TEACHING STATIONS

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2
 Index

1. Teaching Structure 4
2. Epipen 6
3. Urine Dip Stick 10
4. Subcutaneous Injection 16
5. ECG 21
6. BLS 27
7. Pap Smear/ Speculum 32
8. Inguinoscrotal Examination 39
9. Per Rectal Examination 44
10. Testicular Examination 50

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TEACHING STATIONS BASIC STRUCTURE

1. Introduction – My name is…

2. ID check – Met before/ weren’t introduced properly…
3. Build rapport – How’s work/ Study/ Rotations/ Encourage/ Wish Luck for
exams
4. Main Concern – How can I help today / I have been told you have some
concerns; if it’s a patient or relative coming to learn something (Praise
for the interest to learn)
5. Assess Knowledge – 4 W ( How much they know about it and what they
want to learn )
 What do you know about it? (Past)
 What do you want to know? (Future)
 Why do you want to know? (Pt. Reason)
 Why or When we do it (Brainstorming)
6. +/- Patient Safety—PMH/ Drug/Allergies/Jabs/Social
Or if the colleague brings any teaching material ask where did you get
this sample from/ how is that pt. doing/ did you take consent, etc
7. Teach the station
 Before the procedure: (Tell them)
o Gather Materials
o Checklist
 Teach Procedure or Examination /How to do it (Show and Do)
 After the procedure/ What to do next
o What to do after
o Any other concerns
o Common Questions
8. Safety Net – Please come back if want to learn again/ and for example

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 in case of Epipen teaching remind proper dangers to look.

IPS in Teaching is very important

● Check understanding ( pick on the non-verbal cues – remember they don’t
want to see your knowledge of the topic but how much better you can teach)

Doctor/Nurse/Medical Student:

Eye contact, nuances of the voice, body movements,

body orientation, facial expressions,

Patient:
Physical details of Pt, position and movement of,
facial expressions,

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 Teaching EpiPen
Where Are you:
You are an FY2 in GP surgery.
Who is the Patient:
Jason Winslow 8 years old boy was admitted to the hospitalwith anaphylaxis
after ingesting peanuts one week back. His mother Becca Winslow has
questions about how to use the EpiPen
What you must do:
Please talk to the mother and teach her how to use the EpiPen
Special Note:
There is an Epipen Trainer on the table inside the Cubicle

1- Introduction: Introduce yourself and explain your role

2- ID check of the mother and the patient: I can see from my notes that you
came for your son Jason Winslow. Is that correct? It’s nice to meet you Becca.
Could you confirm Jason’s age for me please?
3- Build Rapport: How is he doing/ How was the hospital stay… etc

4- Main concern (she wants to learn about Epipen), here you should praise her
how far she is a caring Mom (IPS)
Ex: I or We are really happy to see that you are interested in learning about
EpiPen. I will do my best to explain it to you.
5- Assess her knowledge

(child , attack , epipen )

Child:
When he has been diagnosed with Allergy, Allergy regarding what-
food/medications?
How is the child now?
Attack:

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Recap what happened and what they did.
What symptoms he had? (Rash, swollen lips, wheeze chest)
For how long did it last?
What was your reaction, who have been around him (what they noticed over
him)
Epipen:
When was the EpiPen prescribed for him?
Or did you use it before / do you know how to use it …?
What if she tried to use the pen but cannot remember how…, called the
ambulance (always acknowledge and reflect)
For Example: Though experienced, you did the right thing.

6- Check / Safety Net

Check that she knows what she might observe or look for (symptoms of
Allergy)
Swollen lips, wheeze, rash, difficulty of breath, fainting… etc
7- Teach - Here it comes the mission of how to learn here the Epipen

Again you can score high in IPS

For example as you said you were afraid to use it (if she said that to you) to the
level that made you panicking … Mrs Winslow... Please try to take your breath
… calm down … you are doing that to save your son’s life.
As a start... at that point she will try to get as much as she can of how to use
this Epipen

- (Before use ) Explain the Pen

-It’s a device, it's like a syringe

-It has to ends (blue and orange)

- The orange end contain the needle (blue to the sky, Orange to the thigh )
Needle is covered and retractable so do not worry to get hurt.
- Check expiration date ( exchange them at GP )
- Check (this small window) it contain the drug watch for any changes

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 (sunlight can affect the medication inside) , that is why it is very
important not to keep it in extremities of temperature.

