Most well trained candidates who have worked in the wards should have reached a clinical diagnosis 80% of the time by taking a good history. Now you can wrap it up by presenting your clinical findings in a sensible way.
Infective endocarditis is now readily detected and antibiotics are administered early so embolic phenomena like Janeway lesions and Roth spots are unlikely to develop. Clubbing has become a late sign of malignancy or purulent disease of the lungs. The possibility of a lesion being detected early is useful if it can help in detecting or diagnosing a disease early not if the sign is seen late in the disease. So please do not start off your presentation by saying ” There is no koilonychia, clubbing, Janeway lesions, Roth spots, splinter hemorrhages.” A list of “no” is very unimpressive. It is better to start your presentation with the most significant finding or sometimes the lack of a finding, For example: this young lady has been treated multiple times for anemia but does not have jaundice so is not likely to be hemolyzing, she does not have a bleeding tendency like excessive menstrual periods or bleeding piles. She does give a history of epigastric discomfort after meals and a history of heartburn, I would like to check her stools for occult blood, look for iron deficiency in the investigations and schedule her for an upper GI endoscopy to look for a peptic ulcer, GI reflux or gastritis and also check for H.pylori infection. Most candidates do not give this information spontaneously but wait for the examiner to ask a question about each of the subjects separately. You are not going to get many marks even if you give the right answer as you should have given the answers on your own. You didn’t know the causes of anemia in a young woman.
When dealing with pyrexia of unknown origin it is a good idea to present like this: This young man has had fever without any recognisable characteristics like rigors or night sweats or periodicity. He has been living in circumstances of poverty and homelessness so tuberculosis is a top priority. He has been deprived of social restrictions so an attempt should be made to look for drug abuse specially IV usage which can cause acute endocarditis and phlebitis. He may have HIV/AIDs accompanying the infection. He has been on multiple antibiotics so a blood culture should be obtained 6-12 hours after withholding the current antibiotic depending on its 1/2 life. An extensive search should be made for abnormal cells in the bloodstream and I would like to look for autoimmune disorders too. This answer shows that you know your subject. I bet if you were asked to give a list of the causes of PUO you would be able to rattle of a list but you will get the marks only if you show that you understand how to set about diagnosing and investigating such a case.
Please remember, like everything around us, priorities and fashions change in medicine as well. Many signs that may have been emphasized to you as “must be said” have become irrelevant and replaced by good investigations. For example most patients will have their iron deficiency anemia treated early as there is a lot of awareness in the medical profession as well as the general public. Iron supplements are available over the counter. The economy now supports better nutrition. Koilonychia has become a rarity and should only be mentioned if present and then you should give a reason as to why the patient remained iron deficient for 6-12 months; refugee situation; prison; mental instability like anorexia nervosa or perhaps malabsorption like adult coeliac disease in which single nutrient deficiency can occur?
Please do not say “No, anything”. It is incorrect English.
So how do you start? Wear cellophane gloves while examining the patient.
- Mention any distress that is present; breathlessness, orthopnoea, pain, an ulcer or a festering wound, a bandage or dressing which has been applied. Mention if the patient obviously has swollen feet or a grossly protruded abdomen. Mention if the patient has a urinary catheter (it is surprising how many candidates miss this) and if there is a crutch, walking stick or wheel chair in the cabin. Examiners leave these things for you to pick up the degree of disability.
- Mention whether the patient looks ill, emaciated, obese, anxious, agitated or depressed; is pale or sallow (darker than usual and waxy looking)
- The vital signs come next; pulse, BP (both sitting and standing), the temperature (remember to remove the thermometer from the axilla and read it as candidates forget to do that), the respiratory rate. Discuss these if you have an abnormal finding.
- If a weighing machine has been placed near the patient take the hint, otherwise ask for one and ask the patient his/her height or guess it and work out the BMI. Mention signs of recent weight loss.
- Look at the patient and note anemia, jaundice, cyanosis, flushing. Here you are justified in giving a short list of “no”.
- Mention lymph nodes even if they are absent.
- If you have looked at the nails and hair it is enough to say that the nails and hair are healthy. Be prepared to answer what abnormalities may be seen in the nails or hair.
- Mention the thyroid even if it is not visible or enlarged.
