This course is about showing you how to impress examiners and also how to avoid common pitfalls.

It is not
about providing you with exhaustive information, it is about giving you the essential information you need to pass
the exam. It focuses on demonstrating how to perform a slick physical examination and present your findings in a
confident and clear fashion. This course also addresses areas of physical examination that doctors tend to be
most weary or uncertain about such as confidently eliciting ankle jerks.
There are numerous good books that focus on the communication skills or talking stations, this course focuses
on the clinical stations. Most books provide the theoretical basis for the exam but few focus on clinical skills and
presentation of findings. This is the focus of this course. The examination stations are marked under 8 headings:

a) Physical examination
b) Identifying physical signs
c) Clinical communication skills
d) Differential diagnosis
e) Clinical judgement
f) Managing patients concerns
g) Maintaining patient welfare
If you can do a slick examination and presentation of findings, you have made a great step towards passing. The
discussion section tends to be brief and the questions are rarely very difficult, provided you are well prepared.
Do not forget that the exam still has a subjective element and many examiners will tell you that they can form an
impression of whether you are a strong candidate or not as soon as you start examining a patient. If you can
impress in these areas, you will be on your way and the examiners may be more lenient about the discussion
section.

why this course is better than other courses Page 1 of 38
The MRCP(UK) Part 2 Clinical Examination (PACES) is composed of five stations (three clinical and two talking), each
assessed by two independent examiners. Candidates start at any one of the five stations and then move round the carousel of
stations at 20-minute intervals until the cycle has been completed (Figure 1). The stations are:

Station 1
Respiratory System Examination (10 minutes)
Abdominal System Examination (10 minutes)
Station 2
History Taking Skills (20 minutes)
Station 3
Cardiovascular System Examination (10 minutes)
Central Nervous System Examination (10 minutes)
Station 4
Communication Skills and Ethics (20 minutes)
Station 5
Brief clinical consultation 1 (10 minutes)
Brief clinical consultation 2 (10 minutes)
THE PACES EXAM - The Carousel Page 2 of 38
THE PACES EXAM - The Carousel Page 3 of 38
The MRCP(UK) Part 2 Clinical Examination (PACES) lasts a total of 120 minutes (including four 5-minute breaks between each
station).
THE PACES EXAM - The Carousel Page 4 of 38
Station 5 used to be the Skin / Locomotor / Endocrine / Eye station but is now called the Brief Clinical
Consultation Station. The station involves two 10-minute encounters which take form of a Brief Clinical
Consultation in which the patient presents with a single clinical problem or symptom of the sort encountered in
day-to-day practice in the medical wards, acute medicine unit or outpatient clinic. Candidates are required to
undertake a brief focused history and brief targeted examination in the 8 minutes available with the patient, before
discussing findings and diagnosis with the examiner for 2 minutes.

It is not necessary for the candidate to undertake a full, comprehensive history (as required in Station 2) or a
thorough, systematic examination (as required in Stations 1 and 3) in these encounters but to demonstrate a
focused and integrated clinical problem solving approach.

All the scenarios are structured to ensure that a capable candidate can undertake the task within the time
available. Real or simulated patients may appear in these encounters. The four disciplines previously represented
at Station 5 (dermatology, ophthalmology, rheumatology and endocrinology) are currently not always
represented in the examination, but clinical problems relating to those disciplines frequently appear at Stations 2,
4 or 5. Patients with problems relating to disciplines such as acute medicine and elderly medicine are now also
encountered.
THE PACES EXAM - The New Station 5 Page 5 of 38
Each candidate receives structured marksheets for each station prior to the start of the PACES examination. The
candidate has to complete the same details (i.e. add his/her personal information) and then hand the appropriate
sheets to the examiners at each station. In the event of failing the examination, the marksheets form the basis for
feedback to the candidate. Sample marksheets can be found on the MRCP UK website
http://www.mrcpuk.org/PACES/Pages/_Home.aspx
Ensure that the marksheets are completed correctly. In addition arrange the mark sheets in order of the stations
so that you can easily hand them over to the examiners. Some candidates have found themselves in a situation
where the marksheets fall from the clipboard and they are then panicking, trying to pick up and hand the
marksheet to the examiner. This can result in unnecessarily stress!
Sixteen mark-sheets in total are completed by the Examiners: two by each examiner at Stations 1 and 3 and 5;
one by each Examiner at Stations 2 and 4. The Station Mark awarded on all sixteen mark-sheets determines the
candidates overall PACES score.

THE PACES EXAM - Marksheets Page 6 of 38
There is a new marking scheme for MRCP PACES. Pairs of examiners assess each candidate at each encounter.
They award marks to candidates on the basis of their performance on each of seven clinical skills. These skills are:
a) Physical examination
b) Identifying physical signs
c) Clinical communication skills
d) Differential diagnosis
e) Clinical judgement
f) Managing patients concerns
g) Maintaining patient welfare
An example of a mark sheet is included in appendix 1.
Examiners mark candidates on each relevant skill at each encounter using a three point marking scale: Satisfactory,
Borderline, and Unsatisfactory. The examiners award marks for each skill and there is no overall judgment.Marks
received for all skills at all encounters are equally weighted and summed to produce an individual candidate mark.
The skills examined and marks available for each station are demonstrated in the table below. It is crucial to
understand the marking scheme in order to maximise your chances of passing. Some candidates have been known
to fail because they underestimated the importance of the 5
th
station which carries most of the marks (56 out of a
total of 172 marks).
Examiners mark independently and have no knowledge of marks at previous stations.
Examiners would have seen the patients first and examined them. They will also consult and agree on a marking
scheme i.e. what they will use to fail or pass candidates. They will take in to consideration whether a sign is difficult
to find i.e. they will be lenient if an early diastolic murmur is difficult to hear. However they will surely mark you
down if you miss an obvious sign such as atrial fibrillation.
Do not be put off by examiners making notes while you are being examined. It is not necessarily a bad thing often
they are noting down good points about you.

