Introduction

These methods of examination are fit for practice in postgraduate medical exams as well as in undergraduate exams. They are the same methods that I use to teach MRCP PACES candidates.

In any encounter, you may be given a short history or have taken a short history yourself.

Use your forename and surname when introducing yourself:

• “Hello, my name is James Bateman” or… “my name is Mr Bateman” not “James”.

It can be seen as unprofessional to only use your first name and is not acceptable for clinical use.

Seek permission for the examination. “May I examine your chest?    Thank you”

REMEMBER TO WASH YOUR HANDS !

Positioning and inspection

Position the patient appropriately for the examination – this is very important and you can be marked down for not being seen to do this.

This means exposing the patient appropriately / suggesting to the examiner how the patient should be exposed at the start of the examination.

If it is necessary to keep someone covered up then do so. Ask the examiners for a towel.

Never leave patients unnecessarily exposed. When you have finished your examination recover them.

For example:

System	Position and Exposure
CVS	Sit patient at 45o. Patients should have no clothing on the chest. However this may be considered inappropriate in some examination settings: be guided by the examiners.
GIT	Flat and exposed – from chest to lower abdomen. Most examiners would prefer you not to expose external genitalia etc and therefore don’t routinely do this.
Resp	45 degrees – as for CVS examination
Upper limbs	As per CVS
Lower Limbs	Flat, lower limbs exposed

“Stop me at any time if it becomes uncomfortable or I cause you any discomfort.”

Inspection of patient and around the bed

Walk to the end of the bed. Put your hands behind your back. Inspect. Look at the patients face. Look at their neck. Look at their upper and lower limbs. Look at their torso etc….

This is essentially irrespective of whatever examination you wish to do. There may be relevant clues e.g. the patient for the cranial nerve examination may have rheumatoid arthritis, or goitre. Look around the bed for additional information and remember to comment on this in your summary.

Presentation and Summing Up

Hands behind your back, holding your stethoscope. Look directly at the examiner rather than the patient when presenting your findings.

Presenting the findings systematically

Using a respiratory case as an example: at the end of the examination, the candidate should say:

“I would complete my respiratory examination by checking the peak expiratory flow rate, the oxygen saturation and by examining for features of cor pulmonale.”

I was asked to examine X

He/she has presented with a…………. (E.g. 6 day history of haemoptysis end fever)

“On inspection: from the end of the bed

The hands: there are features consistent with a right ulnar nerve palsy. There is finger clubbing and peripheral cyanosis.

The face (if normal “no stigmata of respiratory disease”)

The neck

On inspection there is a sign of a possible recent thoracocentesis in the right mid zone posteriorly.

The Thorax

From the anterior chest examination the chest expansion was

The percussion note was…

Breath sounds were…

Tactile Vocal Fremitus was….

In conclusion the findings suggest

In terms of this patients functional status they are breathless at rest.

Given the history of haemoptysis and fever I suspect that the most likely diagnosis is a pleural effusion related to either a mitotic lung lesion, a pulmonary embolism or mycobacterial infection. Other possibilities would include an empyema. Evidence to support a mitotic lesion include…… I suspect the plaster over the right midzone most likely represents a diagnostic thoracocentesis.

The differential diagnosis of this includes pleural effusion of any other cause. I would divide the causes of pleural effusions into transudates and exudates….”

Present your findings logically as you found them:

On general inspection…On examination of the hands… The pulse was… the jugular venous pressure… *

Then Summarise

Link to the initial history given / you have taken and suggest a likely cause:

eg. “Given the history of recurrent urinary tract infections, I wonder about the possibility of nitrofurantoin induced pulmonary fibrosis. Evidence in favour of this is… Evidence against this is….The differential diagnoses would include…..”

And finally:

When you run out of ‘causes’ for something, state those as the main considerations and let the examiner go on to ask questions.

*Do not abbreviate and this goes for JVP/ ECG/ CXR/ CT/ MRI/ BM.

 X-ray (it’s a plain radiograph unless you are Batfink and have x-ray vision)

and… it’s a thoracocentesis not a pleural tap, a paracentesis not an ascitic tap It’s a cannula not a venflon© etc. CT’s are generally in the ‘axial’ plain (transverse cuts).