Presenting
General points to consider when presenting examination findings are to report all the positive findings and mention the important negatives (important signs that you looked for, but were not present). Follow these key 5 steps to nail presenting! Click here for the info-graphic and click here to watch the video.
Step 1: Patient demographic (name, age & gender) and current status.
“Today I performed a cardiovascular (CVS) examination on a 60-year-old man who from the end of the bed, looked alert and oriented.”
Step 2: Inspection findings.
Report on anything you observed on general inspection around the bed, hand, arms, neck, face, chest/abdomen, and rest of body. Include all positive findings and important negatives (important signs that you looked for, but were not present). “On inspection there was a GTN spray by the bedside, no peripheral stigmata of CVS disease in the arms or face, no splinter haemorrhages, Osler nodes or Janeway lesions, xanthelasma, xanthomata or conjunctival pallor. JVP not raised. On inspection of the chest, there was a midline sternotomy scar and a scar on the medial right leg.”
Step 3: Palpation & Percussion finding.
Report on anything you observed on palpation of the hand, arms, neck, face, chest/abdomen, and rest of body. And report on the sounds you heard on percussion of the chest/ abdomen. “Cap-refil was less than 2 seconds, heart rate was 64 bpm, warm and well perfused, no radio-radial delay or collapsing pulse. Normal character, rhythm and volume of a central pulse (carotid). Apex beat was un-displaced. No heaves or thrills.”
Step 4: Auscultation findings.
Report what sounds you heard both normal and added sounds. “Normal heart sounds S1 and S2 present with no added sounds”.
Step 5: Summarise & suggest further examinations & investigations.
Summarise all the findings in 1 sentence to suggest what the diagnosis could be and suggest further investigations to complete. “In summary, this is consistent with a patient with a previous coronary artery bypass graft (CABG). To complete, I would request CUPEF. C= capillary blood glucose, CXR, U=urinalysis, P= peripheral vascular exam, E=ECG and F=fundoscopy.”
