I examined in MRCP(UK) Practical Assessment of Clinical Examination Skills (PACES) for 34 years. Most of what follows will not be found in standard texts and will be useful in standard medical life. Read my advices and, like all advices, consider each one and decide whether you will use it or not.
GENERAL COMMENTS
PACES patients will be out-patients, will be well, and will not have acute conditions. This limits the range of patients available for clinical examinations.
Some candidates suffer from counterproductive anxiety. The best advice I have read for dealing with performance anxiety comes from Keith Dutton who studied psychopaths and Andy Mc Nab who wrote of his experiences in the SAS in his book Bravo Two Zero, and who is a psychopath.[1] They advise against trying to alter emotions but rather asking yourself what you would do if you were a psychopath and didn’t care and then act it out. In other words alter your behaviour and this often empowers you to disown your anxiety.
Take a general look around the scenario. Diagnostic clues are visible. A splint (footdrop), a wheelchair, or the patient wearing a Muscular dystrophy tee shirt (only half of the candidates noted this as far as I could tell!).
Do not make long lists whilst waiting before each examination station. For each station write down short important points in large print so you can glance down quickly.
Make it obvious to examiners when you have noted an abnormality – perhaps mumble to yourself (examiners cannot read minds).When asked difficult questions it is impressive to delay your answer for about five seconds to organise your thoughts, Resist the temptation to commence an immediate improvisation.
If you are certain of a diagnosis then state it and give your reasons and follow up with “I would confirm this by ….” If you find a case difficult say so and then talk sense – discuss alternatives and watch examiner’s response. State “We could consider …. and note the examiner’s response at being included – they almost subliminally nod their heads in approval or shake them if disapproving!
Anticipate being asked which tests you would do and take the initiative and do not wait to be asked but rather say “To confirm this I would…” Apart from the routine testrs (unless of course they are relevant, in which case say why) the most important test(s) would be … Note that electrocardiograms do not identify valve lesions other than, perhaps, identifying secondary chamber hypertrophy.
In brief the clinical consultation station you have to take a history and exam the patient. In other stations you are not supposed to ask questions but you can “automatically” ask brief questions that any normal doctor would ask.
Work out in advance a brief account of common findings. For example “The patient has an irregularly irregular pulse, it is likely to be atrial fibrillation rather than multiple ectopics because…the likely causes are … and the investigations I would do are …
If time is running out say what you would normally have done.
Finally, do not worry if one examiner gives you a hard time. Examiners are paired and hawks are often paired with doves.
CARDIOVASCULAR
Patients over the age of 60 usually have degenerative heart problems, notably aortic sclerosis/stenosis and/or mitral incompetence.
Look for scars suggesting valve replacements and/or coronary artery bypass grafting or underlying pacemaker or defibrillator. Listen for metallic clicks signifying metallic valves. Mumble “metallic valve” so the examiners know you have noted it but then impress by adding whether the rhythm was regular or irregular.
If you suspect a collapsing pulse and aortic incompetence ask to take the blood pressure “to look for a wide pulse pressure.” The answer will be “No”as time constraints apply.
Ask patient to hold their breath whilst auscultating. Anything you hear then is cardiovascular in origin.
Aortic murmurs may be audible over all of the precordium but do not fade away laterally in the axilla. Mitral murmurs are unlikely to radiate along the clavicles.
Always conclude the presentation of findings with the most important – is the patient in heart failure?
RESPIRATORY
Make a point of looking for a sputum pot even if one is not there.
Ask patient to cough, blow against your hand (the poor man’s peak expiratory flow) and listen to their breathing. If there is a wheeze note whether there is asymmetrical intercostal muscle recession. Signs of pulmonary fibrosis (not uncommon in my exam experience) and chronic obstructive pulmonary disease are usually symmetrical.
The abnormal side is the one with reduced movement.
