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Nilo S Manikins For Plab 2 PDF
Nilo S Manikins For Plab 2 PDF
Nilo S Manikins For Plab 2 PDF
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 responsiveness
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 manikins mouth.
Check breathing for 10 seconds, count loudly (with head tilt and chin lift look at the
chest for movement, listen at victims 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 dont 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)
Tell the massage: Hello I am Drcalling 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).
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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 dont interrupt resuscitation.
Tip: when the examiner asking you how long you will do this. Dont interrupt,
answer while resuscitation. Tell him: I will continue until patient start
breathing, or ambulance comes or I become exhausted. Sorry I lost my
counts 1, 2, 3 He will tell you thank you. You can have a seat.
References:
http://www.cetl.org.uk/learning/CPR/player.html
http://www.redcross.org.uk/standard.asp?id=56929#section1
http://www.resus.org.uk/pages/bls.pdf
Danger
Response
Shout for help
Airway
Breathing
Circulation
Safety + Cervical spine: I will ensure that I am safe, patient is safe, and environment
is safe.
Tip: do not sit while verbalizing this. Say it in a stylish way while standing.
Sit and Check the patient and say: As there is no sign of injury in upper part of the
body, I assume there is no cervical spine injury.
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Check responsiveness
If no response => one hand at the shoulder, other
hand on the head or both hands on the shoulder,
shake firmly and shout in both ears. Command:
open your eyes. Can you hear me?
Check airway (with head tilt and chin lift look for any
foreign body)
If there isnt any foreign body, say The airway is
clear.
Tip: if the patient is unresponsive, but is breathing and has a pulse, they need to be
placed in the recovery position.
5
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.
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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 Drcalling 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.
Signs of life
Airway
Breathing for 5 seconds (if no breathing)
Give 2 rescue breaths
Check for signs of circulation for 5 sec ( look for signs of circulation like any
movement, coughing, or normal breathing (not agoral gasps, these are
infrequent, irregular breaths) if no pulse
Continue CRP 15:2
If pulse is >60/min, give 1 rescue breath for every 3 seconds
Reference:
http://www.cetl.org.uk/learning/paediatric-bls/player.html
http://www.resus.org.uk/pages/pbls.pdf
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 dont need to mention this because it is not written in the task
about case of trauma I rule out contraindications which are suspected urethral injury
(trauma: blood noted at the tip of urinary meatus or high riding prostate on rectal
exam)
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9. Do I have an assistant?
10.Where is my sterile area?
11.check trolley / instruments:
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?)
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Tip: (the trickiest part) you wont 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. Ill 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.
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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 dont talk about the procedure, dont force the examiner listen
to you.
Procedure
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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 sharps 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 (patients 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.
5. IV Cannulation
1. Ideally I would greet the patient, introduce myself to the patient, and check the
identity.
2. I would explain the procedure and take a verbal consent.
3. I would tell the patient that for purpose of the giving medications and fluids I need to
introduce cannula in his forearm, I would inform that he would feel a sharp scratch but
I would be as gentle as possible. Also I would inform that I would repeat procedure
again if I fail in first attempt.
4. I would ask for the arm preference, any soreness in arm and ask him to roll up his
sleeves.
5. I would maintain adequate privacy and ask for a chaperone.
6. checking trolley
1. 1 pair of gloves
2. Cannula (pink or blue)
3. alcohol sterets
4. gauze piece
5. tegaderm
6. tourniquet
7. 2cc syringes filled with normal saline
8. clinical waste bin
9. sharp bin - yellow
Make sure sharps bin is close by and open the sharps bin.
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Procedure:
1. Ask: where is the clean area? If there is a kidney tray thin use it. If there is none
then assume.
2. Assume you have washed your hands and wear a clean pair of gloves. (Sometime it is
written that assume you are gloved, if not, ask can I have a pairs of glove please?)
