cmecde 2052

 

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

• Squeeze and release the collecting chamber of the giving set until it is about half full.

General skills

Station 4 Cannulation and setting up a drip 9

• 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.

• Nerve damage. • Thrombophlebitis.

• Haematoma. • Septic thrombophlebitis.

• Embolism. • Local infection.

Clinical Skills for OSCEs

10 Station 5

Blood cultures

Before starting

• 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 18g needle and 20ml syringe)

• Apron

• Non-sterile or sterile gloves

• Disposable tourniquet

• Alcohol sterets (x2)

• Chlorhexidine sponge

• Sterile gauze

• Sharps bin

• 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 commonly 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 10ml 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

anaerobic sample. If using a needle and syringe, collect at least 20ml of blood into the syringe

General skills

Station 5 Blood cultures 11

so as to inject a minimum of 10ml 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.

Clinical Skills for OSCEs

12 Station 6

Blood transfusion

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

temperature).

Cannulation

See Station 4.

Blood transfusion

1. Sample collection

• 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 administered over a period of 4 hours.

• 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 compatibility label attached to the blood unit.

D. Check the expiry date on the unit of blood.

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

General skills

Station 6 Blood transfusion 13

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.

Infectious • Hepatitis.

• HIV/AIDS.

• Other viral agents.

• Bacteria.

• Parasites.

Cardiovascular • Left ventricular failure from volume overload.

Complications of massive

transfusion (>10 U)

• Hypothermia.

• Coagulopathy (from dilution of platelets and clotting factors).

• Acid–base disturbances.

• Hyperkalaemia.

• Citrate toxicity (from additive in bag of packed red blood cells).

• Iron overload.

Other • Air embolism.

• Thrombophlebitis.

cmecde 569

 

• 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 commonly 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.

Clinical Skills for OSCEs

6 Station 3 Venepuncture/phlebotomy

• 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.

Examiner’s questions

If the veins are not apparent

• Lower the arm over the bedside.

• Ask the patient to exercise his arm by repeatedly clenching his fist.

• Gently tap the venepuncture site with two fingers.

• Apply a warm compress to the venepuncture site.

• Do not cause undue pain to the patient by trying over and over again (more than 2–3 times) –

call a more experienced colleague instead.

• Use femoral stab only as a last resort (usually in CPR situations).

In the event of a needlestick injury

• Encourage bleeding, wash with soap and running water.

• Immediately report the injury to your supervisor or the occupational health service.

• If there is a significant risk of HIV, post-exposure prophylaxis should be started as soon as

possible.

• Fill out an incident form.

For more information on the management of needlestick injury, refer to local or national protocols.

7General skills

Station 4

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.

Clinical Skills for OSCEs

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.

Table 1. IV cannulae

Colour Size Water flow (ml/min)*

Blue

Pink (most common)

Green

Grey

Orange

22G

20G

18G

16G

14G

33

54

80

180

270

* 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,

erythema).

• Thank the patient.

Setting up a drip

The equipment

In a clean tray, gather:

• A pair of gloves • An adhesive plaster

• A tourniquet • A sharps box

• Alcohol sterets • An appropriate fluid bag

• An IV cannula of appropriate size • A giving set

The procedure

• 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.

cmecde 56

 

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 process. And then go off to that Greek island.

1General skills

Station 1

Hand washing

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 jewellery, and fake nails or nail varnish (fingernails should be kept short, ideally not exceeding 1mm

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.

Clinical Skills for OSCEs

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

5 6

3 4

1 2

3General skills

Station 2

Scrubbing up for theatre

The equipment

• Scrubs • Sterile gown pack

• Theatre clogs or plastic overshoes • Sterile gloves

• Theatre cap • Brush packet containing a nail brush and

• Surgical mask nail pick

Before handwashing

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).

Clinical Skills for OSCEs

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.

