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Examination techniques
  1. P D Welsby
  1. Western General Hospital, Edinburgh EH4 2XY, uk;

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    Some exam techniques are clinically useful. Some are just exam techniques. Sadly, both can earn marks in this unfair world.

    Clinically useful exam techniques

    Differentiation between mitral systolic and diastolic murmurs is easy. “Feel the carotid.” But it is difficult to correlate what you feel with what you hear, especially when anxious. It is easier to use movement of the stethoscope at the apex. Murmurs when the stethoscope is seen or felt to be pushed outwards are systolic, and murmurs when the stethoscope is returning are diastolic.

    Identifying whether a murmur is louder during inspiration is easy. Correlate what you see with what you hear. But it is easier to do one thing at a time. Close your eyes while listening, get in rhythm with the murmur, and open your eyes to see if the patient is breathing in or out at the time of loudness.

    Just exam techniques

    Hold the stethoscope by squeezing the stethoscope waist (between the diaphragm and bell) between the ends of you index and middle fingers with the tube passing beneath your palm. This looks far more professional than plonking the stethoscope on the chest by holding it between the tips of your thumb, index and middle fingers.

    “Place your left hand beneath the spleen and lifting it forward makes it easier to feel the spleen with your right finger tips” It does encourage the feeling that you are trapping the spleen and it does prevent you from falling to your right (every action has an opposite reaction). But does anyone believe that you can move the spleen forward in this way?

    What do you say when you have no idea whether there is a palpable intra-abdominal organ such as a spleen? Say “There is equivocal splenomegaly.” That is a definitive statement of the organ involved and a definitive statement of its palpability. Scientific and rigorous. Full marks!

    You have presented you cardiac findings and the examiner asks “What about the diastolic murmur?”, which you had not heard. Answer “It was difficult to hear.” This suggests that you had heard it and also congratulates the examiner because he or she had heard it. It helps if you smile while replying thus—the examiner might be testing you and there might not be a diastolic murmur at all!