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To recap, here is our 36-year old’s patient history and findings:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”
Hands Normal.
Pulse 80.
No Signs in the face.
BP 182/92 Pan systolic murmur left sternal edge.
Otherwise NAD.
Tip 6. Group your thoughts logically every time
a) By the most likely causes
“The differential includes the following:…”
b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”
Tip 7. Let the examiners know you are finished every time
Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.
Tip 8. Acknowledge what you don’t know
If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.
Tip 9. Have a set way of presenting examination findings every time
Practice this, it is the same every time. For the above case here would be our example:
“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”
If you do this the same every time it will stop you making mistakes.
Tip 10. Thank and ‘look after’ your exam patient (and the examiners).
This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.
We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.
Hands Normal. Pulse 80. No Signs in the face. BP 182/92 Pan systolic murmur left sternal edge. Otherwise NAD.
One topic that continually crops up in medical student questions is exam technique, and issues that can revolve around it. For this reason we have produced a list of the most important things you need to know.
This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.
Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.
Let’s consider the following features and clinical examination…
A 36 year old male gives the following history:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.
Your Examination Findings are:
Hands Normal.
Pulse 80.
No Signs in the face.
BP 182/92 Pan systolic murmur left sternal edge.
Otherwise NAD.
Tip 1. Look professional
Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.
Tip 2. Organise your presenting posture to minimise nerves
This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.
Tip 3. Structure your presentation of medical terminology
This needs to be structured in the same was that you elicited the history. PC, HPC PMHx, for example:
Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…
Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!
Tip 4. Interpret as you go
Don’t be afraid to explain your interpretations as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”
Tip 5. Learn to summarise in one sentence
Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”
We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!
A medical student is practising for her OSCE exams on the ward…
She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.
The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.
BP 128/70
Pulse 98 regular
Fingerprick blood glucose 8.3
Oxygen Sats 97% on Air
She performs a cardiovascular and opthalmological examination.
Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.
Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…
Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!
Why not have a go at the questions below? We’ll put up the answers in a couple of days…
The Festive period doesn’t always bring Christmas cheer to medical students in the UK and abroad. Whatever your religious standing, the Christmas break brings a welcome bit of respite from university study and placements, but normally brings up extra exam work.
We took a straw poll of our colleagues and friends who will be at work over the Christmas period: this will give some insight for those students who may not be too far away from the coal face:
Mistletoe can have unpredictable effects when placed in or around gatehrings of medical students. Under no circumstances should you approach a medical student with mistletoe, there may be unpredictable results...
Internal Medicine
Working up to the new year and its full steam ahead with our rolling rota. No breaks over the Christmas period sees me working the weekend but not Christmas day, so it will simply be time with the family
Medical Specialities
Ill be working the Christmas weekend (Saturday 26th and Sunday 27th) but not on the big day, which makes a change from night shifts! Had some fun teaching some of the students from Keele University on the Musculoskeletal Examination, makes you hark back to the days of having to know a little bit about everything… I wish I was breaking up for a couple of weeks though…
One of our Students:
Ill be doing absolutely no work over the Christmas period, watching lots of Tv, watching lots of TV and watching lots of TV. My Iphone should be arriving too which will be nice. Exams on return, have about 6 weeks off.
Anaesthetics:
Our Anaesthetic contributor was unavailable for comment after going in to work this morning on his day off, much to his disgust…He does have Christmas off though…
General Practice:
Well the surgery is shut, so even if I wanted too i won’t be working. As ever there is an out of hours service, but its supplied through an agency, so none of the other GPs will be contributing to the out of hours work. Its lucrative for those who don’t mind putting in a few shifts.
Accident and Emergency:
Too busy to comment. Period.
Our Verdict…. Its a bit of a lottery, unless you’re in General Practice, in which case you have already won the festive lottery!
We reckon most medical students will be taking things pretty easy up until the post new year time-frame, then the roll into the busy exam period starts. Stick to questions about naming all eight of Santa’s original reindeer, watch Rage Against the Machine parodies on YouTube and enjoy the festive break!
What percentage of your free time will you spend revising this Christmas period?
30-50%. Im pretty happy things are going ok thanks. (50%)
10-30%. No sweat, I'm ahead of the curve or oblivious to it. (50%)
>90%, I am intending to spend christmas in the library. (0%)
60-90%. Its either that or look for another university degree. (0%)
<5%. I eat OSCEs for breakfast on toast with raw chopped green chillies. (0%)
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Tchestito Rojdestvo Hristovo, God jul, dah Saidan Wa Sanah Jadidah, Feliz Navidad y próspero Año Nuevo,Nadolig Llawen a Blwyddyn Newydd Dda, Have a merry Christmas from the Medical Educator Team.
We had some great input and debate from students on this question of the day from a nero exam. Congrats to those of you who correctly guessed it as Guillain Barre Syndrome.