- How to use it (Show and do)

- Hold it Like a grip (blue to the sky , Orange to the thigh – remember
this to always know which way to hold)
- Remove the Blue cap
- Swinging motion to the thigh ( like so )
- Push it until you hear the click
- It can go through all the clothing, but make sure there is no button
or anything in the pocket while injecting
- Keep it in place and count 10 elephants.( Why you count? So that you
can make sure all the medication is injected in that 10 seconds)

- What to do next
- Call 999, and you need to say (‘ANAPHYLAXIS’ or Severe Allergic
reaction if you forget to remember that— why? To elicit a fast
response by the ambulance and paramedics team)
- Please again don’t panic, lie your child on floor and stay beside
him

Involve her in the conversation … Do you know why you should stay near him?
To watch for any signs... if he gets better or not … after 5 minutes if your son
didn’t get better or the ambulance didn’t arrive yet 
You will be in need to give him another shot typically as I just illustrated for you
After that: It’s necessary to put your child under observation for few hours
As there is risk of delayed reaction and your child’s health and safety is our
priority.

You already safety netted her early, you can also add

 We can refer your child to Allergy Clinic where he can be assessed

further
 Make sure that you will replace the two EpiPen because it is a SINGLE
USE , from nearest Pharmacy or GP . We can set a reminder for that.

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  Make sure his school and anyone taking care knows about his conditions
and let him carry them all the time, in the hard covering box,
 Remind her the signs to look for in a severe allergic reaction – SOB,
Cyanosis, Rash, Wheeze, Swelling of lips or Lump in the throat, fainting,
Offer a Leaflet with all information she might need later.

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 URINE DIPSTICK TEST - Teaching
Where are you:
You are an FY2 in Medicine Department.
Who is the Patient:
Jaden Smith, a nurse who started his first day in clinical attachment wants to
learn about the urine dipstick test
What you must do:
Please talk with Jaden and teach him about urine dipstick test.
Special Note:
There is Urine Dipstick Test Equipment in the cubicle to teach.

1. Introduction: Hey you must be Jaden if I am not wrong? I am Dr. X working

in this department.
2. ID check: Done with introduction part above
3. Build rapport: Ask about work/ How is his first day going… etc.
4. Main concern (how can I help you): Jaden how can I help you if you need
anything to know from me?

– Yes please could you teach me how to do Urine Dipstick Test?

– Yes definitely I would love to show you how to do them. I appreciate that
you are already filled with so much enthusiasm… (Acknowledge & IPS)

5. Assess knowledge (4 W)

 So before we start could you tell me What do you know about in

particular?
 What exactly you want to know about it?
 Why do you want to know about it any reasons in particular?
 And do you know Why we do it? (Brainstorming for colleague)

6. Teach the Urine Dip Stick Test

Before – Collecting materials

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 Remember in the Start (from Equipment in front of you what you see)
 Gloves and Apron (Be sterile and to prevent cross contamination)
 Urine Sample ( Ask who’s urine sample is this and if consent has been
taken or is just for teaching purpose)
 Dipstick Test Kit (Bedside Testing kit)
 Paper Towels
 Waste Bin
You already built Rapport with your colleague and checked how far he wants to
know about urine dipstick
Now from things you have in front of you tell them about each
 Urine :
We check Colour, Clarity and Smell – But it is outdated, we don’t do it
now, but I want to tell you everything what I might know.
Then, Talk about each
Colour: What if we found there is a change in colour
For example.. If it is red or dark what might come in your mind (here
you involve them)
Clarity : What if it is unclear/ cloudy? So what is normal … Yes , to be
clear
So if it is unclear.. we might consider infection
Odour :
Offensive odour: suggests infection.
Sweet odour: suggests glycosuria
Again , Assessment of urinary odour is rarely performed in practice.

 Urine Dipstick Container; Check Expiry date and strips having the
chemicals on them.
How to do it (Show and do)
o Wash your hands and wear your gloves
o Remove a dipstick from the container without touching the

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 reagent squares.
o Replace the container lid to prevent oxidation.
o Insert dipstick into the sample, ensuring all reagent squares are
immersed.
o Remove the dipstick and tap off any residual urine using the edge
of the container, making sure to hold the dipstick horizontally to
avoid cross-contamination of the reagent squares
o Lay the dipstick flat on a Paper towel.
o Wait for 60-120 seconds ( According to whatever you look for ) Ex:
glucose, leukocytes
o See the urinalysis guide on the side of the testing strip container
to interpret the result
After Analysing
o Discard everything in its suitable place … take off your gloves and
apron.
o Sit and document everything and the findings in the notes.

Suggest further investigations based on urinalysis results.

