Clinical Skills for OSCEs, 5e (Jun 30, 2015)_(1907904662)_(Scion Publishing Ltd) - Copy

• Remove the needle from the vein and apply pressure on the puncture site for at least 30 seconds the patient may assist with this, or you may use tape or plaster.. • Ensure that baselin

OSCEs C L I N I C A L S K I L L S F O R

55

SENIOR EDI T OR

Neel Burton

BSc (Hons), MBBS, MRCPsych, MA (Phil), AKC

Tutor in Psychiatry Green Templeton College University of Oxford

S T UDEN T EDI T OR

John Lee Allen

3rd Year GEM Student

Imperial College London

SENIOR EDI T OR

Neel Burton

BSc (Hons), MBBS, MRCPsych, MA (Phil), AKC

Tutor in Psychiatry Green Templeton College University of Oxford

S T UDEN T EDI T OR

John Lee Allen

3rd Year GEM Student

Imperial College London

Life is short, the art long, opportunity fleeting,

experiment treacherous, judgement difficult.

Hippocrates (c 460–370 BC) Aphorisms, Aph 1.

Fifth edition © Neel Burton, 2015Fifth edition published in 2015 by Scion Publishing LtdISBN 978 1 907904 66 0

First edition published in 2003 by BIOS Scientific PublishersSecond edition published in 2006 by Informa HealthcareThird edition published in 2009 by Scion Publishing LtdFourth edition published in 2011 by Scion Publishing LtdAll rights reserved No part of this book may be reproduced or transmitted, in any form or by any means, without permission

A CIP catalogue record for this book is available from the British Library

Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Rd, Banbury OX16 9UX, UKwww.scionpublishing.com

Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from sources believed by us to be reliable However, while every effort has been made to ensure its accuracy,

no responsibility for loss or injury whatsoever incurred from acting or refraining from action as

a result of the information contained herein can be accepted by the authors or publishers

Readers are reminded that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications, and procedures are based on current best practice, there may be specific practices which differ between communities You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the region or country in which you are practising

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention

Registered names, trademarks, etc used in this book, even when not marked as such, are not

to be considered unprotected by law

Cover design by Andrew Magee Design Limited

Typeset by Phoenix Photosetting, Chatham, Kent, UKPrinted in the UK

7 Intramuscular, subcutaneous, and intradermal drug injection 14

9 Examination of a superficial mass and of lymph nodes 18

II CARDIOVASCULAR AND RESPIRATORY MEDICINE

14 Peripheral vascular system examination 33

15 Ankle-brachial pressure index (ABPI) 36

20 Drug administration via a nebuliser 50

III GI MEDICINE AND UROLOGY

Second edition published in 2006 by Informa HealthcareThird edition published in 2009 by Scion Publishing Ltd

Fourth edition published in 2011 by Scion Publishing LtdAll rights reserved No part of this book may be reproduced or transmitted, in any form or by

any means, without permission

A CIP catalogue record for this book is available from the British Library

Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Rd, Banbury OX16 9UX, UKwww.scionpublishing.com

Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from sources believed by us to be reliable However, while every effort has been made to ensure its accuracy,

no responsibility for loss or injury whatsoever incurred from acting or refraining from action as

a result of the information contained herein can be accepted by the authors or publishers

Readers are reminded that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications, and procedures are based on

current best practice, there may be specific practices which differ between communities You should always follow the guidelines laid down by the manufacturers of specific products and

the relevant authorities in the region or country in which you are practising

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent

reprints or editions any omissions brought to our attention

Registered names, trademarks, etc used in this book, even when not marked as such, are not

to be considered unprotected by law

Cover design by Andrew Magee Design Limited

Typeset by Phoenix Photosetting, Chatham, Kent, UKPrinted in the UK

vi Contents

IV NEUROLOGY

33 Motor system of the upper limbs examination 86

34 Sensory system of the upper limbs examination 89

35 Motor system of the lower limbs examination 91

36 Sensory system of the lower limbs examination 95

37 Gait, co-ordination, and cerebellar function examination 97

V PSYCHIATRY

48 Assessing capacity (the Mental Capacity Act) 127

49 Common law and the Mental Health Act 130

VI OPHTHALMOLOGY, ENT AND DERMATOLOGY

51 Vision and the eye examination (including fundoscopy) 136

52 Hearing and the ear examination 140

53 Smell and the nose examination 145

54 Lump in the neck and thyroid examination 147

VII PAEDIATRICS AND GERIATRICS

vii Contents

VIII OBSTETRICS, GYNAECOLOGY, AND SEXUAL HEALTH

74 Speculum examination and liquid based cytology test 200

80 Combined oral contraceptive pill (COCP) explanation 217

IX ORTHOPAEDICS AND RHEUMATOLOGY

X EMERGENCY MEDICINE AND ANAESTHESIOLOGY

92 Choking 250

95 The primary and secondary surveys 258

96 Management of medical emergencies 260

– acute myocardial infarction 261

97 Bag-valve mask (BVM/’Ambu bag’) ventilation 266

98 Laryngeal mask airway (LMA) insertion 267

101 Patient-Controlled Analgesia (PCA) explanation 275

102 Epidural analgesia explanation 276

viii Contents

XI DATA INTERPRETATION

104 Blood glucose measurement 280

105 Urine sample testing/urinalysis 282

106 Blood test interpretation 284

107 Arterial blood gas (ABG) sampling 290

108 ECG recording and interpretation 294

109 Chest X-ray interpretation 306

110 Abdominal X-ray interpretation 311

XII PRESCRIBING AND ADMINISTRATIVE SKILLS

XIII COMMUNICATION SKILLS

John Lee Allen

3rd Year GEM student

Imperial College London

Daniel Ashmore

5th Year Medical Student

University of Leeds

Vartan Balian

House Officer (FY1)