Now check your hypothesis against the clinical signs:
Tone
Any sign of UMN lesion or hypotonia (cerebellar?) NO
But there is some reduced tone in the left arm:
Power
He is weak and its come on
over the past few days: this is classical of GBS: an ascending peripheral
motor and sensory poylneuropathy.
Coordination
Normal: as expected
Sensation
Normal: So can it still be
GBS???
YES! The sensory signs are often vary vague: there may be only back
pain as the presenting feature.
Reflexes
Clinical tip: no reflexes
Auggests a lower motor neurone problem. Could it me MND? Very unlikely:
there’s only LMN signs and the onset of the illness is too acute.
Other things
GBS: measure the Forced Vital Capacity:
If this is low: the patient may need ventilation.
Also remember: cardiac conduction deficits (monitor the patient on
a cardiac monitor)
Here at Medical Educator we beleive in the power of sharing and communities. The web has made this much easier – now people in your community may not just be those people around you, but also people spread across the globe online!
Our community at Medical Educator is quite specific – its a student exam revision community. When you think about it, passing on tips and nuggets between friends and peers has always been a great way of learning, especially when you are revising and under pressure.
We believe student to student knowledge sharing is a great extra to have ontop of the professional content, and will help make Medical Educator an even better resource!
If you do want to take part its great for you also, as any work that is used on the site will be credited to your name – that’s published work to go on your CV!
We are mainly looking for multiple choice questions but are also happy for guides and tips that you think will help your fellow students. Obviously plagiarism is not allowed!
You are the medical students of the future. What do you think about educator planning increasingly more simulation based teaching sessions to seemingly replace clinical encounters?
If done right, the feedback seems to be universally positive from our own cohort of students, but what do the students of tomorrow think?
Numerous programmes will change the way that students learn, and these changes will be being driven over the next few years. In the following interview with EViP, a virtual patient consortium funded by the European Union, we discuss perspectives on the future of virtual patients.
By the way, if you have had any good, or bad experiences with simulation in OSCE or medical exams why not let us know? The more catastrophic, the better…
Writers at Medical Educator have watched the news coverage with interest of this introduction of a 48 hour working week.* The asterisk is an important one. For example, junior doctors will still be working more than 48 hours in one week (it’s an averaged figure over several weeks), and it doesn’t do much to inspire non medical readers!
Listening to BBC reports of the introduction will lead to “serious accusations” being made by junior doctors that they were essentially instructed to falsify monitoring data. True? It remains an indisputable fact that hospital trusts continue to practice inappropriate monitoring practices which fall short of the accepted published standards. A quick poll of junior doctors shows that 0 of our sample of 10 understood the monitoring basics (how hospitals should practice the process of monitoring), however 9 out of 10 knew it was a contractual obligation! We suspect that is because of the keenness of monitoring bodies to point this out to us. One junior doctor recounts his own experiences of monitoring to us:
The trust essentially conducted the monitoring without due warning. The results were not disseminated in the required way. The management was reluctant to allow the process of monitoring to be transparent. Junior Doctors who should not have been monitored as working the full shift rota actively colluded to distort the monitoring figures. Annual leave and holidays were not properly accounted for. Legal action via the BMA was threatened.
Another told us the following
Only until an employment tribunal was threatened by the junior doctor representatives did the trust acknowledge that the rota was not compliant. It was not an argument over break times, rest, sleep patterns or any other caveats. It was simply that the number of hours was outside of the banding which we were being paid (and not by a small amount). The trust went to the extent of claiming typographical errors on the published rota.
On balance the hospitals have a very difficult job in managing rotas: no one doubts that the overall interest remains patient care despite all the potential wrangling. That said, the new cohort of junior doctors starting work in the UK and the European Union will not just be struggling with acute pulmonary oedema in the early hours, they will be grappling with complicated employment and payment issues that has dogged the training of juniors over the past decade.
We call for a no nonsense guide to the hours that doctors can work in the EU, and that all rotas distributed to juniors should include average hours worked per week, and a clear breakdown of how the rota has been applied to the British banding system. We’d be interested to hear the views of students and qualified doctors here about how their new jobs shape up over the coming weeks, and months. We’re particularly interested to hear how interns from the US, Canada and Australia cope with working patterns, and doctors from India and Pakistan on how they contrast their own working conditions with those described here.
Please do not name organisations or individuals, for legal reasons we will not publish such comments.
Links to National organisations representing junior doctors and students below.
Ever caught medical student’s syndrome? Or come across a googlechondriac on ward rounds? If you haven’t a clue what we are on about check out new site slangRN.com – it’s essentially the urban dictionary for Medical Students.
Site co-founder owner Peter M. Tran says:
“It’s an attempt at collecting medical slang from users around the world, written the way they understand it. Our user base includes: nurses, techs, residents, med students, or anyone interested in decoding the mysterious and tacit language of medicine. It’s part entertainment and part informative.”
Anyone can add slang to the growing database, and rate their favourite slang. We’re waiting to see what slang people come up with for Medical Educator….!
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