How to use this book
Examination

This section provides a template for examination of each particular system.

Have your own system based on the accepted sequence of inspection, palpation, percussion and auscultation. Examiners expect a certain progression although they accept that each person has their own particular adaptations to the general formula. Find out what works for you and have a reliable method for finding each sign. You can use any method you like as long as you can justify it, for example, you may want to auscultate the front of the chest before going on to palpate, percuss and auscultate the back, simply to prevent an elderly patient from having to move forwards and backwards all the time. Always be considerate, do not cause the patient pain.

Remember there is a concrete cause for the signs that you pick up. Try to imagine what’s physically happening in the body. For example, colon cancer and deep palpation of the abdomen: picture the firm mass of the tumour and feel for it, under the skin amongst the soft intestines. You can practice this hiding a ping pong ball under a soft pillow and feeling for it. If you prod the pillow here and there, you’ll never find it. If you feel the pillow systematically with your whole hand, pressing down far enough with a rolling motion, you’re much more likely to find it.

Examination combines the ability to take in what is jumping out at you with the skill of searching for what you suspect. So, inspection is not just about seeing the obvious signs in a patient, is also about looking for more subtle clues that your medical knowledge tells you might be there. The same idea holds for palpation, percussion and auscultation.

Examination is a thinking process and not about mindlessly carrying out a set of independent movements. Form an idea of what is happening as you go along and spot the connection between signs as this will point to the underlying pathology. Likewise, be surprised and reevaluate your diagnosis if things aren’t adding up.

Practice makes perfect. Examination should be slick and second nature so that you can concentrate on what you are finding rather than worrying about which part of the examination comes next.

TEMPLATE:

Introduce

Always introduce yourself, state your name and role. Ask for consent before starting your examination.

Think “HELP”
Hello
Expose
Lighting
Position

Name/Age/Occupation
Don't forget this one or you'll be stuck when you start to present the patient and realise you don't have this basic information.

Observe
First observe the patient’s surroundings, then the patient themselves. Do this from the foot of the bed to demonstrate to the examiner this is what you are doing.

Hands/ Wrist/ Arms/ Face / Neck/ Chest/ Back/ Abdomen
This template is followed for each system, which allows you to integrate the examination of all systems into one if necessary.

Legs
Start with the hands and end with the legs!

Legs are often forgotten and are important, if only to look for oedema which is relevant to every system.

“To complete my examination, I would like…”
This includes simple bedside tests, rather than anything more complex. For example, dipsticking urine, but not sending urine for an MSU.

Turn and talk to the examiner. Following this they will ask you to present your findings.

 

 

 

 

 

 
     
     
 
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Thinking Medicine
2007