Warrington & Halton NHS Foundation Trust

Daniel Campbell

5th Year Medical Student

Barts and the London School of Medicine and

Dentistry (QMUL)

Anthony Carver

House Officer (FY1)

East Kent Hospitals University NHS Foundation

Trust

Mohsin Chaudhary

5th Year Medical Student

St George’s Hospital Medical School

2nd Year Medical Student

Barts and the London School of Medicine and

Dentistry (QMUL)

Ali Rezaei Haddad

2nd Year Medical Student

Jane Hamilton

4th Year Medical Student University of Glasgow

Randeep Singh Heer

3rd Year Medical Student King’s College London

x Contributors

Charlotte McIntyre

Core Surgical Trainee

Imperial College Healthcare NHS Trust

Preface

The first edition of Clinical Skills for OSCEs came out in 2003, a slim volume formed from my revision

notes together with a few contributions from my then housemates At the time, OSCEs had suddenly

become very big, but medical publishing lagged behind, leaving our generation of medical students

to scramble for preparation materials

All the big houses rejected my publishing proposal, mostly, I think, because it came from a 23-year-old

medical student I persisted, and in the end, a small publishing house called Bios took a chance on the

book Today Bios, having been bought out, is no more But, remarkably, the book is still here, having

been through no less than three publishers and five editions

Back in 2003, I could not have dreamt that in 12 years’ time I would be working alongside a team of

40 medical students, junior doctors, publishers, designers, etc to produce the fifth edition of my little

‘recipe book’ Of course, the book is not so little any more, and, in truth, contains much more than I

ever knew as a medical student or even a house officer – a testament (I hope) to the rising standards

of medical education

To me, this fifth edition very much represents a return to the roots The first edition boasted having

been ‘written by students for students’, and with the fifth edition this is once again the case I am

hugely indebted to each and every student contributor and to the student editor, John Allen, for

having reinvigorated these pages, advising on everything from the broad topics covered to the specific

language used

Students are the lifeblood of this book, which, to remain useful and relevant, has to be alive to their needs

and concerns I do not just mean the student contributors, but all students, including – of course – you

Please do get in touch with me if you have any ideas, however small or large, for improving this book, or

if you would like to form part of the team for the next edition

Good luck with your exams!

Neel Burton

www.neelburton.com

OSCE tips

• Don’t panic Be philosophical about your exams Put them into perspective And remember

that as long as you do your bit, you are statistically very unlikely to fail Book a holiday to a sunny Greek island starting on the day after your exams to help focus your attention

• Read the instructions carefully and stick to them Sometimes it’s just possible to have

revised so much that you no longer ‘see’ the instructions and just fire out the bullet points like

an automatic gun If you forget the instructions or the actor looks at you like Caliban in the ror, ask to read the instructions again A related point is this: pay careful attention to the facial expression of the actor or examiner Just as an ECG monitor provides live indirect feedback

mir-on the heart’s performance, so the actor or examiner’s facial expressimir-on provides live indirect feedback on your performance, the only difference being – I’m sure you’ll agree – that facial expressions are far easier to read than ECG monitors

• Quickly survey the cubicle for the equipment and materials provided You can be sure that

items such as hand disinfectant, a tendon hammer, a sharps bin, or a box of tissues are not just random objects that the examiner later plans to take home

• First impressions count You never get a second chance to make a good first impression As

much of your future career depends on it, make sure that you get off to an early start And who knows? You might even fool yourself

• Prefer breadth to depth Marks are normally distributed across a number of relevant domains,

such that you score more marks for touching upon a large number of domains than for exploring any one domain in great depth Do this only if you have time, if it seems particularly relevant, or if you are specifically asked Perhaps ironically, touching upon a large number of domains makes you look more focused, and thereby safer and more competent

• Don’t let the examiners put you off or hold you back If they are being difficult, that’s their

problem, not yours Or at least, it’s everyone’s problem, not yours And remember that all that

is gold does not glitter; a difficult examiner may be a hidden gem

• Be genuine This is easier said than done, but then even actors are people By convincing

your-self that the OSCE stations are real situations, you are much more likely to score highly with the actors, if only by ‘remembering’ to treat them like real patients This may hand you a merit over a pass and, in borderline situations, a pass over a fail Although they never seem to think

so, students usually fail OSCEs through poor communications skills and lack of empathy, not through lack of studying and poor memory

• Enjoy yourself After all, you did choose to be there, and you probably chose wisely If you

do badly in one station, try to put it behind you It’s not for nothing that psychiatrists refer to

