Nilo s Manikins

MANIKINS

1.

Adult Basic life support (CPR)

2.

Paediatric Basic Life Support (CPR)

3.

Male Catheterisation

4.

Blood sampling (sharps)

5.

IV cannulation (sharps)

6.

ABG (sharps)

7.

Suturing (sharps)

8.

Blood pressure

9.

Spacer

10.

Breast examination

11.

Bimanual examination

12. Examination of a lady of third trimester of pregnancy 13. PAP smear 14. Per rectal examination 15. Testicular Examination 16. Fundoscopy 17. Otoscopy 18. Dose calculation (sharps)

1. Basic cardio-pulmonary resuscitation (adult) Adult CPR > puberty DrsABC is a useful acronym to help you to remember each stage in sequence:  Danger  Response  Shout for help  Airway  Breathing  Call 999 Safety + Cervical spine: “I will ensure that I am safe, patient is safe, and environment is safe.” 

Tip: do not sit while verbalizing this. Say it in a stylish way while standing.

Sit and Check the patient and say: “As there is no sign of injury in upper part of the body, I assume there is no cervical spine injury.”

Check time: “time is e.g.9.15” 

Tip: memorise it, you need to repeat time when calling 999.

Check responsiveness If no response => one hand at the shoulder, other hand on the head or both hands on the shoulder, shake firmly and shout in both ears. Command: “open your eyes. Can you hear me?” ‘Are you all right?’

Shout for HELP in 3 directions In hospital: “Can I have a hand over here NOW please!” Check airway (with head tilt and chin lift look for any foreign body) “There is no obstruction on airway.”  Tip. In the exam, sometimes they put foreign body in manikin’s mouth.

Check breathing for 10 seconds, count loudly (with head tilt and chin lift – look at the chest for movement, listen at victim’s mouth for breathing sounds and feel for air on your cheeks.

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“I am looking for the chest movement, feeling the air on my cheeks and listening to breathing sounds.” Tip: if the patient is unresponsive, but is breathing and has a pulse, they need to be placed in the recovery position. (they don’t give this scenario in the exam)

If no breathing => Call 999 from outside of the hospital for ambulance Call 2222 (if in the hospital call cardiac arrest team) Ask the examiner: “can I have a phone please?” Tell the massage:” Hello I am Dr…calling from …place (is written in your task). I have found an unconscious man about ….years (is written in your task), unresponsive who is not breathing. I have started CPR at …time (You have checked the time). Could you please activate the cardiac arrest team? / Ambulance? Am I clear in my massage? Do you want me to repeat? Could you please reconfirmed what I have told? Thank you.” 30 second compressions (rate is 100/min, rescuers to place their hands in the centre of the chest.

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Tip: The heel of the hand is placed in the middle of the lower half of the sternum, indicated by the rectangle on the picture on the left. Tip: try to show the examiner that you are checking end of the ribs and xiliform before placing your hands. Tip: Try to compress not too slow and not too fast. Try to compress 30 per 17 sec (rate is 100/min).

2 rescue breaths (heath tilt, chin lift and nose pinch and make a good seal around the mouth. Give each rescue breath over 1 second

Continue with chest compression and rescue breaths in a ratio of 30:2

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Continue until: Victim starts breathing normally Qualified help arrives and takes over You become exhausted

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No reassessment at any point. Stop to recheck the victim only if he starts breathing normally; otherwise don’t interrupt resuscitation. 

Tip: when the examiner asking you how long you will do this. Don’t interrupt, answer while resuscitation. Tell him: I will continue until patient start breathing, or ambulance comes or I become exhausted. Sorry I lost my counts… 1, 2, 3…” He will tell you thank you. You can have a seat.

References: http://www.cetl.org.uk/learning/CPR/player.html http://www.redcross.org.uk/standard.asp?id=56929#section1 http://www.resus.org.uk/pages/bls.pdf

2. Basic cardio-pulmonary resuscitation (child) A child is between 1 year and puberty. (DrsAB5C 15:2 x3)      

Danger Response Shout for help Airway Breathing Circulation

Safety + Cervical spine: “I will ensure that I am safe, patient is safe, and environment is safe.” 

Tip: do not sit while verbalizing this. Say it in a stylish way while standing.

Sit and Check the patient and say: “As there is no sign of injury in upper part of the body, I assume there is no cervical spine injury.”

. 

Check time: “time is e.g.9.15”

Tip: memorise it, you need to repeat time when calling 999.

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Check responsiveness If no response => one hand at the shoulder, other hand on the head or both hands on the shoulder, shake firmly and shout in both ears. Command: “open your eyes. Can you hear me?”

Shout for HELP in 3 directions In hospital: Can I have a hand over here NOW please! Check airway (with head tilt and chin lift look for any foreign body) If there isn’t any foreign body, say “The airway is clear.”

Check breathing for 10 seconds, count loudly “1,2,3,…,10” (with head tilt and chin lift – look at the chest for movement, listen at victim’s mouth for breathing sounds and feel for air on your cheeks. “I am looking for the chest movement, feeling the air on my cheeks and listening to breathing sounds.”

Tip: if the patient is unresponsive, but is breathing and has a pulse, they need to be placed in the recovery position.

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5 rescue breaths (while performing rescue breathing note any gag or cough response to your action, maintain heath tilt, chin lift and nose pinch and make a good seal around the mouth.  Tip: Give a rescue breath and wait for 1 second and leave the nose pinch, look for the chest movement.

Check for signs of circulation: signs of life) For 10 seconds count loudly “1,2,3,…,10” look for signs of circulation like any movement, coughing, or normal breathing – not agonal gasps, these are infrequent, irregular breaths – if no pulse or “Can I have a phone, please?” Call 999 from outside of the hospital for ambulance Call 2222 (if in the hospital call Paediatric arrest team) Tell the massage:” hello I am Dr…calling from …place. I have found an unconscious man aged …years, unresponsive who is not breathing. I have done 1 minute of CPR. Could you please activate the Paediatric arrest team? (if calling from hospital) / Ambulance? Am I clear in my massage? Do you want me to repeat? Could you please reconfirmed what I have told? Thank you.” Come back and check for: (AB⁵2C⁵ 15:2)     

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Signs of life Airway Breathing for 5 seconds (if no breathing) Give 2 rescue breaths Check for signs of circulation for 5 sec ( look for signs of circulation like any movement, coughing, or normal breathing (not agoral gasps, these are infrequent, irregular breaths) if no pulse Continue CRP 15:2 If pulse is >60/min, give 1 rescue breath for every 3 seconds

Reference: http://www.cetl.org.uk/learning/paediatric-bls/player.html http://www.resus.org.uk/pages/pbls.pdf

3. Performing Urinary Catheterisation 1. Greet the patient: “Ideally I would greet the patient.” 2. Introduce yourself:” And introduce myself.” 3. check her/his identity 4. Explain the procedure/ purpose of visit: “I would explain to the patient that I am here to introduce a rubber tube into his water pipe to relieve his waterworks (bladder).” 5. Privacy and Chaperone:” I would maintain enough privacy and I would ask for a chaperone.” 6. Consent:” I would obtain the verbal consent of the patient.” 7. Exposure/ position: “I would ask the patient to undress below waist and lie comfortably on his back.” 8. Contraindications: you don’t need to mention this because it is not written in the task about case of trauma “I rule out contraindications which are suspected urethral injury (trauma: blood noted at the tip of urinary meatus or high riding prostate on rectal exam)”

