BUSYSPR MRCP

Embed Size (px)

DESCRIPTION

Busyspr notes for MRCP

Citation preview

  • This course is about showing you how to impress examiners and also how to avoid common pitfalls. It is not

    about providing you with exhaustive information, it is about giving you the essential information you need to pass

    the exam. It focuses on demonstrating how to perform a slick physical examination and present your findings in aconfident and clear fashion. This course also addresses areas of physical examination that doctors tend to be

    most weary or uncertain about such as confidently eliciting ankle jerks.

    There are numerous good books that focus on the communication skills or talking stations, this course focuses

    on the clinical stations. Most books provide the theoretical basis for the exam but few focus on clinical skills and

    presentation of findings. This is the focus of this course. The examination stations are marked under 8 headings:

    a) Physical examination

    b) Identifying physical signs

    c) Clinical communication skills

    d) Differential diagnosis

    e) Clinical judgement

    f) Managing patients concerns

    g) Maintaining patient welfare

    If you can do a slick examination and presentation of findings, you have made a great step towards passing. The

    discussion section tends to be brief and the questions are rarely very difficult, provided you are well prepared.

    Do not forget that the exam still has a subjective element and many examiners will tell you that they can form an

    impression of whether you are a strong candidate or not as soon as you start examining a patient. If you can

    impress in these areas, you will be on your way and the examiners may be more lenient about the discussion

    section.

    why this course is better than other courses Page 1 of 38

  • The MRCP(UK) Part 2 Clinical Examination (PACES) is composed of five stations (three clinical and two talking), eachassessed by two independent examiners. Candidates start at any one of the five stations and then move round the carousel of

    stations at 20-minute intervals until the cycle has been completed (Figure 1). The stations are:

    Station 1

    Respiratory System Examination (10 minutes)

    Abdominal System Examination (10 minutes)

    Station 2

    History Taking Skills (20 minutes)

    Station 3

    Cardiovascular System Examination (10 minutes)

    Central Nervous System Examination (10 minutes)

    Station 4

    Communication Skills and Ethics (20 minutes)

    Station 5

    Brief clinical consultation 1 (10 minutes)

    Brief clinical consultation 2 (10 minutes)

    THE PACES EXAM - The Carousel Page 2 of 38

  • THE PACES EXAM - The Carousel Page 3 of 38

  • The MRCP(UK) Part 2 Clinical Examination (PACES) lasts a total of 120 minutes (including four 5-minute breaks between each

    station).

    THE PACES EXAM - The Carousel Page 4 of 38

  • Station 5 used to be the Skin / Locomotor / Endocrine / Eye station but is now called the Brief Clinical

    Consultation Station. The station involves two 10-minute encounters which take form of a Brief Clinical

    Consultation in which the patient presents with a single clinical problem or symptom of the sort encountered inday-to-day practice in the medical wards, acute medicine unit or outpatient clinic. Candidates are required to

    undertake a brief focused history and brief targeted examination in the 8 minutes available with the patient, before

    discussing findings and diagnosis with the examiner for 2 minutes.

    It is not necessary for the candidate to undertake a full, comprehensive history (as required in Station 2) or a

    thorough, systematic examination (as required in Stations 1 and 3) in these encounters but to demonstrate a

    focused and integrated clinical problem solving approach.

    All the scenarios are structured to ensure that a capable candidate can undertake the task within the time

    available. Real or simulated patients may appear in these encounters. The four disciplines previously represented

    at Station 5 (dermatology, ophthalmology, rheumatology and endocrinology) are currently not always

    represented in the examination, but clinical problems relating to those disciplines frequently appear at Stations 2,

    4 or 5. Patients with problems relating to disciplines such as acute medicine and elderly medicine are now also

    encountered.

    THE PACES EXAM - The New Station 5 Page 5 of 38

  • Each candidate receives structured marksheets for each station prior to the start of the PACES examination. The

    candidate has to complete the same details (i.e. add his/her personal information) and then hand the appropriate

    sheets to the examiners at each station. In the event of failing the examination, the marksheets form the basis forfeedback to the candidate. Sample marksheets can be found on the MRCP UK website

    http://www.mrcpuk.org/PACES/Pages/_Home.aspx

    Ensure that the marksheets are completed correctly. In addition arrange the mark sheets in order of the stations

    so that you can easily hand them over to the examiners. Some candidates have found themselves in a situation

    where the marksheets fall from the clipboard and they are then panicking, trying to pick up and hand the

    marksheet to the examiner. This can result in unnecessarily stress!

    Sixteen mark-sheets in total are completed by the Examiners: two by each examiner at Stations 1 and 3 and 5;

    one by each Examiner at Stations 2 and 4. The Station Mark awarded on all sixteen mark-sheets determines the

    candidates overall PACES score.

    THE PACES EXAM - Marksheets Page 6 of 38

  • There is a new marking scheme for MRCP PACES. Pairs of examiners assess each candidate at each encounter.They award marks to candidates on the basis of their performance on each of seven clinical skills. These skills are:

    a) Physical examination

    b) Identifying physical signsc) Clinical communication skills

    d) Differential diagnosise) Clinical judgement

    f) Managing patients concernsg) Maintaining patient welfare

    An example of a mark sheet is included in appendix 1.

    Examiners mark candidates on each relevant skill at each encounter using a three point marking scale: Satisfactory,Borderline, and Unsatisfactory. The examiners award marks for each skill and there is no overall judgment.Marks

    received for all skills at all encounters are equally weighted and summed to produce an individual candidate mark.

    The skills examined and marks available for each station are demonstrated in the table below. It is crucial to

    understand the marking scheme in order to maximise your chances of passing. Some candidates have been known

    to fail because they underestimated the importance of the 5th station which carries most of the marks (56 out of a

    total of 172 marks).

    Examiners mark independently and have no knowledge of marks at previous stations.

    Examiners would have seen the patients first and examined them. They will also consult and agree on a marking

    scheme i.e. what they will use to fail or pass candidates. They will take in to consideration whether a sign is difficult

    to find i.e. they will be lenient if an early diastolic murmur is difficult to hear. However they will surely mark you

    down if you miss an obvious sign such as atrial fibrillation.

    Do not be put off by examiners making notes while you are being examined. It is not necessarily a bad thing often

    they are noting down good points about you.

