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Taut teachings: history and physical examination tips for examinations
  1. Philip Welsby
  1. Correspondence to Dr Philip Welsby, Edinburgh EH12 8UB, UK; philipwelsby{at}aol.com

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What have I learnt from 40 years in the medical trade? First, medicine is more than the sum of its parts. Specialists specialise and their purity of thought and protected environment often shields them from the rough and tumble of generalised medicine. Specialists provide authoritative advice that is almost invariably correct but often uncontaminated by elements derived from other specialties. Second, a lot of useful general advice never makes it into textbooks and guidelines. Third, collections of such general advice tend to be, indeed have to be, rather unspecialised, unstructured and a bit random. This sums up the author and what I write below.

Exam techniques

Certain questions are best presented as requiring an unequivocal answer. ‘When did you last ____?’ or ‘have you ever ___?’ are far more likely to be definitive than ‘Any coughing up of blood?’, which may be misinterpreted by the patient as meaning only recent haemoptysis.

Asking the patient ‘is there anything else of relevance you want to tell me?’ is risky as it suggests that your history taking has been incomplete. Better to ask ‘anything else you wish to tell me?’ as it sounds far more caring. If the patient has been investigated in the past always ask what conclusions were reached. If asked to discuss a diagnosis with your patient a good strategy is to say ‘I'm going to tell you three things’. Almost always you can find three relevant things, and stating a number initially makes you seem very organised.

Even if asked to examine a system always conduct a quick general visual assessment. Make it obvious that you have taken a global view of the patient and not immediately focused on what you were told to do on the instructions. For example, if told to examine the patient's abdomen it would be daft not …

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