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9. “Do I have an assistant?” 10.“Where is my sterile area?” 11.check trolley / instruments: pair of sterile gloves Sterile drape Kidney tray sterile forceps Adequate number of gauze and swabs Antiseptic solution (Most of the time there is an empty bowl written antiseptic solution and you should use it for cleaning.) Prefilled syringe with anaesthetic jelly Appropriate size Foley’s catheter (size 16 for mannequins) Prefilled syringe with distilled water (Most of the time there is an empty bowl written distilled water and you should fill the syringe to inflate the balloon.) Urine bag Sticking tape Clinical waste bin Procedure: 1. “Ideally I wash my hands” or say “sir, can I wash my hands?” he says “assume you have washed your hands.” 2. Wear a sterile pair of gloves. (Sometime it is written that assume you are gloved, if not, ask “can I have a pairs of glove please?”) 3. Put drape paper on manikin. 4. Put kidney tray in front of it. (If you do it now, you will not forget it.) 5. Take a piece of gas with forceps put it on the shaft. Hold the shaft with your left hand. (you won’t leave it until finishing introducing tube) 6. Clean glans with antiseptic solution – from meatus to periphery in a circumferential manner. Discard it in clinical bin. (3 times with 3 gauzes) 7. Send the forceps for sterilization if it is metal. If it is plastic, discard it in clinical bin. 8. Inject anaesthetic jelly – “ideally I would warn my patient that I am introducing the jelly and he will feel a little bit cold sensation.” Apply it on surrounding area, then inside. Say:” ideally I would wait for a few minutes.” 9. Warn the patient: “I warn my patient I’m about to insert the rubber tube.” 10. push catheter with a no touch technique (don’t touch catheter with hand)

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Tip: (the trickiest part) you won’t have problem to push the catheter inside, the difficulty is the moment you try to get cover out, catheter will come out with it. Remember you are using only your right hand, so push catheter inside and try to fold the bag and leave it to open carefully. 11. Push up to Y junction, then remove plastic holder and put it in clinical waste bin. 12. Discard the shaft holding gauze piece to clinical bin and hold Y junction with left hand. 13. Connect the urine bag. (You can leave the bag on the floor) 14. Inflate the bulb with distilled water based on what has written on the catheter, verbalize: “ideally I would inflate with eg30 ml of distilled water.” 15. Discard the syringe to clinical waste bin. 16. Tear the drape. Discard it to clinical waste bin. 17. Tug it slightly to the place. (Just a little ) 18. “I’ll apply plaster.” (Show how you imaginary stick catheter to the thigh) 19. “I would record the volume of urine, size of catheter, type of fluid I have inflated the bulb, and time and date.” 20. Ask the patient to redress: “I would thank the patient and ask him to dress up.” 21. Thank the chaperone and the examiner.

4. Performing Venepuncture (Blood Sampling)

1. Greet the patient. 2. Introduce yourself. 3. Check her/his identity. 4. Explain the procedure/ purpose of visit: “I would tell the patient that for purpose of investigations I need to draw some blood of his blood channel. For that I would introduce a needle in his forearm, he would feel a sharp scratch but I would be as gentle as possible. I would ask for his arm preference and any arm soreness. I will inform that I will repeat the procedure if I fail at the first attempt.” 5. privacy and Chaperone: 6. Consent: 7. Exposure/ position: “I will ask him for his permission and ask to roll up his sleeve and I would maintain adequate privacy and I would ask for a chaperone.”

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Tip: if it is written the consent in taken and procedure is told to the patient say: “as the consent is taken and procedure is explained to the patient I start with checking the identity.”

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Tip: in blood sample there is no contraindication.

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Tip: if it is written don’t talk about the procedure, don’t force the examiner listen to you.

8. check trolley / instruments:

1. vacutainer holder, vacutainer needle, vacutainer

2. 3. 4. 5. 9.

alcohol sterets, gauze pieces tourniquet sharps bin (yellow) waste bin (white plastic box)

Ensure that sharps bin is close by and open.

Procedure 1. Assume you have washed your hands. 2. Wear a clean pair of gloves. (Sometime it is written that assume you are gloved, if not, ask “can I have a pairs of glove please?”) 3. Check tourniquet and apply it. (loose not tight) 4. Remove the correct end (smaller, white) of the needle and load vacutainer holder with needle. throw cap in clinical waste bin  Tip: if you open the wrong end or touch it discard it in the sharps bin and take a new one. 5. Palpate the vein. (above Y junction) 6. Fasten tourniquet. 7. Palpate the vein again. 8. Wipe the alcohol sterets, one stroke only then discard in the waste bin. 9. Unsheathe needle (green end) and throw cap in clinical waste bin. 10. Warn the patient before inserting needle “I will warn my patient for sharp scratch.” 11. Stretch the skin and introduce needle.  Tip: Don’t try to insert the whole needle inside. The moment the resistance has gone, you’re inside the vein. 12. Stabilise vacutainer holder with left hand and insert vacutainer one by one. 13. Shake the bottles and put it inside the kidney tray.

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14. Loosen the tourniquet at the end of the last vacutainer to be filled.(or after that) 15. Take gauze piece and press on needle and withdraw the needle. 16.Discard the vacutainer holder in sharp’s bin with the needle. 17. “Ideally I ask my patient to press for a few minutes without bending the arm.” 18. “I would label tubes (patient’s name, DOB and hospital number, procedure, date and signature and send tubes to lab.” 19. Remove the gloves and discard in clinical waste bin. 20. “I would enquire how the patient feels and thank the patient for his cooperation and ask him to dress up” 21. Thank the examiner. How to avoid D & E  Ask for arm preference.  Open correct end of the needle.  Load the vacutainer initially  Discard the vacutainer holder with needle into the sharp’s bin. Vacutainer is a registered brand of test tube specifically designed for venipuncture. Refrences;http://www.learnerstv.com/video/video.php?video=1869&cat=Medical 5. IV Cannulation

1. Ideally I would greet the patient, introduce myself to the patient, and check the identity. 2. I would explain the procedure and take a verbal consent. 3. I would tell the patient that for purpose of the giving medications and fluids I need to introduce cannula in his forearm, I would inform that he would feel a sharp scratch but I would be as gentle as possible. Also I would inform that I would repeat procedure again if I fail in first attempt. 4. I would ask for the arm preference, any soreness in arm and ask him to roll up his sleeves. 5. I would maintain adequate privacy and ask for a chaperone. 6. checking trolley 1. 2. 3. 4. 5. 6. 7. 8. 9.

1 pair of gloves Cannula (pink or blue) alcohol sterets gauze piece tegaderm tourniquet 2cc syringes filled with normal saline clinical waste bin sharp bin - yellow

Make sure sharps bin is close by and open the sharps bin.

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Procedure: 1. Ask: “where is the clean area?” If there is a kidney tray thin use it. If there is none then assume. 2. Assume you have washed your hands and wear a clean pair of gloves. (Sometime it is written that assume you are gloved, if not, ask “can I have a pairs of glove please?”) 3. Check tourniquet and apply it. (loose not tight) 4. Check the site and the vein. (below Y junction) 5. Remove cannula with no touch technique. 6. Take out stopper; place it on the table (sterile area) facing upwards. 7. Fasten tourniquet. 8. Palpate the vein again. 9. Clean the area with alcohol sterets in one direction. Discard it into clinical waste bin. 10. Take a three point grip of the cannula, with your thumb on the white cap, index finger on the coloured cap, and middle finger on the wing. Apply countertraction to the overlying skin with your other hand to help anchor the vein during insertion. 11. “I would warn the patient that he may feel sharp scratch.” 12. Scratch the skin and insert cannula with bevel end upwards at 30 to 40. Then reduce to a 15° angle to advance the needle inside the vein. 13. When blood gushes back, change your grip, so the thumb and middle finger are on the white cap to withdraw the needle about 5 mm to produce the second flashback. Importantly the index finger provides countertraction on the wing. 14. With just the index finger remaining in place at the wing, advance the cannula along the vein. 15. Release the tourniquet. 16. Press over the vein around the tip of cannula with the index finger of left hand. 17. Remove the needle and discard into sharps bin. 18. Position and stabilise the cannula with left thumb. 19. Put the stopper at the end of cannula. 20. Take 2cc syringe with normal saline and flush through third opening (up), feel for the flow and see for patient’s comfort. (I would check any resistance or swelling or reports of pain from the patient.)

