BMJ  2004;329:797 (2 October), doi:10.1136/bmj.329.7469.797-a

Filler

A memorable patient

Beating the test

An 89 year old woman with dementia is currently being managed in the community with six monthly visits from the community elderly mental health nurse and intensive family support. She is vivacious and intelligent and still regularly attempts the Daily Telegraph crossword, having previously held a prestigious position in the City of London. Her short term memory has recently deteriorated, and she depends on her diary for keeping appointments and knowing people's contact details.

We were therefore surprised to learn that she regularly receives high marks in the Folstein mini-mental state examination, which she completes during the visits from the mental health nurse. We were determined to discover the reason for this apparent anomaly.

It became clear that at the end of every visit by the nurse, while making the appointment for the next visit, the patient would record the correct answers to the mini-mental test in her diary. Just before the nurse's next arrival, she would read in her diary that she should "revise for test" and would learn the answers by heart, hence earning high marks. Several hours later, she would be unable to recall the questions or answers, but she would have the date of the next test and the required answers already written in her diary.

This case highlights two important lessons. Firstly, that objective tests form only one part of a clinical evaluation—along with history, examination, instinct, and experience. Secondly, it is a charming example of strength of personality and forethought overcoming adversity.

Midwest Urology Research Foundation, Chicago, IL, USA (jonathanosborn{at}doctors.net.uk),

accident and emergency department, Royal United Hospital, Bath

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Rapid Responses:

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This isn't cheating, you know -- recommend it!

Hank Roberts
bmj.com, 30 Sep 2004 [Full text]

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bmj.com, 3 Oct 2004 [Full text]

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