Introduction to Short Cases & OSCES for M3s Eugene Gan Class of 2016

Outline

!   Approach to evaluating a patient (4 parts)

!   Approach to Physical Examination/OSCE

-  How you will encounter PE in med school and beyond

-  Overview of steps of Physical Examination

-  Presentation Format

!   Case scenarios and building of approaches

!   Advice and Conclusion

Evaluation of a patient

!   4 Aspects: Medical, Functional, Social, Psychological

!   Medical – 6 Cs

!   Functional – Body function, activity, participation

!   Social – Patient, Family, Community

!   Psychological

Aspects of patient evaluation

Medical

!   Condition – and Severity (Mild, Moderate, Severe)

!   Cause (Secondary Cause, Risk Factors, Precipitating Factors)

!   Complications - Disease & Treatment

!   Control a) Pharmacological (Application, Adherence, Adverse Effects) b) Non-Pharmacological c) Monitoring

!   Compliance

!   Concerns

Functional

http://www.cdc.gov/nchs/data/icd/ICFoverview_FINALforWHO10Sept.pdf

Functional

!   BADLs

!   IADLs

 Social  

Disease

Patient – Occupation, Insurance etc..

Family – Background? Financial?

Community – Support services etc…

Symptoms

Credits: A/Prof Simon Ong, NCCS

Psychological (Largely covered in M4)

!   Decision Making Capacity

!   Cognition

!   Psychoses

!   Mood

!   Anxiety related

Approach to Physical Examination/OSCE

Goal of Physical Examination/OSCE Station

!  To aid in making a definite diagnosis from the history taking

!  Make as complete an evaluation as possible

of the patient -  Medical (6Cs) -  Functional -  (Social, Psychological)

How you might encounter Physical Examination (i.e. How you should think and

prepare)

1. Short Case

a)  Please examine the cardiovascular system of this gentleman with a 3 month history of breathlessness

b)  Please examine the hands of this man who has a 2 month history of joint pain

2. Long Case/Real Life:

a)  You are a doctor in a GP practice and you are taking over the follow up of a 60 year old lady with Type II diabetes mellitus.

b)  You have just seen a 56 year old uncle who complains of breathlessness for the past week. He has no known past medical history

Short Case

a)  Please examine the cardiovascular system of this gentleman with a 3 month history of breathlessness

-  You are to examine only the CVS system (Diagnosis)

-  There is a fixed (i.e. anticipatable) number and type of cases that come out

a)  Please examine the hands of this man who has a 2 month history of joint pain

-  This is a case where the examination is NOT system specific

-  Differentials are broad and wide

Long Case a)  You are a doctor in a GP practice and you are taking over the follow up

of a 60 year old lady with Type II diabetes mellitus.

-  This is a known chronic case

-  You examine every system that the condition involves to look for associated conditions, complications (and the other Cs) of the disease.

b)  You have just seen a 56 year old uncle who complains of breathlessness for the past week. He has no known past medical history

-  This is a diagnostic case.

-  You examine the systems relevant to the differential diagnoses. E.g. Respiratory - Pneumonia? Cardiovascular - Heart failure? GIT - PR bleed causing anemia?

Starting Point- What you have from M2

End point - What you should have by M5 This is a patient who is alert, in respiratory distress supported by 2L NP oxygen, is not cyanosed/jaundiced/pale, and by the bedside I note a 4 wheel walker. On examination of her respiratory system, the significant findings are fine end inspiratory crepitations heard in the bilateral lung bases, more prominently posteriorly. Air entry is fair and equal, the percussion note is normal, and vocal resonance is normal. Interstitial lung disease is the most likely diagnosis. The likely aetiology of this is Rheumatoid Arthritis because I noted that she has characteristic bilateral symmetrical arthropathy with swan neck deformity and rheumatoid nodules. I looked out for complications of the disease and noted signs of pulmonary hypertension (loud P2, RV heave). Other complications such as Cor pulmonale, asterixis were not detected. I did not find any cervical lymphadenopathy to suggest malignancy. I looked for complications of chronic steroid use but I did not note any Cushingnoid appearance, abdominal striae or clear evidence of proximal myopathy. Her functional status is likely to be significantly impaired given her dependance on oxygen and requirement of a 4 wheel walker for ambulation.