Posteriorly the lungs are higher in the chest than most candidates think they are (relevant percussion reveals this). Abnormal lung sounds will be over the lungs but pleural liquid will (unless loculated) fill the diaphragmatic recesses beneath the lungs. Musically, unilateral pleural liquid causes a reduction in percussion note of about an octave whereas consolidation reduces it by a fourth or fifth (a dull percussion note refers to the pitch not the volume).
Auscultating with the stethoscope diaphragm whilst using it for percussion is often more useful than using digital percussion (this will interest most examiners!)
GASTROINTESTINAL SYSTEM
Show you have noticed scars.
Ask if there are any tender areas. Some problems are not painful until palpated.
You can ask quick question about an abnormality. ”That will be a gall bladder scar?”
When palpation for organomegaly you are usually feeling for edges and you may need to move your hands if organs do not move on respiration. Always keep the palpating hand relaxed. Enhance feeling potential by pressing downwards on the palpating hand with the non-palpating hand.
If obese percussion often more revealing than palpation.
Don’t forget palpation and percussion for midline structures (aorta, bladder, uterus) but if you suspect an aortic aneurism stop palpating and tell the examiner you would need an ultrasound first.
Do not palpate for a spleen – let it come to feel your fingers.
The only way to clinically suspect a small liver is by percussion.
An abdominal mass is likely to be a kidney if the patient has evidence of a dialysis shunt.
Do not forget to test, or say that you would test, for ascites (if ankle oedema then a swollen abdomen is most likely caused by ascites).
CENTRAL NERVOUS SYSTEM
Take a general look. Conditions such as Parkinsonism, dystrophia myotonica may be obvious. If you are asked to examine the lower limbs and you note the patient has nystagmus and problems separate from the eyes then multiple sclerosis is highly likely.
The limbs
Ask if it would be painful if you were to move the limbs yourself. Then slip in “Any weakness?” and “Any loss of sensation?” If the patient tells you it would be painful them to move the limbs if they can.
If on initial “automatic” questioning you are told that the feet are numb ensure that you give sufficient time to identify all characteristics of peripheral neuropathy.
· Stocking type loss of sensation: this should take ten seconds. Use descending paper clip points in vertical strips down the legs “Tell me when the feeling changes” (paper clips are cheap, disposable, can be used to test touch without the risk of using sharper points and when opened out can test for two-point discrimination)
· Impaired sharp: blunt discrimination. This does not need the patient to tell you sharp or blunt, merely that there is a difference between the two. Ask if they can tell the difference between a paperclip point and the curvature. There is no need to complicate by asking about sharp or blunt
· Touch sensation impairment. “Does this feel like a finger should feel?” Test for two-point discrimination (use paper clip)
· Reduced reflexes
· Impaired vibration sense distally. If unimpaired distally it is most unlikely to be impaired proximally. Initial testing at the periphery can save time
Do not forget to ask the patient to close their eyes when testing for any cutaneous sensation impairment.
If you are certain of diagnosis say so then justify it using the mantra tone, power, sensation, coordination, reflexes. If uncertain of the diagnosis go through these and watch examiner’s responses. Often they will stop you in this process to ask you about the causes of, say, hypotonia, and this will confirm that that is what the patient has.
Tone – if you detect clonus mumble “Upper motor neurone.” When flexing the patient’s knee joint the leg should fold up and the ankle touch the buttock. But with upper motor neurone lesions the leg will be stiff and the lower part should give a “little kick” (you are in effect also eliciting a knee jerk reflex). Cerebellar lesions produce hypotonia and if combined with nystagmus {that you noted this although you were only asked to examine the limbs} then multiple sclerosis is almost certain). Cerebellar lesions cannot be compensated for by vision, unlike most other incoordinating lesions
Power There is no need for wrestling! If the limbs do not droop when tested at the peripherally then almost certainly power will be normal proximally, so ask the patient to stretch out both arms or lift both legs from the couch and see if they can maintains the position when gentle bilateral downward pressure is applied to the fingers or toes.
