Hi folks. Here are some commonly made mistakes in the assessment of the short cases component of the FCPS 2 (and other) practical post graduate exams. Undergraduates can also pay heed.
How to fail while performing the general physical examination.
- Don’t bother to check the weight, the pulse, the blood pressure, respiratory rate and do remember to say “Oh I forgot my thermometer” .
- Do start by checking for clubbing, kolionychia, blue sclerae before checking the vital signs.
- Remember to ignore any skin changes specially petechaie, bruising, rashes, urticaria, maculopapular nodules on the shins and toes, discoid lesions on the face or scalp, color changes and ulcers on the digits. Please make sure you do not examine the back, buttocks and abdomen when looking for skin changes. After all you do not want to point out the rash or skin hemorrhage in case the examiner asks you questions about them. Keep it under your hat
- If you find that the patient is anemic, do not look for jaundice, ignore the rest of the examination, go straight to the abdomen to palpate the liver and spleen. Having discovered a large firm spleen in a 40 year old man make an immediate diagnosis of sickle cell anemia specially if the liver is also enlarged.
- If you find a lymph node in the axilla do tell the examiner that it is “insignificant” and make no attempt to palpate lymph nodes in the neck or groins. If you see surgical dressing on one side of the neck (where a biopsy has obviously been taken) avoid palpating lymph nodes on that side. Examine the other side and say “there is no lymph adenopathy”.
By now you have gathered that I am suffering from the frustration that is likely to send an examiner to an early death.
The general physical examination usually does not lead to a “spot” diagnosis but will often give you a starting point from where to start your search for a disease or a differential diagnosis. Repeating a GPE at subsequent examination may lead to new clues or evidence of progression of the disease or hopefully a remission in the disease. The GPE is a very useful tool. Please remember the logic behind the different findings.
Weight. Do check the weight and do it repeatedly for a patient under your care specially if you are dealing with fluid retention and edema, and in malabsorption where the nutritional consequences can lead to weight loss or improvement in the response to treatment can cause weight gain. Other chronic diseases will show a similar response. If a patient continues to lose weight then revise your diagnosis or review your diagnosis. Use the weight to check the state of nutrition. In a grossly obese person take a dietary history with the specific objective of advising what to cut down on. In a malnourished or underweight person ask about the reason for the calorie deficiency: unable to access an adequate diet either because of financial constraints or a disaster situation like flood, famine, refugee situation or loss of appetite or inability to swallow or retain a diet i.e excessive vomiting. Ask if the weight change is a recent phenomenon. This aspect of the examination and history is usually ignored by the student. Work out the BMI.
Initial inspection of the patient. It is not enough to say “the patient is lying comfortably”. Both you and the examiner know you are only saying that because it is a habit. Preferably say that the patient is lying flat and is not orthopneic, not in obvious pain and is not anxious or distressed. Mention here that the patient is thin or obese or malnourished. If you can see obvious edema or abdominal distension mention it