How you will participate today

-  Re-organising the CSFP templates we have from M2

-  Identifying the range of conditions for adults and children (this cuts across all postings, medical and surgical)

-  Making use of some good resources available to help you prepare notes

-  Learn about some ways to categorize and organize your finding

-  Preparing a template for yourself that you can add on in the future

Overview of a physical examination

!   WIPE

!   Inspection of patient and the environment

!   The physical examination

!   The things to offer

!   Consolidation and presentation

WIPE

!   Wash Hands

!   Introduce

!   Position

!   Exposure - Always state the ideal exposure, but for the sake of the patient’s modesty you will…

Inspection

!   A – Alert vs. Drowsy vs. Comatose (GCS), Toxic?

!   B – Breathing (Respi Distress/Laboured, Abdominal, Deep/Shallow, Kussmal, Cheyne Stokes)

!   C – Colour (Pale, Cyanotic, Jaundiced, Plethoric)

!   D – Disability (Functional Aids)

!   E – Environment (Vitals, Supportive, Related to system)

!   General assessment of nutritional status (Cachectic? In children, well thrived?)

!   In children include observation of dysmorphism/any syndromic features

Make a point to understand the rationale behind the signs

!   A – What affects alertness?

!   B – What are the components of breathing? What controls and therefore affects breathing?

!   C – What causes cyanosis, jaundice or plethora?

!   D – What is the significance of quadstick vs. walking frame vs. two or four wheel walker?

!   E – What is in the drip? Inhalers/Respiratory support etc..

!   Nutritional State: What are conditions that can give you cachexia?

The other aspects (will be covered later)

!   Physical Examination

!   Things you will offer at the end of the PE

!   Presentation

Building  Your  Approach  (Hands  on!!  :D)  

Building Your Approach (Hands On! :D)

Resources

!   CSFP Physical Examination Sequence

!   Talley O’Conner

!   Black Book of Clinical Examination by Prof Erle Lim

!   Jansen Koh’s MRCP

Scenario 1: Please examine the respiratory system/chest of:

a) This 55 year old woman who has developed progressive breathlessness over the past 3 months

b) This 2 year old child who has a chronic cough who is brought to you because he appears to be more breathless today

Type of Case: Short Case – Examine one System

Starting Point- What you have from M2

First step: Learn to understand your physical signs

-  Why does one get asterixis?

-  What is dullness? (Not consolidation only, but rather a denser medium than air – collection of inflammatory material, collapsed lung, plugging of mucous)

-  What is clubbing and why do you get it?

What are my range of conditions? (Go to my EPA)

Anatomic Location Aetiology (Adult) Aetiology (Paeds)

Upper Airway Epiglottitis/Croup

Lower Airway COPD/Asthma/Bronchiectasis/Foreign

Body/Anaphylaxis

Asthma/Bronchiectasis/Bronchiolitis/Bronchitis/Foreign Body/Anaphylaxis

Parenchyma Lobectomy/Interstitial Lung Disease/Abscess/

Pneumonia

Lobectomy/Abscess/Pneumonia

Pleura Parapneumonic effusion/TB/Cancer/Albumin loss/Fluid

overload state

Parapneumonic effusion/TB/Albumin loss/Fluid

overload state

Broad Aetiologies

Pathologic Common physical signs (Adult)

Common physical signs (Paeds)

Infection Tachycardia/Sweating/Toxic/Drowsy

Malignancy/Chronic Infection e.g. TB

Cachexia Poor nutritional state

Obstructive Airway Disease

Barrel Chest/Pursed Lip breathing

Inhaler by the side

Hyperinflated chest

Sorting out the complications

-  Respiratory Distress: Tachypnea, Accessory muscle use, Supplemental oxygen, NIV

-  RVH & pHTN: Palpable P2, Loud P2

-  Cor Pulmonale (RHF): JVP, Pedal Edema

-  CO2 retention: Drowsy, Asterixis, Bounding pulse, Tachypnoea

-  Cyanosis

Inspection – Many Clues!

!   A – Alert vs. Drowsy vs. Agitated

!   B – Breathing (Respi Distress, Abdominal, Pursed-Lip/Barrel chested)

!   C – Colour (Cyanotic, Plethoric)

!   D – Disability (Walking Stick, 4 wheeler, Wheelchair)

!   E – Environment (SpO2, HR, Supplemental Oxygen Tank, CPAP/BiPAP, Inhaler, Sputum Mug)

!   General state of nutrition: Cachectic?

