UGI : Upper gastrointestinal
UGIB : Upper gastrointestinal bleed
URTI : Upper respiratory tract infection
UTI : Urinary tract infection
US/USG : Ultrasonogram
VA : Visual acuity
VAP : Ventilator acquired pneumonia
VC : Vital capacity
VDRL : Venereal disease research laboratory
VPC : Ventricular premature contractions
VSD : Ventricular septal defect
VT : Ventricular tachycardia
V/Q scan/ratio: Ventilation/perfusion
VUR : Vesicouretreric reflux
WHO : World health organisation
WPW : Wolff–Parkinson–White syndrome
ZES : Zollinger ellison syndrome
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Prerequisites for
Practical Examination
and Common
Examination Cases
C H A P T E R
1
PREREQUISITES FOR PRACTICAL
EXAMINATION
Clinical skills, such as the physical examination remain an important
instrument in the physician’s armamentarium and assessment of
these skills form the basis of the final clinical examination. Every
student appearing for the examination will be under a lot of stress,
which even though justifiable becomes detrimental for the
performance of the student. Here are some suggestions:
The first and foremost is preparation. Try to have a timetable and
cover all important cases well in advance. You have a set of
cases that are usually kept for the examination and most of the
questions asked are also predictable. Do not keep any important
things pending to read on the day prior to examination.
Sleep is of utmost importance on the day prior to the exam. You
need to sleep for a minimum 4–5 hours on the day prior to the
exam. The curriculum being vast, compromising a few hours of
sleep would do more harm than good.
Have a light breakfast. Hypoglycemia hampers your thought
process, delays your reaction time and severely impairs the
performance. Agreed that the feel of exam maybe like
undergoing a surgery, but NIL PER ORAL status is not needed.
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Attire is important. Be neatly groomed and dressed. Wear a clean
apron with a number badge.
Carry all your instruments.
Write a detailed case sheet. Examine each case thoroughly.
Never rely on expert’s diagnosis. Make your own diagnosis.
Always justify it with your own views.
Stick to the set time limits. Do not waste time.
Be gentle to the patient when you examine. The more
cooperative the patient is, the better will be your performance.
Always take the permission of the patient and explain before
examining and do not forget to thank them at the end.
Never forget to wish the examiner good morning/evening. If you
do not know an answer, say sorry! (Most of the examiners will
change the question or give you a clue). Always finish with a
thank you!
Confidence is of paramount importance. Practice presenting
cases without referring to the case sheet. Be clear in the order of
presentation, both history and examination. Stress on relevant
important findings. To be expressive is important, but not over
expressive. Eye-contact is essential. Answer clearly and to the
point. Do not speak about rare causes. When demonstrating
signs, do it clearly.
Most importantly, have faith in yourself and your preparation. You
shall succeed.
CHECKLIST FOR PRACTICAL EXAMINATION
Clean apron with roll number tag
Hall ticket
Stationery
Stethoscope with a bell
Knee hammer
Key (to test plantar reflex, stereognosis)
Wristwatch with seconds needle
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Measuring tape
Two scales
Pins
Glass slides
Two small boxes for testing smell (soap and coffee)
Four boxes for testing taste (sugar, salt, bitter and sour)
Four cards with the words “sweet”, “sour”, “bitter” and “salt”
written on them.
Snellen’s chart
Ishihara’s chart
Cotton
Tuning forks (128 Hz and 512 Hz)
Divider
Ophthalmoscope with full batteries
Torch with full batteries
Thermometer
Tongue depressor
Cotton wick/throat swab stick—gag reflex
Two test tubes preferably aluminum for temperature testing
(glass test tubes may be used if aluminium test tubes are not
available)
Pulse oximeter (not mandatory)
Gloves
Mask
Hand rub
FORMAT OF CLINICAL EXAMINATION
The general format of cases in the examination is as follows:
Type of case Time given for
examination of patient
Time for
clinical viva
Marks
Long 45–60 min 15–20 min 50/40
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Detailed case sheet
needed
marks
Short 15 min 7–10 min 20 marks
Semilong 15 min 7–10 min 20 marks
Spotters 1 min 2–3 min 5 marks
each
Charts (laboratory
data, clinical)
1 min 2–3 min 5 marks
each
OSCE (any clinical
sign)
5 min 5 min—
observed
5–10 marks
each
Viva voce 4 table vivas, each carrying 5 marks, each timed for 5
minutes
Topic—X-rays, ECG, instruments, drugs, charts, general
viva
COMMON EXAMINATION CASES
Respiratory system
Long case Short case
Bronchial asthma
Emphysema
Chronic bronchitis
Bronchiectasis
Pleural effusion/empyema
Lung abscess
Bronchial carcinoma
Consolidation
Pneumothorax
Hydropneumothorax
Collapse of the lung
Diffuse parenchymal lung
disease/Interstitial lung disease
Fibrosis/fibrocavity
Fibrothorax
Bronchial asthma
Emphysema
Chronic bronchitis
Bronchiectasis
Pleural effusion/empyema
Lung abscess
Bronchial carcinoma
Consolidation
Pneumothorax
Hydropneumothorax
Collapse of the lung