‘repression’ as a ‘defence mechanism’, and a selectively bad memory will do you no end of good

• Keep to time but do not appear rushed If you don’t finish by the first bell, simply tell the

examiner what else needs to be said or done, or tell him indirectly by telling the patient, for example, “Can we make another appointment to give us more time to go through your treatment options?” Then summarise and conclude Students often think that tight protocols impress examiners, but looking slick and natural and handing over some control to the patient

is often far more impressive And probably easier

xiii

xiv OSCE tips

• Be nice to the patient Have I already said this? Introduce yourself, shake hands, smile, even

joke if it seems appropriate – it makes life easier for everyone, including yourself Remember to explain everything to the patient as you go along, to ask him about pain before you touch him, and to thank him on the second bell The patient holds the key to the station, and he may hand

it to you on a silver platter if you seem deserving enough That having been said, if you reach the end of the station and feel that something is amiss, there’s no harm in gently reminding him, for example, “Is there anything else that you feel is important but that we haven’t had time

to talk about?” Nudge-nudge

• Take a step back to jump further Last minute cramming is not going to magically turn you

into a good doctor, so spend the day before the exam relaxing and sharpening your mind Go

to the country, play some sports, stream a film And make sure that you are tired enough to fall asleep by a reasonable hour

• Finally, remember to practise, practise, and practise Look at the bright side of things: at

least you’re not going to be alone, and there are going to be plenty of opportunities for good conversations, good laughs, and good meals You might even make lifelong friends in the proc-ess And then go off to that Greek island

Hands must be washed before every episode of care that involves direct contact with a patient’s skin,

their food or medication, invasive devices, or dressings, and after any activity or contact that potentially

contaminates the hands

The procedure

• Your arms should be bare below the elbows: roll up your sleeves, remove your watch, any

jewel-lery, and fake nails or nail varnish (fingernails should be kept short, ideally not exceeding 1 mm from the edge of the nail bed)

• Turn on the hot and cold taps with your elbows and thoroughly wet your hands once the water

is warm

• Apply liquid soap (used in most hospital situations) or disinfectant from the dispenser (used

in the operating theatre) Disinfectants include pink aqueous chlorhexidine (‘Hibiscrub’) and brown povidone iodine (‘Betadine’) Alcohol hand rubs offer a quicker alternative to liquid soaps and disinfectants, though they should be applied for at least 20–30 seconds Mere soap bars are to be avoided

• Wash your hands using the Ayliffe hand washing technique (see Figure 1 overleaf):

➀ palm to palm

➁ right palm over left dorsum and left palm over right dorsum

➂ palm to palm with fingers interlaced

➃ back of fingers to opposing palms with fingers interlocked

➄ rotational rubbing of right thumb clasped in left palm and left thumb clasped in right palm

➅ rotational rubbing, backwards and forwards, with clasped fingers of right hand in left palm and clasped fingers of left hand in right palm

• Rinse your hands thoroughly

• Turn the taps off with your elbows

• Dry your hands with a paper towel and discard it in the foot-operated bin, remembering to use

the pedal rather than your clean hands!

• Consider applying an emollient if you have dry skin

[Note] Alcohol hand rubs are ineffective against spores and should be avoided if there is contamination with biological

remnants such as faeces, blood, or urine; if there is visible dirt; or if the patient is infected with Clostridium difficile.

2 Station 1 Hand washing

Figure 1 Ayliffe hand washing technique:

1 Palm to palm

2 Right palm over left dorsum and left palm over right dorsum

3 Palm to palm fingers interlaced

4 Backs of fingers to opposing palms with fingers interlocked

5 Rotational rubbing of right thumb clasped in left palm and vice versa

6 Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

State that you would:

• Change into scrubs and ensure that your arms are bare below the elbows

• Exchange your shoes for theatre clogs or use plastic overshoes

• Don a theatre cap, tucking all your hair underneath it

• Enter the scrubbing room and put on a surgical mask, ensuring that it covers both your nose

and mouth

• Depending on the clinical situation, consider wearing eye protection (goggles/visor)

• Open out a sterile gown pack on a clean, flat surface without touching the gown.

• Open out a pair of sterile gloves (in your size) using a sterile technique, letting them drop into

the sterile field created by the gown pack

Handwashing

• Open a brush packet containing a nail brush and nail pick

• Turn on the hot and cold taps and wait until the water is warm

From here on, keep your hands above your elbows at all times.

The social wash

• Wash your hands with liquid disinfectant, either pink chlorhexidine (‘Hibiscrub’) or brown

povidone iodine (‘Betadine’), lathering up your arms to 2 cm above your elbows

The second wash

• Use the nail pick from the brush packet to clean under your fingernails

• Dispense soap onto the sponge side of the brush and use the sponge to scrub from your

fingertips to 2 cm above your elbows (30 seconds per arm)

Dispense soap using your elbow or a foot pedal, not your hands.