    Station

    A

    PhysicalExamination

    B

    Identifying

    PhysicalSigns

    C

    ClinicalCommunication

    D

    DifferentialDiagnosis

    E

    ClinicalJudgment

    F

    Managing

    Patients'Concerns

    G

    Maintaining

    PatientWelfare

    Total

    1 0-8 0-8 0-8 0-8 0-8 402 0-4 0-4 0-4 0-4 0-4 203 0-8 0-8 0-8 0-8 0-8 40

    4 0-4 0-4 0-4 0-4 165 0-8 0-8 0-8 0-8 0-8 0-8 0-8 56

    Total 24 24 16 28 32 16 32 172

    THE PACES EXAM - The New Marking Scheme Page 7 of 38

  • The pass mark is defined by a formal standard setting process that also takes account of the current PACES

    pass standard. The overall standard of the examination therefore remains the same.

    To pass MRCP(UK) Part 2 Clinical Examination (PACES) candidates must attain a minimum standard in each

    of the seven skills and also a minimum total score across the whole assessment.

    For the year October 2011September 2012 the pass marks will be:

    Skill Pass Mark (% of marks available)

    A Physical Examination 14 (58.3%)

    B Identifying Physical Signs 14 (58.3%)

    C Clinical Communication 10 (62.5%)

    D Differential Diagnosis 16 (57.1%)

    E Clinical Judgement 18 (56.3%)

    F Managing Patient Concerns 10 (62.5%)

    G Managing Patient Welfare 28 (87.5%)

    In addition, candidates must achieve an overall score of 130 to be eligible to pass.

    For more details about pass marks, go the MRCP website

    http://www.mrcpuk.org/PACES/Pages/_Home.aspx

    THE PACES EXAM - Pass Marks Page 8 of 38

  • The PACES exam is a practical exam and the only way to prepare for it is to PRACTICE. You must make the

    mistakes early on, in front of colleagues and senior staff in order to avoid making the mistakes in the exam. The

    more patients you examine or take histories from, the more confident you become.

    1. Start as early as possible. It is so easy to keep on postponing or avoiding preparing for the exam. All

    posts are busy but you must make the time. The sooner you start preparing, the better. Do notprocrastinate.

    2. One of the things I found most useful was practising with other exam candidates. Put together a groupand make sure you go round as often as possible, preferably every day. Phone the wards on a daily basis to

    identify potential patients without asking for the diagnosis. Even simple things such as rheumatoid hands,

    bilateral ankle oedema and hemiplegia appear in the exam. The simple things are often the easiest to fail but

    you can easily impress the examiners if you have practised. There are always patients to examine on medical

    wards so you cannot make excuses that that there aren't interesting cases on the wards.

    3. Try and get registrars or consultants to provide specialist teaching in their fields. For example, they can

    identify a number of respiratory cases and take you through a mock examination and teaching. Do not make

    excuses to avoid being put on the spot practising in front of seniors and making mistakes can only help to

    build your confidence when you sit the exam.

    4. If you know what is normal, you can easily identify the abnormal. Examining your friends or relatives

    (assuming they are healthy) will also help. For example you can do ophthalmoscopy on your friends or

    colleagues in order to be sure what a normal fundus looks like.

    5. As well as this online course, also attend a practical course. Most courses do similar things andprovide a wide range of cases. The courses are exam oriented and you must be aware of how to impress the

    examiner. It is much more comforting and less expensive long-term if you pass first time. If you can afford it,

    attend specialist courses e.g. cardiology or neurology as well as general PACES courses.

    HOW TO PREPARE FOR THE EXAM Page 9 of 38

  • The MRCP PACES is a competitive exam and you must approach it as such. You will find it hard to pass if your

    performance is mediocre. You must go into the exam to impress the examiners! They should be able to picture

    you working as their specialist registrar!

    1. You must be seen to be confident in examining patients, presenting findings and discussing management

    plans.

    2. Do not invent signs or symptoms. This is a recipe for failure. Be honest with your findings!

    3. Have a broad mind and observe every minute detail. Some findings may seem obvious but must be

    stated e.g. identifying nicotine stain marks on a patients fingers for the respiratory case, bruising for someonewith AF, likely to be on warfarin

    4. The examiners must have the impression that you see hundreds of patients and that it has becomesecond nature

    5. Do not wait for things to be "milked" or "squeezed" out of you if you know them. Simply move on and

    tell them how you would manage a case if you are sure of the diagnosis. You should make it easy for the

    examiners to tick the boxes and give you the marks.

    6. Keep in mind which station you are being assessed on. For example in the brief clinical consultationstation, you may come across a difficult case of Ehlers-Danlos syndrome with fish-mouth wounds and

    multiple scars. Remind yourself that you need to demonstrate that you can take a brief and focused clinical

    history, do a focused physical examination and respond to the patients concerns. You then need to describe

    your findings to the examiners and give your preferred diagnosis and any differential diagnoses.

    7. To pass the exam, you must have a satisfactory score in most of the individual headings for the stations.

    You should not have 2 or more unsatisfactory scores for the maintaining welfare headings as your practice

    will be considered to be unsafe. Most people will make at least one mistake along the way. To compensatetherefore, you must aim for as many satisfactory scores as possible.

    General Approach Page 10 of 38

  • When examining any patient, you should be asking yourself the following questions and looking for potential

    answers:

    1. What are the key clinical findings?

    2. What is the diagnosis or main problem/syndrome and differential diagnosis?

    3. What is the probable cause?

    4. What are the other manifestations or associated features?

    5. Are there any obvious visible side-effects of treatment?

    6. Are there any signs of complications?

    When presenting the case, in general there are 2 main approaches:

    1. Give the diagnosis and explain why with positive clinical findings. This was encouraged in the old style

    of the MRCP clinical exam but can still impress in PACES. The risk of this approach is digging a hole for

    yourself if you get the diagnosis wrong initially.

    2. Present your clinical findings progressively and then conclude by giving the diagnosis. In the context of

    PACES, this appears to be the safest option as you will demonstrate to examiners that you have picked up

    the main clinical findings and make it easy to for them to tick the boxes. In addition you can still get somemarks if your diagnostic conclusion is unreasonable as you will be given credit for the clinical findings

    anyway.

    There is no best way as it will depend on what the examiners prefer. Either way you will not be sanctioned if

    your clinical findings are correct. You may also decide to use both styles depending on how sure you are about

    the diagnosis.

    Be assertive in making a diagnosis. Avoid the following phrases:

    1. I think the diagnosis is

    2. This may be a case of

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONSPage 11 of 38

  • If in doubt use a phrase such as

    1. This is consistent with but I would also consider

    Remember not to put your stethoscope around your neck. It is considered to be impolite. Hold the stethoscope

    in your hands and preferably with your hands behind your back.

    Always look directly at the examiners and avoid turning to look or point at the patient. Patients find it very

    uncomfortable.