Diffuse parenchymal lung
disease/Interstitial lung disease
Fibrosis/fibrocavity
Fibrothorax
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Cardiovascular system
Long case Short case
Mitral stenosis
Mitral regurgitation
Mixed mitral stenosis with mitral
regurgitation
Aortic stenosis
Aortic regurgitation
Mixed aortic stenosis and regurgitation
Multivalvular heart diseases
Subacute bacterial endocarditis
Eisenmenger’s syndrome
Tetralogy of Fallot
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Congestive cardiac failure
Mitral stenosis
Mitral regurgitation
Mixed mitral stenosis with mitral
regurgitation
Aortic stenosis
Aortic regurgitation
Mixed aortic stenosis and regurgitation
Hypertension
Subacute bacterial endocarditis
Rheumatic fever
Eisenmenger’s syndrome
Tetralogy of Fallot
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Coarctation of aorta
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Congestive cardiac failure
Gastrointestinal system
Long case Short case
Jaundice
Acute/chronic hepatitis
Chronic liver disease (cirrhosis of liver)
Liver abscess
Ascites
Hepatomegaly
Splenomegaly
Hepatosplenomegaly
Polycystic kidney disease
Jaundice
Acute/chronic hepatitis
Chronic liver disease (cirrhosis of liver)
Liver abscess
Ascites
Hepatomegaly
Splenomegaly
Hepatosplenomegaly
Polycystic kidney disease
Nervous system
Long case Short case
Cerebrovascular disease Motor system examination
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Ataxia
Peripheral neuropathy
Guillain–Barré syndrome
Chronic inflammatory demyelinating
polyneuropathy
Myasthenia gravis
Spastic paraplegia (cord compression)
Transverse myelitis
Myopathy
Parkinsonism
Motor neuron disease
Multiple sclerosis
Facial nerve palsy
Foot drop
Claw hand
Examination of cranial nerves
Cerebellar signs
Involuntary movements
Sensory system examination
Semilong cases/therapeutic cases
Renal Nephrotic syndrome
Glomerulonephritis
Chronic kidney disease
Rheumatology Systemic lupus erythematosus
Rheumatoid arthritis
Ankylosing spondylitis
Systemic sclerosis
Endocrine Diabetes mellitus
Hypothyroidism
Graves’ disease (with thyrotoxicosis)
Cushing’s syndrome
Addison’s disease
Hypopituitarism
Acromegaly
Obesity
Short stature
Hematology Anemia
Bleeding disorders
Hepatosplenomegaly
Lymphadenopathy
General Pyrexia of unknown origin
Hypertension
Edema
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Heart failure
Dyspnea
Comprehensive geriatric assessment
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A. CASE SHEET FORMAT
PATIENT
Conscious
Oriented
Cooperative
Obeying commands.
BODY MASS INDEX (BMI)
Weight (kg)/Height (m2
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Grading according to World Health Organization (WHO) for Southeast Asian countries.
VITALS EXAMINATION
Pulse
Rate
Rhythm
Volume
Character
Vessel wall thickening
Radio-radial delay and radio-femoral delay
Peripheral pulses
Blood pressure
Right arm
Left arm
Both legs
Respiration
Rate
Abdominothoracic (male) or thoracoabdominal (female)
Usage of accessory muscles
Jugular venous pulse
Waveform
Jugular venous pressure
_____ cm of blood/water above sternal angle (+ 5 cm water from right atrium)
Temperature ____ degree of °C or °F measured at ______ site
Pulse oximetry
Pain
PHYSICAL EXAMINATION
Pallor
Icterus
Cyanosis
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Clubbing
Lymphadenopathy
Edema
OTHERS
Note: General physical examination findings relevant to each system shall be discussed in the
respective chapters.
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B. VITALS EXAMINATION
PULSE
Definition
Pulse is defined as a pressure distension wave produced by the contraction of the left ventricle against a
partially filled aorta which is transmitted to peripheries and is felt on a peripheral artery against a bony
prominence.
Assessment of arterial pulse
Characteristics Best assessed by palpating
Rate
Radial artery
Rhythm
Volume Carotid artery
Character or quality Carotid artery
Exceptions:
Collapsing pulse, pulsus alternans and pulsus paradoxus are appreciated at the radial
artery
Pulsus bisferiens best appreciated in brachial artery
Radio-radial and radio-femoral
delay
Whether all peripheral pulses are
felt
Condition of vessel wall
Example: 72 beats per minute, regular rhythm, normal volume and character, all peripheral pulses are
well felt, no radio radial or radiofemoral delay, no vessel wall thickening
Method of Palpation of Radial Artery (Fig. 2B.1)
Fig. 2B.1: Method of palpation of radial artery.
The radial pulse is felt using 3 fingers. The distal finger is to prevent the backflow, proximal finger is to
stabilize artery on the bone and middle finger is used to feel and count the pulse (3-finger method).
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Another accepted method of palpating the pulse is by using two fingers.
Pulse Rate
Calculate the rate by counting the radial pulse for one full minute. Normal heart rate is 60–100 beats
per minute.
<60 (bradycardia) >100 (tachycardia)
Physiological:
Athletes, sleep
Pathological:
Severe hypoxia
Hypothyroidism/myxedema
Obstructive jaundice
Hypothermia
Sick sinus syndrome
Drugs—β-blockers, verapamil,
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