of the "primary complaint" of the patient. Often in the examination, one may get a case, which is a clear cut diagnosis at the outset itself. For e.g., ptosis, retinitis pigmentosa, and proptosis. We often get carried away thinking about and making a mental flow chart of the medical and surgical treatment, which we aim to rattle out once the examiner, arrives. However, what about the primary complaint of the patient. The patient of proptosis may have blurring of vision as his main complaint and that may be due to a con current cataract. In such cases, it is very important that the primary complaint is discussed during the viva and that the candidate mentions steps to be taken to resolve that.
OSCE related tips
Certain exam patterns like FRCS have an OSCE section. In these sections, it is just not enough to identify the specimen/instrument given to you but to have a logical sequential and complete answer to get full marks. For e.g., if given an Ethibond suture and asked what it is the complete answer should be "Its polybutyrate coated braided polyester suture." Each and every descriptive word would carry relevant marks and would require the candidate to answer completely to score big. Answer in short and to the point. Trying to write long descriptive answers in an OSCE can lead to unnecessary loss of time and can lead you to miss out on answering the next question.
| Specific case based tips|| |
Some common cases are often asked in the examinations. These will require certain specific points to be discussed pertinent to them over and above the routine discussion. In cases, such cases glaucoma or Retinitis Pigmentosa there is a known family predilection. Always ask about similar history in close family members and if possible draw a small pedigree chart on the answer sheet. Both of these illnesses also have severe field constriction in advanced cases. So chart a confrontation perimetry for them. If you do not find a deficit you should still make sure it is put across as a prominent negative finding so that the examiner knows that you are aware of it and made an attempt to chart it.
Drug history becomes important in cases like central serous chorio retinopathy. Ask specifically for any systemic illness and co relate whether there is a possibility of the patient having taken steroids for the same. Systemic history and discussing the general metabolic status is important in cases of diabetic retinopathy and hypertensive retinopathy. Many of these patients are in chronic renal failure. It will give additional credit if you can point out pallor indicating anemia and an AV shunt at the wrist made for dialysis. History of diabetes and hypertension is also pertinent in isolated nerve palsies, which are another common case in the examinations. While presenting the management in such cases do not get carried away with the eye condition alone. Explain that you would like to control systemic parameters at the outset along with ocular treatment. When faced with a case of ptosis be sure to have a quick neurological evaluation of the patient to rule out presence of a neurological ptosis, which once in a while can be kept in the examinations.
We hope to observe these few tips would help the candidates in cracking their cases. Remember this small write up may provide you with the 1% inspiration, but it's up to you to put in the 99% perspiration.
All the best.
| References|| |
|1.||Chuaeyepage. Available from: http://www.mrcophth.com/chua1.html. [Last Accessed on 2013 Mar 1]. |
|2.||Rxpgonline. Available from: http://www.rxpgonline.com. [Last Accessed on 2013 Mar 1]. |