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21. Apply tegaderm. First peel the back (sticky side) and then apply it on cannula. Take the edge and peel the front. Peel again date label, and apply above the visible area. 22. Inform the patient to please not remove his arm. 23. Document the date and apply tegaderm and remove the paper around. 24. I would thank the patient for his cooperation and ask him to dress up. 25. Document findings (what no. cannula inserted ect.) 26. Thank the examiner. How to avoid D & E  Ask for arm preference.  Take out the stopper and keep it on the table.  Don’t touch the proximal end of the cannula.  Stylet into the sharp’s bin

6. ABG 1. Ideally I would greet the patient, introduce myself to the patient, and check the identity. 2. I would explain the procedure and take a verbal consent. 3. I would tell the patient that for purpose of the investigations I need to draw some blood from his forearm by passing a needle, I would inform that he will feel a sharp scratch but I will be as gentle as possible. Also I would inform that I would repeat procedure again if I fail in first attempt. 4. I would ask for the arm preference and ask him to roll up his sleeves. 5. I would maintain adequate privacy and ask for a chaperone. 

Tip: if it is written the consent in taken and procedure is told to the patient say: “as the consent is taken and procedure is explained to the patient I start with checking the identity.”

6. “Ideally I would role out the contraindications by doing the modified Allen’s test.” demonstrate it in your hand. 

I’ll ask my patient to make a tight fist.

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I will … ulnar and radial areas.

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Then I’ll ask my patient to open his hand, check for blanching

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And release the ulnar

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Check for reperfusion

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If reperfusion is less than 7 seconds, I will go ahead with the task.

7. Say: (“can I ask where my clean area is?”) 8. Checking trolley

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1. ABG

set

bubble

(cork, remover,

syringe with needle with stopper) 2. 1 pair of gloves 3. alcohol sterets 4. gauze piece 5. clinical waste bin 6. sharp bin Make sure sharps bin is close by and open the sharps bin.  Tip: sometimes they give you ABG set. Put it in assumed clean area.  Tip: sometimes you pick them from different baskets.  Tip: sometimes they don’t have cork or bubble remover, ask for it. They will say do without it. Procedure: 1. Wear pairs of sterile gloves. (If it is written in the task, assume you’ve washed your hands and are gloved.) 2. Palpate artery. If you don’t feel the pulse, say it. ” I can’t appreciate any pulse.” Tip: sometimes, there is someone sitting there for pumping the pulse. 3. Put 3 fingers on the radial artery. Then bent the middle finger backward and clean the area with alcohol sterets, discard in clinical waste bin. 4. Take syringe, remove cap (with one hand) and discard it in clinical waste bin. If syringe is preloaded with heparin, discard in clinical waste bin. 5. Insert needle in 30 – 45 degrees between two fingers of palpitation, before inserting say: “I will inform my patient for sharp scratch.”  Tip: Don’t try to insert the whole needle inside. The moment the resistance has gone, you are inside the artery.  Tip: hold the needle like pen in your hand with your right hand, blood will come out automatically.  Tip: keep your left fingers in palpating situation. 6. Collect 1 cc of blood. 7. Press gauze pieces and apply pressure with left hand, and remove the needle. 8. “Ideally I press myself for a few minutes or ask one of my assistants to do that.” 9. Put the needle in cork and discard them (needle and cork) in sharp bin. 

Tip: if there is no cork, put the needle inside sharp bins and unscrew anticlockwise. (don’t pull)

10. Apply bubble remover. Remove bubbles; discard it in clinical waste bin.

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Tip: if there is no bubble remover, first ask for it, if the examiner doesn’t give it, remove the needle and take a piece of gauze and remove the bubble and apply the stopper.

11. Apply stopper. 12. “I would thank the patient for cooperation and ask him to dress up.” 13. “I will label the syringe: name of the patient, DOB, time, my signature, oxygen saturation and room temperature, and fill request form and take it personally to Lab immediately. “(If Lab is not working, put it in an ice bag and take it to ABG machine personally.) 14. Thank the examiner.

How to avoid D & E: 

Inform about repeating the procedure.

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Arm preference.

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Do Allen’s test.

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Sharps into sharp’s bin. The modified Allen Test 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial (good collateral circulation) If color does not return or returns after 7–10 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/ cannulated.

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7. Suturing (Wound has been anaesthetised and written consent has been taken)

1. Ideally I would greet the patient, introduce myself to the patient, and check the identity. 2. I will explain the procedure that I am here to clean his wound and take sutures. 3. I will ask for adequate exposure and will maintain adequate privacy and ask for a chaperone. 4. Ask: Do I have an assistant? 

If you are provided with an assistant then assume you are wearing gloves and gown after you greet the examiner. But do not touch anything unsterile. (You can ask your assistant to put everything in your assumed sterile area.) 

If you are not provided with any assistant, check trolley and drop everything into your sterile area without touching the sterile area and then assume that you are wearing gloves and gown.

5. Ask: where is my sterile area? 6. checking trolley 1. 2. 3. 4. 5. 6. 7.

1 pair of gloves 3 forceps 1 fine suture scissors 1 needle holder suture material antiseptic solution 10cc normal syringe with syringe

8. alcohol sterets 9. gauze piece 10. clinical waste bin 11. sharp bin 12. Drape Procedure: 1. Wear pairs of sterile gloves. (or assume)

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2. “I will be looking at the face of the patient and check for anaesthesia.” Press with blunt forceps on both the sides. Discard the forceps in unsterile area. If it is plastic in clinical bin. 3. Take 10cc syringe fill it with normal saline, part wound, flush it. If not clean then take more. 

Tip: If syringes are not provided ask for it with the examiner, but if he doesn’t provide then you assume that you have one and tell him that “Ideally I flush the wound with sterile saline to clean it.”

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Tip: most of the time, syringe is empty and they say assume.

4. Antiseptic solution – dips the gauze piece and clean away from the edge and along the margins. Use 4 gauze pieces, discard second forceps.

Cleaning with 2 gauzes

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Cleaning with 4 gauzes

Tip: If given 1 forceps clean with hand and check anaesthesia with gauze. Now you can use the given forceps for suturing.

5. Remove one pair of gloves in clinical waste bin. 6. Drape the area. 7. Hold needle with needle holder. The needle should be grasped between 1/3 to 1/2 of the distance between the suture attachment and the needle tip. 8. Take the needle with needle holder. The needle holder should be held with the palm grip 

Tip: never touch the needle.

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Tip: take out the needle with forceps and grasp it with needle holder.

9. Inform the patient that “I am about to take sutures. He will feel it, but there will be no pain.” 10. Go vertically and don’t go through both sides in one go. One side, then take the needle out and don’t take it too

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much. Then pinch the other side again. Try to make both side almost equal distance. 

Tip: Keep the needle on left side of drape (because you have started from right side) put the forceps over the needle so you are not by mistake touch it.