3. Check tourniquet and apply it. (loose not tight)
4. Check the site and the vein. (below Y junction)
5. Remove cannula with no touch technique.
6. Take out stopper; place it on the table (sterile area) facing upwards.
7. Fasten tourniquet.
8. Palpate the vein again.
9. Clean the area with alcohol sterets in one direction. Discard it into clinical waste bin.
10. Take a three point grip of the cannula, with your thumb on the white cap, index finger
on the coloured cap, and middle finger on the wing. Apply
countertraction to the overlying skin with your other hand to
help anchor the vein during insertion.
11. I would warn the patient that he may feel sharp scratch.
12. Scratch the skin and insert cannula with bevel end upwards
at 30 to 40. Then reduce to a 15 angle to advance the
needle inside the vein.
13. When blood gushes back, change your grip, so the thumb
and middle finger are on the white cap to withdraw the
needle about 5 mm to produce the second flashback.
Importantly the index finger provides countertraction on
the wing.
14. With just the index finger remaining in place at the wing,
advance the cannula along the vein.
15. Release the tourniquet.
16. Press over the vein around the tip of cannula with the
index finger of left hand.
17. Remove the needle and discard into sharps bin.
18. Position and stabilise the cannula with left thumb.
19. Put the stopper at the end of cannula.
20. Take 2cc syringe with normal saline and flush through third opening (up), feel for the
flow and see for patients comfort. (I would check any resistance or swelling or reports
of pain from the patient.)
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21. Apply tegaderm. First peel the back (sticky side) and then apply it on cannula. Take the
edge and peel the front. Peel again date label, and apply above the visible area.
22. Inform the patient to please not remove his arm.
23. Document the date and apply tegaderm and remove the paper around.
24. I would thank the patient for his cooperation and ask him to dress up.
25. Document findings (what no. cannula inserted ect.)
26. Thank the examiner.
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 Allens test.
demonstrate it in your hand.
Ill ask my patient to make a tight fist.
I will ulnar and radial areas.
Then Ill 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 dont 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 youve washed your
hands and are gloved.)
2. Palpate artery. If you dont feel the pulse, say it. I cant 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: Dont 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. (dont 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 doesnt 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.
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).
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 710 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:
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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 doesnt
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.
Cleaning Cleaning
with 2 with 4
gauzes gauzes
Tip: If given 1 forceps clean with hand and check anaesthesia with gauze. Now
you can use the given forceps for suturing.
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much. Then pinch the other side again. Try to make both side almost equal distance.
Tip: Keep the needle on left side of drape (because you have started from right
side) put the forceps over the needle so you are not by mistake touch it.
11. You can touch the thread. Keep right side short and
start knotting. Take the tip of the thread with needle
holder. Now your right hand keeping needle holder is
still and you left hand rolling thread over it. And get
the knot back toward the short side. (right)
12. 3 anterior, 2 posterior, 1 anterior, I anterior = 7 knots.
Cut thread by 1 cm with scissors.
13. Discard forceps. Discard needle in sharp bin.
14. I will apply sterile gauze piece on wound and put bandage on it. I will give adequate
antibiotics and pain killers if required. I will be requesting the patient to come after 7
days to suture removal.
15. I will be checking for tetanus immunization status.
16. Thank the patient for cooperation and ask him dress up.
17. Thank the chaperone or assistant.
18. Thank the examiner.
http://www.medicalvideos.us/videos-1754-Suturing-a-Wound
1. Turn to the patient (GRIPS) Hello Sir, I am Dr , How can I address you?
2. Explain the procedure: I am here to measure your blood pressure by an instrument
called sphygmomanometer. For that I will wrap the cuff around your arm and squeeze
your arm by inflating a pump. You can sit down comfortable, is it ok with you?
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3. Ask the patient: I just need to ask you few things, have you ever been diagnosed by
high blood pressure? (If he says yes, say I am really sorry about that.) Are you on any
medication? (If he says yes, ask Have you taken tablets today?)Have you done any
excessive exercise from early morning until now? Have you had too much coffee from
early morning until now?