• To rinse, start from your hands and move down to your elbows so that the rinse water drips

away/down from your hands without re-contaminating them

The third wash

• Using the brush side of the brush, scrub your fingernails (30 seconds per arm)

4 Station 2 Scrubbing up for theatre

• Using the sponge side of the brush, scrub:

– each finger and interdigital space in turn (30 seconds per arm)– the palm and back of your hands (30 seconds per arm)– your forearms, moving up circumferentially to 2 cm above your elbows (30 seconds per arm)

Remember to keep the brush well-soaped at all times.

• To rinse, start from your hands and move down to your elbows

• Turn the taps off with your elbows

After handwashing

• Use the two towels in the gown pack to dry your arms from the fingertips down (one towel

per arm)

• Pick up the gown from the inside and shake it open, ensuring that it does not touch anything

• Put your arms through the sleeves, but do not put your hands through the cuffs

• Put on the gloves without touching the outside of the gloves Practise this – it’s not easy!

• Ask an assistant to tie up the inside of the gown, and to hold on to one side of the card (attached

to the front of the gown) while you rotate to tie up the outside of the gown yourself

After scrubbing up, keep your hands in front of your chest and do not touch any non-sterile areas, including your mask and hat.

Specifications: The station consists of an anatomical arm and all the equipment that might be

required Assume that the anatomical arm is a patient and take blood from it

Before starting

• Introduce yourself to the patient

• Confirm his name and date of birth

• Explain the procedure and obtain his consent For example, “I would like to take a blood sample

from you to check how your kidneys are working This is a quick, simple, and routine procedure which involves inserting a small needle into one of the veins on your arm You will feel a sharp scratch when the needle is inserted, and there may be a little bit of bleeding afterwards Do you have any questions?”.

• Ask him from which arm he prefers to have (or normally has) blood taken

• Ask him to expose this arm

• Gather the equipment in a clean tray

The equipment

In a clean tray, gather:

• A pair of non-sterile gloves

• A tourniquet

• Alcohol wipes (sterets)

• A 23G (blue) needle/‘butterfly’ and Vacutainer holder

• The bottles appropriate for the tests that you are sending for (these vary from hospital to hospital, but are generally yellow for biochemistry/U&Es, purple for haematology, pink for group and save and crossmatch, blue for clotting/coagulation, grey for glucose, and black for ESR)

• Cotton wool, swab, or gauze

• Tape or plaster

Make sure you have a yellow sharps box close at hand The key to passing this station is

to be seen to be safe.

The procedure

• Wash your hands (see Station 1).

• Position the patient so that his arm is fully extended Ensure that he is comfortable

• Apply the tourniquet proximal to the venepuncture site

• Select a vein by palpation: the bigger and straighter the better The vein selected is most

com-monly the median cubital vein in the antecubital fossa

• Don a pair of non-sterile gloves

• Clean the venepuncture site with an alcohol steret Explain that this may feel a little cold

• Once the alcohol has dried off, attach the needle to the Vacutainer holder

• Tell the patient to expect a ‘sharp scratch’

• Retract the skin to stabilise the vein and insert the needle into the vein at an angle of 30–45

degrees to the skin

• Keeping the needle still, place a Vacutainer tube on the holder and let it fill

• Once all the necessary tubes are filled, release the tourniquet Remember that the tubes need

to be filled in a certain order (bottles with no additives first) See the guide to Vacutainer tubes

in Station 111.

• Remove the needle from the vein and apply pressure on the puncture site for at least 30

seconds (the patient may assist with this, or you may use tape or plaster)

• Immediately dispose of the needle in the sharps box

• Remove and dispose of the gloves in the clinical waste bin

Ensure that you release the tourniquet before removing the needle, and that you immediately dispose of the needle in the sharps box.

After the procedure

• Ensure that the patient is comfortable

• Thank the patient

• Label the tubes (at least: patient’s name, date of birth, and hospital number; date and time of

blood collection)

• Fill in the blood request form (at least: patient’s name, date of birth, and hospital number; date

of blood collection; tests required)

• Document the blood tests that have been requested in the patient’s notes

Cannulation and setting up a drip

Specifications: The station is likely to require you either to cannulate an anatomical arm and to put

up a drip, or simply to cannulate the anatomical arm This chapter covers both scenarios

Before starting

• Introduce yourself to the patient

• Confirm his name and date of birth

• Explain the procedure and obtain his consent For example, “I would like to insert a thin plastic

tube into one of the veins on your arm The tube will enable you to receive intravenous fluids and prevent you from becoming dehydrated You may feel a sharp scratch when the needle is inserted, but only the plastic tube will remain in the vein Do you have any questions?”

• Ask him on which arm he would prefer to have the cannula

• Ask him to expose this arm

• Gather the equipment in a clean tray

It is important to read the instructions for the station carefully If, for example, the instructions specify that the patient is under general anaesthesia, you are probably not going to gain any marks for explaining the procedure.

Cannulation only

The equipment

In a clean tray, gather:

• A pair of non-sterile gloves

• A tourniquet

• Alcohol sterets or prepackaged chlorhexidine and alcohol sponge

• An IV cannula of appropriate size (Table 1) Size is primarily determined by the viscosity of

the fluid to be infused (e.g blood requires pink or larger) and the required rate of infusion

• A pre-filled 5 ml syringe containing saline flush

• An adhesive plaster/transparent film dressing

• A sharps box

The procedure

• Wash your hands (see Station 1).