Station
A
Physical
Examination
B
Identifying
Physical
Signs
C
Clinical
Communication
D
Differential
Diagnosis
E
Clinical
Judgment
F
Managing
Patients'
Concerns
G
Maintaining
Patient
Welfare
Total
1 0-8 0-8 0-8 0-8 0-8 40
2 0-4 0-4 0-4 0-4 0-4 20
3 0-8 0-8 0-8 0-8 0-8 40
4 0-4 0-4 0-4 0-4 16
5 0-8 0-8 0-8 0-8 0-8 0-8 0-8 56
Total 24 24 16 28 32 16 32 172

THE PACES EXAM - The New Marking Scheme Page 7 of 38
The pass mark is defined by a formal standard setting process that also takes account of the current PACES
pass standard. The overall standard of the examination therefore remains the same.
To pass MRCP(UK) Part 2 Clinical Examination (PACES) candidates must attain a minimum standard in each
of the seven skills and also a minimum total score across the whole assessment.
For the year October 2011September 2012 the pass marks will be:
Skill Pass Mark (% of marks available)
A Physical Examination 14 (58.3%)
B Identifying Physical Signs 14 (58.3%)
C Clinical Communication 10 (62.5%)
D Differential Diagnosis 16 (57.1%)
E Clinical Judgement 18 (56.3%)
F Managing Patient Concerns 10 (62.5%)
G Managing Patient Welfare 28 (87.5%)
In addition, candidates must achieve an overall score of 130 to be eligible to pass.
For more details about pass marks, go the MRCP website
http://www.mrcpuk.org/PACES/Pages/_Home.aspx

THE PACES EXAM - Pass Marks Page 8 of 38
The PACES exam is a practical exam and the only way to prepare for it is to PRACTICE. You must make the
mistakes early on, in front of colleagues and senior staff in order to avoid making the mistakes in the exam. The
more patients you examine or take histories from, the more confident you become.

1. Start as early as possible. It is so easy to keep on postponing or avoiding preparing for the exam. All
posts are busy but you must make the time. The sooner you start preparing, the better. Do not
procrastinate.
2. One of the things I found most useful was practising with other exam candidates. Put together a group
and make sure you go round as often as possible, preferably every day. Phone the wards on a daily basis to
identify potential patients without asking for the diagnosis. Even simple things such as rheumatoid hands,
bilateral ankle oedema and hemiplegia appear in the exam. The simple things are often the easiest to fail but
you can easily impress the examiners if you have practised. There are always patients to examine on medical
wards so you cannot make excuses that that there aren't interesting cases on the wards.
3. Try and get registrars or consultants to provide specialist teaching in their fields. For example, they can
identify a number of respiratory cases and take you through a mock examination and teaching. Do not make
excuses to avoid being put on the spot practising in front of seniors and making mistakes can only help to
build your confidence when you sit the exam.
4. If you know what is normal, you can easily identify the abnormal. Examining your friends or relatives
(assuming they are healthy) will also help. For example you can do ophthalmoscopy on your friends or
colleagues in order to be sure what a normal fundus looks like.
5. As well as this online course, also attend a practical course. Most courses do similar things and
provide a wide range of cases. The courses are exam oriented and you must be aware of how to impress the
examiner. It is much more comforting and less expensive long-term if you pass first time. If you can afford it,
attend specialist courses e.g. cardiology or neurology as well as general PACES courses.
HOW TO PREPARE FOR THE EXAM Page 9 of 38
The MRCP PACES is a competitive exam and you must approach it as such. You will find it hard to pass if your
performance is mediocre. You must go into the exam to impress the examiners! They should be able to picture
you working as their specialist registrar!

1. You must be seen to be confident in examining patients, presenting findings and discussing management
plans.
2. Do not invent signs or symptoms. This is a recipe for failure. Be honest with your findings!
3. Have a broad mind and observe every minute detail. Some findings may seem obvious but must be
stated e.g. identifying nicotine stain marks on a patients fingers for the respiratory case, bruising for someone
with AF, likely to be on warfarin
4. The examiners must have the impression that you see hundreds of patients and that it has become
second nature
5. Do not wait for things to be "milked" or "squeezed" out of you if you know them. Simply move on and
tell them how you would manage a case if you are sure of the diagnosis. You should make it easy for the
examiners to tick the boxes and give you the marks.
6. Keep in mind which station you are being assessed on. For example in the brief clinical consultation
station, you may come across a difficult case of Ehlers-Danlos syndrome with fish-mouth wounds and
multiple scars. Remind yourself that you need to demonstrate that you can take a brief and focused clinical
history, do a focused physical examination and respond to the patients concerns. You then need to describe
your findings to the examiners and give your preferred diagnosis and any differential diagnoses.
7. To pass the exam, you must have a satisfactory score in most of the individual headings for the stations.
You should not have 2 or more unsatisfactory scores for the maintaining welfare headings as your practice
will be considered to be unsafe. Most people will make at least one mistake along the way. To compensate
therefore, you must aim for as many satisfactory scores as possible.
General Approach Page 10 of 38
When examining any patient, you should be asking yourself the following questions and looking for potential
answers:

1. What are the key clinical findings?
2. What is the diagnosis or main problem/syndrome and differential diagnosis?
3. What is the probable cause?
4. What are the other manifestations or associated features?
5. Are there any obvious visible side-effects of treatment?
6. Are there any signs of complications?

When presenting the case, in general there are 2 main approaches:

1. Give the diagnosis and explain why with positive clinical findings. This was encouraged in the old style
of the MRCP clinical exam but can still impress in PACES. The risk of this approach is digging a hole for
yourself if you get the diagnosis wrong initially.
2. Present your clinical findings progressively and then conclude by giving the diagnosis. In the context of
PACES, this appears to be the safest option as you will demonstrate to examiners that you have picked up
the main clinical findings and make it easy to for them to tick the boxes. In addition you can still get some
marks if your diagnostic conclusion is unreasonable as you will be given credit for the clinical findings
anyway.

There is no best way as it will depend on what the examiners prefer. Either way you will not be sanctioned if
your clinical findings are correct. You may also decide to use both styles depending on how sure you are about
the diagnosis.

Be assertive in making a diagnosis. Avoid the following phrases:

1. I think the diagnosis is
2. This may be a case of
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONS Page 11 of 38

If in doubt use a phrase such as

1. This is consistent with but I would also consider

Remember not to put your stethoscope around your neck. It is considered to be impolite. Hold the stethoscope
in your hands and preferably with your hands behind your back.

Always look directly at the examiners and avoid turning to look or point at the patient. Patients find it very
uncomfortable.

Make sure that you answer the questions the examiner asks. It will irritate them if you are beating around the
bush and not answering the question. For example, if they ask for a valvular diagnosis after a cardiovascular
exam answer the question! E.g aortic stenosis. Do not start rambling and describing your findings in detail as
this will irritate them.

