She glanced at her clipboard and announced briskly;  ‘Now, Dr Read, examine this man’s chest.’  

I carefully went through the procedure, inspection, palpation, percussion, auscult……… 

‘Hurry up! Hurry up!’ 

‘I think the patient has a right pleural effusion,’  I offered tentatively. 

‘You only think he has!  You’ll have to do better than that.  Now, examine this mans heart.’  She wafted an imperious arm in the direction of the next bed. 

I got out my stethoscope, bent over the patient, but before I could listen to his heart, I heard the lady comment. 

‘He’s alright, but he’s very nervous!’

A resolve, like controlled anger, stiffened inside me.  I was quick.

‘Opening snap, mid-diastolic murmur with presystolic accentuation, splinter haemorrhages under his nails; Mitral Stenosis with SBE.’

‘OK. Next.’

‘Intention tremor, nystagmus.  This patient has cerebellar ataxia.’

‘Next.’

‘Enlarged liver and spleen.  Rubbery Lymph nodes in both groins.  I suspect lymphoma.’ 

‘Good! Now, just examine this mans eyes and anything else you think might be relevant.’ 

The patient eyed me with mischief.  I got my ophthalmoscope out and noted he had microaneurysms, blot haemorrhages, hard waxy exudates.  I took in the puncture marks, the lumps of fat under the skin of his abdomen. With a pin, I tested sensation in his arms and legs. Finally, I bent down and smelt his breath. 

Feeling confident now, I turned round, faced up to the lady and announced firmly.

‘This patient has long standing insulin-dependant diabetes with retinopathy and neuropathy.  He was probably admitted in diabetic coma, since I can still detect the ketotic smell of Golden Delicious apples on his breath.’

The lady was smiling, a curious almost triumphant smile.  So was the patient!  Confused, I looked down at his plate. My heart sank. It was the patient who broke the silence. 

‘Funny you say that doc!  I’ve just finished that apple.’    

This article was submitted to commemorate the 150^th anniversary of the MRCP examination by the Royal College of Physicians on 15^th September 2009.  My examiner was Professor Dame Sheila Sherlock.   

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