Every step of the physical examination helps you make an inference

!   Hands (Look for asterixis, Look for clubbing)

!   Counting pulse and respiratory rate

!   …

!   Feeling the trachea

!   Feeling apex, feeling for P2, parasternal heave

!   Chest expansion, Percussion, Auscultation, Vocal resonance

How to Dichotomize the physical signs?

How to Dichotomize the phsyical signs?

!   Bilateral/Unilateral

!   Clubbing/No Clubbing

!   Tracheal Deviation/No Deviation

! Creps vs. Wheeze

!   Scar vs. No Scar

!   Dull vs. Resonant

!   Increased vs. Decreased Vocal Fremitus

Working it into your physical examination

!   Is it Sequential?

!   Is it Portable? – Knowing when to stop

TB Abscess

Bronchiectasis Cancer

ILD

The Rest

No Clubbing

Clubbing

L Tracheal Deviation

Hyper-resonant Dull/Stony Dull

R Percussion L Percussion

Tension Pneumothorax L Lobectomy

Pleural Effusion Consolidation +

Effusion

L Tracheal Deviation

Hyper-resonant Dull

R Percussion L Percussion

Pneumothorax Hyper-resonance

(Contralateral lobe) Scar

Lobectomy Collapse

Fibrosis with collapse

Yes No

Vocal Resonance Increased? Vocal Resonance

Dullness to percussion

Breath Sounds

Bronchial Vesicular

Increased Decreased

Pleural Effusion Collapse

What is an algorithm? !   It should be a dichotomy (if not 3 to 4 branches at the

MOST)

!  Comprehensive (At every branch-out, check back to see if you have covered all aspects of the heading)

!  High Yield – Can be dichotomized based on a clinical tool, minimal overlap of conditions between categories

!   Logical - Should follow the sequence of your thought process/physical examination

!  Portable – Simple, pocket sized, not too difficult to remember at the bedside

!  There are always caveats

Functional Impairment

!   Disease, Activity, Participation

!   Analogous to NYHA Class

!   Breathless at Rest?

!   4 wheeler at bedside?

Back to Scenario 1

• 55 year old lady: Over the Left hemithorax, decreased chest expansion, stony dullness to percussion from the 4th to 12th rib posteriorly, decreased air entry and decreased vocal resonance. You also found 2 palpable cervical lymph nodes

• 2 year old boy: You notice some nasal flaring, slight intercostal and subcostal retractions and a hyper inflated chest. Chest examination reveals good air entry with bilateral expiratory rhonchi.

Differentials

!   What are your differentials for the 55 year old lady?

I would like to complete my examination by… (learn to say sensible things)

!   Vitals chart

!   Temperature chart (The pattern of fever matters)

!   Sputum Mug/Hemoptysis chart

!   You may even want to offer to examine spine, neurological system to look for extra-pulmonary sites of disease manifestation

!   In the paeds patient: OFC, Height and weight on age appropriate growth chart…

Presentation

!   Inspection: ABCD

!   Chest examination: (condition)

!   Complications of disease:

!   Underlying cause

!   Functional Status

!   In summary

What follows the presentation?

!   What are your key findings?

!   What are your differentials? (e.g. of a right pleural effusion?)

!   What are the causes of this disease (e.g. the causes of interstitial lung disease)

!   How would you investigate the patient?

!   How would you manage this patient?

How do you prepare?

!   Prepare short notes on how you would answer questions for key conditions (e.g. Pleural effusion, Bronchiectasis, Interstitial Lung Disease)

!   6Cs – Condition, Cause, Complication, Control

!   History, PE, Dx, Investigations, Management

Example !   In a case of pleural effusion as above…

!   Can be classified according to Bilateral vs. Unilateral

!   Differentials of unilateral are parapneumonic, cancer, TB… differentials of bilateral are.

!   Size of effusion – Mild, Moderate, Massive. Moderate – massive, suspicion of TB/Cancer increases

!   Investigate with bloods and imaging

!   Definitive diagnosis with thoracocentesis, send for cytology, biochemistry, relevant cultures

!   Evaluate nature of effusion (transudative vs. excudative) with Light’s criteria

Example of End Product

!   Refer to my word document on respiratory system examination

Learning Points from this scenario • Using dichotomies and broad categories can be useful as it allows you

to group your differentials into broad categories very clearly using clear cut signs. It also aids in making a clearer presentation.

