‫يبرعلاسلجملا‬

‫صاصتخال‬ ‫ةماعلاةحارجلا‬
‫ىفشتسم‬‫يميلعتلادادغب‬
station Name/Type: DVT prophylaxis /
clinical – pre op evaluation
Candidate Name: A = complete answer / satisfactory
B = partial answer / unsatisfactory
Date of examination : C = not attempted / wrong
To the examiner : encircle the grade of each step according to the above labeling

mark C B A introduction
Greeting the patient 1
Self introduction 2
Permission and establishing a plan for the visit 3
mark C B A History
Age 4
Asking about the type of surgery (minor , major, laparoscopic 5
major lower limb surgery ,joints replacement
Asking about the indication for surgery (underlying pathology) 6
,,, malignancy,,, inflammatory bowel disease …ec
Any previous thrombotic phenomena (MI ,CHF ,,,,previous DVT 7
with or without PE)
Mobility (is the patient bed ridden more than 72 h) 8
Drug history ( hormonal replacement or contraceptive pills) 9
Family history ( any congenital hypercoagulable state ) 10
Pregnancy or postpartum less than one month 11
mark C B A Examination
Height and weight ( body mass index calculation) 12
Searching for central venous lines 13
Leg examination Searching for varicose veins 14
mark C B A Finishing
Thanking and covering the patient 15
mark C B A The examiner ask the student about the risk level and prophylaxis
Risk level (low , medium or high ) 16
Prophylaxis ( non specific , mechanical or pharmacological or 17
combination of both

To the examiner :

encircle your overall impression regarding the examinee performance as bellow

Unacceptable Needs Improvement Acceptable Exceeds Expectations

Examiner name and signature

Comity work Station value = Possible full mark = Total mark =

Final mark = station value * total mark / possible full mark =

AIM OF THE STATION : testing your verbal
communication skill with patients and theoretical knowledge
about risk factor and prophylaxis against DVT

DATA : The patient allready had / or will have a surgery

under GA

THE TASK take the necessary history and examine for

relavant signs regarding the risk factor for DVT then you will
be asked about the risk level of the patient and your
suggestion as prophylaxis measures