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)
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Transcript
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)
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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.
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
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.
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<60 bpm
15 second compressions(use one hand)
count loudly “1,2,3,…,10”; 2 rescue breaths
15 second compressions(use one hand); 2 rescue breaths
15 second compressions(use one hand); 2 rescue breaths
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After 1 minute (3 times) call resuscitation team => “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) 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
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)”
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.”
Tip: in blood sample there is no contraindication.
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. alcohol sterets, gauze pieces
3. tourniquet
4. sharps bin (yellow)
5. waste bin (white plastic box)
9. 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.
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.
I will … ulnar and radial areas.
Then I’ll ask my patient to open his hand, check for blanching
And release the ulnar
Check for reperfusion
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 (cork,
bubble 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.
Arm preference.
Do Allen’s test.
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. 1 pair of gloves 2. 3 forceps 3. 1 fine suture scissors 4. 1 needle holder
5. suture material 6. antiseptic solution 7. 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.”
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.
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.
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
Cleaning
with 2
gauzes
Cleaning
with 4
gauzes
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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
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.)
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. ”
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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:
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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
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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.
2. Assessing the size of baby and feeling for the baby's back and limbs.
3. Pawlik's grip - the lower part of the uterus is grasped by
the midwife to determine the presenting part.
4. Pelvic palpation to determine the position of the baby's head.
5. Measuring the height of the fundus which generally corresponds to the number of weeks of gestation
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).
2. Assessing the baby's position and size. Feeling for the baby's head, back
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 PRE-
PROLIFRATIVE 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 Inspection:
First inspect both ears and then say: “On inspection, there is no swelling, no redness, no signs of trauma, external discharge wax.
o 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