Warn patients before examining them e.g. I am about to examine your trachea and it may feel uncomfortable.
I am going to examine your abdomen you may feel uncomfortable because my hands are cold.

Be courteous to patients and before using a phrase, ask yourself if you were the patient, would you want such
descriptions to be used about you? Medical descriptions tend to be quite heartless. If you must use a term or
description which is awkward, apologise to the patient before using it e.g. I apologise sir and I do not want to
offend you but the phrase I am going to use is a textbook description. This gentleman has an expressionless face
suggestive of Parkinson's disease.

Never use the following phrases or diagnostic terms which may frighten or upset patients, instead use medical
jargon:

"demyelinating illness" instead of multiple sclerosis or MS
"mitotic lesion or neoplastic lesion" instead of cancer
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONS Page 12 of 38

Try not to stop talking if you sense that you are on the right tract, unless they stop you. Take the initiative and
move on to answer the questions you were asking yourself when examining the patient:

1. What is the likely diagnosis and differential?
2. What is the likely cause and what are other possible causes?
3. What other manifestations or associated features have you identified?
4. What evidence is present suggestive of treatment or side-effects of treatment?
5. What evidence is there of complications and what were the other possible complications?
6. How would you investigate and treat this case?

In doing this, you allow the examiners to happily tick the boxes, rather than squeezing the information out of
you. This will nearly always make you stand out as a better candidate than most other people.
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW TO IMPRESS IN THE CLINICAL EXAMINATION STATIONS Page 13 of 38
1. Greet the patient, introduce yourself and ask for permission to examine
2. Expose the patient and position appropriately (lying down at 45 degrees and the whole thorax exposed).
Do not compromise even for women unless the patient or the examiner strongly objects to it. You cannot
be penalised for being polite but thorough. For example you may miss a thoracotomy scar hidden behind a
ladys bra.
3. Take a step back and observe for about 15 seconds while counting the respiratory rate (Is the patient
cyanosed? Dyspnoeic? Are they using accessory respiratory muscles? Are there scars or chest wall
deformities? Etc). Most importantly check for oxygen (what type of mask or nasal cannula and what is the
rate of flow of oxygen?), nebulisers, peak flow meters, sputum pots, packets of cigarettes! Observe with
an eagle eye and note everything. Show that you are a holistic doctor who pays attention to detail.
4. Examine the hands for clubbing and distended veins of carbon dioxide retention
5. Examine the pulse for bounding pulse of cabon dioxide retention if appropriate
6. Check for flapping tremors Please stretch your arms in front of you and cock up your fingers like this
demonstrate
7. Examine the eyes for, pallor or congestion
8. Examine the tongue for cyanosis and distended veins
9. Examine the neck for a raised JVP and any scars or obvious masses. Also examine the trachea for its
position (Is the trachea central or displaced to the left or right?). If the JVP is raised determine whether it
is fixed or not (Does not change with respiration or position) suggestive of SVC obstruction.
10. Examine the anterior chest wall:
1. Inspect thoroughly, including under the breast and the axilllary area. You will not be forgiven for
missing a thoracotomy scar so take your time and make sure you are 100% sure. However do not
spend too much time looking hesitant either. Look for scars, distended veins, chest wall deformity.
2. Palpate for chest expansion in the upper thorax and lower thorax. Be sure about whether it is
normal, reduced or increased bilaterally or unilaterally before you stop.
3. Percuss bilaterally starting on top of the clavicles and move downwards and into the axilla.
Compare similar areas on the left and right aspect of the chest progressively. About 4 percussion
points on each side appears to be sufficient. Again make up your mind whether it is dull, hyper-
resonant or normal on one or both sides or a particular area.
4. Auscultate bilaterally starting from above the clavicle and again at corresponding points as during
percussion. Determine whether the breath sounds are reduced, normal or increased and whether
there are added sounds (fine or coarse crackles, bronchial breathing, wheeze, pleural rub).
11. Examine the neck from behind and palpate for cervical lymph nodes
12. Examine the chest from behind in the same way as the anterior chest wall. Some people advocate starting
your examination from the posterior aspect of the chest as this is more informative and you may be short
of time, but it does not really matter as long as you are slick. If you are asked to percuss and auscultate
starting from the back, make sure you follow the instructions.
13. Examine the legs for ankle oedema
14. Offer to help the patient or help the patient to get dressed or covered and reposition in comfortable
position. You must show that you are caring and courteous!
15. Check around for sputum pots and inspect their contents
16. Finish off by saying you would like to finish your examination by noting the patients, temperature, peak
expiratory flow rate (if appropriate), and examining a sputum pot if there isnt one obviously available
around the patient. Do not say you would like to examine a sputum pot if there is one available. It will only
irritate the examiners. Just go ahead and look at it!
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 14 of 38

Now hold your stethoscope in your hands and present your findings.























CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 15 of 38













The following website has recordings of normal and abnormal breath sounds
http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/b-sounds.htm

Figure 2: Anatomical landmarks for the lungs

Figure 3: Anterior and posterior sites of chest percussion and auscultation
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 16 of 38
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Respiratory - examine this patient's chest Page 17 of 38
I find it useful to categorise abdominal cases into renal or non-renal cases. Clues that your are dealing with a
renal case include abdominal scars suggestive of continuous ambulatory peritoneal dialysis (CAPD),
arteriovenous fistulas in the arms, scars in the iliac fossae suggest of previous transplant etc. The key is therefore
to figure out quite early whether you are dealing with a renal or non-renal abdominal case and show examiners
that you know what to look for.