11. You can touch the thread. Keep right side short and start knotting. Take the tip of the thread with needle holder. Now your right hand keeping needle holder is still and you left hand rolling thread over it. And get the knot back toward the short side. (right) 12. 3 anterior, 2 posterior, 1 anterior, I anterior = 7 knots. Cut thread by 1 cm with scissors. 13. Discard forceps. Discard needle in sharp bin. 14. “I will apply sterile gauze piece on wound and put bandage on it. I will give adequate antibiotics and pain killers if required. I will be requesting the patient to come after 7 days to suture removal. 15. I will be checking for tetanus immunization status.” 16. Thank the patient for cooperation and ask him dress up. 17. Thank the chaperone or assistant. 18. Thank the examiner. How to avoid D & E:  Take written consent  Drape the wound  Don’t touch the needle with hand  One good tight suture  Discard needle into sharp bin  Try your best to finish the task by putting both the stitches. If you have not finished by 4 and half min bell. Do not stop but continue suturing and keep verbalising at the same time. (Tell the examiner that once you finish suturing you will clean area, discard sharps in the sharp bin, dress the wound, discharge him and advice him to go to GP for suture removal in 7 to 10 days time. Even if you are not able to throw the needle in the sharp bin, do not worry, as long as have mentioned that you are going to throw that in sharp bin.) http://www.medicalvideos.us/videos-1754-Suturing-a-Wound

8. Checking blood pressure 1. Turn to the patient (GRIPS) “Hello Sir, I am Dr …, How can I address you?” 2. Explain the procedure: “I am here to measure your blood pressure by an instrument called sphygmomanometer. For that I will wrap the cuff around your arm and squeeze your arm by inflating a pump. You can sit down comfortable, is it ok with you?”

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3. Ask the patient:” I just need to ask you few things, have you ever been diagnosed by high blood pressure? (If he says yes, say I am really sorry about that.) Are you on any medication? (If he says yes, ask “Have you taken tablets today?”)Have you done any excessive exercise from early morning until now? Have you had too much coffee from early morning until now?” 4. Privacy and chaperone: I will ask the examiner to be the chaperone. 5. Consent: shall I proceed? 6. Ask for the arm preference: “please let me know which arm you prefer?” 7. Ask for soreness on the arm: “do you have any soreness on the arm?” 8. Ask the patient: “rolled up your sleeves, please.” 9. Check the size of the cuff. (should cover 2/3 arm)

10. Tie the cuff, 2 fingers breadths above the cubital fossa and 2 fingers can be inserted under the tied cuff. So patient can bend his elbow. Keep the arterial typed in the medial side. 11. Ask: “can you bend your elbow?” 12. “Can I ask you what usual your blood pressure reading is?” 13. Measure the blood pressure by palpatory method first. Palpate the radial artery. Inflate until the pulse disappears. Then deflate the pump. The moment you feel the pulse this is your palpatory blood pressure. Verbalize: “My palpatory (estimated systolic) blood pressure in sitting position is 120= one twenty” 14. Take the stethoscope, make sure it is working. Keep it on brachial artery with right hand, don’t press too much. Inflate with left hand. Measure BP. Verbalize: “My auscultatory blood pressure in sitting position is 120/80 = one twenty over eighty”

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15. Tell the patient that “Mr Y, thank you very much, but I thank you to stand up and I will measure your blood pressure during standing. If you feel dizzy at the any point of time, please feel free to sit down even without telling me.” 16. No palpatory blood pressure in standing position. Verbalize: “My auscultatory blood pressure in standing position is 120/80 = one twenty over eighty” 17. Apply stethoscope again. Keep it on brachial artery with right hand, don’t press too much. Measure the auscultatory standing blood pressure. 18. Ask the patient to roll down his sleeve, thank the patient. 19. Thank the examiner. References: http://www.cetl.org.uk/learning/bpm/player.html

9. Spacer Counsel mum of the child who suffers with asthma about how to use the spacer. In GMC exam, Patient is a 5 years old child. 

Good morning I am Dr X

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Ask Mum: “How is your little one doing? I have come through notes that your little one is suffering from asthma…

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She says: Yes

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Say: I am very sorry to hear that. I am here to introducing a device called spacer. Have you ever heard about it?

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She says: No

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“I am here to talk you about it. If you have any question, stop me whenever you want.” Hold the spacer in your hand and say: “Actually it is a device which contains of two parts. (Part it) Show her while describing… and can be fixed easily like this…fix it.

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“Do you have the medication with you?” “Do you know how many puffs you have to give?”

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Tip: If she doesn’t know prescription, don’t tell her on your own. I am giving you example, once you get your prescription you will find it out. If any question, come back to us we will describe it to you.

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Check if spacer is working by moving it gently: “always shake the spacer gently before use, you’ll hear a sound like tic tic tic that means the valve at the mouth piece is working and spacer is fine. If there is no sound it means that valve is stuck and spacer is longer no use”

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Demonstrate the spacer to the mum:

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1.

Remove the protective cap from the puffer.

2.

Shake the puffer and fix it firmly into the end of the spacer. (square end)

3.

Make sure you little one hold the spacer horizontally, and make a tight seal on the mouth.

4.

Press the puffer once to release a dose of the medicine into the spacer. Do not remove the puffer.

5.

Allow your little one to breath in and out 10 times. With each breath in you will hear a sound like this… shake the spacer … and with each breath out you will hear the same click. So in total of 10 breaths you will hear 20 clicks. Is it clear? Do you want me to repeat it?

6.

In summary, 1 puff is equal 10 breaths and with each breath you hear 2 clicks. That means with each puff, you will hear 20 clicks.

7.

“Can you please demonstrate it for me?” give the spacer to her. Tip: if there are 2 spacer, use one and give the other one to her.

8.

Blue capped inhaler is a reliever, a bronchodilator that may cause racing of the heart for example, palpitation.

9.

Brown capped inhaler is a steroid; it is a preventer. Therefore your little one must rinse out her/his mouth after each use to prevent the growth of any bugs in the mouth called oral thrush.

10. 

If another puff is needed, wait for 30 seconds. How to care for your spacer

“Take the spacer to bits and wash it in warm water DO NOT RINSE. Do not scrub its inside to prevent any scratches, and allow dripping dry. Do not rub dry. It should be cleaned at least once a week and more depending on frequently of use. It needs to be replaced when there is obvious breakage, any staining inside and if there is no sound of clicking from the way valve at the mouth piece end.” 

Ask: Does little one go to school? If yes, the school nurse should have a spacer too.



Offer leaflet and websites.

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10. Breast examination In this station, there is a man wearing a breast manikin. 

Greet the patient



introduce yourself



check her/his identity



Explain the procedure/ purpose of visit: “I am here to examine your breasts. For that I will be asking you to do some maneuvers and will be touching you. If you feel uncomfortable on any point, let me know I will stop the examination. ”



Privacy and Chaperone: “as you see we are in a private room and I will ask the examiner to be the chaperone.”



Consent: “can I proceed.” (Verbal consent)



Exposure/ position: Sitting, lying on 45 degrees and standing

“May I ask you kindly undress above the waist and sit down please.” 

“While examining I will verbalize my findings with the examiner.”



Inspection: all in sitting position, both the breasts. 1. “Could you please rest your hand on your thighs?” 

Both the breasts are symmetrical.



The level of nipple on the same line.



There are no skin changes or any pigmentation.



I cannot see any obvious lump.

2. “Could please place your hands on your hips and lean a bit forward?” 

I cannot see any lump or swelling becoming obvious.

3. “Can you lift your breasts with two fingers?” 

There is no eczema or fungal infection in infra-mammary region.

4. “Can you squeeze your nipple with your two fingers?” You must not squeeze. 

There is no blooding or discharge.

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5. “Please raise your hands and put behind the head please?” 

I cannot see Axillary fullness or supra clavicular fullness.



palpitation:

Palpation is in lying position and 45 degree. If it is not 45 degrees ask the examiner. Tell the patient: “Could you lie dawn on the couch?” “I assume the nurse is with me.” Warn the patient: “I m going to touch your breasts now. If you feel discomfort or tenderness please let me know.” 

Tell the examiner that: ideally I would start examine the normal breast. As there is time constraint, I would examine the affected breast first.