• Position the patient so that his arm is fully extended Ensure that he is comfortable

• Apply the tourniquet proximal to the venepuncture site

• Select a vein by palpation: the bigger and straighter the better Try to avoid the dorsum of the

hand and the antecubital fossa if possible (may be uncomfortable on flexion)

• Don a pair of non-sterile gloves

• Clean the skin with an alcohol steret and let it dry

• Remove the cannula from its packaging and remove its needle cap

• Tell the patient to expect a ‘sharp scratch’

• Anchor the vein by stretching the skin and insert the cannula at an angle of approximately 30

degrees

• Once a flashback is seen, advance the whole cannula and needle by about 2 mm

8 Station 4 Cannulation and setting up a drip

• Pull back slightly on the needle and continue to hold the needle while advancing only the

cannula into the vein

• Release the tourniquet

• Occlude the vein by pressing on the vein over the tip of the cannula

• Remove the needle completely, and immediately put it into the sharps box

• Cap the cannula with the same cap that was on the end of the needle

• Apply the adhesive plaster or transparent film dressing to secure the cannula

• Flush the cannula with 5 ml normal saline to prevent blood from occluding it

33 54 80180270

* Approximate values According to Poiseuille’s Law, the velocity of a

Newtonian fluid through a cylindrical tube is directly proportional to the

fourth power of its radius

After the procedure

• Dispose of clinical waste in a clinical waste bin

• Ensure that the patient is comfortable and inform him of possible complications (e.g pain,

• Check the fluid prescription chart (if appropriate)

• Check the fluid in the bag (solution type and concentration) and its expiry date

• Remove the fluid bag from its packaging and hang it up on a drip stand

• Remove the giving set from its packaging The regulating clamp for the IV line should be closed

• Remove the protective covering from the exit port at the bottom end of the fluid bag

• Remove the plastic cover from the large, pointed end of the giving set

• Drive the large, pointed end of the giving set into the exit port at the bottom end of the fluid

bag

• Remove the protective cap from the other end of the giving set

9 Station 4 Cannulation and setting up a drip

• Open the regulating clamp and run fluid through the giving set to expel any air/bubbles

• Close the regulating clamp

• If using an extension ‘octopus’ connector, open and flush with normal saline so that no air

remains

• Wash your hands (see Station 1) and follow the cannulation procedure above.

• Rather than capping the cannula immediately after removing the needle, connect the giving

set directly and flush with fluid from the bag

• Apply the adhesive plaster or transparent film dressing to secure the cannula

• Adjust the drip-rate (1 drop per second is equivalent to about 1 litre per 6 hours)

• Check that there is no swelling of the subcutaneous tissue i.e that the line has not ‘tissued’

• Tape the tubing to the arm

After the procedure

• Discard clinical waste appropriately

• Ensure that the patient is comfortable and inform him of possible complications (e.g pain,

erythema)

• Thank the patient

• Sign the fluid chart and record the date and time

Examiner’s questions: complications of cannula insertion

• Infiltration of the subcutaneous tissue • Phlebitis

• Introduce yourself to the patient, and confirm his name and date of birth.

• Explain the procedure and obtain his consent

• Ask him which arm he prefers to have blood taken from

• Ask him to expose this arm

• Wash your hands

• Gather the equipment in a clean tray

The equipment

In a clean tray, gather:

• Aerobic and anaerobic blood culture bottles

• Winged collection set (or 18 g needle and 20 ml syringe)

• For the blood culture bottles, check types (aerobic and anaerobic) and expiry dates, and ensure

that the broth is clear Do not remove the barcodes

Every effort to use aseptic technique should be made If blood is being collected for other tests, the blood culture sample should be collected first Do not use existing peripheral lines

to obtain blood cultures The most common skin contaminants include Staphyloccus epidermidis, Corynebacterium spp., Propionibacterium spp., and Bacillus spp.

The procedure

• Decontaminate your hands

• Position the patient so that his arm is fully extended Ensure that he is comfortable

• Select a vein by palpation: the bigger and straighter the better The vein selected is most

com-monly the median cubital vein in the antecubital fossa

• Release the tourniquet

• Decontaminate your hands

• Clean the venepucture site with the chlorhexidine sponge

• Decontaminate your hands

• Remove the flip tops from the culture bottles and disinfect the rubber caps each with a fresh

alcohol steret

• Decontaminate your hands and don the apron and gloves

• Warn the patient to expect a ‘sharp scratch’

• Retract the skin to stabilise the vein and insert the butterfly needle into the vein

• Fill each bottle with at least 10 ml of blood, as per the markings on the bottle (let the vacuum in

the bottles do the job for you) Fill the aerobic bottle first to minimise the amount of air in the

11 Station 5 Blood cultures

so as to inject a minimum of 10 ml of blood into each bottle (It is advised not to change needles between drawing blood and injecting into culture bottles since the risk of needlestick injury outweighs that of contamination of the sample with skin flora.)

