Sir, What is the Diagnosis?

Please Note: This article is intended for medical undergraduate and post-graduate students.

I had the opportunity to help in organising several practical exams for the Surgery undergraduate students at various levels. When allotting the case for workup, the student invariably asks one question:

Sir, what is the diagnosis of this patient?

Why do they ask this question? Do they think that some cases are simpler than other? Or, are they not confident enough to tackle any case given to them? Is their knowledge limited to just few conditions? Do they think that on giving a diagnosis they will pass (or perhaps even top) the exam? Do they think that they will get marks only if they diagnose exactly what the person is suffering from?

If the answer is yes to any of the above question, then they do not understand the examination system and the mind of the examiner. Before appearing for your next exam, please read and understand (not just mug up) these few rules:

1) No case is simple and no case is difficult: In so called simple or straightforward cases, the examiner is more likely to expect more out of you. If you do not answer satisfactorily to his questions in a simple case, you are more likely to get fewer marks than if you got a complicated case. Generally, the examiner keeps in mind the difficulty of the case, while asking questions and giving marks.

2) Before going to exam you should be well prepared to tackle any kind of case allotted to you. Remember in undergraduate exam, you performances will be mainly judged on you history taking and examination skills, which will only come by repeated practice in wards before the exam. Your career is precious, do not gamble and prepare only few limited cases.

3) Just reading about the cases generally given in exams should not be the aim of a student preparing for exams. They should approach their studies with the vision in their mind that someone’s life will depend on their knowledge. A broad breadth of knowledge is also necessary for clearing the exams, as you never know where the twist and turn of questions may ultimately lead.

4) Does telling the diagnosis, will ensure that you will get full marks? NO. The clinical exams, especially surgery exams, is not a MCQs paper, where if you tick mark the correct choice, using hard work, educated guess, wild guess, using your telescopic vision to see the answer from other’s answer book, tossing a coin, etc. you will get full marks. You have to justify your answers. You have to explain what points in your history and examination justifies your diagnosis. If you give the correct diagnosis but are not able to explain how you reached the conclusions, the examiner is going to conclude that you have either looked in the patient’s file or have got the diagnosis from the senior resident allotting the cases. In any case, he will assume that you have cheated and he is liable to deduct your marks, no matter how correct you are.

5) Now we come to the million-dollar question: In practical exam, do you have to find out what the person is actually suffering from? Or do you have to find out what the person appears to be suffering from? There may be great difference between the actual diagnosis of the patient and the diagnosis that can be logically reached or justified on the basis of history and examination.

For the clinician managing the case it is most important to find the actual diagnosis. For this, in addition to the history and examination, he may employ various methods such as fine needle aspiration cytology, radiological investigations, etc.

In contrast, in exam you are supposed to make the diagnosis only on the basis of history and examination. The senior resident allotting the case may know the actual diagnosis, but he may not know what the most logical diagnosis can be made on basis of history and examination.

If you say the actual diagnosis, without the support of history and examination findings, you are bound to fail. So give a differential diagnosis that appears most likely and not what is the actual diagnosis. These you can only reach if take good history, do a comprehensive physical examination, logically analyse the clues you get them from them and reach a logical differential diagnosis list, without the bias of knowing what is the actual diagnosis.

For example, one student in AIIMS, New Delhi, worked up a case of kidney swelling one week before the exam. He has seen all his investigations from which he found that the final diagnosis in this patient was of renal cell carcinoma. The patient had presented with lump in lumbar region for last 3 years. The student got the same case in exam. He gave a diagnosis of renal cell carcinoma in the exam.

The examiner asked him, how do you explain that the patient is alive and healthy with a renal cell carcinoma for the last 3 years. In view of the long duration of history, the first diagnosis should have been made of that of benign non-malignant kidney lump. The student was failed, because he gave the actual diagnosis, which was not clinically appropriate and that he could have reached only on the basis of investigations.

So remember, forget the diagnosis and concentrate on working up the case with an open mind in exam and do yourself and your teachers proud.

(Based on true incident)
— ND
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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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