1. Greet the patient, introduce yourself and ask for permission to examine
2. Expose the patient and position appropriately (lying flat, hands by the patients side and exposed from the
lower thorax to just above the symphysis pubis)
3. Take a step back and observe for about 15 seconds. Look for scars, pallor, jaundice, distended
abdominal veins, abdominal scars suggestive of CAPD, arteriovenous fistulas in the arms, scars in the iliac
fossae suggest of previous transplant etc. It is helpful to figure out quite early whether you are dealing with
a renal or nonrenal abdominal case so that you can focus on the key signs.
4. Examine the hands for signs of chronic liver disease (spider naevi, palmar erythema, Dupuytrens
contracture, pallor, leuconychia, koilonychias, abscesses, needle marks of intravenous drug abuse,
bruising, paronychia, flapping tremor, scratch marks, jaundice, pigmentation, cyanosis, xanthomata,
oedema, muscle wasting, tattoos)
5. Examine the arms for arterio-venous fistulas and signs of chronic liver disease. Be careful to note scars as
some fistulas may have been tied off and only very small scars may remain. If you find a fistula, note
whether there are fresh scars suggestive of recent usage for hemodialysis i.e. is the fistula functional or not?
6. If you think you are dealing with a liver case, elicit flapping tremors
7. Examine the conjunctiva for pallor and the sclera for jaundice (ask the patient to look upwards while you
lower the eyelid)
8. Examine the gums for gingival hypertrophy suggestive of treatment with ciclosporin
9. Examine the neck for scars and obvious swellings suggestive of cervical lymph nodes. For a renal case,
ensure that you examine the neck for parathyroidectomy scars which would have been done to treat
tertiary hyperthyroidism as a result of chronic renal failure.
10. Examine the abdomen:
1. Kneel down on the floor or bend down to bed level and inspect the abdominal wall for scars (make
sure you know the position and description of all the scars see figure), deformities suggestive of a
mass, abnormal movements, ileostomy or colostomy bags, distended abdominal veins etc. Note if
CAPD scars are fresh or old.
2. Warm up your hands by rubbing them together and ask if there are any tender areas before starting
palpation. Reassure that patient and palpate tender areas with a lot of care. Palpate all 9 areas of
the abdomen systematically. First palpate superficially and then more deeply. If you see scars in the
iliac fossae, palpate for transplanted kidneys which should superficial. Also check for tenderness
which could indicate rejection of the kidney transplant.
3. Examine specific organs.
i. The liver: Palpate from the right iliac fossa
upwards to the lower costal margin, asking the patient to take a deep breath in and out
and progressing upwards when the patient expires. If you feel the liver, note its
consistency, edge, whether it is tender or not and the amount of hepatomegaly. Percuss
the liver from the chest (level of the nipple) downwards and note the size of the liver. See
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 18 of 38
figure for normal liver landmarks.
ii. The spleen: Palpate the spleen from the
right iliac fossa obliquely to the left lower costal margin, asking the patient to take a deep
breath in and out and progressing upwards each time the patient expires. Place your left
hand below the left hypochondrium posteriorly and while pushing upwards with this
hand, continue palpating for the spleen in order not to miss a small splenomegaly. See
figure. Also see figure for normal spleen landmarks. Percuss in the left mid-axillary line
from the level of the nipple downwards and obliquely towards the umbilicus to confirm
splenomegaly.
iii. The kidneys. Do a bimanual exam of each
kidney by putting your left hand behind the loin and balloting the kidney between your
left and right hand.

1. Examine for ascites: Percuss for shifting dullness, from the umbilicus to the left flank whilst checking for
dullness. Your fingers should be parallel to the midline. Only proceed to test for shifting dullness if the flank
is dull to percussion. If you find dullness, keep you finger in position and turn the patient to the right lateral
position and then percuss from the left flank down to the right flank. Has the position of dullness changed?
This represents shifting dullness suggestive of ascites.
2. Keep the patient in the right lateral position and examine for the splenomegaly once more. Ask the patient
to take a deep breath and palpate again for splenomegaly from the right iliac fossa to the left
hypochondrium. Percuss again for splenomegaly. This should help you detect a mild splenomegaly. .
3. Auscultate the abdomen in the egigastrium for renal bruits and around the umbilicus for bowel sounds.
Most people forget to do this and this can easily lead to failure. Auscultate over transplanted kidneys for
bruits suggestive of renal artery stenosis and over the liver if you find hepatomegaly.
4. Sit the patient forward and inspect the posterior abdomen for scars of nephrectomy.
5. Examine the neck posteriorly for lymphadenopathy if you suspect malignancy
6. Examine the legs for ankle oedema
7. Offer to help the patient get dressed or covered and reposition the patient in a comfortable position. You
must show that you are caring and courteous!
8. Finish off by saying you would like to finish your examination by examining the patients genitalia, doing a
rectal examination and doing urine dipstix for blood and protein.
9. Now present your findings.

Figure 4: Types of abdominal scars
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 19 of 38
1. Subscostal - cholecystectomy
2. Right paramedian
3. Midline
4. Nephrectomy/loin
5. Gridiron = appendicectomy
6. Laparoscopic
7. Left paramedian- anterior rectal resection
8. Transverse suprapubic pfannenstiel hysterectomy or pelvic surgery
9. Hernia repair


CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Abdominal - Examine this patient's abdomen Page 20 of 38
1. Greet the patient, introduce yourself and ask for permission to examine
2. Expose the patient and position appropriately (seated at 45 degrees and the whole of thorax exposed).
Do not compromise even for women unless the patient or the examiner strongly objects to it. You cannot
be penalised for being polite and thorough. For example you may miss a valvotomy scar for mitral stenosis
under a ladys bra.
3. Hold the patients right wrist with one hand and start taking the radial pulse with the other hand. Inspect the
patients hands at the same time. Is there cyanosis? Clubbing? Or signs of sub-acute bacterial endocarditis
(sub-ungual splinter haemorrhages; tender Oslers nodes on the pulp of the fingers and toes, palms or
soles; non-tender Janeway lesions which are macules on the often on the soles and palms)?
4. Examine both radial pulses simultaneously for equality and count the rate over 15 seconds. At the same
time assess the character (normal, slow rising, collapsing?) and rhythm (regular, irregular in rate and
volume i.e. AF or irregular with periods of regularity suggestive of extrasystoles). Determine whether the
pulse is collapsing or not (figure). Is the patient on oxygen? If so how much? Are there obvious carotid
pulsations? If so, is the pulse collapsing suggestive of aortic regurgitation. The key in cardiovascular
examinations is to be able to make a diagnosis before you get to auscultation of the heart. Once you have
an idea what to expect, auscultation becomes much easier and you should no longer worry about missing
the murmur.
5. Examine the conjunctivae for pallor (lower eye lid),
6. Examine the tongue for cyanosis and teeth/gums for dental caries if you suspect SBE
7. Examine the neck:
1. Palpate the right carotid pulse by sliding your 2
nd
-5
th
finger of your left hand under the patients
neck and palpating the carotid pulse with the thumb of your left hand. Is the pulse collapsing or
slow rising?
2. Examine the jugular venous pulse. Ensure the patient is lying at 45 degrees and that the occiput rests
back on the bed or on a pillow. Say to the patient "lift your chin and turn your head to the left
please". Since you are standing on the right side of the patient, start by examining the right JVP and
only check on the left one if you still cannot make up your mind whether the JVP is raised or not. It
looks clumsy to be stretching over to examine the left JVP when you are on the right side of the
patient. If the head is not laid on the bed, you cannot accurately access the JVP. It is sometimes
useful to shine light from a bed side lamp or torch as this will make a JVP which is difficult to see
more obvious. If the JVP is raised, what wave forms are present? A or V? V waves are more
common and easier to see. Palpate the carotid pulse simultaneously and v waves should be
synchronous with the carotid pulsation. If the JVP is raised, what is the height above the sternal
angle (see figure)?