    Make sure that you answer the questions the examiner asks. It will irritate them if you are beating around the

    bush and not answering the question. For example, if they ask for a valvular diagnosis after a cardiovascularexam answer the question! E.g aortic stenosis. Do not start rambling and describing your findings in detail as

    this will irritate them.

    Warn patients before examining them e.g. I am about to examine your trachea and it may feel uncomfortable.

    I am going to examine your abdomen you may feel uncomfortable because my hands are cold.

    Be courteous to patients and before using a phrase, ask yourself if you were the patient, would you want such

    descriptions to be used about you? Medical descriptions tend to be quite heartless. If you must use a term ordescription which is awkward, apologise to the patient before using it e.g. I apologise sir and I do not want to

    offend you but the phrase I am going to use is a textbook description. This gentleman has an expressionless facesuggestive of Parkinson's disease.

    Never use the following phrases or diagnostic terms which may frighten or upset patients, instead use medical

    jargon:

    "demyelinating illness" instead of multiple sclerosis or MS

    "mitotic lesion or neoplastic lesion" instead of cancer

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONSPage 12 of 38

  • Try not to stop talking if you sense that you are on the right tract, unless they stop you. Take the initiative and

    move on to answer the questions you were asking yourself when examining the patient:

    1. What is the likely diagnosis and differential?

    2. What is the likely cause and what are other possible causes?

    3. What other manifestations or associated features have you identified?

    4. What evidence is present suggestive of treatment or side-effects of treatment?

    5. What evidence is there of complications and what were the other possible complications?

    6. How would you investigate and treat this case?

    In doing this, you allow the examiners to happily tick the boxes, rather than squeezing the information out of

    you. This will nearly always make you stand out as a better candidate than most other people.

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONSPage 13 of 38

  • 1. Greet the patient, introduce yourself and ask for permission to examine

    2. Expose the patient and position appropriately (lying down at 45 degrees and the whole thorax exposed).

    Do not compromise even for women unless the patient or the examiner strongly objects to it. You cannotbe penalised for being polite but thorough. For example you may miss a thoracotomy scar hidden behind a

    ladys bra.

    3. Take a step back and observe for about 15 seconds while counting the respiratory rate (Is the patient

    cyanosed? Dyspnoeic? Are they using accessory respiratory muscles? Are there scars or chest wall

    deformities? Etc). Most importantly check for oxygen (what type of mask or nasal cannula and what is the

    rate of flow of oxygen?), nebulisers, peak flow meters, sputum pots, packets of cigarettes! Observe with

    an eagle eye and note everything. Show that you are a holistic doctor who pays attention to detail.

    4. Examine the hands for clubbing and distended veins of carbon dioxide retention

    5. Examine the pulse for bounding pulse of cabon dioxide retention if appropriate

    6. Check for flapping tremors Please stretch your arms in front of you and cock up your fingers like this

    demonstrate

    7. Examine the eyes for, pallor or congestion8. Examine the tongue for cyanosis and distended veins

    9. Examine the neck for a raised JVP and any scars or obvious masses. Also examine the trachea for its

    position (Is the trachea central or displaced to the left or right?). If the JVP is raised determine whether itis fixed or not (Does not change with respiration or position) suggestive of SVC obstruction.

    10. Examine the anterior chest wall:

    1. Inspect thoroughly, including under the breast and the axilllary area. You will not be forgiven for

    missing a thoracotomy scar so take your time and make sure you are 100% sure. However do not

    spend too much time looking hesitant either. Look for scars, distended veins, chest wall deformity.

    2. Palpate for chest expansion in the upper thorax and lower thorax. Be sure about whether it is

    normal, reduced or increased bilaterally or unilaterally before you stop.

    3. Percuss bilaterally starting on top of the clavicles and move downwards and into the axilla.

    Compare similar areas on the left and right aspect of the chest progressively. About 4 percussion

    points on each side appears to be sufficient. Again make up your mind whether it is dull, hyper-

    resonant or normal on one or both sides or a particular area.4. Auscultate bilaterally starting from above the clavicle and again at corresponding points as during

    percussion. Determine whether the breath sounds are reduced, normal or increased and whetherthere are added sounds (fine or coarse crackles, bronchial breathing, wheeze, pleural rub).

    11. Examine the neck from behind and palpate for cervical lymph nodes12. Examine the chest from behind in the same way as the anterior chest wall. Some people advocate starting

    your examination from the posterior aspect of the chest as this is more informative and you may be short

    of time, but it does not really matter as long as you are slick. If you are asked to percuss and auscultate

    starting from the back, make sure you follow the instructions.

    13. Examine the legs for ankle oedema

    14. Offer to help the patient or help the patient to get dressed or covered and reposition in comfortable

    position. You must show that you are caring and courteous!

    15. Check around for sputum pots and inspect their contents

    16. Finish off by saying you would like to finish your examination by noting the patients, temperature, peak

    expiratory flow rate (if appropriate), and examining a sputum pot if there isnt one obviously available

    around the patient. Do not say you would like to examine a sputum pot if there is one available. It will only

    irritate the examiners. Just go ahead and look at it!

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 14 of 38

  • Now hold your stethoscope in your hands and present your findings.

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 15 of 38

  • The following website has recordings of normal and abnormal breath sounds

    http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/b-sounds.htm

    Figure 2: Anatomical landmarks for the lungs

    Figure 3: Anterior and posterior sites of chest percussion and auscultation

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 16 of 38

  • CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 17 of 38

  • I find it useful to categorise abdominal cases into renal or non-renal cases. Clues that your are dealing with a

    renal case include abdominal scars suggestive of continuous ambulatory peritoneal dialysis (CAPD),

    arteriovenous fistulas in the arms, scars in the iliac fossae suggest of previous transplant etc. The key is thereforeto figure out quite early whether you are dealing with a renal or non-renal abdominal case and show examiners

    that you know what to look for.

    1. Greet the patient, introduce yourself and ask for permission to examine

    2. Expose the patient and position appropriately (lying flat, hands by the patients side and exposed from the

    lower thorax to just above the symphysis pubis)

    3. Take a step back and observe for about 15 seconds. Look for scars, pallor, jaundice, distended

    abdominal veins, abdominal scars suggestive of CAPD, arteriovenous fistulas in the arms, scars in the iliac

    fossae suggest of previous transplant etc. It is helpful to figure out quite early whether you are dealing with

    a renal or nonrenal abdominal case so that you can focus on the key signs.