• It also helps you to take a step back and discuss differentials even if you cannot elicit further distinguishing signs (e.g. dullness to percussion but you have no idea what was going on with the breath sounds)

• Between adults and children: The approach, complications etc are largely similar. But the signs may differ (e.g. manifestations of respiratory distress). Also, there are a few unique differences (e.g. impact on growth)

• Listen very carefully to the stem and ask for additional information and give differentials that make sense in light of the clinical context

Similar Scenarios

!   Breast

!   Abdomen

!   CVS

!   Neck/Thyroid

!   Arterial/Venous

! Neuro

!   Pelvic (O&G)

CVS Examination

!   Take me through how you would prepare for this scenario

What you have from M2 CSFP

Conditions

!   Adults:

-  Murmur

-  Valve replacement

!   Children (Mostly congenital heart disease):

-  Acyanotic vs. Cyanotic heart disease

Complications !   Complications of cardiovascular disease

-  AF and stroke

-  Pulmonary Hypertension: Loud and palpable P2, Parasternal Heave

-  CCF: Dilated heart, S3/S4, Bibasal Creps, JVP, Hepatomegaly/Ascites, Pedal edema

-  Infective Endocarditis

!   Complications associated with a metallic valve

-  Hemolysis: Jaundice and pallor

-  Infective Endocarditis: You know the routine

-  Over anti-coagulation: Purpura, Ecchymoses

Sequence of Examination !   Peripheries

-  Mid line sternotomy scar? Any accompanying saphenous vein graft scar?

-  Clubbing vs. no Clubbing

-  Pulse: Irregularly irregular? Collapsing?

-  Jaundice, Pallor, Cyanosis

-  JVP: Raised, Giant v, Giant a?

! Praecordium

-  Apex beat: Deviated vs. not deviated

-  Signs of pulmonary HTN

-  Murmur: Systolic/Diastolic, What type, Best heard where, Grade

-  S1 S2, any additional heart sounds

-  Etc….

Presentation !   I would like to complete my examination by…

!   This patient is ABCDE…

!   On general inspection, I note that there is a midline sternotomy scar accompanied by a saphenous vein graft suggestive of a history of IHD and a CABG

!   On examination there is a … (condition and its severity)

!   I looked for complications of this lesion and I found…

!   The cause of this lesion is possibly cardiomyopathy secondary to ischemic heart disease. Other causes include…

!   My patient’s functional status is likely to be significantly limited as I noted a 4 wheel walker by his bedside

Abdominal Examination

-  Introducing another way of preparing your physical examination notes.

Making a List of Conditions

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• Main Organs: Liver, Spleen, Kidney • Will not cover: Hernia, Testicular conditions,

other abdominal organs, PR Exam • Medicine, Paediatrics, Surgery •  (Refer to word doc.)

Categorizing the List of Conditions

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• Liver & Spleen -  Chronic Liver Disease -  Malignancy -  Hematological -  Infective/Inflammatory -  Infiltrative • Kidney (Will not cover today)

Grouping the Physical Signs

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Chronic Liver Disease •  Stigmata of Chronic Liver Disease (Clubbing, Palmar erythema, Spider Naevi,

Loss of Axillary Hair, Gynaecomastia) •  Liver may/may not be enlarged or shrunken (Cirrhosis) • Complications of Chronic Liver Disease (Asterixis, Malignancy & LN,

Spleenomegaly, Ascites & SBP) Hematological • Myeloproliferative (Anemia, Bruising, Bone Marrow Biopsy scars) •  Lymphoproliferative (Diffuse Lymphadenopathy)

Malignancy •  Cachexia, Lymph Nodes •  Liver may/may not be enlarged or shrunken (Cirrhosis)

Choosing High Yield Diagnostic Features

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•  Jaundice

• Anemia

• Hepatomegaly, Spleenomegaly or Hepatospleenomegaly

Grouping your Examination findings (word doc.)

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Presentation

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• Sir, this patient presents with the main findings of…

• Hepatomegaly/HSM/Spleenomegaly

• Prove it is a Liver and/or Spleen and provide measurements

• Any other masses?