- Mention the neck veins and in almost the same breath mention edema.
- In the hands mention the nails; well rounded, pink with no pitting or depression and not bulbous (clubbed) with no periungual bleeding or fibromas. Also mention if there are signs of arthritis or tremors. Look for wasting of the small muscles. Look for any deformity.
- Mention a rash or petechial hemorrhage and scratch marks.
- Mention an abnormal posture or tremors.
- With the frequency of diabetes being so high and the fact that our population in Pakistan have not left off smoking it is a good idea to examine and talk about the pulses in the feet especially if there is an ulcer or blue toes or an amputated toe.
- Mention an iv cannula, an a-v fistula or a dual lumen catheter in the neck vein or any other device the patient has in or on his body.
- If the patient has a bandage on, ask for permission to undo it and also ask for a dressing tray so that you can replace it with a fresh one.
What should you examine next and present next? This depends on the history. If the patient has a neurological problem then obviously you must examine and present the nervous system first. Remember to examine the fundus at the same time and do not leave it to the end of the examination. You may not get time later. The common neurology cases seen in the examinations are cranial nerve palsy, cerebellar and other ataxias, tremors and Parkinson’s disease, epilepsy, sensory neuropathy, paraplegia, monoplegia, hemiplegia, myasthenia gravis. However you can expect any disease except acute emergencies. Examine the affected part first. For paraplegia start with the legs, remember it is the loss of sensation which will help you reach an upper level in traumatic paraplegia. Do look at the anatomy of the vertebrae and the relationship of the spinal cord to the vertebrae. Be familiar with the innervation of the bladder and the male sexual organs. You should know about rehabilitation techniques and how to provide catheter care without causing urinary infection.
Say that the patient has anemia and you find that there is loss of sensation on the feet? What else should you look for or comment on? Down going planters and absent ankle and knee jerks should make you think of peripheral neuropathy. Remember diabetes is more common than vitamin deficiency now a days. Alcohol in excess can result in deficiency of thiamine. In B12 deficiency there is sub-acute combined degeneration of the spinal cord and peripheral neuropathy so loss of sensation on the feet with absent ankle jerks and upgoing plantars and increase in the muscle tone and brisk knee jerks and anemia.
Remember the unusual combination of clinical findings or interesting facts. What odor on the breath would make you think of uremia, ketoacidosis, liver failure etc? What are the medical uses of marijuana? How will you treat the pain of peripheral neuropathy, herpes zoster neuropathy and trigeminal neuralgia? They are all nerves but require different therapy. Think of unusual groupings of clinical signs.
If you are asked to perform the general physical examination what should you do? first observe the patient: orthopnea or breathlessness, is the patient in pain, looks ill or depressed, is there evidence of recent weight loss i.e. loose skin and wrinkles. Weigh the patient and ask them their height. Work out the BMI. Check the vital signs; pulse (rate, rhythm, regularity and volume), BP in the upper arm in the supine position and then the upright position, the temperature and respiratory rate. It is sensible to look for colour changes next: cyanosis, anemia, jaundice; if there is an obvious abnormality like an ulcer or gangrene or a swollen joints or joint, eruptions on the skin, a limb which is wasted or paralysed, then please be quick to note it first. look for the thyroid, examine its size, mobility, tenderness and a bruit and texture i.e. cystic or not, look for signs of heart failure such as a raised JVP, edema and look for a palpable liver. When you are a examining for a group of signs then systemic signs become part of the GPE. Look for lymph nodes. See if you can pick up signs of chronic liver disease. Look for a tremor, localised wasting and quickly examine the peripheral pulses including the carotid.
Te command “Do the GPE” is often given when the sign you are expected to pick up cannot be picked up in one systemic exam or asking the candidate to examine the system takes too long and is unnecessary. So you may be expected to pick up signs of peripheral ischemia, or muscle wasting caused by a nerve compression or myopathy, abnormal movements like tremor or torticollis etc. If you pick up the significant sign at once then your GPE should be designed to cover that first. If you find a non-healing ulcer then look for the relevant pulses and sensory loss before you look for the JVP etc. If you find anemia check for jaundice, signs of weight loss, check the weight, examine the lymph nodes, look for hypoalbuminemia and hair loss etc.
Have fun examining your patient!!!