    4. Examine the hands for signs of chronic liver disease (spider naevi, palmar erythema, Dupuytrens

    contracture, pallor, leuconychia, koilonychias, abscesses, needle marks of intravenous drug abuse,bruising, paronychia, flapping tremor, scratch marks, jaundice, pigmentation, cyanosis, xanthomata,

    oedema, muscle wasting, tattoos)

    5. Examine the arms for arterio-venous fistulas and signs of chronic liver disease. Be careful to note scars as

    some fistulas may have been tied off and only very small scars may remain. If you find a fistula, note

    whether there are fresh scars suggestive of recent usage for hemodialysis i.e. is the fistula functional or not?6. If you think you are dealing with a liver case, elicit flapping tremors

    7. Examine the conjunctiva for pallor and the sclera for jaundice (ask the patient to look upwards while you

    lower the eyelid)

    8. Examine the gums for gingival hypertrophy suggestive of treatment with ciclosporin

    9. Examine the neck for scars and obvious swellings suggestive of cervical lymph nodes. For a renal case,

    ensure that you examine the neck for parathyroidectomy scars which would have been done to treattertiary hyperthyroidism as a result of chronic renal failure.

    10. Examine the abdomen:

    1. Kneel down on the floor or bend down to bed level and inspect the abdominal wall for scars (make

    sure you know the position and description of all the scars see figure), deformities suggestive of a

    mass, abnormal movements, ileostomy or colostomy bags, distended abdominal veins etc. Note if

    CAPD scars are fresh or old.

    2. Warm up your hands by rubbing them together and ask if there are any tender areas before starting

    palpation. Reassure that patient and palpate tender areas with a lot of care. Palpate all 9 areas of

    the abdomen systematically. First palpate superficially and then more deeply. If you see scars in the

    iliac fossae, palpate for transplanted kidneys which should superficial. Also check for tenderness

    which could indicate rejection of the kidney transplant.3. Examine specific organs.

    i. The liver: Palpate from the right iliac fossa

    upwards to the lower costal margin, asking the patient to take a deep breath in and outand progressing upwards when the patient expires. If you feel the liver, note its

    consistency, edge, whether it is tender or not and the amount of hepatomegaly. Percuss

    the liver from the chest (level of the nipple) downwards and note the size of the liver. See

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 18 of 38

  • figure for normal liver landmarks.

    ii. The spleen: Palpate the spleen from the

    right iliac fossa obliquely to the left lower costal margin, asking the patient to take a deep

    breath in and out and progressing upwards each time the patient expires. Place your left

    hand below the left hypochondrium posteriorly and while pushing upwards with this

    hand, continue palpating for the spleen in order not to miss a small splenomegaly. See

    figure. Also see figure for normal spleen landmarks. Percuss in the left mid-axillary line

    from the level of the nipple downwards and obliquely towards the umbilicus to confirm

    splenomegaly.

    iii. The kidneys. Do a bimanual exam of each

    kidney by putting your left hand behind the loin and balloting the kidney between yourleft and right hand.

    1. Examine for ascites: Percuss for shifting dullness, from the umbilicus to the left flank whilst checking for

    dullness. Your fingers should be parallel to the midline. Only proceed to test for shifting dullness if the flank

    is dull to percussion. If you find dullness, keep you finger in position and turn the patient to the right lateral

    position and then percuss from the left flank down to the right flank. Has the position of dullness changed?This represents shifting dullness suggestive of ascites.

    2. Keep the patient in the right lateral position and examine for the splenomegaly once more. Ask the patient

    to take a deep breath and palpate again for splenomegaly from the right iliac fossa to the left

    hypochondrium. Percuss again for splenomegaly. This should help you detect a mild splenomegaly. .

    3. Auscultate the abdomen in the egigastrium for renal bruits and around the umbilicus for bowel sounds.

    Most people forget to do this and this can easily lead to failure. Auscultate over transplanted kidneys forbruits suggestive of renal artery stenosis and over the liver if you find hepatomegaly.

    4. Sit the patient forward and inspect the posterior abdomen for scars of nephrectomy.

    5. Examine the neck posteriorly for lymphadenopathy if you suspect malignancy

    6. Examine the legs for ankle oedema

    7. Offer to help the patient get dressed or covered and reposition the patient in a comfortable position. You

    must show that you are caring and courteous!

    8. Finish off by saying you would like to finish your examination by examining the patients genitalia, doing arectal examination and doing urine dipstix for blood and protein.

    9. Now present your findings.

    Figure 4: Types of abdominal scars

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 19 of 38

  • 1. Subscostal - cholecystectomy

    2. Right paramedian

    3. Midline

    4. Nephrectomy/loin

    5. Gridiron = appendicectomy

    6. Laparoscopic

    7. Left paramedian- anterior rectal resection

    8. Transverse suprapubic pfannenstiel hysterectomy or pelvic surgery

    9. Hernia repair

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 20 of 38

  • 1. Greet the patient, introduce yourself and ask for permission to examine

    2. Expose the patient and position appropriately (seated at 45 degrees and the whole of thorax exposed).

    Do not compromise even for women unless the patient or the examiner strongly objects to it. You cannotbe penalised for being polite and thorough. For example you may miss a valvotomy scar for mitral stenosis

    under a ladys bra.

    3. Hold the patients right wrist with one hand and start taking the radial pulse with the other hand. Inspect the

    patients hands at the same time. Is there cyanosis? Clubbing? Or signs of sub-acute bacterial endocarditis

    (sub-ungual splinter haemorrhages; tender Oslers nodes on the pulp of the fingers and toes, palms or

    soles; non-tender Janeway lesions which are macules on the often on the soles and palms)?

    4. Examine both radial pulses simultaneously for equality and count the rate over 15 seconds. At the same

    time assess the character (normal, slow rising, collapsing?) and rhythm (regular, irregular in rate and

    volume i.e. AF or irregular with periods of regularity suggestive of extrasystoles). Determine whether the

    pulse is collapsing or not (figure). Is the patient on oxygen? If so how much? Are there obvious carotid

    pulsations? If so, is the pulse collapsing suggestive of aortic regurgitation. The key in cardiovascular

    examinations is to be able to make a diagnosis before you get to auscultation of the heart. Once you havean idea what to expect, auscultation becomes much easier and you should no longer worry about missing

    the murmur.

    5. Examine the conjunctivae for pallor (lower eye lid),6. Examine the tongue for cyanosis and teeth/gums for dental caries if you suspect SBE

    7. Examine the neck:

    1. Palpate the right carotid pulse by sliding your 2nd-5th finger of your left hand under the patientsneck and palpating the carotid pulse with the thumb of your left hand. Is the pulse collapsing or

    slow rising?