5General skills

Station 3

Venepuncture/phlebotomy

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

cmecde 2

 

Contributors ix

Sara Ahmadi

4th Year Medical Student

University of Oxford

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

Christopher Chopdar

Independent Psychiatrist

Oxford

Akbar de’ Medici

Associate Director

Institute of Sport, Exercise and Health (UCL)

Patrick Elder

2nd Year Medical Student

University of Warwick

Naomi Foster

4th Year Medical Student

University of Dundee

Jay Goel

2nd Year Medical Student

Barts and the London School of Medicine and

Dentistry (QMUL)

Ali Rezaei Haddad

2nd Year Medical Student

University of Warwick

Jane Hamilton

4th Year Medical Student

University of Glasgow

Randeep Singh Heer

3rd Year Medical Student

King’s College London

Patrick Holden

3rd Year Medical Student

University of Cambridge

Benjamin Huggon

1st Year Medical Student

University of Oxford

Sadhia Khan

5th Year Medical Student

University of Manchester

Guglielmo La Torre

2nd Year Medical Student

Brighton and Sussex Medical School

Lilian Lau

3rd Year Medical Student

University of Leicester

Lucy Li

5th Year Medical Student

University of Edinburgh

David Liddiard

Osteopath

Function Health, New Zealand

Katherine Mackay

5th Year Medical Student

University of Oxford

Genevieve Marsh-Feiley

2nd Year Medical Student

University of Aberdeen

Jacob Matthews

5th Year Medical Student

University of Birmingham

Jonathan Mayes

4th Year Medical Student

Newcastle University

Philip McElnay

NIHR Academic Clinical Fellow in Cardiothoracic

Surgery

Newcastle University

x Contributors

Charlotte McIntyre

Core Surgical Trainee

Imperial College Healthcare NHS Trust

Shu Ng

1st Year Medical Student

University of Leeds

Gedalyah Shalom

5th Year Medical Student

University of Liverpool

Abigail Shaw

4th Year Medical Student

University of Bristol

Katherine Stagg

5th Year Medical Student

University of Oxford

Anthony Starr

5th Year Medical Student

University of Lancaster

Tom Stockmann

Fellow in Medical Education

North East London NHS Foundation Trust &

Honorary Research Fellow

Barts and the London School of Medicine and

Dentistry (QMUL)

Amy Szuman

3rd Year Medical Student

Hull York Medical School

Abigail Taylor

5th Year Medical Student

University of Oxford

Daniah Thomas

3rd Year Medical Student

Cardiff University

Rachel E. Wamboldt

4th Year Medical Student

Norwich Medical School, UEA

Preface xi

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 mirror, 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

on the heart’s performance, so the actor or examiner’s facial expression 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 yourself 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

cmecde 1

 

OSCEs

CLINICAL SKILLS FOR

5 T H EDITION

5

Life is short, the art long, opportunity fleeting,

experiment treacherous, judgement difficult.