4. Privacy and chaperone: I will ask the examiner to be the chaperone.
5. Consent: shall I proceed?
6. Ask for the arm preference: please let me know which arm you prefer?
7. Ask for soreness on the arm: do you have any soreness on the arm?
8. Ask the patient: rolled up your sleeves, please.
9. Check the size of the cuff. (should cover 2/3 arm)
10. Tie the cuff, 2 fingers breadths above the cubital fossa and 2 fingers can be inserted
under the tied cuff. So patient can bend his elbow. Keep the arterial typed in the medial
side.
11. Ask: can you bend your elbow?
12. Can I ask you what usual your blood pressure reading is?
13. Measure the blood pressure by palpatory method first. Palpate the radial artery. Inflate
until the pulse disappears. Then deflate the pump. The moment you feel the pulse this
is your palpatory blood pressure. Verbalize: My palpatory (estimated systolic) blood
pressure in sitting position is 120= one twenty
14. Take the stethoscope, make sure it is working. Keep it on brachial artery with right
hand, dont press too much. Inflate with left hand. Measure BP. Verbalize: My
auscultatory blood pressure in sitting position is 120/80 = one twenty over eighty
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15. Tell the patient that Mr Y, thank you very much, but I thank you to stand up and I will
measure your blood pressure during standing. If you feel dizzy at the any point of time,
please feel free to sit down even without telling me.
16. No palpatory blood pressure in standing position. Verbalize: My auscultatory blood
pressure in standing position is 120/80 = one twenty over eighty
17. Apply stethoscope again. Keep it on brachial artery with right hand, dont press too
much. Measure the auscultatory standing blood pressure.
18. Ask the patient to roll down his sleeve, thank the patient.
19. Thank the examiner.
References: http://www.cetl.org.uk/learning/bpm/player.html
9. Spacer
Counsel mum of the child who suffers with asthma about how to use the spacer.
In GMC exam, Patient is a 5 years old child.
Good morning I am Dr X
Ask Mum: How is your little one doing? I have come through notes that your little one
is suffering from asthma
She says: Yes
Say: I am very sorry to hear that. I am here to introducing a device called spacer. Have
you ever heard about it?
She says: No
I am here to talk you about it. If you have any question, stop me whenever you want.
Hold the spacer in your hand and say: Actually it is a device which contains of two
parts. (Part it) Show her while describing and can be fixed easily like thisfix it.
Do you have the medication with you? Do you know how many puffs you have to
give?
Tip: If she doesnt know prescription, dont tell her on your own. I am giving you
example, once you get your prescription you will find it out. If any question, come
back to us we will describe it to you.
Check if spacer is working by moving it gently: always shake the spacer gently
before use, youll hear a sound like tic tic tic that means the valve at the mouth piece
is working and spacer is fine. If there is no sound it means that valve is stuck and
spacer is longer no use
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1. Remove the protective cap from the puffer.
2. Shake the puffer and fix it firmly into the end of the spacer. (square end)
3. Make sure you little one hold the spacer horizontally, and make a tight seal on the
mouth.
4. Press the puffer once to release a dose of the medicine into the spacer. Do not
remove the puffer.
5. Allow your little one to breath in and out 10 times. With each breath in you will
hear a sound like this shake the spacer and with each breath out you will hear the
same click. So in total of 10 breaths you will hear 20 clicks. Is it clear? Do you want me
to repeat it?
6. In summary, 1 puff is equal 10 breaths and with each breath you hear 2 clicks. That
means with each puff, you will hear 20 clicks.
7. Can you please demonstrate it for me? give the spacer to her.
Tip: if there are 2 spacer, use one and give the other one to her.
8. Blue capped inhaler is a reliever, a bronchodilator that may cause racing of the
heart for example, palpitation.
9. Brown capped inhaler is a steroid; it is a preventer. Therefore your little one must
rinse out her/his mouth after each use to prevent the growth of any bugs in the mouth
called oral thrush.