    2. Examine the jugular venous pulse. Ensure the patient is lying at 45 degrees and that the occiput rests

    back on the bed or on a pillow. Say to the patient "lift your chin and turn your head to the left

    please". Since you are standing on the right side of the patient, start by examining the right JVP and

    only check on the left one if you still cannot make up your mind whether the JVP is raised or not. Itlooks clumsy to be stretching over to examine the left JVP when you are on the right side of the

    patient. If the head is not laid on the bed, you cannot accurately access the JVP. It is sometimesuseful to shine light from a bed side lamp or torch as this will make a JVP which is difficult to see

    more obvious. If the JVP is raised, what wave forms are present? A or V? V waves are morecommon and easier to see. Palpate the carotid pulse simultaneously and v waves should be

    synchronous with the carotid pulsation. If the JVP is raised, what is the height above the sternal

    angle (see figure)?

    Remember, if you see a vascular pulsation in the neck, you must decide whether it is venous or arterial. Is it

    palpable? Arterial pulsations are palpable e.g. dancing carotids or corrigan's sign suggestive of aorticregurgitation. Venous pulsations are mobile with respiration, change with position (lying flat or sitting up) and the

    presence of hepatojugular reflux suggests, the pulsation is venous. The presence of a and v waves also suggests

    that the pulsation is venous.

    1. Examine the precordium

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 21 of 38

  • 1. Inspect the chest wall thoroughly for any scars. Make sure you check under the breast for a

    valvotomy scar of mitral stenosis, they can be easily missed and you will not be forgiven! If you see

    a midline sternotomy scar, immediately expose the legs to see if there is a scar suggesting that a

    saphenous vein may have been used for a coronary artery bypass graft. If not, you are probably

    dealing with a patient who has had a valve replacement.

    2. Palpate the apex and determine its character (heaving, thrusting, palpable or tapping?). Also locate

    its position by counting intercostal spaces from the sternal angle downwards and estimating its

    lateral position with respect to the axilla.3. Palpate for right ventricular heave and for pulmonary/aortic thrills

    4. Ausculate. First determine whether you are dealing with mitral stenosis. Listen very keenly for S1,

    then S2 and in between for murmurs. Palpate the carotid at the same time as in order to identify S1

    and S2 as S1 is synchronous with the carotid pulse. S2 is heard when the carotid pulse

    disappears.

    I find it easier and more comfortable for the patient to first use the drum in the mitral area. Then ask

    the patient to turn unto their left side and auscultate again with the drum. You should be able to make

    up your mind whether the patient has mitral stenosis or not. Then ask the patient to turn back to

    position and now auscultate in the mitral area with the diaphragm for mitral regurgitation. Ask the

    patient to "take a deep breath in, then out and stop breathing". Breath sounds may make cardiac

    auscultation difficult. In addition, mitral regurgitation murmurs tend to be louder with inspiration whiletricuspid regurgitation murmurs are louder in expiration. Then auscultate into the axilla to find out if

    there is a murmur radiating to the axilla. Now ausculate in the tricuspid area (left lower sternal

    border), pulmonary area and aortic area. See diagram. Now auscultate below the right clavicle and

    the left and right aspects the neck for aortic stenosis murmurs radiating to the clavicle or neck and for

    carotid bruits. It helps to ask the patient to "take a deep breath in, then out and stop breathing" asbreath sounds may make auscultation very difficult. Lastly auscultate for aortic regurgitation by

    asking the patient to "sit up and lean right forward, take in a deep breath, breath right out" and

    auscultate again at the left sternal border, mid sternal area. With the patient still in this position andleaning forward, conveniently examine the lung bases for crackles. Do not do a full respiratory

    auscultation, simple examine at one basal point on each side.

    1. Examine the abdomen for hepatic pulsation if you suspect tricuspid regurgitation by putting your left handunder the right hypochondrium and the right hand on the right hypochondrium. It tricuspid regurgitation,

    you should feel pulsation between your two hands.

    2. Check the limbs for ankle oedema. Remember to ask if there are any painful areas before palpating so

    that you dont cause discomfort!

    3. Finish off by saying you would like to finish your examination by taking this patients blood pressure,

    temperature and doing a dipstix of urine for protein and blood.

    Now hold your stethoscope in your hands and present your findings.

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 22 of 38

  • Figure 6: Eliciting a collapsing pulse

    Figure 7: Pictured of JVP land marks to show height above sternal angle

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 23 of 38

  • Figure 8: Cardiac auscultation landmarks

    A useful website with normal and abnormal heart sounds/murmurs is

    http://www.blaufuss.org/tutorial/index2.html

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 24 of 38

  • You will never be asked to do a full neurological exam because it takes too much time.

    1. Cranial nerve examination

    While examining, keep you eyes open for clues to the diagnosis e.g. obvious weakness or lack of movement of

    one part of the body suggestive of a stroke. They may be scars from previous surgery for an acoustic neuroma

    behind the ears. Examine the cranial nerves in chronological order. You must make it slick and you should be

    able to get up suddenly at night and do the routine. They must not sense that you are thinking about what to do

    next! It must flow smoothly as if it is second nature.

    Greet the patient, introduce yourself and ask for permission to examine. Ideally, get the patient to sit down on a

    chair and you should sit on a chair facing the patient at about 1.5-2 arm lengths from the patient.

    I: Have you noticed any change in your sense of smell?

    II: The most common problems will involve a change in acuity, visual fields or eye movements. It is therefore

    logical to exclude these first as they are the most common and important. A mnemonic to use is AFMP (Acuity,

    Fields, Movement, Pupils). Make sure you have a pocket Snellen Chart to use at the end of the bed to measure

    visual acuity. Ask the patient put on their glasses if they use glasses and assess each eye in turn with the other

    being closed. If the patient cannot see the letters on the Snellen chart assess whether the patient can see your

    fingers, finger movements, hands and finally light.

    To test for visual fields, first test for visual inattention or neglect in the middle, superior and inferior fields. If you

    notice any obvious field lesion, ask the patient to look at your face and tell you if there is any part of your face

    that cannot be seen. This will often give you the visual field defect. Then move on to formally test each quadrant.

    Test for eye movements by asking the patient to follow your finger and let you know if they see double as you

    move your finger forming the usually H configuration. Also check for squints at rest, nystagmus and pupillary size.

    You have assessed the 3rd, 4th and 6th cranial nerves.

    Test for pupillary response to light both directly and consensual. Make sure you put your hand in the middle to

    separate both fields and make sure you bring the light from outside right into the pupils. Also assess pupillary

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 25 of 38

  • response to accommodation.

    Lastly volunteer to test do fundoscopy and do it if you are allowed to. However most often you will be asked not

    to.

