Tips and tricks for clinical skills exams

Being tested on examining patients can seem like a daunting task, but with enough practice you will develop a routine and the examination will become less intimidating.

When you practice patient encounters, go through the entire case and write the patient note, following the tips and guidelines offered here. Some patient encounters have a slightly different structure (see “Special scenarios” below), so be aware of these.

• Knock on the door and enter (even if you do not hear a response from within the room).
  • Introduce yourself and confirm the patient's identity.
  • Smile.
  • Shake hands.
  • Speak up and enunciate clearly. Patients will appreciate your confidence in the exam room.
• Drape the patient if needed.

• Begin taking the history of present illness, review of systems, and past medical history.
  • Begin with open-ended questions.
  • Listen actively and maintain eye contact.
  • Make sure the patient is comfortable and address any discomfort/aggressive attitudes.
  • Use professional and clear language. Avoid medical jargon.
  • Before you end the history, ask the patient if there is anything else they would like to tell you.
• After every AMBOSS practice case, review the check boxes in the case and note the questions you forgot to ask.

• Tell the patient that you would like to perform a physical examination and ask for permission to begin.
• Wash your hands with soap and water.
  • OR use hand sanitizer
  • OR use gloves

The time while you wash your hands can be used to bond with the patient or ask questions about their social history (e.g., job, family).

ALWAYS

• Try to begin with the most pertinent system.
• Perform a FOCUSED physical examination. You will not be able to perform a complete physical examination.
• Ensure that the patient is comfortable.
  • If you recline the examination table, do not forget the leg rests.
• Cover the patient respectfully using the drapes.
  • Ask the patient for permission to lower their gown.
  • Try to expose the patient only to the extent that is necessary.
• Avoid being unnecessarily forceful when you examine the patient.
• Talk to the patient and describe what you are doing/about to do.
• Observe the patient carefully for any pathological findings that they might be mimicking.

NEVER

• Examine through the patient's gown.
• If you can avoid it, do not repeat painful exam maneuvers.

• Counsel the patient on relevant points regarding health promotion and/or disease prevention (e.g., counseling on smoking cessation).
• Respond to the patient's (challenging) questions.
  • Show empathy.
  • Do not give false hope – be honest, but do not be abrasive or rude.
  • Address fears and concerns.
  • Ask if the patient has any further concerns.
  • Often patients are scared to openly address important concerns!
• Closure
  • Communicate your findings from the history and physical exam (mention both positive and negative findings).
  • Explain which diagnostic steps you would like to take and why.
  • Avoid medical jargon!

• Say “Thank you.”
• Say goodbye and leave the room.

ALWAYS

• Write up the most important information first.
• Copy and paste the vital signs from the examinee instructions to save time.
• Use correct medical terminology and abbreviations.
• List the diagnoses in order of likelihood!
• List the positive and negative aspects of the patient history and physical examination findings that are pertinent to your diagnoses!
• Be as specific as possible when you note examination findings or supporting arguments.
• Copy and paste supporting arguments from the history and physical exam sections.
• Stick to the strategy and time management that you have practiced.
• Order the appropriate tests.
  • If needed: breast/pelvic/genital/rectal exams

NEVER

• Use medical abbreviations that are ambiguous or unclear.
• Treat, refer, or admit the patient.
• Counsel the patient. (Do this in the encounter, not the note!)

• Add the last few important findings, and make sure that every differential diagnosis has at least one or two supporting arguments.