10. If another puff is needed, wait for 30 seconds.
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
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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.
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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.
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.
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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.
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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. Ill 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: Ill check for any bleeding or discharge.
19. Ill thank the patient. Offer the tissue wipes to clean and ask her to dress up.
20. Ill 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.
Inspection:
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On inspection of abdomen there is a distended abdomen consistent with the days of
amenorrhea.
I cant 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.
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.
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.
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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)
Pawliks 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.
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.
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.
3. Pawlik's
grip - the 4. Pelvic palpation
lower part of to determine the
the uterus is position of the
grasped by baby's head.
the midwife to
determine the
presenting
part.
6. Listening to the
5. Measuring baby's heartbeat.
the height of
the fundus
which generally
corresponds to
the number of
weeks of
gestation
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1. Checking the 2. Assessing the
height of the fundus baby's position and
(the highest point of size. Feeling for the
the uterus). At 20 baby's head, back
weeks this and limbs.
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).
References:
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Antenatal_checks_of_your
_baby?open
1. Ideally I would greet the patient, introduce myself to the patient, and check the patients
identity.
2. I would explain the procedure and take a verbal consent. I would tell the patient that for
purpose, I would be taking few cells from the neck of the womb.
3. I need to rule out the contraindication.
Active menstruation
Active vaginal bleeding
Recent use of spermicidal gel
Recent sexual intercourse
4. I would ask her to empty her bladder and undress below her waist.
5. I would maintain adequate privacy and ask for a chaperone.
6. I would ask her to lie on her back with thighs and knees bent; knees apart and ankles
together.
7. checking trolley
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1. Adequate light (assume: ideally I need a good source of light.)
2. 1 pair of gloves (mostly assume)
3. A bowl of lukewarm normal saline (Assume)
4. Cuscos speculum
5. clinical waste bin
6. few wipes
Old method New method
7. Ayers spatula 7. cervical brush
8. Cytobrush 8. ThinPrep: rinse cervical brush
9. fixator 10X
10. 2 pre-labelled slides 9. (or) SurePath: drop the
detachable part into it.
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18. Close the bath and say: ideally I label it and I send it to the lab.
19. Ill warn the patient that I am about to remove the speculum. release the screw,
unlock the blades, and remove it little outside (to
make the cervix free), de-rotate the speculum.
Check it for bleeding and discharge. Ill send it for
sterilization.
20. Remove your gloves and throw it in the clinical
waste bin. Or if you assumed u r gloved say: Ill
thank my patient, remove my gloves and give her
wipes to clean herself and ask her to dress up.
21. Ill inform her that she might experience spotting
for few days; and her result will send to her GP in
2-3 weeks time.
22. I would thank the chaperone.
23. Thank the examiner.
13. Insert the spatula under direct vision. Rotate it to 360 degree
1. Ideally I would greet the patient, introduce myself to the patient, and check the
patients identity.
2. I would explain the procedure and take a verbal consent I would tell the patient that I
am going to examine the glands situated at the base of the water bag (bladder) by
introducing my gloved and lubricated finger through his back passage.
3. I would take a verbal consent before proceeding.
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4. I would maintain adequate privacy and ask for a chaperone.
5. I would ask him to undress below her waist. I would ask him to lie on his left side and
fold his legs as close as possible to his chest and the buttocks at the edge of the table.
6. (Check the correct position of the Manikin)
7. checking trolley
1. clean pair of gloves
2. Lubricating Gel
3. few wipes
4. clinical waste bin
5. adequate light
Procedure:
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7. I would warn the patient that you I am about to remove my finger. before which
I will ask him to grip my finger to check for anal tone.
8. Remove your finger; see the glove for any blood, mucosa or any faeces.
9. I would thank the patient for his cooperation, I would give him wipes, to wipe
himself and ask him to get dressed.