    V: Test for sensation in the 3 divisions of the trigeminal nerve, comparing both sides simultaneously. Do not

    forget to test for motor function by testing the strength of the massetters and pterygoids. Also do a jaw jerk and

    go on to test for corneal reflex. Most often you will not be allowed to do corneal reflexes as it is uncomfortable

    for patients.

    VII: Test for facial nerve palsy by asking the patient to do a series of manoeuvres

    "raise your eye brows" "close your eyes" "Blow you cheeks" "show me your teeth"

    VIII. Test for hearing by using a ticking watch or whispering into one ear, the patients other auditory canal being

    closed with one of your fingers. Go on to perform Weber's test and Rinne's test and make sure you understand

    their significance.

    IX and X: Ask the patient to open their mouth wide open and say "aahh" while you look for palatal immobility

    and drift.

    XI: Test for power by asking the patient to shrug the shoulders and then push against your hands while provideresistance.

    XII: Ask the patient to protrude their tongue while you look for deviation of the tongue and muscle wasting. Also

    look out for fasciculation (bulbar palsy) and a spastic tongue (pseudobulbar palsy).

    1. Upper limb neurological examination

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 26 of 38

  • 1. Greet the patient, introduce yourself and ask for permission to examine

    2. Expose the patient by asking the patient to take is or her top off. If dealing with a lady, cover the chest

    with a cloth, sheet or garment. While doing this, look out for any signs that may suggest a diagnosis e.g

    facial weakness, nystagmus, expressionless face of parkinsons, horners' syndrome

    3. Inspect the shoulder, arms, and hands looking for wasting, abnormal movement (e.g. tremor), fasciculation

    or deformity.

    4. Test the tone. Ask the patient to let their arms go floppy or loose and passively flex and extend each joint.

    Compare each left and right joint simultaneously as you proceed.

    5. Test for power: "I will like to test how strong your arms are". There are many complex ways of testing forpower and you can test for nearly every muscle if you want but the essential muscles a general physician

    would be expected to know how to test are:

    1. Global power of the arms: Ask the patient to put both arms stretched out in front of you and close

    his/her eyes. Observe for parietal drift, myelopathy hand sign and examine the back for winging of

    the scapula.

    2. Test for shoulder abduction (Deltoid muscles, axillary nerve, C5) "Put your arms out to the side

    with your elbow flexed - demonstrate to the patient as you give the instruction" "Don't let me push

    your arm down"3. Test for elbow flexion (Biceps, musculocutaneous nerve, C5/6) "Flex your elbow, don't let me stop

    you" Use your left hand to support the elbow.

    4. Test for elbow extension (Triceps, radial nerve, C7). With the elbow in neutral position, ask the

    patient to push you away, do not let me stop you. Use your left hand to support the elbow.

    5. Test for wrist extension (C7 or radial nerve): Make a fist and cock up your wrist like this

    (demonstrate), don't let me stop you.6. Test for power of the small muscles of the hand (C8/T1). "Squeeze my two fingers. Compare the

    left and right hand simultaneously.

    7. Test for power of specific hand muscles. Make sure the hands are laid on a pillow or on the bed

    with palms upwards.

    i. Median nerve: Point your thumb at the

    ceiling, don't let me stop you (abductor pollicis brevis); Put your thumb and little fingertogether, don't let me pull them apart (opponens pollicis)

    ii. Ulnar nerve: Spread your fingers apart,

    don't let me bring them together (dorsal interossei); Hold this piece of paper between

    your fingers, don't let me pull it out (palmar interossei).

    1. Test the tendon reflexes: Biceps (C5/6), Triceps (C6), and Supinator (C5/6). Are they normal, brisk,

    reduced or absent. Make sure know what normal is by testing your colleagues, relatives or friends

    (assuming that they are normal!). It is only by doing this that you will be able to determine what is

    abnormal. Make sure you compare the left and right reflexes for each tendon as you proceed.

    2. Test for co-ordination:

    3. finger-nose-finger testing: Make sure you finger is at a good distance from the patient so that they have to

    straighten their arm completely in order to do this. Without this, you will miss subtle cerebellar ataxia.

    4. Test for dysdiadochokinesis: Quickly tap your left palm alternately with both sides of you right hand. Now

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 27 of 38

  • do the same on the other hand. - demonstrate.

    5. Test for sensation:

    1. Test for light touch and pin prick sensation: Use cotton wool and a neurotip on the sternum to demonstrate

    what they should feel. Ask them to let you know if it feels different or if they do not feel it at all. Test each

    dermatome moving from the hands proximally. If the sensory loss does not fit a particular dermatome , test

    for glove and stocking sensory loss as a result of peripheral neuropathy. Start from the hands and move

    proximally, "Does this feel the same as on your chest? Tell me when it does".

    2. Joint position: Use the distal interphalangeal joint of the thumb. With the patient's eyes open, demonstrate

    what you mean by up and down. "Now close your eyes and tell me if I am moving your thumb up or

    down". Ensure that you hold the thumb at the sides of the phalanx. Do not hold the thumb at the joint ordorsal/palmar aspects as it may give a false positive result.

    3. Vibration: Use a 128 Hz tuning fork. After demonstrating on the patient's sternum what he/she should feel,

    test for vibration sense by starting at the proximal interphalangeal joint and only continue to move

    proximally if it is absent or reduced distally. "Tell me if it feels different to the way it felt on your chest or if

    you do not feel it at all"

    Tel the examiners, to complete your examination you will like to examine the patients back and lower limbs and

    proceed to present your findings.

    1. Lower limb examination

    1. Greet the patient, introduce yourself and ask for permission to examine2. Expose the patient by asking the patient to take is or her trousers or skirt off. Ensure that the genital area

    is covered with a cloth, sheet or garment. While doing this, look out for any signs that may suggest adiagnosis e.g facial weakness, nystagmus, expressionless face of parkinsons, horners' syndrome, wasted

    hand muscles etc3. Inspect the thighs, legs and feet for wasting, abnormal movement (e.g. tremor), fasciculation, deformity,

    pes cavus.

    4. Test the tone. Ask the patient to let their legs go floppy or loose and passively roll the legs sideways to

    and fro. Watch for the movement of the feet. If the feet move very floppily, there is hypotonia. If the feet

    does not flop, then there is hypertonia. Also lift the knee and let it drop passively observing for movement

    of the feet. Lastly passively flex and extend the knee. If there is increased tone or spasticity, you must

    move on to test for patellar and ankle clonus. This step is often missed.

