Ref: Viva Tips

1. General considerations
2. Examining: alone, with examiners
3. Common questions: etiology, complications, management, investigations, treatment
4. Short cases

General considerations

• Bonus points if up to date with the good journals. Read the abstracts of major dz's on your handheld running up to the most important examinations.

Examining: alone

• If possible, do some of the examination, esp. inspection, while you are asking a low-yield part of the Hx, like a systems review.
• If it is an important examination, let pt know, as they may have had other times where a student came to visit just as a ward assignment or to prepare for a tutorial: "This is my final medical examination, my entire future career depends on it. I have 30 minutes to ask you some questions in order and do a quick examination. I'm quite nervous and I'm dependent on your help".
• Ask pt to point out all their relevant scars to you.
• Fetal heart auscultation: ask pt where the nurses are measuring it.
• If potential to be asked to examine something later with examiners, have things ready:
  • Place whatever relevant equipment on table: tape measure, reflex hammer, fundoscope. This drops a hint to examiners that it would be a good question, and also prevents fumbling pockets looking for the particular tool.
  • Have pt in relevant position (45degrees, etc), and sheets folded neatly at the level at which to show the presenting part (ie abdominal: folded across at the level of the pubic symphysis).
  • Know how bed and siderail moves up and down.
  • Have corner of sheets loose enough that can smoothly remove them if asked to test leg reflexes.
• If will be presenting in pt's room: remove glossy magazines from table at end of pt's bed so examiners can't read the covers and lose interest while you are presenting.
• Tidy the room if things are scattered all over, it looks better.
• Place your relevant clinical examination tools laid out on the end-of-bed-table before examiners return.  This is so you aren't fumbling in pockets to look for them. This is also is a good cue for the examiners to ask you to use the tools you have laid out, so you can lead them somewhat by what tools you laid out.
• If you finish the history and examination early, consider jotting down your management plans, complications, risk factors, etiology, etc about the pt's disease. These are the most likely questions that your examiners will ask when they return, and you can respond quicker and in more detail if you have already organized them.
• If you feel that you may be nervous, you may wish to write out your introductory and concluding sentences in full, so that you can read them off if needed, as these are the most important two sentences to deliver well.

Examining: with examiners

• Can either present as go, or present at end.
• Obs/Gyn: Use a plastic tape measure for examination, not a paper tape, as sweaty nervous hands will break a paper tape.

Presenting the findings

• A good line to start with when presenting findings after examining alone: "My name is <Robert O'Connor>, my student number is <34523>. I would like to introduce <Mrs. Johnston>. These are my examiners: <Dr. O'Donnell> and <Dr. Bryne>". [They will usually shake hands at this point, or say "Nice to meet you"]. "Would you like me to begin my presentation?" [The examiners will then say "Yes", and you are off and running].
• When presenting the findings, you need a strong introduction of the case, and a strong conclusion of the case. Some examiners may lose attention to the middle, especially as the day wears on.
• Don't mention anything you don't know much about, or aren't prepared to be quizzed upon at the end of your presentation.
• If the history is difficult and many admissions, you may wish to cut out all the individual admissions, and instead say: "She has a long, complicated history of <endometriosis>, <being admitted to hospital 6 times between 1992 and 2002>".
• If the pt has multiple problems, it is better to give a warning first and then itemize, so the examiner doesn't get confused. Something like: "He has <3> problems currently. Number 1:...".  If fact, you should prewarn anytime that you will unexpectedly be presenting multiple items, instead of just one.
• Only use even numbers for pulse and respiratory rate, as you should only measure for 15 or 30 seconds then multiply to get a figure per minute: and odd number per minute sounds fishy.
• Depending on the device, most blood pressure readings are in gradations of 2 mmHg--only report in the gradations possible on the device. Also, only a statistical probability of 1:25 of getting an actual BP reading where they both end in a zero--an even 130:80 reading seems fishy as though you didn't actually take it properly.
• Pull things together towards a diagnosis. Conclusion should sum up risk factors that were gained during a history.
• If you are asked about something that you didn't get to examine, a good response is: "Given the time constraints of this exam, I did not have the chance <her eyes>. It would be important because she is <diabetic>. What I would be looking for is ..."

Questions: etiology

• See Differential Reference.

Questions: complications

1. Short term complications.
2. Long term complications.

Questions: management

• If an emergency dz, then begin with "An emergency situation begins with assessment of airway, breathing, and circulation. Other dz: begin with "I would take a full history and perform a complete examination".
• Then investigations, treatment.

Questions: investigations

1. Blood tests:
   • Hematological: FBC, ESR, WBC, clotting time
   • Biochemical: LFT, TFT, U&E, amylase, glucose
   • Hormonal: PSA
2. Urinalysis: See Urinalysis Reference.
3. Function tests:
   • ECG
   • EEG
   • Lung tests: FEV 
4. Imaging:
   • X-rays: plain film or contrast [eg barium]
   • Angiography
   • Ultrasound, dopplers 
   • CT scan, MRI, PET
5. Endoscopy:
   • Colonoscopy
   • Gastroscopy
   • Bronchoscopy
   • Hysteroscopy, colposcopy
6. Biopsy:
   • Histology
   • Cytology

• Some dz's may have an order of investigation, such as first a blood test, then gastroscopy/biopsy, then CT scan.
• If surgical treatment, almost always need an ECG and CXR to help assess candidacy.

Questions: treatment

1. Conservative:
   • Reduce risk factors
   • All allied health services [eg homecare, social services]
2. Medical:
   • Drugs 
   • Radiotherapy
   • Chemotherapy
3. Surgical:
   • Local resection

Short cases

• Look around room for a classical examination item: glass of water in exam room may mean goiter examination.
• When asked to examine something not visible yet, ask the pt to point to the problem, as saves some time.
• Always expose/uncover/inspect the opposite side so can compare for asymmetry.
• Always glance at the whole pt for systemic clues, even when asked to examine one body part.
• Huge parts of full examination will be cut out for time, so mention somewhere that "Ideally, I would like to also examine...."