• Release the tourniquet

• Withdraw the needle and apply pressure to the puncture site

• Unscrew the adaptor and immediately dispose of the needle in the sharps bin

After the procedure

• Ensure that the patient is comfortable

• Thank him

• Dispose of clinical waste in a clinical waste bin

• Decontaminate your hands

• Label the bottles, including clinically relevant information e.g the puncture site and any

antibiotics that the patient has been taking (ideally, blood cultures should be taken before the administration of antibiotics; if not, they should be taken immediately before the next dose, with the exception of children)

• Fill in a blood request form

• Convey the samples to the microbiology laboratory without delay (or else incubate the bottles)

• Document the procedure

Specifications: This station requires you either to cannulate an anatomical arm and set up a blood

transfusion, or, more likely, simply to set up a blood transfusion You may be instructed to talk through

parts of the procedure

Before starting

• Introduce yourself to the patient

• Confirm his name and date of birth

• Explain the requirement for a blood transfusion, explain the risks, and obtain his consent

• Ensure that baseline observations have been recorded (pulse rate, blood pressure, and

• Re-confirm the patient’s name and date of birth and check his identity bracelet

• Extract 10 ml of blood into a pink tube (some hospitals may require two tubes for new patients)

• Immediately label the tube and request form with the patient’s identifying data: name, date of

birth, and hospital number

• Fill out a blood transfusion form, specifying the total number of units required

• Ensure that the tube reaches the laboratory promptly

2 Blood transfusion prescription

• Prescribe the number of units of blood required in the intravenous infusion section of the

patient’s prescription chart Each unit of blood should be prescribed separately and be istered over a period of 4 hours

admin-• If the patient is elderly or has a history of heart failure, consider prescribing furosemide (loop

diuretic) with the second and fourth units of blood

• Arrange for the blood bag to be delivered The blood transfusion must start within 30 minutes

of the blood leaving the blood refrigerator

3 Checking procedures

Ask a registered nurse or another doctor to go through the following checking procedures with you:

A Positively identify the patient by asking him for his name, date of birth, and address

B Confirm the patient’s identifying data and ensure that they match those on his identity bracelet,

case notes, prescription chart, and blood compatibility report

C Record the blood group and serial number on the unit of blood and make sure that they match

the blood group and serial number on the blood compatibility report and the blood ibility label attached to the blood unit

compat-D Check the expiry date on the unit of blood

E Inspect the blood bag for leaks or blood clots or discoloration

13 Station 6 Blood transfusion

4 Blood administration

• Attach one end of the transfusion giving set to the blood bag and run it through to ensure that

any air in the tubing has been expelled Note that a transfusion giving set has an integral filter and is not the same as a standard fluid giving set

• Attach the other end of the giving set to the IV cannula which should be a grey (16G), wide-bore

cannula (minimum pink/20G, or larger for resuscitation situations)

• Adjust the drip rate so that the unit of blood is administered over 4 hours Because one unit of

blood is 300 ml, and because 15 drops are equivalent to about 1 ml, this amounts to about 19 drops per minute

• Sign the prescription chart and the blood compatibility report recording the date and time the

transfusion was started The prescription chart and blood compatibility report should also be signed by your checking colleague

5 Patient monitoring

• Record the patient’s pulse rate, blood pressure, and temperature at 0, 15, and 30 minutes, and

then hourly thereafter

• Ensure that the nursing staff observe the patient for signs of adverse transfusion reactions such

as fever, tachycardia, hypotension, urticaria, nausea, chest pain, and breathlessness

• Make an entry in the patient’s notes, specifying the reason for the transfusion, the rate of the

transfusion, the total number of units given, and any adverse transfusion reactions

Examiner’s questions: complications of blood transfusion

Immune • Acute haemolytic reaction, (usually due to ABO incompatibility)

• Delayed haemolytic reaction, (usually due to Rhesus, Kell, Duffy, etc., incompatibility)

• Non-haemolytic reactions such as febrile reactions, urticarial reactions, and anaphylaxis

• Introduce yourself to the patient.

• Confirm his name and date of birth

• Discuss the procedure and obtain consent

• Ask the patient if he has any allergies and what happens when he develops a reaction

• Gather the appropriate equipment

• 21G (green) needle and 23G (blue) or 25G (orange) needle*

*Note that the colour scheme for needles is not the same as that for cannulae (see Station 4)

The procedure

• Consult the prescription chart and check:

– the identity of the patient– the prescription: validity, drug, dose, diluent (if appropriate), route of administration, date and time of administration

– drug allergies, anticoagulation

• Consult the BNF and check the form of the drug, whether it needs reconstituting, the type and

volume of diluent required, and the speed of administration

• Check the name, dose and expiry date of the drug on the vial, and ask another member of the

healthcare team to countercheck them

• Wash your hands and don the gloves

• Attach a 21G needle to the syringe and draw up the correct volume of the drug, making sure to

tap out and expel any air For a powder, inject the appropriate type and volume of diluent into the ampoule and shake until the powder has dissolved

• Dispose of the needle and attach a new 23G needle to the syringe for IM/SC administration or

a 25G needle for ID administration

• Ask the patient to expose his upper arm or leg and ensure that the target muscle is completely

relaxed

• Identify landmarks in an attempt to avoid injuring nerves and vessels

• Clean the exposed site with an alcohol steret and allow it to dry

• Warn the patient to expect a ‘sharp scratch’