Temperature: Warm your hands and check for the local rise of temperature comparing with the opposite breast of each quadrant and say: “There is No rise in temperature.”



Tenderness: Start for the superficial palpitation; come to pathological site at the end. Do an ante clockwise palpation. Check the patient’s face for tenderness. “There is no tenderness in superficial palpation.”



Deep palpation: Warn the patient: “this time I m going to touch your breast deeper.”



Then do a deep palpation.



Check for peri-alveolar region for any swelling.



If a lump present, describe the lump.

1. site: upper outer quadrant 2. size: 2*2 3. surface: smooth / irregular 4. consistency: smooth / firm 5. check for tenderness by seeing the patient’s face 6. skin overlying is not fixed

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7. Move it horizontally and vertically and comment if it is fixed to deeper structures or not. 8. Check for mobility: horizontally, vertically. “In deep palpation, there is a mass of about 2cm in 2 cm, present in left upper outer quadrant, which is not tenderness in palpation, not attached to over lying skin, attached to deep structure and it is mobile.” Axillary lymph nodes: Inform the patient that: “I will be examining the few nodes in you. Could you stand up for me please? ” For checking patient’s right side, say: “Can you please put your right hand on my left shoulder? Put your right hand on his right shoulder and examine axilla with left hand. Examine apical, medial, anterior Ask the patient: “can you please cross your hands like this?” Go to the back of him and examine lateral and posterior lymph nodes. You can examine both sides together. “Ideally I finish my examination by examining supraclavicular lymph nodes.” “Thank you very much, you can dress up.” In 30 seconds ring say: Most probably it can be Breast cancer, Fibroadenoma, Fibroadenosis, Fatty necrosis. I will discuss this with my senior and I will do more investigation to rule out the diagnosis.

11. Bimanual Examination



“Ideally I would Greet the patient



Introduce myself.



Check her identity by asking her name.



Explain the procedure/ purpose of visit: “I would explain that I am going to examine her front passage by means of two gloved lubricated fingers to find the cause of her symptoms. If you are uncomfortable, let me know I will stop examination. ”

24



Privacy and Chaperone: I will ensure adequate privacy and a chaperone.



I would ask for a verbal consent before proceeding.



Before I start I will ask her to empty her water bag. (important)



Exposure/ position: “I would ask her to undress below her waist and lie flat on her back on the couch with both thighs and knees flexed. Knees apart and ankle together.”



I would check my trolley: 

A pair of clean gloves



Lubricating gel



Few wipes



Clinical waste bin



Good source of light (assume: “ideally I need a good source of light.”)

1. Wear gloves in both hands, and apply jell. 2. “I would tell the patient that I am going to inspect her front passage.” 3. Part the labia with the left index and left thumb 4. “On inspection, I can appreciate normal labia majora, labia minora, and clitoris. I cannot appreciate any scars, sinuses, bleeding, and discharge.” 5. “I cannot appreciate any abnormality with Bartholin’s cyst at 5 o’clock and 7 o’clock position.” (You can leave it.) 6. “I will ask the patient to cough to check for any stress incontinence.” 7. “I will warn my patient I am about to introduce my fingers in to her front passage.” if she feels any discomfort, she can let me know, and I will stop the procedure. 8. Part the labia with the left index and left thumb (your left hand is at the same position for inspection) and then introduce the right index and right middle finger. Move your left hand to suprapubic region. 9. When you are going in, tell the examiner, “I can appreciate normal vaginal rugosities.” 10. “I will ask the patient to strain to check for any prolapse.” 11. “I can appreciate the cervix, is downward and backward, it seems to be firm in consistency, and cervical os is closed and circular.” 12. Turn your fingers towards up (right hand) put your left hand on right side of manikin and check right lateral fornix and say: “right lateral fornix seems to be free.” Check for face for any tenderness” Ideally I check the face of the patient for any tenderness.” 13. Put your left hand on left side of manikin and check left lateral fornix with your right fingers and say: “left lateral fornix seems to be free.” Check for face for any tenderness” Ideally I check the face of the patient for any tenderness.”

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14. Go back to the middle (suprapubic region) with left hand and say: “I cannot appreciate posterior fornix because I need to do PR.” 15. “Anteriorly I can appreciate a mass through the anterior fornix. It most likes the uterus, seems to be firm in consistency, smooth in surface, anteverted, corresponded to 14 to 16 weeks gestation. 16. “I end up my examination by doing cervical excitation test.” move your fingers right left, check for tenderness. “I’ll check my patient for any tenderness.” 17. “I will warn my patient I am about to remove my fingers.” 18. Look at your fingers and say:” I’ll check for any bleeding or discharge.” 19. “I’ll thank the patient. Offer the tissue wipes to clean and ask her to dress up.” 20. “I’ll thank the chaperone.” 21. Tell the examiner that “most probably my diagnosis is fibroid, pregnancy, carcinoma of cervix or uterus, bladder or colon, it can be adenomyosis or piometra. I will consult with my seniors to confirm it.”

12. Examination of a lady in 3rd trimester of pregnancy 

Greet the patient



introduce yourself



check her/his identity



Explain the procedure/ purpose of visit: “I am here to examine her tummy for her well being and her baby’s (fetus) well being.”



Exposure/ position, privacy and Chaperone: “for the sake of examination she has to undress below her breasts, keeping underwear on. For which I will ensure adequate privacy and a chaperone.”



Consent: “can I proceed?” (Verbal consent)

Ask the examiner: “Where is the head end?” undress gently from the down side. Tip: never expose the breast. If examiner didn’t show the head end, undress manikin gently. If you expose the breast, Say sorry and roll down and go back the other side. Inspection:

26



On inspection of abdomen there is a distended abdomen consistent with the days of amenorrhea.



I can’t appreciate cutaneous signs of pregnancy, such as striae gravidarum and linea nigra.



There are no visible scars, veins peristalsis, bruises; umbilicus seems to be inverted inside.



There are no obvious fetal movements.

Palpation: 

I would ask mother if she is tender anywhere on abdomen before touching, and also ask if she feels discomfort or pain to let me know.

1. Temperature: Warm your hands and compare temperature with the other side. “There is no local rise in temperature.” 2. Tenderness: “Ideally I will look for any tenderness.” 3. Deep palpation: For palpation, start from the middle to up and come back to down. (by changing position)

 Lie: fix one hand and palpate with the other hand, while checking the sides.  (Lie: relationship of cephalocaudal axis (spinal column) of fetus to c. a. of mother) Longitudinal: parallel Transverse: fetal c.a. is 90° to woman’s spine Oblique lie: (unstable lie)

 Presentation: (99 % cephalic, breech, or shoulder.) palpate upper pole and lower pole separately. Lower pole= hard globular= head “on the lower pole, I can appreciate hard globular structure, most likely it is head.” Upper pole= round soft= buttocks “on the upper pole, I can appreciate soft round structure; most likely it is buttock of fetus.” Back of the fetus: (either left or right) Left side= irregular structure= limbs” on the left, I can appreciate irregular structures, most likely is limbs.”

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Right side= curved structure= back” on the right, I can appreciate curved structures, most likely is back of fetus.”



Engagement: Head is free or engaged in the pelvis 

Insertion of fingers (Figure 3)



Pawlik’s Grip (Figure 4)

“Presenting part is not engaged/ or is engaged.”



Height:

Measure the symphysio-fundal height from pubic symphysis to the maximum of the fundus with the help of measuring tape. The measurement in centimeters and should closely match the fetus gestational age in weeks, within 1 or 2 cm, e.g., a pregnant woman's uterus at 22 weeks should measure 20 to 24 cm. Fetus is clinically normal/ small/ large of dates If the fundal height is high: Polyhydramnios Multiple pregnancies Wrong datary Large baby Auscultation: 

The fetal heart is best heard in the back of the fetus



In cephalic or normal fetus, it is on either sides of the umbilicus (below and lateral to umbilicus) along the back of the fetus.