Remember, if you see a vascular pulsation in the neck, you must decide whether it is venous or arterial. Is it
palpable? Arterial pulsations are palpable e.g. dancing carotids or corrigan's sign suggestive of aortic
regurgitation. Venous pulsations are mobile with respiration, change with position (lying flat or sitting up) and the
presence of hepatojugular reflux suggests, the pulsation is venous. The presence of a and v waves also suggests
that the pulsation is venous.

1. Examine the precordium
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 21 of 38
1. Inspect the chest wall thoroughly for any scars. Make sure you check under the breast for a
valvotomy scar of mitral stenosis, they can be easily missed and you will not be forgiven! If you see
a midline sternotomy scar, immediately expose the legs to see if there is a scar suggesting that a
saphenous vein may have been used for a coronary artery bypass graft. If not, you are probably
dealing with a patient who has had a valve replacement.
2. Palpate the apex and determine its character (heaving, thrusting, palpable or tapping?). Also locate
its position by counting intercostal spaces from the sternal angle downwards and estimating its
lateral position with respect to the axilla.
3. Palpate for right ventricular heave and for pulmonary/aortic thrills
4. Ausculate. First determine whether you are dealing with mitral stenosis. Listen very keenly for S1,
then S2 and in between for murmurs. Palpate the carotid at the same time as in order to identify S1
and S2 as S1 is synchronous with the carotid pulse. S2 is heard when the carotid pulse
disappears.

I find it easier and more comfortable for the patient to first use the drum in the mitral area. Then ask
the patient to turn unto their left side and auscultate again with the drum. You should be able to make
up your mind whether the patient has mitral stenosis or not. Then ask the patient to turn back to
position and now auscultate in the mitral area with the diaphragm for mitral regurgitation. Ask the
patient to "take a deep breath in, then out and stop breathing". Breath sounds may make cardiac
auscultation difficult. In addition, mitral regurgitation murmurs tend to be louder with inspiration while
tricuspid regurgitation murmurs are louder in expiration. Then auscultate into the axilla to find out if
there is a murmur radiating to the axilla. Now ausculate in the tricuspid area (left lower sternal
border), pulmonary area and aortic area. See diagram. Now auscultate below the right clavicle and
the left and right aspects the neck for aortic stenosis murmurs radiating to the clavicle or neck and for
carotid bruits. It helps to ask the patient to "take a deep breath in, then out and stop breathing" as
breath sounds may make auscultation very difficult. Lastly auscultate for aortic regurgitation by
asking the patient to "sit up and lean right forward, take in a deep breath, breath right out" and
auscultate again at the left sternal border, mid sternal area. With the patient still in this position and
leaning forward, conveniently examine the lung bases for crackles. Do not do a full respiratory
auscultation, simple examine at one basal point on each side.
1. Examine the abdomen for hepatic pulsation if you suspect tricuspid regurgitation by putting your left hand
under the right hypochondrium and the right hand on the right hypochondrium. It tricuspid regurgitation,
you should feel pulsation between your two hands.
2. Check the limbs for ankle oedema. Remember to ask if there are any painful areas before palpating so
that you dont cause discomfort!
3. Finish off by saying you would like to finish your examination by taking this patients blood pressure,
temperature and doing a dipstix of urine for protein and blood.

Now hold your stethoscope in your hands and present your findings.

CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 22 of 38
Figure 6: Eliciting a collapsing pulse

Figure 7: Pictured of JVP land marks to show height above sternal angle

CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 23 of 38
Figure 8: Cardiac auscultation landmarks

A useful website with normal and abnormal heart sounds/murmurs is

http://www.blaufuss.org/tutorial/index2.html

CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Cardiovascular - Examine this patient's heart Page 24 of 38
You will never be asked to do a full neurological exam because it takes too much time.

1. Cranial nerve examination

While examining, keep you eyes open for clues to the diagnosis e.g. obvious weakness or lack of movement of
one part of the body suggestive of a stroke. They may be scars from previous surgery for an acoustic neuroma
behind the ears. Examine the cranial nerves in chronological order. You must make it slick and you should be
able to get up suddenly at night and do the routine. They must not sense that you are thinking about what to do
next! It must flow smoothly as if it is second nature.

Greet the patient, introduce yourself and ask for permission to examine. Ideally, get the patient to sit down on a
chair and you should sit on a chair facing the patient at about 1.5-2 arm lengths from the patient.

I: Have you noticed any change in your sense of smell?

II: The most common problems will involve a change in acuity, visual fields or eye movements. It is therefore
logical to exclude these first as they are the most common and important. A mnemonic to use is AFMP (Acuity,
Fields, Movement, Pupils). Make sure you have a pocket Snellen Chart to use at the end of the bed to measure
visual acuity. Ask the patient put on their glasses if they use glasses and assess each eye in turn with the other
being closed. If the patient cannot see the letters on the Snellen chart assess whether the patient can see your
fingers, finger movements, hands and finally light.

To test for visual fields, first test for visual inattention or neglect in the middle, superior and inferior fields. If you
notice any obvious field lesion, ask the patient to look at your face and tell you if there is any part of your face
that cannot be seen. This will often give you the visual field defect. Then move on to formally test each quadrant.

Test for eye movements by asking the patient to follow your finger and let you know if they see double as you
move your finger forming the usually H configuration. Also check for squints at rest, nystagmus and pupillary size.
You have assessed the 3
rd
, 4
th
and 6
th
cranial nerves.

Test for pupillary response to light both directly and consensual. Make sure you put your hand in the middle to
separate both fields and make sure you bring the light from outside right into the pupils. Also assess pupillary
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 25 of 38
response to accommodation.

Lastly volunteer to test do fundoscopy and do it if you are allowed to. However most often you will be asked not
to.