•  Justify Aetiology (CLD, Hematological, Malignancy, Infective/Inflammation)

• Complications

• Control, Compliance

Scenario 2: Please examine

a) The hands of this 56 year old man … who has vague complaints of weakness and stiffness in his hands (you may not get this part)

Type of Case: Diagnostic Case – Examine a region of the body

Starting Point – What you have from M2 CSFP

!   Nothing

Setting out list of conditions

!   How will you go about doing this? There are so many differentials…

!   Look at the postings where the hand could possibly be involved

!   Adopt methods of classification: Anatomic, Etiologic, etc…

!   Give it a try yourself NOW (:

Setting out the list of conditions (Go to your EPA/Notes)

Medicine & Paeds Ortho

Rheumatology

-  Inflammatory Arthritis

-  Connective Tissue Disease

-  Crystal Arthropathy

Joint

-  Degenerative (OA)

-  Infective (Septic Arthritis)

Neurology

-  Any pathology from brain all the way to muscle

Nerve

-  Nerve palsy, Plexus injury

Connective Tissue

-  Tendon inflammation, deformity, injury

Of course there are things like lumps and bumps etc…

Inspection – Still applies (extract what is relevant)

!   A – Alert vs. Drowsy vs. Comatose (GCS), Toxic?

!   B – Breathing (Respi Distress/Laboured, Abdominal, Deep/Shallow, Kussmal, Cheyne Stokes)

!   C – Colour (Pale, Cyanotic, Jaundiced, Plethoric)

!   D – Disability (Functional Aids)

!   E – Environment (Vitals, Supportive, Related to system)

!   General assessment of nutritional status (Cachectic? In children, well thrived?)

!   In children include observation of dysmorphism/any syndromic features

Broad Principles of a Hands examination !   Look

-  Inspection of palmar and dorsal aspects, up to elbows

-  Quick nerve screen

!   Feel

-  Bone

-  Joint

-  Tendon and muscle

!   Move

-  Active ROM

-  Passive ROM

Hands Examination (Cont’d)

!   Nerves

!   Vessels

!   Functional Assessment

-  Gross Motor

-  Fine Motor

Evaluation

!   Localized Problem

-  Nerve Palsy, Tendon issue, Lump and Bump

-  Make a diagnosis, assess complications, functional impact

!   Generalized Problem

-  Multiple joint involvement

-  Usually a “rheumatology” scenario, consideration of systemic involvement is necessary

Arthritis - Generalised

!   This patient has: - Bilateral vs. Unilateral - Symmetrical vs. Asymmetrical - Mono, Oligo or Polyarthritis

!   Pathology - Condition - Complications (Joint related, Systemic) - Causes

!   Activity (Active vs. Quiscent disease)

!   Function - Gross Motor - Fine Motor

Condition Osteoarthritis Rheumatoid Arthritis

Psoriasis Connective Tissue Disease

(Jacoud’s)

Sites of Involvement

Causes and Risk Factors

Complications

Bilateral Symmetrical Polyarthritis

Condition Gout Pseudogout Spondyloarthropathy

Infection

Sites of Involvement

Causes and Risk Factors

Complications

Bilateral Asymmetrical Polyarthritis

An example – Gouty Arthritis

!   Sites of involvement – Hands, Olecranon, Helix of ears, Patellar tendon, Achilles Tendon, Big toe

!   Causes – Increased production (Tumor lysis, Myeloproliferative), Decreased Excretion (CRF, NSAIDs/Aspirin, Thiazide diuretics)

!   Risk factors – Men, DM/Obesity

!   Precipitants – Dehydration, Surgery/Trauma

!   Complications – Joint related (Deformity, Tendon subluxation, Muscle wasting), Systemic (Nephrolithiasis, CKD/ESRF)

Presentation

!   Try (:

Scenario 3

!   You are a GP who has diagnosed this 60 year old man with diabetes after he came into your clinic with an infected foot ulcer.

!   Please examine him as necessary in light of your diagnosis.

Type of Case: Known Chronic Case – Examine for associated conditions, complications etc!

How would you organize your examination?

•  Importantly, the examination in this scenario should be very targeted to identify specific signs

•  You will NOT do a full neuro exam, a full CVS exam etc…

Complications – What are the signs accompanying each of the conditions?

! Vasculopathy - Macrovascular (Heart, Peripheral Vascular, Cerebrovascular) - Microvascular (Retina, Nerve, Renal)

! Immunopathy

!   Neuropathy

Control – How do you assess this?

Example of examination sequence

!   Foot (Infected ulcer)

-  Arterial system: Is this critical limb ischemia? Look for cardinal signs, feel for pulses and temperature to determine localize the level of arterial stenosis

-  Neurological: Examine for peripheral glove and stocking neuropathy

-  General: Any cuts, assess hygiene, footwear

Example of examination sequence

!   Other complications of diabetes

-  Signs of end stage renal failure (any AV fistula/Tenckoff catheter?)