In the GMC manikin, there is actual heart sounds that means you should try to hear any sound on the tummy of the manikin with the help of the fetoscope provided to you. Wider part of fetoscope should be on the tummy and smaller part to your ear to listen to the heart of the fetus.



We have to listen it by fetoscope. Tell the examiner “Ideally I would confirm heart beats with the (CTG) Cardiotocography machine.”



Thank the patient and ask her to dress up

Summarize: 

The liquor volume appears clinically normal

These diagrams show the position of the baby and demonstrate the technique of ‘abdominal palpation’ - which means to examine by touching and feeling. The midwife or doctor uses

28

this technique during antenatal visit to examine fetal development. Baby in vertex - or 'head' down position. 1. Assessing the height of the fundus (lower area of the baby) - seeing how many fingerbreadths below the xiphisternum (bottom of the woman’s sternum bone) the baby is laying.

3. Pawlik's grip - the lower part of the uterus is grasped by the midwife to determine the presenting part.

5. Measuring the height of the fundus which generally corresponds to the number of weeks of gestation

2. Assessing the size of baby and feeling for the baby's back and limbs.

4. Pelvic palpation to determine the position of the baby's head.

6. Listening to the baby's heartbeat.

Baby in breech position - or 'bottom' down position

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1. Checking the height of the fundus (the highest point of the uterus). At 20 weeks this measurement is taken from the belly button. When the pregnancy is at term (37-40 weeks), it's taken from the lower end of the woman's sternum bone (the xiphisternum).

3. Using ‘Pawlik's grip’ to check that the baby's buttocks are in the pelvis.

2. Assessing the baby's position and size. Feeling for the baby's head, back and limbs.

4. Listening to the baby's heartbeat.

References: http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Antenatal_checks_of_your _baby?open

13. Taking a cervical smear 1. Ideally I would greet the patient, introduce myself to the patient, and check the patient’s identity. 2. I would explain the procedure and take a verbal consent. I would tell the patient that for purpose, I would be taking few cells from the neck of the womb. 3. I need to rule out the contraindication.    

Active menstruation Active vaginal bleeding Recent use of spermicidal gel Recent sexual intercourse

4. I would ask her to empty her bladder and undress below her waist. 5. I would maintain adequate privacy and ask for a chaperone. 6. I would ask her to lie on her back with thighs and knees bent; knees apart and ankles together. 7. checking trolley

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1. Adequate light (assume: “ideally I need a good source of light.”) 2. 1 pair of gloves (mostly assume) 3. A bowl of lukewarm normal saline (Assume) 4. Cusco’s speculum 5. clinical waste bin 6. few wipes Old method New method 7. Ayer’s spatula 7. cervical brush 8. Cytobrush 8. ThinPrep: rinse cervical brush 9. fixator 10X 10. 2 pre-labelled slides 9. (or) SurePath: drop the detachable part into it.

Procedure: (new method) 1. Wear pairs of sterile gloves. ( maybe you assumed) 2. Take the speculum and prepare it. Hold it with your right hand. 3. “I will warn the patient that I’ll be touching her.” 4. Then I will sit on a chair in front of her. 5. Part the labia with left hand. 6. “On inspection I cannot appreciate any sinus, any discharge or bleeding. I can appreciate normal labia minora and majora.” 7. “Ideally I deep and warm the speculum in the Lukewarm normal saline.” (For warming) 8. “I will apply jell according to hospital protocol.” 9. “I’ll warn the patient I am about to insert the speculum.” 10. Warn the patient that you are going to introduce speculum/instrument in her front passage. 11. Part the labia, introduce the speculum, rotate and open the blades. 12. When

you

visualise

the

cervix,

self

retain

the

speculum. 13. Take

the

cervical

brush,

and

insert

it

through

speculum. 14. Verbalise: “I can visualise the cervix, no bleeding, and no foreign body.” The os is closed and there is no cervical erosion. 15. Rotate it clockwise. (5 times) 16. Take it out gently and rinse it inside the ThinPrep, up and down for 10 times. 17. Discard the cervical brush in the waste bin.

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18. Close the bath and say: “ideally I label it and I send it to the lab.” 19. “I‘ll warn the patient that I am about to remove the speculum.” release the screw, unlock the blades, and remove it little outside (to make the cervix free), de-rotate the speculum. Check it for bleeding and discharge. “I’ll send it for sterilization.” 20. Remove your gloves and throw it in the clinical waste bin. Or if you assumed u r gloved say: “I’ll thank my patient, remove my gloves and give her wipes to clean herself and ask her to dress up.” 21. “I’ll inform her that she might experience spotting for few days; and her result will send to her GP in 2-3 weeks time.” 22. I would thank the chaperone. 23. Thank the examiner.

Procedure: (old method) 13. Insert the spatula under direct vision. Rotate it to 360 degree and take the spatula out and apply it on the slide. 14. Throw the spatula in the clinical waste bin and apply fixator to the slide. 15. Insert the Cytobrush under direct vision. Rotate it to 180 degree. Take it out, roll it on pre-labelled slide, discard the Cytobrush in the clinical waste bin and apply fixator to the slide.

14.Per rectal examination 1. Ideally I would greet the patient, introduce myself to the patient, and check the patient’s identity. 2. I would explain the procedure and take a verbal consent I would tell the patient that I am going to examine the glands situated at the base of the water bag (bladder) by introducing my gloved and lubricated finger through his back passage. 3. I would take a verbal consent before proceeding.

32

4. I would maintain adequate privacy and ask for a chaperone. 5. I would ask him to undress below her waist. I would ask him to lie on his left side and fold his legs as close as possible to his chest and the buttocks at the edge of the table. 6. (Check the correct position of the Manikin) 7. checking trolley 1. 2. 3. 4. 5.

clean pair of gloves Lubricating Gel few wipes clinical waste bin adequate light

Procedure: 1. Wear pairs of gloves. 2. “I would warn the patient that I am going to touch his buttocks.” Inspection: bend and part his buttocks with left hand. 1. “On inspection, I cannot appreciate any discharge, any bleeding, any redness, any sinuses or scars.” 2. I will ask the patient to strain to check for any rectal prolapse.” Examination: apply jell on your index right finger. 1. Place the pulp of your finger on his sphincter, giving some time for sphincter to relax and slowly introduce your finger. (If the patient finds it very painful, stop the procedure.) Verbalise: “I’ll keep it for 2 seconds to relax his sphincter.” 2. “I cannot appreciate any fecal.” 3. Turn your finger to the right side. (up) “I can appreciate the right lateral wall seems to be free. I’ll check the patient’s face for any tenderness.” 4.

Turn your finger to the posterior side. (back or left) “I can appreciate the posterior wall seems to be free. I’ll check the patient’s face for any tenderness.”

5. Turn your finger to the left side. (down) “I can appreciate the left lateral wall seems to be free. I’ll check the patient’s face for any tenderness.” 6. Sit Dawn rotate the palm of your finger and say: anteriorly I can feel a gland, which feels like a prostate as it is. It has got two lobes, I can feel the median sulcus and it’s normal in size. The surface is smooth, it’s firm in consistency. Anterior rectal mucosa is free. I will check for the tenderness by seeing the patient’s face. 

Tip: The lobe which is dawn is the left lobe.