Intramuscular (IM) injection technique

15 Station 7 Intramuscular, subcutaneous, and intradermal drug injection

needle may not reach the muscle and there is a risk of damage to the sciatic nerve, not to mention the general embarrassment of the thing In infants and toddlers, the vastus lateralis muscle in the anterolateral aspect of the middle or upper thigh is the preferred IM injection site

• With your free hand, slightly stretch the skin at the site of injection

• Introduce the needle at a 90 degree angle to the patient’s skin in a quick, firm motion

• Pull on the syringe’s plunger to ensure that you have not entered a blood vessel If you aspirate

blood, you need to start again with a new needle, and at a different site

• Slowly inject the drug and quickly remove the needle

Subcutaneous (SC) injection technique

• Bunch the skin between thumb and forefinger, thereby lifting the adipose tissue from the

underlying muscle (‘tenting’)

• Insert the needle, bevel uppermost, at a 45 degree angle in a quick, firm motion You are aiming

for the tip of the needle to be in the ‘tent’

• Release the skin

• Pull on the syringe’s plunger to ensure that you have not entered a blood vessel

• Slowly inject the drug

Intradermal (ID) injection technique

• Stretch the skin taut between thumb and forefinger

• Hold the needle so that the bevel is uppermost

• Insert the needle at a 15 degree angle, almost parallel to the skin

• Ensure that the needle is visible beneath the surface of the epidermis

• Slowly inject the drug

• A visible (and uncomfortable) bleb should form If not, immediately withdraw the needle and

start again – you may have inserted the needle too deeply

After the procedure

• Immediately dispose of the needle in the sharps box

• Apply gentle pressure over the injection site with some cotton wool (the patient may assist

with this)

• Ensure that the patient is comfortable

• Ask him if he has any questions or concerns

• Thank him

• Sign the prescription chart and record the date, time, drug, dose, and injection site of the

injec-tion in the medical records

Figure 2 Intramuscular, subcutaneous, and intradermal injection techniques.

Intramuscular Subcutaneous Intradermal

EpidermisAdipose tissueDermis

Muscle

Intravenous drug injection

Specifications: Anatomical arm in lieu of a patient This station is likely to require you to demonstrate

and/or talk through the administration of an intravenous (IV) drug with a needle and syringe There may

be a cannula in situ, enabling the drug to be administered through the cannula.

Before starting

• Introduce yourself to the patient

• Confirm his name and date of birth

• Discuss the procedure and obtain consent

• Ask the patient whether he has any allergies and what happens when he develops a reaction

• Gather the appropriate equipment

• Consult the prescription chart and check:

– the identity of the patient– the prescription: validity, drug, dose, diluent (if appropriate), route of administration, date and time of administration

– drug allergies

• Consult the BNF and check the form of the drug, whether it needs reconstituting, the type and

volume of diluent required, and the speed of administration

• Check the name, dose and expiry date of the drug on the vial and the name and expiry date of

the diluent Ask another member of the healthcare team to countercheck them

• Wash your hands and don the gloves

• Attach a 21G (green) needle to a syringe and draw up the correct volume of the diluent

• Reconstitute the drug by injecting the diluent into the ampoule and shaking it until it is

com-pletely dissolved

• Draw up the reconstituted drug into the same syringe, making sure to tap out and expel any air

• Remove the needle and attach a new 21G needle to the syringe

• Apply a tourniquet to the model arm and select a suitable vein

• Clean the venepuncture site with an alcohol steret

• Retract the skin with your non-dominant hand to stabilise the vein, tell the patient to expect a

‘sharp scratch’, and insert the needle into the vein until a flashback is seen

• Undo the tourniquet

• Administer the drug at the correct speed (too fast may cause adverse reactions such as emesis)

• Withdraw the needle and immediately dispose of it in the sharps box

• Apply gentle pressure over the injection site using a piece of cotton wool

• Remove the gloves

17 Station 8 Intravenous drug injection

After the procedure

• Ensure that the patient is comfortable and ask him to notify a member of the healthcare team

if he notices any adverse effects (it may be necessary to monitor the patient)

• Ask him if he has any questions or concerns

• Thank him

• Sign the prescription chart and record the date, time, drug, dose, and injection site of the

intra-venous injection in the medical records

• Indicate that you would have your checking colleague countersign it

• Introduce yourself to the patient

• Confirm his name and date of birth

• If allowed, take a brief history from him, for example, onset, course, effect on everyday life

• Explain the examination and obtain consent

• Consider the need for a chaperone

• Ask the patient to expose the lump completely; for example, by undoing the top button of his shirt

• Position him appropriately and ensure that he is comfortable

The examination (IPPA: Inspection, Palpation, Percussion, Auscultation)

• Inspect the patient from the end of the bed, looking for other lumps and any other signs

• Inspect the lump and note its site, colour, and any changes to the overlying skin such as

inflamma tion or tethering Note also the presence or absence of a punctum

• Ask the patient if the lump is painful before you palpate it Is the pain only brought on by

palpa-tion or is it a more constant pain?