V: Test for sensation in the 3 divisions of the trigeminal nerve, comparing both sides simultaneously. Do not
forget to test for motor function by testing the strength of the massetters and pterygoids. Also do a jaw jerk and
go on to test for corneal reflex. Most often you will not be allowed to do corneal reflexes as it is uncomfortable
for patients.

VII: Test for facial nerve palsy by asking the patient to do a series of manoeuvres

"raise your eye brows" "close your eyes" "Blow you cheeks" "show me your teeth"

VIII. Test for hearing by using a ticking watch or whispering into one ear, the patients other auditory canal being
closed with one of your fingers. Go on to perform Weber's test and Rinne's test and make sure you understand
their significance.

IX and X: Ask the patient to open their mouth wide open and say "aahh" while you look for palatal immobility
and drift.

XI: Test for power by asking the patient to shrug the shoulders and then push against your hands while provide
resistance.

XII: Ask the patient to protrude their tongue while you look for deviation of the tongue and muscle wasting. Also
look out for fasciculation (bulbar palsy) and a spastic tongue (pseudobulbar palsy).


1. Upper limb neurological examination
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 26 of 38

1. Greet the patient, introduce yourself and ask for permission to examine
2. Expose the patient by asking the patient to take is or her top off. If dealing with a lady, cover the chest
with a cloth, sheet or garment. While doing this, look out for any signs that may suggest a diagnosis e.g
facial weakness, nystagmus, expressionless face of parkinsons, horners' syndrome
3. Inspect the shoulder, arms, and hands looking for wasting, abnormal movement (e.g. tremor), fasciculation
or deformity.
4. Test the tone. Ask the patient to let their arms go floppy or loose and passively flex and extend each joint.
Compare each left and right joint simultaneously as you proceed.
5. Test for power: "I will like to test how strong your arms are". There are many complex ways of testing for
power and you can test for nearly every muscle if you want but the essential muscles a general physician
would be expected to know how to test are:
1. Global power of the arms: Ask the patient to put both arms stretched out in front of you and close
his/her eyes. Observe for parietal drift, myelopathy hand sign and examine the back for winging of
the scapula.
2. Test for shoulder abduction (Deltoid muscles, axillary nerve, C5) "Put your arms out to the side
with your elbow flexed - demonstrate to the patient as you give the instruction" "Don't let me push
your arm down"
3. Test for elbow flexion (Biceps, musculocutaneous nerve, C5/6) "Flex your elbow, don't let me stop
you" Use your left hand to support the elbow.
4. Test for elbow extension (Triceps, radial nerve, C7). With the elbow in neutral position, ask the
patient to push you away, do not let me stop you. Use your left hand to support the elbow.
5. Test for wrist extension (C7 or radial nerve): Make a fist and cock up your wrist like this
(demonstrate), don't let me stop you.
6. Test for power of the small muscles of the hand (C8/T1). "Squeeze my two fingers. Compare the
left and right hand simultaneously.
7. Test for power of specific hand muscles. Make sure the hands are laid on a pillow or on the bed
with palms upwards.
i. Median nerve: Point your thumb at the
ceiling, don't let me stop you (abductor pollicis brevis); Put your thumb and little finger
together, don't let me pull them apart (opponens pollicis)
ii. Ulnar nerve: Spread your fingers apart,
don't let me bring them together (dorsal interossei); Hold this piece of paper between
your fingers, don't let me pull it out (palmar interossei).
1. Test the tendon reflexes: Biceps (C5/6), Triceps (C6), and Supinator (C5/6). Are they normal, brisk,
reduced or absent. Make sure know what normal is by testing your colleagues, relatives or friends
(assuming that they are normal!). It is only by doing this that you will be able to determine what is
abnormal. Make sure you compare the left and right reflexes for each tendon as you proceed.
2. Test for co-ordination:
3. finger-nose-finger testing: Make sure you finger is at a good distance from the patient so that they have to
straighten their arm completely in order to do this. Without this, you will miss subtle cerebellar ataxia.
4. Test for dysdiadochokinesis: Quickly tap your left palm alternately with both sides of you right hand. Now
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 27 of 38
do the same on the other hand. - demonstrate.
5. Test for sensation:

1. Test for light touch and pin prick sensation: Use cotton wool and a neurotip on the sternum to demonstrate
what they should feel. Ask them to let you know if it feels different or if they do not feel it at all. Test each
dermatome moving from the hands proximally. If the sensory loss does not fit a particular dermatome , test
for glove and stocking sensory loss as a result of peripheral neuropathy. Start from the hands and move
proximally, "Does this feel the same as on your chest? Tell me when it does".
2. Joint position: Use the distal interphalangeal joint of the thumb. With the patient's eyes open, demonstrate
what you mean by up and down. "Now close your eyes and tell me if I am moving your thumb up or
down". Ensure that you hold the thumb at the sides of the phalanx. Do not hold the thumb at the joint or
dorsal/palmar aspects as it may give a false positive result.
3. Vibration: Use a 128 Hz tuning fork. After demonstrating on the patient's sternum what he/she should feel,
test for vibration sense by starting at the proximal interphalangeal joint and only continue to move
proximally if it is absent or reduced distally. "Tell me if it feels different to the way it felt on your chest or if
you do not feel it at all"

Tel the examiners, to complete your examination you will like to examine the patients back and lower limbs and
proceed to present your findings.

1. Lower limb examination

1. Greet the patient, introduce yourself and ask for permission to examine
2. Expose the patient by asking the patient to take is or her trousers or skirt off. Ensure that the genital area
is covered with a cloth, sheet or garment. While doing this, look out for any signs that may suggest a
diagnosis e.g facial weakness, nystagmus, expressionless face of parkinsons, horners' syndrome, wasted
hand muscles etc
3. Inspect the thighs, legs and feet for wasting, abnormal movement (e.g. tremor), fasciculation, deformity,
pes cavus.
4. Test the tone. Ask the patient to let their legs go floppy or loose and passively roll the legs sideways to
and fro. Watch for the movement of the feet. If the feet move very floppily, there is hypotonia. If the feet
does not flop, then there is hypertonia. Also lift the knee and let it drop passively observing for movement
of the feet. Lastly passively flex and extend the knee. If there is increased tone or spasticity, you must
move on to test for patellar and ankle clonus. This step is often missed.
5. Test for power: "I would like to test how strong your legs are". There are many complex ways of testing
for power and you can test for nearly every muscle if you want but the essential muscles a general
physician would be expected to test are:
- Hip flexion: (iliopsoas, femoral nerve, L1/2) "Lift your leg straight up from the bed,
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 28 of 38
don't let me stop you"
- Knee flexion (Hamstring, sciatic nerve, L5/S1/S2). "Bend your knee, don't let me
stop you"
- Knee extension (Quadriceps, femoral nerve, L3/L4): With the knee still bent, push
my hand away, don't let me stop you."
- Dorsiflexion of the ankle (Peroneal or anterior tibial nerve, L4/L5): "Cock up your
foot, don't let me stop you"
- Plantar flexion of the ankle (Gastronemius muscle, S1) "push my hand away, don't
let me stop you"

