11.4  Clinical Examinations

• Structure your approach to all the stations the same and you will feel much more comfortable and come across more confident

1. Enter the exam room when asked and wash your hands
2. Introduce yourself to your patient and your examiner
3. Listen carefully to the stem the examiner leads with. It will direct your examination. If asked to examine the posterior pole, the answer is there. Do not spend thirty seconds describing the patient’s blepharitis
4. Always ask for the patient’s visual acuity and intraocular pressures. Flag immediately in your mind if the patient does not meet private / commercial driving standards. Write these down if you need to, as forgetting is common with stress, and appears unprofessional
5. Talk through your findings as you examine the patient and listen to the examiner’s responses. If the examiner asks you to look at something again, look again - you have something or incorrectly identified something
6. Retract a statement at any time if you think you need to, and it will be forgotten
7. If you would like the results of an uncomfortable examination like gonioscopy or lid eversion, ask
8. A summary sentence post-examination of a patient of their presentation / condition is always welcomed but not necessary for a pass. This can help you collect your thoughts before offering a management plan

• Have an approach to each system. Practice your physical exam technique until it is autonomous, especially those which are technically involved and sometimes confusing such as orbit and squint. You do not want to be trying to remember what step of your exam comes next while you are examining real patients, you will need this precious time to think of the diagnosis / investigations and management

• Red flags appear as in the written exam and the same scenarios should always ring alarm bells in your head. Examiners will move on quickly from your comment on ensuring the young female patient with diabetic macula oedema is not pregnant but will fail you for not considering it and proceeding with possibly contraindicated treatment

• Specifically answer the question asked of you. The examiner has a list of questions and answers they need you to discuss in order to pass you. Let them ask you, give a direct and succinct response and let them move on to the next. Providing a huge rambling of information may spark interest in your answer and prompt difficult questions. You want to be a solid candidate and not provoke controversy during the exam, this gives you the best opportunity to pass

Preparation is key. Here are some tips that may help you prepare for the clinical exam:

1. Practice “suiting up” in clinics prior to the actual examination. That way you will reflexively know where to find each piece of equipment. Have those pieces of equipment that you are more likely to use within “easy reach”. Practice putting each piece of equipment into the same place (e.g. pocket) immediately after use, so that they don’t get mixed up (or even worse, lost!) during the examination
2. Minimise the amount of equipment that you need to carry. Ideally all equipment should be on your body, rather than having a separate bag that can spill open during the examination (we’ve all seen that before!). Having a non-head mounted indirect ophthalmoscope (BIO) around your neck is invaluable for quick fundoscopy, to check pupils and brightness saturation. Carrying lenses without their cases reduces weight and time in accessing them
3. Purchase your equipment early, so that you can get used to it. Although in most cases equipment will be provided, using your own equipment is always easier. Some pieces of equipment are harder to find than others. Small toys (keyring sized) with independent light (but not sound) are invaluable for the paediatric examination. Larger, less commonly used pieces of equipment such as exophthalmometers and stethoscopes for ocular bruits will be provided if appropriate to the examination. If they are placed beside the patient, they are there to be used!
4. Write down before the examination your equipment “inventory” and where you are going to keep it. This helps on the day to avoid forgetting a piece
5. Remember to check your equipment the night before. Clean all your lenses and charge all your batteries. If possible, ensure that all light bulbs are new

• Indirect ophthalmoscope (BIO) around your neck

Small bag (either clipped to belt or slung across shoulder)

• Retinoscope
• Cross cylinder
• Trial frames
• Direct ophthalmoscope head
• 2.2D in a case
• Pentorch
• Optokinetic nystagmus tape
• Diagram of eye (may facilitate consent)
• Near vision chart
• Spare pen

Belt

• Clipped battery pack for indirect ophthalmoscope

Watch

• Generally, you won’t have time to “time yourself” during the examination. Candidates should “time themselves” prior to examinations to get used to the duration of each station. This way you can get a feel for how long to spend examining each patient and discussing your findings / management