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7. “I would warn the patient that you I am about to remove my finger.” before which I will ask him to grip my finger to check for anal tone. 8. Remove your finger; see the glove for any blood, mucosa or any faeces. 9. “I would thank the patient for his cooperation, I would give him wipes, to wipe himself and ask him to get dressed.” 10. “I would tell him I will get beck to him after discussing my finding with my senior.” 11. “I would thank the chaperone.” Discuss your findings with the examiner. 3. there are 5 kind: 

Normal prostate: median sulcus is normal, consistency is firm.



Bilateral benign enlargement BPH: Median sulcus is depressed



Unilateral benign enlargement BPH



Bilateral carcinoma: “I can’t appreciate median sulcus (absent). It is hard and fixed to the anterior mucus.”



Unilateral carcinoma: “surface is irregular. Anterior mucus is fixed/ mobile.” Size: enlarged in all except normal. Medial sulcus: absent in bilateral carcinoma. Surface: smooth in all except carcinoma (irregular) Anterior rectal mucosa: Freely mobile: normal, BPH, unilateral benign enlargement Fixed: both carcinoma

15.Testicular Examination

1. Ideally I would greet the patient, introduce myself to the patient, and check the patient’s identity.

2. I would explain the procedure and take a verbal consent I would tell the patient that I am here to examine his private parts down below.

3. I would take a verbal consent before proceeding. 4. I would maintain adequate privacy and ask for a chaperone.

34

5. I would ask him to undress below her waist. I would request him to stand up for the purpose of examination. I would ask him to lift the water pipe up during the examination.

6. (Check the correct position of the Manikin: it is a very small manikin). 7. Ask the examiner: “May I know this is the anatomical position of manikin?” If he says yes, it means this is anterior part. (R,L)

8. Ask the examiner: “can I hold the manikin?” 9. Hold the manikin with your left two fingers vertically. (index and middle) Inspection: On inspection … 1. “I can appreciate normal testicular rugosities.” 2. “I cannot appreciate any redness, sinuses and discharge.” 3. “I’ll ask my patient to cough to check for any hernia.” Don’t inspect back of the testis. 

Tip: left testis is a little bit lower than right side.

Palpation: 1. “I’ll warn my patient I will be touching him.” 2. Temperature: “Ideally I’ll check for any localised rise temperature by comparing with the thighs.” 3. Tenderness: “I will warn my patient I will be touching him deeper, checking for any tenderness by looking to the patient’s face.”

4.

Deep palpation:” I’ll warn my patient I will be touching him deeply. On the left side, I can appreciate spermatic cord, epididymis and left testis. In case of mass, say: “I can appreciate a mass in the anterior aspect of left side,

35

round, 2 cm in diameter, unattached to overlying skin, unattached to deep structure.” 

Tip: start palpating from up to down. Location of lumps in manikin Right testis

Left testis

Anterior

Anterior

Posterior- medial

Lateral

Special tests: 1.

Fluctuation test: “I’ll like to do fluctuation test.” a. For the right side: hold the manikin with your 2 left fingers vertically and hold it crossly with 2 fingers of right hand and b. For the left side: change hands. hold the manikin with your 2 right fingers vertically and hold it crossly with 2 fingers of left hand and

2.

Transillumination test: (Hydrocele) “can I put the manikin on the table?”



You need torch and luminoscope: “can I have a torch and luminoscope?”



Put luminoscope on the right and left testis, respectively and light the torch from lateral side and look through the luminoscope.

 3.

Verbalise: “Transillumination test is negative in both sides.” Prehn’s test: “Ideally I do Prehn’s test, by asking my patient to lift his private parts.”

Prehn’s test shows whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion. According to Prehn's sign, the physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion.  Negative Prehn's sign indicates no pain relief with lifting the affected testicle, which points towards testicular torsion which is a surgical emergency and must be relieved within 6 hours.  Positive Prehn's sign indicates there is pain relief with lifting the affected testicle, which points towards epididymitis.

10. “I’ll thank the patient and ask him to dress up.”

36

11. “I’ll thank the chaperone.” 12. “Most probably it is either a benign or malignant testicular tumour, for this I need to consult with my senior. I finish my examination by checking PR, Lymph node examination, abdominal examination and spine. I want to consult my senior to do ultrasound and excisional biopsy”

13. Thank the examiner.

16. Eye (Fundoscopy)

1. Greet the patient 2. Introduce yourself 3. Check her/his identity 4. Explain the procedure/ purpose of visit: “I am here to examine the back of your eye with a special instrument called ophthalmoscope. For that I will be shining a bright light into your eyes. During the examination I will be coming very close to you. If you are uncomfortable any time, tell me.”

5. Exposure/ position: “you can blink during the procedure but don’t move your head and sit comfortably I will be dimming the light of room and you should fix your vision at a distant object. My head may disturb your focus of vision but please focus on distance as far as you can.”

6. privacy and Chaperone 7. take a verbal consent 8. Role out the contraindications (for dilating drops): During procedure I will be using some dilating drops; I d like to ask you, have you ever diagnosed with glaucoma? Do you see halos around the light? No… after procedure you might experience dim or blur vision; therefore you are advised not to drive home alone or to sign any important legal documents during the day.” Tip: In the exam you may have to examine for red reflex and inspection on a simulator /examiner and then proceed to the manikin for the rest of examination. 1. Inspection: coming at eye level “can you look at me?” 

“I can not appreciate any swelling, any ptosis, and any redness.”

37

“Could you look at the ceiling please?” go behind the patient and say: “I cannot



appreciate any proptosis.” 2. check ophthalmoscope: (make sure it is working) 

check power of lens (negative numbers are red, positive are black or grey)



check light – big full moon



no glasses; not you nor the patient

1. Right eye of patient, Right eye of examiner, Right hand of examiner. 2. Left eye of patient, Left eye of examiner, Left hand of examiner. 3. Do a red reflex: He is sitting and you are standing. Bend a little bit for making 30 degrees angle. Shine the light to his eye, then bring your eye near the ophthalmoscope and about one arm distance you can see the red reflex. Verbalize: “Media is clear so I precede the Funduscopy.” 4. Go to the manikin, sit on a chair and say: In real patient, I would have examined with funduscope light on but in exam since there is a bright light shining from back, I may have reflection or glare so I would like to examine now with funduscope light switched off. 5. optic disc: 

colour



margin



contour



Cup Disc Ratio (CD Ratio)

6. origin of blood vessels 7. periphery and rest of retina 8. Macula

Normal findings: optic disc:

Always Nasal



colour

Pinkish pale or pinkish yellow



margin

Well defined



contour

Circular or rounded



Cup Disc Ratio (CD Ratio)

0.3 – 0.5

origin of blood vessels periphery and rest of retina Macula

Straight not torturous, A:V 2:3 Healthy and normal: no exudates, no hemorrhage Healthy and normal

http://www.nhsrecruits.com/plab.asp

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Normal funduscope “I can see the Optic disc pinkish pale or pinkish yellow in colour, well defied margins, circular in contour, Cup Disc ratio is normal. Vessels are originating from CD, straight not torturous, normal in caliber. Periphery and rest of retina and macula appears healthy and normal. Therefore my diagnosis is a NORMAL FUNDUS.” Optic atrophy “I can see the Optic disc pale or chalky white in colour, well defined margins, and circular in contour, cup cannot be appreciated. Origins of vessels are not clear. They are straight and normal in caliber. Periphery and rest of retina and macula appears healthy and normal. Therefore my diagnosis is an OPTIC ATROPHY.” Disc cupping “I can see the Optic disc pinkish pale in colour, ill defied margins, and Cup Disc ratio is increased in size. Origins of vessels are not clear. They are straight, not tortuous and normal in caliber. Periphery and rest of retina and macula appears healthy and normal. Therefore my diagnosis is DISC CUPPING, Most probably due to glaucoma.”

