Rational Clinical Examination

You are in the emergency room and a 53 years old gentleman presents with a 3-day history of fever and headache. You think that you should role out meningitis. You perform your physical examination including looking for meningeal signs. Youe examination is negative. Can you role out meningitis for sure and not think about performing a lumbar puncture?


Saudi medical schools do a very good job in teaching clinical examination. Our clinical exams were very serious (and sometimes felt like life-or-death events!). I believe we were taught good skills in King AbdulAziz University.

What I’m writing about here is something that we were never taught though. I heard about this term for the first time after I started my residency program in University of British Columbia.

The term refers to a series of articles that are being published in the Journal of the American Medical Association (JAMA) since May 20,1992 until now. The editorial when the first article in the series appeared described as follows:

The articles look into a variety of clinical problems ranging from assessment of patient with suspected migraine to ventilator-associated pneumonia. In addition to being very valuable in day to day practice, the language of these articles has been the standard language when speaking about physical examination in the Canadian medical institutes.

In order to view the articles you will need a subscription. Most of the university libraries offer subscriptions as well. You just need to ask. KAAU might offer that as well.

If you prefer to read from a book then just wait for this book to be released.



  1. Rabaa

    “Our clinical exams were very serious (and sometimes felt like life-or-death events!).”

    For me all the time not sometimes
    lo0ol 🙂
    I am a 4th year medical student studying at KAU and I am having an OSKE exam for the first time next Sat
    إن شاء الله

    Looking for the bright side, it is good for us to practice from now

    Pray for me 🙂

  2. Bassem

    Hey, I actually disagree with you regarding the OSCE… it does have bias and the problem is that you can’t counteract it.

    In long and short cases, you can always impress the examiner with your answers even if they weren’t true regarding the specific case but they could demonstrate that you’re thinking logically and applying your thinking in a sensible manner.

    However, in OSCE, you have to say what’s written in that sheet of paper in front of the examiner and well, our OSCE’s this year (5th year) were far from reasonable.

    In conclusion, there’s always the chance of having to suffer from bias whether in OSCE or clinical cases, so if I had to choose, I’d pick the cases.

  3. Bassem

    Oh yeah another point regarding a different topic, Dr. Hisham Akbar was talking to us about something similar to the meningitis/LP scenario you mentioned. He was saying that clinical examination might become obsolete one day because a well-detailed history should give you most of the information you need to know to direct your investigations and those are what you depend on to finally make up your mind regarding a diagnosis rather than history and examination alone. So why not start with history, ditch the examination and head on to investigations directly?

  4. The Blood Doctor


    It is great to have you here again. I have tried to post comments in your blog but the system for posting comments is not very user friendly for wordpress users! (I admit I was using blogger before!)

    I see your point. I think this makes OSCE kind of a not-very-deep assessment tool. I remember clearly, as we were the first group ever to have OSCE in KAAU, that we had really to act at some point. It looks like a play sometimes!

    What I meant by bias was the bias in the diagnosis of the cases. In OSCE you are sure that the whole group got same stations. No body gets a DVT in a surgery exam while somebody else gets a sarcoma!

    One of the things that should be implemented in KAAU is the continuous clinical assessment of medical students during their rotations. This will never happen unless the groups are smaller and every single student has a lot of interaction with consultants/teaching faculty. I can’t see this happening in the near future.

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