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

SENIOR EDITOR

Neel Burton

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

Tu t o r i n P s y c h i a t r y

G reen Tem p l et o n C o l l e g e

University of Oxford

STUDENT EDITOR

John Lee Allen

3rd Year GEM Student

Imperial College London

OSCEs

CLINICAL SKILLS FOR

5 T H EDITION

Fifth edition © Neel Burton, 2015

Fifth edition published in 2015 by Scion Publishing Ltd

ISBN 978 1 907904 66 0

First edition published in 2003 by BIOS Scientific Publishers

Second edition published in 2006 by Informa Healthcare

Third edition published in 2009 by Scion Publishing Ltd

Fourth edition published in 2011 by Scion Publishing Ltd

All 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, UK

www.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, UK

Printed in the UK

Contents v

Contributors ix

Preface xi

OSCE tips xiii

I. GENERAL SKILLS

1. Hand washing 1

2. Scrubbing up for theatre 3

3. Venepuncture/phlebotomy 5

4. Cannulation and setting up a drip 7

5. Blood cultures 10

6. Blood transfusion 12

7. Intramuscular, subcutaneous, and intradermal drug injection 14

8. Intravenous drug injection 16

9. Examination of a superficial mass and of lymph nodes 18

II. CARDIOVASCULAR AND RESPIRATORY MEDICINE

10. Chest pain history 21

11. Cardiovascular risk assessment 24

12. Blood pressure measurement 26

13. Cardiovascular examination 28

14. Peripheral vascular system examination 33

15. Ankle-brachial pressure index (ABPI) 36

16. Breathlessness history 38

17. Respiratory system examination 41

18. PEFR meter explanation 46

19. Inhaler explanation 48

20. Drug administration via a nebuliser 50

III. GI MEDICINE AND UROLOGY

21. Abdominal pain history 52

22. Abdominal examination 55

23. Rectal examination 60

24. Hernia examination 62

25. Nasogastric intubation 65

26. Urological history 67

27. Male genitalia examination 69

28. Male catheterisation 71

29. Female catheterisation 73

vi Contents

IV. NEUROLOGY

30. History of headaches 75

31. History of ‘funny turns’ 78

32. Cranial nerve examination 81

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

38. Speech assessment 100

V. PSYCHIATRY

39. General psychiatric history 103

40. Mental state examination 106

41. Cognitive testing 111

42. Dementia diagnosis 113

43. Depression history 116

44. Suicide risk assessment 118

45. Alcohol history 120

46. Eating disorders history 123

47. Weight loss history 125

48. Assessing capacity (the Mental Capacity Act) 127

49. Common law and the Mental Health Act 130

VI. OPHTHALMOLOGY, ENT AND DERMATOLOGY

50. Ophthalmic history 134

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

55. Dermatological history 151

56. Dermatological examination 153

57. Advice on sun protection 156

VII. PAEDIATRICS AND GERIATRICS

58. Paediatric history 157

59. Developmental assessment 159

60. Neonatal examination 162

61. The six-week surveillance review 166

62. Paediatric examination: cardiovascular system 169

63. Paediatric examination: respiratory system 173

64. Paediatric examination: abdomen 176

65. Paediatric examination: gait and neurological function 179

66. Infant and child Basic Life Support 181

67. Child immunisation programme 184

68. Geriatric history 186

69. Geriatric physical examination 188

Contents vii

VIII. OBSTETRICS, GYNAECOLOGY, AND SEXUAL HEALTH

70. Obstetric history 189

71. Obstetric examination 192

72. Gynaecological history 195

73. Gynaecological (bimanual) examination 198

74. Speculum examination and liquid based cytology test 200

75. Breast history 203

76. Breast examination 207

77. Sexual history 210

78. HIV risk assessment 214

79. Condom explanation 215

80. Combined oral contraceptive pill (COCP) explanation 217

81. Pessaries and suppositories explanation 220

IX. ORTHOPAEDICS AND RHEUMATOLOGY

82. Rheumatological history 222

83. The GALS screening examination 226

84. Hand and wrist examination 229

85. Elbow examination 232

86. Shoulder examination 233

87. Spinal examination 236

88. Hip examination 239

89. Knee examination 242

90. Ankle and foot examination 245

X. EMERGENCY MEDICINE AND ANAESTHESIOLOGY

91. Adult Basic Life Support 247

92. Choking 250

93. In-hospital resuscitation 252

94. Advanced Life Support 255

95. The primary and secondary surveys 258

96. Management of medical emergencies 260

– acute asthma 260

– acute pulmonary oedema 260

– acute myocardial infarction 261

– massive pulmonary embolism 262

– status epilepticus 262

– diabetic ketoacidosis 262

– acute poisoning 263

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

98. Laryngeal mask airway (LMA) insertion 267

99. Pre-operative assessment 269

100. Syringe driver operation 273

101. Patient-Controlled Analgesia (PCA) explanation 275

102. Epidural analgesia explanation 276

103. Wound suturing 278

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

111. Requesting investigations 315

112. Drug and controlled drug prescription 318

113. Oxygen prescription 323

114. Death confirmation 325

115. Death certificate completion 326

XIII. COMMUNICATION SKILLS

116. Explaining skills 330

117. Imaging tests explanation 333

118. Endoscopies explanation 337

119. Obtaining consent 339

120. Breaking bad news 340

121. The angry patient or relative 341

122. The anxious or upset patient or relative 342

123. Cross-cultural communication 343

124. Discharge planning and negotiation 344

cmecde 210.pdf

 

TIORFAN 10 MG للرضع ، كيس عن طريق الفم

 

عرض

علبة 16

الجرعة

10 ملغ

برينسيبس

نعم

الموزع أو الصانع

مافار

التركيبة

راسيكادوتريل

الدرجة العلاجية

مضاد للإسهال ، مثبطات إنكيفاليناز

 

دواعي الإستعمال)

يشار بالإضافة إلى معالجة الجفاف عن طريق الفم كعلاج من أعراض الإسهال الحاد.

الجرعات وطريقة الإعطاء

اليوم الأول: تناول واحد على الفور ثم 3 مآخذ موزعة على اليوم.

الأيام التالية: 3 جرعات موزعة على مدار اليوم.

- للرضع أقل من 9 كجم: كيس واحد 3 مرات في اليوم.

- الرضع من 9 إلى 13 كجم: 2 كيس 3 مرات في اليوم.

سيستمر العلاج حتى عودة برازين مصبوبين دون تجاوز 7 أيام.

نوع المنتج

دواء