Remember that during the FCPS 2 examination and most other clinical examinations you are being observed either by an examiner or you are being recorded so that your methods can be observed later as in a mini CEX. What are you being observed for? Have you identified the priority of which system to examine, what is important in examining the patient, are you looking for a particular clinical entity or are you doing your clinical examination just for the sake of doing it? Have you taken the history in the logical sequence? Were you polite and empathetic towards the patient? Did you show frustration or boredom? Did you repeat the questions? This is a common mistake. Write down anything you think you might forget like names of the spouse, address, telephone number, dates of events or procedures or treatment received by the patient in the past etc.
Let us take the respiratory system. You are thinking in terms of COPD from the history you have taken.
If the patient has complained of wheezing, breathlessness or exertional dyspnoea do a quick check for cyanosis. Mention cigarette stains on the fingers. At the same time note if there is clubbing. You do not need to mention clubbing if it is clinically unlikely to be present or has no bearing on your diagnosis. If you can hear a wheeze without a stethoscope then mention it. If the patient can sit up then see if the chest is round like a barrel or flat on one side or if there is significant scoliosis or kyphosis which can affect the lung volume. Note the respiratory rate and type of breathing: is the patient using the abdominal muscles to breath or the respiratory muscles or both. You should know why this is so; there may be gross ascites or a pregnant uterus or some other mass, or the abdominal muscles are stiff because of underlying peritonitis. Respiratory excursion can be checked with a tape measure, in inspiration and expiration. You can confirm if a part of the chest is not moving by placing the flat of your palms over the chest with the thumbs approximated, either one thumb will move less in the up and down direction or there will be unequal horizontal movement on one side. See if the the trachea is central and so is the apex beat. This means that the mediastinal structures are in the mid-line. Percuss next and see if you can pick up an area of unusual dullness or a tympanic area.
When auscultating mention the breath sounds first. Vesicular sounds are the sounds of the air moving in the bronchioles modified by the passage of the sound through the alveoli. When the alveoli are consolidated as in pneumonia or a pulmonary infarct the bronchiolar sounds are transmitted directly to the chest wall and are heard as “tubular” sounds i.e inspiration then a gap then expiration, the duration of the inspiration and expiration being equal. In vesicular sounds there is a short inspiration, no gap and a longer expiratory phase. Added sounds come next. At the end of all this, which should not take more than 6 minutes you should have made up which of the following is present; no detectable abnormality, consolidation ( tubular sounds), bronchospasm, mediastinal shift, collapse or fibrosis of the lungs, pulmonary edema, fluid in the pleura. No detectable abnormality does not mean there is none. You should then say what investigations you need and why depending on the history. Tuberculosis usually shows up on an x ray of the chest as does bronchopneumonia. Interstitial fibrosis and other interstitial lung diseases need a high resolution CT for a diagnosis. You should know when to do a bronchoalveolar lavage, that is the indications for it.
Pleural effusion is an easy clinical diagnosis yet candidates often fail to answer the questions they are asked.
- Is there underlying consolidation? Aegophony or clearly audible voice sounds through the stethoscopes on asking the patient to say “nine nine nine” or when whispering indicates that there is some compression or consolidation.
- What is the significance of a mediastinal shift in a pleural effusion? In a large effusion the shift will be away from the side of the effusion. If the shift is towards the effusion then think of underlying collapse of the lung.
- How will you distinguish inflammatory (exudative) effusion from a transudative effusion?
- How can you diagnose tuberculosis using the fluid from an effusion?
- Why can malignant cells be found in a pleural effusion?
- What is the treatment of a malignant effusion?
- What drugs can you instill into the pleural cavity?
- How can you do pleurodesis?
- When do you need to aspirate an exudative effusion?
- Do you need to aspirate the pleural effusion in heart failure?
You should be prepared to answer these questions. These are designed to assess your understanding of the subject, not just see if you can remember what you memorized.
- How can you prove the presence of Mycobacterium TB in the fluid? Be prepared to discuss culture techniques like the slow classic culture on LJ medium, quicker liquid culture techniques using radioactive CO2 emission.
- How will you detect resistance to drugs?
- How will you treat multidrug resistant TB?
- Which drugs can be used to treat simultaneous HIV infection if the patient has tuberculosis as well?
- Which anti-TB drugs damage the liver or the kidneys?
- What are the advantages or disadvantages of using drugs combined in one tablet?
Which system should you examine next? You have a choice between the cardiovascular system and the abdomen. If the history favors COPD or bilateral pleural effusions which may be you should look for signs of heart failure hence examine the chest for the cardiovascular system and also look for signs of heart failure such as a raised JVP, peripheral edema, a palpable liver etc. If you anticipate metastatic lung disease, lymphoma, tuberculosis etc then look for evidence in the abdomen.