10. I would tell him I will get beck to him after discussing my finding with my senior.
11. I would thank the chaperone.
15.Testicular Examination
1. Ideally I would greet the patient, introduce myself to the patient, and check the
patients identity.
2. I would explain the procedure and take a verbal consent I would tell the patient that I
am here to examine his private parts down below.
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5. I would ask him to undress below her waist. I would request him to stand up for the
purpose of examination. I would ask him to lift the water pipe up during the
examination.
Palpation:
4. Deep palpation: Ill warn my patient I will be touching him deeply. On the
left side, I can appreciate spermatic cord, epididymis and left testis. In case
of mass, say: I can appreciate a mass in the anterior aspect of left side,
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round, 2 cm in diameter, unattached to overlying skin, unattached to deep
structure.
Tip: start palpating from up to down.
Special tests:
3. Prehns test: Ideally I do Prehns test, by asking my patient to lift his private
parts.
Prehns test shows whether the presenting testicular pain is caused by acute
epididymitis or from testicular torsion.
According to Prehn's sign, the physical lifting of the testicles relieves the pain of
epididymitis but not pain caused by testicular torsion.
Negative Prehn's sign indicates no pain relief with lifting the affected testicle,
which points towards testicular torsion which is a surgical emergency and must be
relieved within 6 hours.
Positive Prehn's sign indicates there is pain relief with lifting the affected testicle,
which points towards epididymitis.
10. Ill thank the patient and ask him to dress up.
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11. Ill thank the chaperone.
12. Most probably it is either a benign or malignant testicular tumour, for this I need to
consult with my senior. I finish my examination by checking PR, Lymph node
examination, abdominal examination and spine. I want to consult my senior to do
ultrasound and excisional biopsy
5. Exposure/ position: you can blink during the procedure but dont move your head
and sit comfortably I will be dimming the light of room and you should fix your vision at
a distant object. My head may disturb your focus of vision but please focus on distance
as far as you can.
Tip: In the exam you may have to examine for red reflex and inspection on a
simulator /examiner and then proceed to the manikin for the rest of examination.
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Could you look at the ceiling please? go behind the patient and say: I cannot
appreciate any proptosis.
2. check ophthalmoscope: (make sure it is working)
check power of lens (negative numbers are red, positive are black or grey)
check light big full moon
no glasses; not you nor the patient
3. Do a red reflex: He is sitting and you are standing. Bend a little bit for making 30
degrees angle. Shine the light to his eye, then bring your eye near the
ophthalmoscope and about one arm distance you can see the red reflex. Verbalize:
Media is clear so I precede the Funduscopy.
4. Go to the manikin, sit on a chair and say: In real patient, I would have examined with
funduscope light on but in exam since there is a bright light shining from back, I may
have reflection or glare so I would like to examine now with funduscope light switched
off.
5. optic disc:
colour
margin
contour
Cup Disc Ratio (CD Ratio)
6. origin of blood vessels
7. periphery and rest of retina
8. Macula
Normal findings:
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Normal funduscope
Optic atrophy
Disc cupping
Papilloedema
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I can see the Optic disc which is
swollen, edematous and bulging,
margins are blurred or ill defined,
and Cup cannot be appreciated.
Origins of vessels are not clear. They
are engorged, tortuous and
congested.
Periphery and rest of retina appears
hyperemic. Therefore my diagnosis is
PAPILLOEDEMA.
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Senile macular degeneration
41
Pre-proliferative diabetic retinopathy
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Laser photocoagulation
Hypertensive retinopathy
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17. Otoscopy
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
Otoscopy:
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:
WAX
46
Acute otitis media with effusion
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Central perforation with tympanosclerosis
Tympanosclerosis
Grommet
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Secretory otitis media
Rhines 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)
Webers test: this time, I will be placing it on your forehead, please tell me in which ear
you hear better?
(No lateralisation= normal Webers test)
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References: http://medweb.cf.ac.uk/otoscopy/newpage7.htm
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