The cup-to-disc ratio here is about 0.8—much greater than the physiologic limit of 0.5! Papilloedema

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“I can see the Optic disc which is swollen, edematous and bulging, margins are blurred or ill defined, and Cup cannot be appreciated. Origins of vessels are not clear. They are engorged, tortuous and congested. Periphery and rest of retina appears hyperemic. Therefore my diagnosis is PAPILLOEDEMA.”

Central retinal vein occlusion “I cannot appreciate optic disc. Origins of vessels are not clear. But veins are engorged, tortuous and congested. I can appreciate flame shaped hemorrhages and hard exudates. Periphery and rest of retina appears hyperemic and seems to be a stormy sunset or tomato splash appearance. Therefore my diagnosis is CENTRAL RETINAL VEIN OCCLUSION.”

40

Senile macular degeneration “I can see the Optic disc which is pale towards temporal side. Margins are well defined, circular in contour, cup cannot be appreciated. Origins of vessels are not clear. They are straight, not tortuous and normal in caliber. I can appreciate macula, there are few unusual pigmentation around it and are also scattered around periphery of retina. Therefore my most probably diagnosis is SENILE MACULAR OR AGE RELATED MACULAR DEGENERATION.”

Background diabetic retinopathy (non-proliferative) “Optic disc is not clear. Origins of vessels are not so clear. They are straight, not tortuous. I can appreciate hard exudates which are numerous in number, discrete, having irregular surface. Margins are ill defined. I can also appreciate dot and blot hemorrhages and few micro aneurysms. Therefore my most probably diagnosis is BACKGROUND DIABETIC RETINOPATHY.”

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Pre-proliferative diabetic retinopathy “By initial description of background, I can appreciate single soft exudates in inferior arcade and few more in superior arcade, fluffy in appearance, soft surface and having well defined margins. I can appreciate hard exudates, dot and blot hemorrhages and few micro aneurysms. Therefore my most probably diagnosis is PREPROLIFRATIVE DIABETIC RETINOPATHY.”

Proliferative diabetic retinopathy “I can appreciate new vascularation around Optic disc and in superior quadrant. I can appreciate hard exudates, dot and blot hemorrhages and few micro aneurysms. Therefore my most probably diagnosis is PROLIFERATIVE DIABETIC RETINOPATHY.”

Sub- hyaloids haemorrhage “I can appreciate massive extensive haemorrhage in inferior cascade which is most probably a sub hyaloid haemorrhage. I can also appreciate a few hard exudates, dot and blot hemorrhages and few micro aneurysms. Therefore my most probably diagnosis is BACKGROUND DIABETIC RETINOPATHY.”

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Laser photocoagulation “I can appreciate few scar marks at the periphery of retina, which are homogenously distributed throughout periphery and are most probably due to laser burns. Therefore my most probably diagnosis is DIABETIC RETINOPATHY treated with LASER PHOTOCOAGULATION.”

Hypertensive retinopathy “I can see diffuse narrowing and tortuosity of arteries is superior as well as inferior arcade. I can also appreciate AV nipping in both arcades and silver wire appearance seen running through arteries. Therefore my most probably diagnosis is hypertensive RETINOPATHY.”

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17. Otoscopy

1. Greet the patient 2. Introduce yourself 3. Check her/his identity 4. Explain the procedure/ purpose of visit: “I am here to examine the inside of your ear with a special instrument called otoscope. During the examination I will be coming very close to you. If you are uncomfortable any time, tell me.” I will perform a special test with another instrument called tuning fork.

5. Exposure/ position: “you can sit with head and neck slightly tiltes to the other side.” 6. privacy and Chaperone 7. take a verbal consent 8. check instruments: Otoscope in working position Tuning fork- 512 Hz or 256 Hz

o 

o 

Inspection: First inspect both ears and then say: “On inspection, there is no swelling, no redness, no signs of trauma, external discharge wax. Palpation: Temperature: Warm your hands and compare each ear with lateral of neck. “There is no local rise of temperature.”

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Tenderness: you are at the right side of the patient; examine the ears on by one by looking at his face for tenderness. 1. pre-auricular – pulp of finger 2. auricular – thumb and index finger 3. post auricular – pulp of finger 

Role out the contraindications:  Tragus test: “tragus test is negative on the right side. I will precede Otoscopy.”

Otoscopy:

1. Change the sputum. 2. Make sure it is working 3. Hold it like a pen in your right hand. 4. Hold the ear backward, upward with left thumb and index fingers.

5. Before going inside, check external for any bleeding or foreign body. “I cannot appreciate any bleeding, any foreign body.”

6. Don’t talk while doing Otoscopy. 7. take it out; Check for any bleeding or discharge. “I’ll check speculum for any bleeding or discharge. And discard it. I’ll thank the patient.”

8. I can appreciate… my most probably diagnosis is … 9. Description of slides: Comment on: 1. Cone of light 2. Handle of malleus 3. Umbo 4. Annulus 5. Pars flaccida/ pars tensa

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Normal tympanic membrane: “I can appreciate cone of light in antero- inferior quadrant, handle of malleolus in anterio- superior quadrant; and umbo in the junction of cone of light and handle of malleolus. No retraction, no bulging, no air fluid level, no perforation, no bleeding, no discharge, no wax over tympanic membrane. Therefore, my diagnosis is normal tympanic membrane.” WAX “I can appreciate tympanic membrane, obstructed with a brown material; colour of wax in transition from pale yellow, golden yellow, golden brown, finally brown. Cone of light, handle of malleolus and umbo cannot be appreciated. Therefore, my diagnosis is wax over tympanic membrane.”

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Acute otitis media with effusion “I can see tympanic membrane which is red, inflamed, congested, oedematous, and tense. I can appreciate an air fluid level in antero superior and postero-superior quadrants. Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. Therefore, my diagnosis is acute otitis media with effusion.”

Acute otitis media without effusion “I can see tympanic membrane which is red, inflamed, congested, oedematous, and tense. There is no air fluid level. Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. Therefore, my diagnosis is acute otitis media without effusion.”

Acute otitis media with bulging “I can see tympanic membrane which is red, inflamed, congested, oedematous, and tense. I can appreciate bulge in TM which is the postero-inferior quadrant due to pus or fluid behind TM. Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. Therefore, my diagnosis is acute otitis media with bulging which may progress to perforation or it is an impending perforation.”

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Central perforation with tympanosclerosis “I can see tympanic membrane. Cone of light and umbo cannot be appreciated; but can appreciate handle of malleolus which is distorted. I can appreciate a large central perforation in antero-inferior and postero-inferior quadrants. I can also appreciate few white calcified plaques over tympanic membrane. Therefore, my most probably diagnosis is Central perforation with tympanosclerosis.”

Tympanosclerosis “I can see tympanic membrane Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. I can also appreciate white calcified plaque in antero- superior quadrant. Therefore, my most probably diagnosis is tympanosclerosis.”

Grommet “I can see tympanic membrane Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. I can also appreciate a foreign body in postero inferior quadrant, most probabely a grommet. Therefore, my most probably diagnosis is grommet in TM.”

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Secretory otitis media “I can see tympanic membrane which is red, inflamed, congested, oedematous, and tense. There is no air fluid level or bulge. Cone of light, handle of malleolus and umbo cannot be appreciated. Annulus can be appreciated. Therefore, my diagnosis is secretory otitis media.”

Tuning fork test:

Rhine’s test: “this is a buzzing instrument. I will be placing at two point – show the patient while saying- tell me where you hear that?” place it on the mastoid bone and in front of hearing canal. AC>BC = normal or sensorineural … AC< BC conductive CSSO (Conductive Same Sensorineural Opposite) Weber’s test: “this time, I will be placing it on your forehead, please tell me in which ear you hear better?” (No lateralisation= normal Weber’s test)

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References: http://medweb.cf.ac.uk/otoscopy/newpage7.htm

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