    5. Test for power: "I would like to test how strong your legs are". There are many complex ways of testing

    for power and you can test for nearly every muscle if you want but the essential muscles a general

    physician would be expected to test are:

    - Hip flexion: (iliopsoas, femoral nerve, L1/2) "Lift your leg straight up from the bed,

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 28 of 38

  • don't let me stop you"

    - Knee flexion (Hamstring, sciatic nerve, L5/S1/S2). "Bend your knee, don't let me

    stop you"

    - Knee extension (Quadriceps, femoral nerve, L3/L4): With the knee still bent, push

    my hand away, don't let me stop you."

    - Dorsiflexion of the ankle (Peroneal or anterior tibial nerve, L4/L5): "Cock up your

    foot, don't let me stop you"

    - Plantar flexion of the ankle (Gastronemius muscle, S1) "push my hand away, don't

    let me stop you"

    1. Test the tendon reflexes: Knee jerk (L4), Ankle jerk (S1). Practice eliciting ankle jerks. This is the most

    difficult reflex to elicit and you must be confident in eliciting this before the exam. Make sure you get

    someone (perhaps a neurologist) to show you a confortable and easy way to elicit ankle jerks. Do not

    leave it to chance! Make up your mind whether the reflexes are normal, brisk, reduced or absent. Makesure you know what is normal by testing your colleagues, relatives or friends (assuming that they are

    normal!). Make sure you compare the left and right reflexes for each tendon as you proceed.

    2. Test for the plantar response: Warn the patient that you are going to tickle the underside of their feet.

    Divide the foot into 3 and stimulate the outer portion of the sole from the heel and then across the ball to

    the base of the big toe (following the line that divides the upper third and the middle third of the foot). Is

    the response downgoing or upgoing? You can take a key or an orange stick to use for the exam. Do notuse the pointed section of the tendon hammer.

    3. Test for co-ordination:

    - Heel-shin test: Put your heel just below your knee and now run it down your shin and

    up again as fast as you can"

    1. Test for sensation:

    - Test for light touch and pin prick sensation: Use cotton and a neurotip respectively on

    the sternum to demonstrate what they should feel like. Ask them to let you know if it feels

    different or if they do not feel it at all. Test each dermatome moving from the feet proximally.

    If the sensory loss does not fit a particular dermatome, test for sock and stocking sensory

    loss as a result of peripheral neuropathy. Start from the feet and move proximally, "Does thisfeel the same as on your chest? Tell me when it does".

    - Joint position: Use the distal interphalangeal joint of the big toe. With the patient's

    eyes open, demonstrate what you mean by up and down. "Now close your eyes and tell me

    if I am moving your toe up or down". Ensure that you hold the toe at the sides of the tarsal

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 29 of 38

  • bone. Do not hold the toe at the joint or dorsal/plantar aspects as it may give a false positive

    result.

    - Vibration: Use a 128 Hz tuning fork. After demonstrating on the patient's sternum

    what he/she should feel, test for vibration sense by starting at the proximal

    metatarsophalangeal joint of the big toe and only continue to move proximally if it is absent

    or reduced distally (medial malleoli, knee, iliac crest). "Tell me if it feels different to the way it

    felt on your chest or if you do not feel it at all"

    1. Examine the gait and test for Romberg's sign:

    I find it best to test for Rombergs sign before examining the gait. Ask the patient to stand feet together with the

    arms outstretched. Ask the patient to close their eyes and tell you if they feel unsteady. Stand behind the patient

    and be ready to catch him.

    Then ask the patient if they are able to walk on their own without help. If not, reassure the patient that you will

    provide some assistance or support. If they can, then ask them to stand and walk. When they stand do a globalinspection for- nystagmus, tremor, the question mark spine of ankylosing spondylitis (easily missed),

    expressionless face of Parkinson's disease, Callipers of a patient with foot drop etc. The key is to try and make a

    diagnosis before the patient sets off walking.

    - Ask the patient to walk to a certain point, turn round and walk back. Are the arms

    swinging? If not, think of Parkinson's disease.

    - Then ask the patient to walk heel to toe (demonstrate), on his toes (suggests the

    presence of an S1 lesion if unable) and on his heels (suggests foot drop if unable)

    1. Other neurological cases:

    For each neurological case on the list of possible cases, you must have a plan on how to proceed if you suspect

    a particular diagnosis. For example:

    1. Parkinson's syndrome: Observe for involuntary tremor, expressionless, unblinking facies, drooling;

    examine the arms for tremor, rigidity and bradykinesia, examine the face for glabellar tap, assess speech,

    writing and function e.g. undo a button; assess gait. Offer to examine for cerebellar signs, pyramidal signs

    and autonomic dysfunction (lying and standing blood pressures).

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 30 of 38

  • 2. Cerebellar syndrome: Examine the eyes for nystagmus, examine the speech for ataxic dysarthria, examine

    the legs fully (for hypotonia, reduced power, intention tremor, past pointing, dysdiadochokinesis), examine

    the gait for cerebellar ataxia.

    You should have a plan or routine for each possible diagnosis.

    Brief Clinical Consultation Station

    This station is difficult to prepare for since there are endless possibilities that can appear in the exam. However it

    is also one of the easiest to pass because there is very little time to ask you questions. You must have plan of

    action on how to proceed:

    - Identify the patients main problem or concerns

    - Clarify the problem or concern with a focussed history

    - Do a focused physical examination

    - Explain you findings and management plan

    - Demonstrate that you are caring and that you empathise with patients

    There is only one way of learning how to use an ophthalmoscope - practicing!!! Get used to the ophthalmoscope

    by examining patients eyes, even if you expect them to be normal. Also practice by examining your relatives and

    friends. It is like learning how to use chop-sticks or a knife and fork for the first time, the more your practice, the

    better you become. Keep some tropicamide handy for use in the ward. I use to do an ophtalmoscopy roundwhen I would ask for permission and examine the eyes of all the patients in the ward. You may also find it useful

    to attend a diabetic eye clinic or one of the retinal clinics in your local eye department.

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 31 of 38

  • You will not impress the examiner:

    By hesitating when examining patients and not doing a slick physical examination

    By presenting your findings in a disorganised manner

    By making up signs

    By not asking for permission and reassuring the patientBy causing discomfort to the patient

    By not identifying key signs and symptoms

    CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW NOT TO IMPRESS Page 32 of 38

  • This station is difficult to prepare for since there are endless possibilities that can appear in the exam. However it

    is also one of the easiest to pass because there is very little time to ask you questions. You must have plan of

    action on how to proceed:

    - Identify the patients main problem or concerns

    - Clarify the problem or concern with a focussed history

    - Do a focused physical examination

    - Explain you findings and management plan

    - Demonstrate that you are caring and that you empathise with patients

    There is only one way of learning how to use an ophthalmoscope - practicing!!! Get used to the ophthalmoscope

    by examining patients eyes, even if you expect them to be normal. Also practice by examining your relatives andfriends. It is like learning how to use chop-sticks or a knife and fork for the first time, the more your practice, the

    better you become. Keep some tropicamide handy for use in the ward. I use to do an ophtalmoscopy round

    when I would ask for permission and examine the eyes of all the patients in the ward. You may also find it useful

    to attend a diabetic eye clinic or one of the retinal clinics in your local eye department.