1. Test the tendon reflexes: Knee jerk (L4), Ankle jerk (S1). Practice eliciting ankle jerks. This is the most
difficult reflex to elicit and you must be confident in eliciting this before the exam. Make sure you get
someone (perhaps a neurologist) to show you a confortable and easy way to elicit ankle jerks. Do not
leave it to chance! Make up your mind whether the reflexes are normal, brisk, reduced or absent. Make
sure you know what is normal by testing your colleagues, relatives or friends (assuming that they are
normal!). Make sure you compare the left and right reflexes for each tendon as you proceed.
2. Test for the plantar response: Warn the patient that you are going to tickle the underside of their feet.
Divide the foot into 3 and stimulate the outer portion of the sole from the heel and then across the ball to
the base of the big toe (following the line that divides the upper third and the middle third of the foot). Is
the response downgoing or upgoing? You can take a key or an orange stick to use for the exam. Do not
use the pointed section of the tendon hammer.
3. Test for co-ordination:
- Heel-shin test: Put your heel just below your knee and now run it down your shin and
up again as fast as you can"

1. Test for sensation:

- Test for light touch and pin prick sensation: Use cotton and a neurotip respectively on
the sternum to demonstrate what they should feel like. Ask them to let you know if it feels
different or if they do not feel it at all. Test each dermatome moving from the feet proximally.
If the sensory loss does not fit a particular dermatome, test for sock and stocking sensory
loss as a result of peripheral neuropathy. Start from the feet and move proximally, "Does this
feel the same as on your chest? Tell me when it does".
- Joint position: Use the distal interphalangeal joint of the big toe. With the patient's
eyes open, demonstrate what you mean by up and down. "Now close your eyes and tell me
if I am moving your toe up or down". Ensure that you hold the toe at the sides of the tarsal
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 29 of 38
bone. Do not hold the toe at the joint or dorsal/plantar aspects as it may give a false positive
result.
- Vibration: Use a 128 Hz tuning fork. After demonstrating on the patient's sternum
what he/she should feel, test for vibration sense by starting at the proximal
metatarsophalangeal joint of the big toe and only continue to move proximally if it is absent
or reduced distally (medial malleoli, knee, iliac crest). "Tell me if it feels different to the way it
felt on your chest or if you do not feel it at all"

1. Examine the gait and test for Romberg's sign:

I find it best to test for Rombergs sign before examining the gait. Ask the patient to stand feet together with the
arms outstretched. Ask the patient to close their eyes and tell you if they feel unsteady. Stand behind the patient
and be ready to catch him.

Then ask the patient if they are able to walk on their own without help. If not, reassure the patient that you will
provide some assistance or support. If they can, then ask them to stand and walk. When they stand do a global
inspection for- nystagmus, tremor, the question mark spine of ankylosing spondylitis (easily missed),
expressionless face of Parkinson's disease, Callipers of a patient with foot drop etc. The key is to try and make a
diagnosis before the patient sets off walking.
- Ask the patient to walk to a certain point, turn round and walk back. Are the arms
swinging? If not, think of Parkinson's disease.
- Then ask the patient to walk heel to toe (demonstrate), on his toes (suggests the
presence of an S1 lesion if unable) and on his heels (suggests foot drop if unable)

1. Other neurological cases:

For each neurological case on the list of possible cases, you must have a plan on how to proceed if you suspect
a particular diagnosis. For example:

1. Parkinson's syndrome: Observe for involuntary tremor, expressionless, unblinking facies, drooling;
examine the arms for tremor, rigidity and bradykinesia, examine the face for glabellar tap, assess speech,
writing and function e.g. undo a button; assess gait. Offer to examine for cerebellar signs, pyramidal signs
and autonomic dysfunction (lying and standing blood pressures).
CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 30 of 38
2. Cerebellar syndrome: Examine the eyes for nystagmus, examine the speech for ataxic dysarthria, examine
the legs fully (for hypotonia, reduced power, intention tremor, past pointing, dysdiadochokinesis), examine
the gait for cerebellar ataxia.

You should have a plan or routine for each possible diagnosis.

Brief Clinical Consultation Station

This station is difficult to prepare for since there are endless possibilities that can appear in the exam. However it
is also one of the easiest to pass because there is very little time to ask you questions. You must have plan of
action on how to proceed:

- Identify the patients main problem or concerns
- Clarify the problem or concern with a focussed history
- Do a focused physical examination
- Explain you findings and management plan
- Demonstrate that you are caring and that you empathise with patients

There is only one way of learning how to use an ophthalmoscope - practicing!!! Get used to the ophthalmoscope
by examining patients eyes, even if you expect them to be normal. Also practice by examining your relatives and
friends. It is like learning how to use chop-sticks or a knife and fork for the first time, the more your practice, the
better you become. Keep some tropicamide handy for use in the ward. I use to do an ophtalmoscopy round
when I would ask for permission and examine the eyes of all the patients in the ward. You may also find it useful
to attend a diabetic eye clinic or one of the retinal clinics in your local eye department.

CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - Neurology Page 31 of 38
You will not impress the examiner:
By hesitating when examining patients and not doing a slick physical examination
By presenting your findings in a disorganised manner
By making up signs
By not asking for permission and reassuring the patient
By causing discomfort to the patient
By not identifying key signs and symptoms

CLINICAL EXAMINATION STATIONS (STATIONS 1 AND 3) - HOW NOT TO IMPRESS Page 32 of 38
This station is difficult to prepare for since there are endless possibilities that can appear in the exam. However it
is also one of the easiest to pass because there is very little time to ask you questions. You must have plan of
action on how to proceed:

- Identify the patients main problem or concerns
- Clarify the problem or concern with a focussed history
- Do a focused physical examination
- Explain you findings and management plan
- Demonstrate that you are caring and that you empathise with patients

There is only one way of learning how to use an ophthalmoscope - practicing!!! Get used to the ophthalmoscope
by examining patients eyes, even if you expect them to be normal. Also practice by examining your relatives and
friends. It is like learning how to use chop-sticks or a knife and fork for the first time, the more your practice, the
better you become. Keep some tropicamide handy for use in the ward. I use to do an ophtalmoscopy round
when I would ask for permission and examine the eyes of all the patients in the ward. You may also find it useful
to attend a diabetic eye clinic or one of the retinal clinics in your local eye department.
BRIEF CLINICAL CONSULTATION (STATION 5) Page 33 of 38
Capitalise on the time you have while outside the room waiting to go in for the station. Use this time to structure
your history and already identify key points from the information you are given outside the station. You can then
use this as an aide memoire to consultation.