-  Targeted CVS examination (signs of cardiomyopathy, CCF?)

-  Gross neuro exam (previous stroke?)

-  Fundoscope (Retinal abnormalities?)

Example of examination sequence

!   Assess control

-  Is he insulin dependant?

-  If so, examine abdomen for injection sites. Any lipodystrophy? Does he inject at those dystrophic sites?

!   Functional

-  Walking aids? (Especially if previous stroke)

-  Footwear

Scenario 4

!   You are an enthusiastic medical student who clerked 18 year old Mr Ong who has come in to hospital for monthly blood transfusions for his Thal Major.

!   How would you examine and evaluate him?

Presentation

!   This is … who has Thal Major

!   On inspection (ABCDE) – What is relevant here?

!   He has features suggestive of Thal Major (condition) because there is…

!   I looked for complications (go by systems!) of Thal Major and I noted…

!   I looked for complications of regular blood transfusion…. Complications of iron chelation therapy and I found…

!   I would like to complete my examination by…

Evaluation

!   The goal is to be able to examine each system of interest systematically (Abdo, CVS …)

!   But run through the following routine in your mind as you examine (C – Is this thal? C – Any complications of the disease? Any complications of transfusion or iron chelation?)

Example

!   General inspection – Pallor, Jaundice, Frontal bossing and maxillary hyperplasia suggestive of Thal major

!   Hands – Multiple puncture marks from transfusion. Clubbing due to chronic liver disease

!   Eyes, Mouth

!   Chest – Deviated apex suggestive of iron induced cardiomyopathy. Flow murmur suggestive of high output state due to anemia

!   Abdomen – Scar of previous spleenectomy. Spleenomegaly. Puncture marks suggests of desferroxamine injection, Hepatomegaly suggesting CLD from iron overload.

!   …

!   Offer vitals, temperature chart (infection can precipitate hemolysis), plot growth chart (chronic anemia stunts growth)

Scenario 5:

!   Please examine this 60 year old auntie who has a 1 year history of progressive breathlessness

How would you do this?

!   Causes of breathlessness – Cardiac, Respiratory, Abdomen (Mass splinting diaphragm), Neuromuscular (MG, myopathy), Hematologic (Anemia from GI bleed)

!   Look for complications once your diagnosis is ascertained.

Scenario 6

!   Please examine this 55 year old man who comes to you with sudden severe upper abdominal pain that began 2 hours ago

How to approach?

!   Causes of upper abdominal pain – Abdominal vs. Thorax

!   Should still rule out an AMI

!   Upper abdomen ?Epigastric – Stomach/Duodenum, Gall bladder/Liver, Pancreas, Abdominal Aorta

!   Complications? – Sepsis, Haemorrhage, Perforated viscus and peritonitis

!   Causes?

Looking at the checkpoints

!   M3 Pros – Get the signs, know how to offer differentials, very basic investigations/management

!   How does M4 knowledge come in? – Completes your breath of knowledge (e.g. Causes of BOV originating from the eye, O&G – finding a pelvic mass on abdo exam)

!   MBBS – Signs & Differentials are expected, know how to carry out a solid discussion on justifying one diagnosis over the other, how to thoroughly investigate and manage a patient in context.

The first checkpoint – M3 pros

!   Show diagram on M3 pros preparation document on the algorithms that need to be created.

!   Completed Algorithms for various PEs. (refer word doc.)

Nothing beats actual practice!

!   Nothing beats actual practice, but practicing repeatedly without reorganising and refining at home is not productive.

!   Practice helps to refine your clinical judgement, and to be tuned to non-classical presentations, which is real life

!   E.g. not all collapses/pneumothoraces with have a tracheal deviation, not all pneumonias give you consolidation, and not all Aortic Stenoses are always best heard over the Aortic area. But you need to know how to offer them as differentials

Some Advice

!   Begin with the end in mind

!   Get into the habit of working through things by yourself.

!   Be comfortable with categories of disease/clinical problems without having to know minute details.

!   Be very clear about what is better learnt via studying vs. what is better learnt via practicing on patients

!   The same method of evaluating patients 6Cs actually applies to almost everything (describing CXR, interpreting investigations etc…)