    BRIEF CLINICAL CONSULTATION (STATION 5) Page 33 of 38

  • Capitalise on the time you have while outside the room waiting to go in for the station. Use this time to structure

    your history and already identify key points from the information you are given outside the station. You can then

    use this as an aide memoire to consultation.

    Take the history just as you would normally take a history in the outpatient clinic but this time with greater detail.

    Show that you have taken thousands of histories and that it has become second nature. Some candidates tend tominimise this section because they think they are so good at taking histories. It is one of the areas where you can

    easily fail.

    Make sure you history is taken in a structured way so that the examines can clearly see that you are organised.

    Have a watch available during the exam and stick to time. Aim for 10-12 minutes for history, 2 minutes to talk to

    the patient. You will then have 1 minute to think to think about how you to present your findings. Listen to the

    examiners question and answer the specific questions they ask do not ramble. While preparing for the exam,

    practice time keeping for both the clinical and history taking stations so that you are confident that you can keepto time.

    You are unlikely to get complex cases for these stations. Most scenarios will involve problems that you have hadto deal with on the wards or in clinic.

    I find it useful to take background information first as it helps to build a rapport with the patient and already givesyou clues to your diagnosis. For example, breathlessness in a patient who keeps birds is most likely related to

    Bird Fanciers disease or to psittacosis.

    I find it easier to make notes as you go as you may forget with the stress of the exam. Before you go into the

    station, you are given time to read the background or GP referral letter and write down notes. It is extremely

    useful to note the key sections of a history including areas such as travel history and immunisation and consider if

    it may be relevant in the case you are dealing with. It also ensures that you do not miss large chunks of the history

    which could guarantee a fail in this section.

    During this period, also read the history carefully and note the key points. Then note the key problems e.g. chest

    pain and brain storm on paper the possible causes of chest pain. This will enable you ask questions related to

    differential diagnosis and allow you to broaden your thinking. The diagnosis may seem obvious but the examiners

    want to see that you can think laterally and consider other possible causes even though less likely. A diabetic

    HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 34 of 38

  • with chronic diarrhoea may possible have autonomic neuropathy but there are other causes of chronic diarrhoea

    and it is often useful to consider all the causes of diarrhoea.

    At the end of the discussion with the patient. Summarise the key problems you have identified and ask the patient

    if there are any areas of concern you have not covered. Ask if the patient has any questions. Also explain what

    the key problems are according to you without using medical jargon i.e. use down to earth language. Also

    explain what will happen next and involve the patient in decision making. You must have a plan of action.

    Explain that you will examine the patient before making any decisions.

    The sections in the history that many people tend to neglect or not do so well are:

    1. Systems enquiry: It must be detailed and cover all systems. There are no short cuts and do not assume

    that the diagnosis is obvious and some questions are irrelevant. You will be surprised how relevant some

    questions are in hindsight, when you start considering differential diagnosis.

    2. Social history: This section must be detailed, including areas such as work (past and present), housing,

    recreation, sexuality when appropriate and make sure you warn the patient you are going to ask personal

    questions and explain why, driving and activities of daily living. Also explore the effect of the illness on her

    daily life and relatives or friends.

    3. Drug or treatment history: Ask about medication including recent changes in drugs or dosages. Askabout inhaler techniques. Ask about eye drops, inhalers and over the counter medication. Also ask about

    alternative medication and over the counter medication the patient may be on. Ask about recent blood results

    and complications or side-effects of treatment.

    When presenting the summary of the case or the main problems, be concise. Again do not wait for things to be

    squeezed out of you. Imagine that you are teaching medical students and keep on talking, explaining what the

    main problems are and the likely causes or differential diagnosis. Keep talking sense!

    Consider how you would investigate such a patient if you were in an outpatient clinic. What are the initial

    investigations you would request and what are the other investigations you would consider?

    You are not expected to manage or deal with specialist problems. You are expected to be able to function as a

    general physician. For example, if you are referred a case of Churg-Strauss disease with worsening

    HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 35 of 38

  • breathlessness. Do not get frightened if you do not know what Churg-Strauss disease is. Ask the patient if you

    do not know in a nice, polite an honest way e.g. excuse my ignorance but I am not a respiratory specialist. Can

    you tell me what Churg-Strauss disease is? You may know more about it than I do. Tackle the case as you

    would all cases of breathlessness and explore all cardiac, respiratory and other causes of breathlessness. You

    should be able to deal with most common medical complaints.

    The aim of the station is not to see how you can make a diagnosis without prior knowledge of previous

    investigations or treatment. Most patients will already have a diagnosis or investigations would have already been

    carried out. The aim of this station is to see how you can obtain relevant information from a patient in a structured

    and professional manner and make sense of it. Ask about all previous investigations, diagnosis, treatment,

    complications, side-effects of treatment just as you would in real life in your outpatient clinic e.g. ask what sensehas been made of all these symptoms? Has a diagnosis been made? What treatment have you had so far? How

    did you respond or react to the treatment? What side-effects of treatment have you had?

    At station 4, always mention that you will involve other members of the team e.g. senior colleagues, nurses,

    physiotherapists, pharmacists etc.

    In addition, always introduce yourself and explain your role why you are here.

    It is always useful to get the patient to explain their understanding of the problem or treatment before you start

    providing any explanations.

    HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 36 of 38

  • 1. By not listening to the patient. The patient should do most of the talking, not you! Most patients have

    been well briefed so if you can listen and encourage them to speak, they will volunteer most if not all of the

    relevant history.

    2. By interrupting the patient

    3. By asking the same questions over and over. Patients and examiners get irritated.

    4. Not giving an opportunity for the patient to ask questions

    5. Not involving the patient in decision making

    6. Forgetting key sections of the history e.g. drug history. This will almost certainly earn you a fail.

    HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How not to impress Page 37 of 38

  • 1. An Aid to the MRCP Short Cases, Ryder

    2. Clinical Medicine for the MRCP Cases Gautam Mehta, Bilal Iqbal and Deborah Bowman.

    3. 250 cases in clinical medicine, Baliga For Case Management Issues4. MRCP 2: Success in PACES, P Kelly

    recomended reading Page 38 of 38