Take the history just as you would normally take a history in the outpatient clinic but this time with greater detail.
Show that you have taken thousands of histories and that it has become second nature. Some candidates tend to
minimise this section because they think they are so good at taking histories. It is one of the areas where you can
easily fail.

Make sure you history is taken in a structured way so that the examines can clearly see that you are organised.

Have a watch available during the exam and stick to time. Aim for 10-12 minutes for history, 2 minutes to talk to
the patient. You will then have 1 minute to think to think about how you to present your findings. Listen to the
examiners question and answer the specific questions they ask do not ramble. While preparing for the exam,
practice time keeping for both the clinical and history taking stations so that you are confident that you can keep
to time.

You are unlikely to get complex cases for these stations. Most scenarios will involve problems that you have had
to deal with on the wards or in clinic.

I find it useful to take background information first as it helps to build a rapport with the patient and already gives
you clues to your diagnosis. For example, breathlessness in a patient who keeps birds is most likely related to
Bird Fanciers disease or to psittacosis.

I find it easier to make notes as you go as you may forget with the stress of the exam. Before you go into the
station, you are given time to read the background or GP referral letter and write down notes. It is extremely
useful to note the key sections of a history including areas such as travel history and immunisation and consider if
it may be relevant in the case you are dealing with. It also ensures that you do not miss large chunks of the history
which could guarantee a fail in this section.

During this period, also read the history carefully and note the key points. Then note the key problems e.g. chest
pain and brain storm on paper the possible causes of chest pain. This will enable you ask questions related to
differential diagnosis and allow you to broaden your thinking. The diagnosis may seem obvious but the examiners
want to see that you can think laterally and consider other possible causes even though less likely. A diabetic
HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 34 of 38
with chronic diarrhoea may possible have autonomic neuropathy but there are other causes of chronic diarrhoea
and it is often useful to consider all the causes of diarrhoea.

At the end of the discussion with the patient. Summarise the key problems you have identified and ask the patient
if there are any areas of concern you have not covered. Ask if the patient has any questions. Also explain what
the key problems are according to you without using medical jargon i.e. use down to earth language. Also
explain what will happen next and involve the patient in decision making. You must have a plan of action.

Explain that you will examine the patient before making any decisions.

The sections in the history that many people tend to neglect or not do so well are:

1. Systems enquiry: It must be detailed and cover all systems. There are no short cuts and do not assume
that the diagnosis is obvious and some questions are irrelevant. You will be surprised how relevant some
questions are in hindsight, when you start considering differential diagnosis.
2. Social history: This section must be detailed, including areas such as work (past and present), housing,
recreation, sexuality when appropriate and make sure you warn the patient you are going to ask personal
questions and explain why, driving and activities of daily living. Also explore the effect of the illness on her
daily life and relatives or friends.
3. Drug or treatment history: Ask about medication including recent changes in drugs or dosages. Ask
about inhaler techniques. Ask about eye drops, inhalers and over the counter medication. Also ask about
alternative medication and over the counter medication the patient may be on. Ask about recent blood results
and complications or side-effects of treatment.

When presenting the summary of the case or the main problems, be concise. Again do not wait for things to be
squeezed out of you. Imagine that you are teaching medical students and keep on talking, explaining what the
main problems are and the likely causes or differential diagnosis. Keep talking sense!

Consider how you would investigate such a patient if you were in an outpatient clinic. What are the initial
investigations you would request and what are the other investigations you would consider?

You are not expected to manage or deal with specialist problems. You are expected to be able to function as a
general physician. For example, if you are referred a case of Churg-Strauss disease with worsening
HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 35 of 38
breathlessness. Do not get frightened if you do not know what Churg-Strauss disease is. Ask the patient if you
do not know in a nice, polite an honest way e.g. excuse my ignorance but I am not a respiratory specialist. Can
you tell me what Churg-Strauss disease is? You may know more about it than I do. Tackle the case as you
would all cases of breathlessness and explore all cardiac, respiratory and other causes of breathlessness. You
should be able to deal with most common medical complaints.

The aim of the station is not to see how you can make a diagnosis without prior knowledge of previous
investigations or treatment. Most patients will already have a diagnosis or investigations would have already been
carried out. The aim of this station is to see how you can obtain relevant information from a patient in a structured
and professional manner and make sense of it. Ask about all previous investigations, diagnosis, treatment,
complications, side-effects of treatment just as you would in real life in your outpatient clinic e.g. ask what sense
has been made of all these symptoms? Has a diagnosis been made? What treatment have you had so far? How
did you respond or react to the treatment? What side-effects of treatment have you had?

At station 4, always mention that you will involve other members of the team e.g. senior colleagues, nurses,
physiotherapists, pharmacists etc.

In addition, always introduce yourself and explain your role why you are here.

It is always useful to get the patient to explain their understanding of the problem or treatment before you start
providing any explanations.

HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How to impress Page 36 of 38
1. By not listening to the patient. The patient should do most of the talking, not you! Most patients have
been well briefed so if you can listen and encourage them to speak, they will volunteer most if not all of the
relevant history.
2. By interrupting the patient
3. By asking the same questions over and over. Patients and examiners get irritated.
4. Not giving an opportunity for the patient to ask questions
5. Not involving the patient in decision making
6. Forgetting key sections of the history e.g. drug history. This will almost certainly earn you a fail.
HISTORY TAKING, COMMUNICATION AND ETHICS STATIONS - How not to impress Page 37 of 38
1. An Aid to the MRCP Short Cases, Ryder
2. Clinical Medicine for the MRCP Cases Gautam Mehta, Bilal Iqbal and Deborah Bowman.
3. 250 cases in clinical medicine, Baliga For Case Management Issues
4. MRCP 2: Success in PACES, P Kelly
recomended reading
Page 38 of 38