Let’s see what information you can gain by examining the abdomen. There are many organs and systems in the abdominal cavity which can be affected individually and involve the lungs. Or a systemic illness can involve the lung and the organs in the abdomen, like lymphoma and leukemia. You are likely to find the cause of anemia by examining the abdomen i.e. an enlarged spleen or a mass caused by lymph nodes or part of the large gut. The liver can enlarge in heart failure, leukemia, myelofibrosis or infiltrative diseases like amyloidosis or cancers and can also be enlarged in diseases of the liver itself. So keep thinking and analyzing your findings.
When you are inspecting the abdomen please do not say “I will expose the patient from the breast to the mid thigh”. It is unnecessary, undignified and impracticable. Expose the patient from upper abdomen to the groins ensuring the patient’s privacy. When you need to examine the genitalia or the hernial orifices then ask the patient’s permission, have a chaperone present and use a sheet to cover the patient up as much as possible or do it behind a screen. See if the abdomen is bulging or protruding; or if it is flat often described as scaphoid or boat shaped, or see if there is a bulge in the flank. Measuring the abdominal girth, this is useful for further follow up but may not be essential. Look for ascites or free fluid in the abdominal cavity. Palpate gently first and be on the lookout for tenderness or a change in the consistency or the presence of an obvious mass. Then palpate the liver and spleen and remember to palpate the kidneys with both hands. If you are suspecting chronic liver disease look for evidence of disturbed blood flow in the abdominal wall. Normally the venous flow is upwards from just above the umbilicus towards the superior epigastric vein and down from below the umbilicus towards the inferior epigastric vein. In cirrhosis of the liver the direction is not changed but the veins around the umbilicus become very prominent as more blood flows into the systemic veins to accommodate the impaired portal system. This is sometimes referred to as “caput Medusae” or Medusa’s head, a rather imaginative reference to the serpents which had replaced her hair. If there is inferior vena caval obstruction there are large veins running up the flanks with the flow upwards and in superior vena caval obstruction the flow is downwards. A bruit in the renal artery can be heard at the back in the renal angle or from about 2-3 inches from the midline about an inch higher than the level of the umbilicus. The Cruveilhier-Baumgarten murmur is a venous hum that may be auscultated in patients with portal hypertension. It results from collateral connections between the portal system and the remnant of the umbilical vein. It is best appreciated when the stethoscope is placed over the epigastrium. The murmur is augmented by maneuvers that increase intraabdominal pressure, such as the Valsalva maneuver, and diminished by applying pressure on the skin above the umbilicus.
Remember to get your investigations right when examining the abdomen. There will be a different set of investigations if the liver is involved, or you suspect a blood dyscrasia if both the liver and spleen are involved. You may need to investigate for a hemolytic anemia, keeping in mind that most congenital hemolytic anemias will have been diagnosed in childhood and are unlikely to present for the first time in an adult. If you feel that a 30 year old man is presenting with thalasemia for the first time then you must be able to discuss the natural history of the disease and what number of patients will remain asymptomatic until this age and whether there is splenomegaly in thalasemia trait. When planning investigations for ascites think of infective causes like tuberculosis or subacute bacterial peritonitis, think of pancreatitis, then think of the liver, kidney and heart as the causes. Plan your investigations accordingly.
What if you find signs of heart failure: edema, raised JVP, enlarged liver, an irregular or rapid or slow pulse? If the first two signs are present do palpate the liver even if you have been asked to do the GPE giving the reason, if asked, that you are confirming the presence of CCF. Check the blood pressure, look for a displaced apex beat, a gallop rhythm, a pulse which is irregularly irregular as AF is common in older patients with ischemic heart disease. These people will not have any accompanying murmur unless there is gross cardiomegaly when a murmur of tricuspid incompetence is likely to be heard. The left heart also dilates but a murmur of functional mitral incompetence is much less commonly heard. Listen for an organic murmur in younger patients.
When examining the nervous system, if the patient has diabetes or hypertension examine the optic fundus first of all. This will give you useful information and will help you follow up your patient. In diabetes look for sensory loss, non-healing ulcers (look between the toes) and peripheral pulses; then look for motor weakness making sure that you have examined the proximal muscles in particular. Make sure you have practiced the examination of the proximal muscles before the examination. In peripheral neuropathy the tendon reflexes will be difficult to elicit as the sensory arc will be interrupted and there will be hypotonia. Remember to read up the pathways of the reflexes and their spinal levels; also how the tone is maintained so you should know about the structure of the muscle spindle and its innervation and the reflex arc it makes in the spinal cord. You should have read up the common lesions causing the upper motor neuron lesions, their location in the brain and spinal cord.
When asked to examine the joints you should know how to examine each joint. You should be able to determine the degree of disability in each joint so practice in advance.
Please remember that when you are answering questions keep in mind that your priority is the likely lesion in the patient you are examining now. So give appropriate answers according to the current findings and give a list of other likely findings only if asked to elaborate further.