Examination Stations

Presentation

Classical Structure

1. Introduction: usually I examined Ms Jones, can comment on age if young. 

2. State positive signs firstly with basic intepretation- 'this could be consistent with'

3. Offer differentials often qualifying each, often with how common or likely it would be

4. Signs of severity- e.g. organ decompensation or multi-organ failure (e.g. core pulmonale)

5. Signs of underlying aetiology- again qualifying this

6. Signs of medication or therapy side effects

7. Complete assessment: history, examination, observations

8. Investigations

9. Management

Example

I've examined Mr Jones' today. My positive findings were an ejection systolic murmur, loudest at the right sternal edge, exacerbated by expiration and radiating to the carotids. This would be consistent with aortic stenosis. I also note a midline sternotomy and anterior shin scars bilaterally which could be consistent with a CABG. Mr Jones was euvolaemic and there were no signs of cardiac decompensation. Given Mr Jones's age, age related calcification would be the commonest cause of his aortic stenosis. In order to complete my assessment I would like to take a history, particularly asking about shortness of breath, angina and syncope (SAD) and ask about his functional status. I would like a HR and BP to complete my examinations. My investigation of choice would be an ECHO to look for mean and peak flow rate across the aortic valve and to look for signs of cardiac compensation- such as left ventricular hypertrophy or reduced left ventricular function. I would also request a proBNP to look for heart failure. Other investigations at the bedside woudl be an ECG to look for LVH; baseline bloods- FBC for anaemia, LFTs and U&Es for starting medications, CRP & neutrophils for an infection and a CXR to look for cardiac congestion. This condition would be managed by an MDT approach led by a cardiologist, cardiothoracic surgeon and radiologist - with specialist interests in aortic stenosis. Given Mr Jones' that is likely above 75 years old, the MDT would assess the appropriateness of a TAVI. 

Notes 1-9

1.  Some people believe it is a little medical studenty. I like a quick introduction, remembering the patients name. Usually you don't need to state the examination you've done but can be helpful to yourself. If they are young or sob, it can be reasonable to mention this here. 

2. State positive signs clearly and quickly. The examiner cannot give you marks for examination findings unless you mention it here. Therefore the first step is have you identified the correct signs. 

3. A little intepretation can be reasonable, in e.g. a renal transplant- I've found a RIF scar with a palpable mass consistent with a renal transplant. It is good practice to be cautious- there are other causes of an pansystolic murmur so a differential is good and reflects that examination findings are rarely diagnositc, but screening tools. 

4. It is usually an easy thing to say but important:

   1. Euvolaemic- ESRD, Heart transplant or valve repair, liver transplant

   2. Short of breath/ hypoxic- lung transplant

   3. Liver decompensation- ascites, jaundice, bleeding, encephalopathy

5. If unsure say commonest thing, e.g. chronic liver disease- alcohol & MASLD, if stating Wilson's qualify this by stating it is rare

6. Really for transplants- steroids- moonfacing/ metabolic sequelea/ diabetes, tacrolimus- tremor, cyclosporin- gum hypertrophy, MMF - diarrhoea, vomiting, abdo pain

7. Complete Assessment: history- e.g. 3 core questions with justification, examination and observations- justifying relevance

8. Investigations: bedside, body samples, imaging, interventions (useful to have a structure)

9. Management: 1) MDT, 2) Lifestyle, 3) Medications, 4) Surgical/ interventions

General Notes

• This is a long structure and it can be a good sign if you are able to answer the examiners questions, many examiners will however interrupt. 

• Be careful what you mention as it examiners may try and be helpful by building on what you've said, so be cautious around mentioning concepts your familiar with. 

• It is very easy to jump into the differentials and be incorrect. Ultimately this is a clinical examination and you should be cautious with your presentation, using phrases suggest as "these signs are consistent with". This allows the examiner to give you marks for the signs and lead the discussion as they see fit. 

• Appear non verbally confident about findings- you cannot say- I'm not sure if there is hepatomegaly. If unsure- omit it and if relevant the examiner will bring it up or caveat it, 'I wondered if I could feel hepatomegaly- although this was inconsistent in my examination, I would like to get an ultrasound to assess for this'.

• If your unsure about a sign, usually best to state is normal and it is usually obvious.

• Try to listen to the examiner's non verbal hints. 

• If you are not sure, keep your answers succinct. Do not elaborate on your incompetence but let yourself be guided by the examiner. 

Do the basics well:

• Use the patient's name- if you don't remember this, use 'this gentleman' or 'this lady' NOT: 'he' or 'she'. 

• Speak clearly at an appropriate pace and volume using appropriate medical terminology 

• Maintain eye contact with both examiners, although one will ask the majority of the questions with appropriate formal posture without fidgeting

Tips

• Rehearse at the end of the station

• Practice in front of consultants

• Ensure the logic between signs and differentials is clear and accurate

• Do not be tempted to make up signs, better to state I did not elicit this if unsure

• Try to remember all of the positive signs

• Do not highlight your errors, omissions or signs you are unsure of as they may easily be missed by the examiner

• Some examiners will interrupt the presentation with questions +++, whereas others will allow you to present