Sensation Do not forget to test for limb sensory inattention – normal when tested on each side but when both sides are simultaneously tested one side is not felt (more common in left hemiparesis).
Coordination Ask the patient to “Play the piano.” Ask the patient to tap your hand with his toes – elderly patients often cannot do the heel shin test because they have arthritis. Anyone who asks the patient to touch the examiner’s finger and then their nose should be reprimanded. Cerebellar incoordination increases as the target (the patient’s nose) gets nearer and thus the patient may jab his eye. The reason eye damage rarely occurs is that the blink reflex is usually preserved despite other neurological abnormalities. Instead ask the patient to repeatedly touch your index finger that you move to various positions.
Reflexes Please learn how to elicit the five routine reflexes skillfully! Surprisingly candidates often elicit reflexes as if it were their first ever attempt Use minimal threshold to identify slight differences. Tap the tendon to find the least eliciting response and then transfer the same stimulus to the corresponding tendon on the other side. Use finger jerks to elicit signs of an upper motor neurone lesion in which the thumb moves across the palm when the fingers are flexed by being tapped with a tendon hammer.
Nearly everyone thinks they are testing the supinator reflex but the are in fact testing the brachioradialis reflex,
The cranial nerves
Test visual fields by direct facial confrontation with your face about 20cms in front of the patient’s face. Ask “Is there any part of my face missing?” (with both of the patient’s eyes open then each masked in turn). Do not forget to test for visual inattention by waving a hand separately in turn on each side of the patient’s field of view and if both are seen then wave both hands simultaneously on each side and only one will be seen (more common in left hemiparesis).
HISTORY TAKING
After the introduction say “Tell me exactly what the problem is.” The patient should then give you the unembroidered scenario that they were given.
When the patient reveals an important symptom say “That’s important. Tell me more.” This shows the examiners you can grade the relative importance of various aspects of the history. Try to deal with all aspects of each important symptom at the time – you might forget to do this later.
Always discover what drugs the patient is on (this often confirms your diagnosis)
Make sure you cover the brief basic questions for each system – presenting complaint, CVS, RS, GIS, CNS, PMH
COMMUNICATION SKILLS
Ask if indicated “What else can I do to help?”
Whatever the scenario. Conclude the interview with the examiners by stating “I would record the discussion in the notes.”
Breaking bad news. Ask what the patient suspected and, if it is correct and serious, say “OK” rather than “Yes” because the former sounds less final. Then say “That’s all the bad news. To be positive…”and then weigh in with all the help that is available. There are some advantages in having a cancer diagnosis, for example extra help from the hospice services. Indeed suggesting a hospice worker visit can be a soft way to confirm a suspected diagnosis. If asked it is terminal it is perhaps kinder to say “I’m sorry but it will end in tears.”
Surprizingly some patients often want to know the doctor’s personal adice. You an say “If I were you I would do … but I am not you and you have to decide.”Conclude the interview by stating the three major points (usually it is three – I’ve no idea why) and when giving out leaflets underline major points you wish to make. In exams there will be no leaflets so consider writing a simple list of major points and give it to the patient to take away. Examiners will not expect this sensible initiative.
Dealing with relatives
A common scenario is that relatives don’t want their elderly relative informed of a serious or terminal diagnosis. Relatives have to understand that patient autonomy usually demands that you have to answer direct questions from a patient if you are convinced they want to know the answer. I was very impressed by a candidate who greatly assisted a relative by saying “ It’s not medical but if your father dies intestate (without a will) then the legal consequences will be complex and often long drawn out.
If relevant conclude by saying “If you think of any other questions I am on duty…”
CONCLUDING EACH ENCOUNTER
Thank the patient and the examiners.
[1] Dutton K, McNab A. The Good Psychopath’s Guide to Success. Transworld Publishers 2014. ISBN 9780593073995.