• Wash and warm your hands

• Assess the temperature of the lump with the back of your hand

• Palpate the lump with the pads of your fingers; if possible, from behind the patient Consider:

– number: solitary or multiple– size: estimate length, width, and height, or use a ruler or measuring tape– shape: spherical, ovoid, irregular, other

– edge: well or poorly defined– surface: smooth or irregular– consistency: soft, firm, hard, rubbery– fluctuance: rest two fingers of your left hand on either side of the lump and press on the lump with the index finger of your right hand: if your left hand fingers are displaced, the lump is fluctuant– pulsatility: rest a finger of each hand on either side of the lump: if your fingers are displaced, the lump is pulsatile

– mobility or fixation: consider the mobility of the lump in relation both to the overlying skin and the underlying muscle

– compressibility and reducibility: press firmly on the lump to see if it disappears; if it immediately reappears, it is compressible; if it only reappears upon standing or coughing, it is reducible

• Percuss the lump for dullness or resonance

• Auscultate the lump for bruits or bowel sounds

• Transilluminate the lump by holding it between the fingers of one hand and shining a pen torch to it

with the other A bright red glow indicates fluid whereas a dull or absent glow suggests a solid mass

• Examine the draining lymph nodes (see below), or indicate that you would do so

After examining the lump

• Ensure that the patient is comfortable

• Ask him if he has any questions or concerns

• Thank him

• Wash your hands

• Summarise your findings and offer a differential diagnosis

19 Station 9 Examination of a superficial mass and of lymph nodes

Lymph node examination

Head and neck

Preauricular

PosteriorauricularOccipital

Posteriorcervical

Figure 3 Lymph nodes in the head and neck.

Upper body

• Palpate the supraclavicular and infraclavicular nodes on either side of the clavicle

• Expose the right axilla by lifting and abducting the arm and supporting it at the wrist with your right hand

• With your left hand, palpate the following lymph node groups:

– the apical

– the anterior

– the posterior

– the nodes of the medial aspect of the humerus

• Now expose the left axilla by lifting and abducting the left arm and supporting it at the wrist with your left hand

• With your right hand, palpate the lymph node groups, as listed above

Figure 4 Lymph nodes of the upper body.

Lower body

Palpate the superficial inguinal nodes (horizontal and vertical), which lie below the inguinal ligament

and near the great saphenous vein respectively, then the popliteal node in the popliteal fossa

Conditions most likely to come up in a lump examination station

Epidermoid (sebaceous) cyst:

– Severity: “How would you rate the pain on a scale of 1 to 10, with 1 being no pain at all and 10

being the worst pain you have ever experienced?”

– effect on everyday life: ask in particular about exercise tolerance and sleep

– troponins to look for or help rule out myocardial infarction

– D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the diagnosis but a positive result does not confirm it)

– inflammatory markers such as white cell count and CRP for suggestion of pneumonia

If you cannot differentiate angina from gastro-oesophageal reflux disease and there are

no signs of ischaemia on the ECG, advise an exercise ECG stress test If this is negative, consider a therapeutic trial of an antacid or a nitrate

Cardiovascular risk assessment

Cardiovascular risk factors can usefully be divided into fixed (non-modifiable) and modifiable risk

The risk assessment

If this information has not already been provided or disclosed, find out the patient’s reason for

average number of cigarettes smoked per day Does the patient also smoke roll-ups and can-9 Alcohol Ask about the number of units of alcohol consumed in a day and typical week Note

that depending on the amount and type that is drunk, alcohol can be either protective or a risk factor

10 Diet In particular, ask about fried food and takeaways.

11 Lack of exercise Ask about amount of exercise taken in a day or week Does the patient walk

to work or walk to the shops?

Table 2 Desirable lipid levels

• Address any remaining concerns

• State to the examiner that appropriate investigations include:

– BMI (should be between 18.5 kg/m2 and 24.9 kg/m2)

– waist circumference (should be less than 102 cm for men and 89 cm for women)

– blood pressure (should be under 140/90 mmHg)

– fasting blood glucose levels (should be under 6.0 mmol/L)

– fasting lipid levels (see Table 2)

• Suggest calculating the patient’s 10-year cardiovascular risk score using the Framingham risk

terol, HDL cholesterol, smoking status, and blood pressure

equation, which takes into account a number of risk factors including gender, age, total choles-• Indicate that the management of cardiovascular risk factors includes lifestyle modification and,

if appropriate, medical intervention (see Table 3).

Table 3 Management of cardiovascular disease

Lifestyle modification Medical intervention

Advise patient to:

• Stop smoking

• Reduce alcohol intake (to 3–4 units/day

in men and 2–3 in women, and avoid binges)

• Lose weight

• Adopt a healthy diet: reduce saturated fatty acids, trans-fatty acids and cholesterol; increase fibre and omega-3 fatty acids, e.g from fish

• Place the stethoscope over the brachial artery pulse, ensuring that it does not touch the cuff

• Reduce the pressure in the cuff at a rate of 2–3 mmHg per second

– the first consistent Korotkov sounds indicate the systolic blood pressure

After the procedure