Interpretation of dipstick results
The following tests are ordered by the time at which the reagent square
should be interpreted.
Glucose
● Time at which the reagent square should be interpreted: 30 seconds
● The absence of glucose in the urine is normal.
● Causes of glycosuria include DM, renal tubular disease and some
medications
Bilirubin
● Time at which the reagent square should be interpreted: 30 seconds
● The absence of bilirubin in the urine is normal.
● The presence of bilirubin in the urine
suggests increased serum levels of

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 conjugated bilirubin
Ketones
● Time at which the reagent square should be interpreted: 40 seconds
● The absence of ketones in the urine is normal.
● The presence of ketones in the urine suggests
increased fatty acid metabolism,which occurs
during starvation and in conditions such as
diabetic ketoacidosis.
- Specific gravity
● Normal range: 1.002 – 1.035 mOsm/kg
● Time at which the reagent square should be interpreted: 45 seconds
● Causes of low specific gravity include : diabetes insipidus and acute
tubular necrosis.
● Causes of raised specific gravity include dehydration, glycosuria &
proteinuria
pH
● Normal range: 4.5 – 8
● Time at which the reagent square should be interpreted: 60 seconds
● Causes of low urinary pH include starvation, DKA and otherconditions
● Causes of raised urinary pH include urinary tract infection,
Blood
● Time at which the reagent square should be interpreted: 60 seconds
● The absence of red blood cells, haemoglobin and myoglobin in the
urine is normal.
● The presence of RBCs, haemoglobin and myoglobin
indicate infection, renal stones,injury to the urinary
tract, (rhabdomyolysis), nephritic syndrome and
malignancy
Protein

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 ● Time at which the reagent square should be interpreted: 60 seconds
● The absence of protein in the urine is normal.
● Causes of proteinuria include nephrotic syndrome and chronic kidney
disease.
Nitrites
● Time at which the reagent square should be interpreted: 60 seconds
● The absence of nitrites in the urine is normal.
● The presence of nitrites in the urine is suggestive of urinary tract
infection.
Urobilinogen
● Normal range: 0.2 – 1.0 mg/dL
● Time at which the reagent square should be interpreted: 60 seconds
● The presence of increased levels of urobilinogen in the urine can be
caused byhaemolysis (e.g. haemolytic anaemia, malaria).
● Low levels of urobilinogen can be caused by biliary obstruction.
Leukocyte esterase
● Time at which the reagent square should be interpreted: 2 minutes
● A negative leukocyte esterase test is normal.
● Causes of a positive leukocyte esterase include urinary tract infection
and anycondition that could result in haematuria.

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15
 Teaching Subcutaneous Heparin injection
Where are you:
You are an FY2 in Medicine Department.
Who is the Patient:
Jamie Watson, a 2nd year medical student who is undergoing a rotation in your
department
He has been on the ward for weeks and he would like to learn how to perform
subcutaneous injection
What you must do:
Teach the student the basics of subcutaneous injection.
Special Note:
None

1. Introduction / ID check as like the structure

2. Build rapport
3. Main concern ( how can I help you )
4. Assess knowledge ( 4 w )
- What do you know about it ( past )

- What do you want to know (future )

- Why do you want to know
- Why we do it (for colleague )
Common route of delivery for medications such
as insulin and low molecular weight heparin
(LMWH) and palliative medications

5. Teach Subcutaneous Heparin injection

A. Before we do the test
- collect Materials

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 ● Gloves & apron Be sterile and To prevent cross
contamination
● Equipment tray

● Syringe ( smallest syringe that will accommodate the

medication volume)
● 2 needle
- Injecting needle (26–30 gauge)
- Drawing-up needle (when drawing up
medications from ampoules)
● Gauze or cotton swab
● Sharps container/ Bin

● The medication to be administered ( Heparin)

● The patient’s prescription
● Injection Site chart
- checks Before the procedure
● Introduce yourself to the patient including your name and role
● Briefly explain what the procedure
● Gain consent ( Right to refuse )
● Do check List :
1) Right person: ask the patient to confirm
their details and then compare this tothe
patient’s wristband (if present) and the
prescription

2) Right drug: check the labelled drug against

the prescription and ensure themedication
hasn’t expired.
3) Right dose: check the drug dose

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 against the prescription to ensure it is
correct.
4) Right time: confirm the appropriate time to be
administering the medication
5) Right route: check the planned route of administering
drugs.
6) Right to refuse: ensure that valid consent has been gained
prior to medication administration.
7) Right documentation of the prescription and allergies

B. How to do it (Show and do)

1) Wash your hands and wear your gloves
2) Wipe the top of the medicine bottle with alcohol pad
3) Choose the injection site
4) Open syringe package and put on a clean surface
5) Insert the drawing needle into the top of the bottle at angle of
90 degrees
6) Pull back the plunger to fill the medication
7) Remove the needle and replace it with theinjecting needle one
8) Hold needle upward , tap it gently and then push the plunger
9) Use you non-dominant hand (pinching the skin increases the
depth of the subcutaneous tissue available).
10) Warn the patient of a sharp scratch.
11) Inject the contents of the syringe whilst holding
the barrel firmly. Aspiration is not recommended
for subcutaneous injections, as there are no major
blood vessels in the subcutaneous tissue and the
risk of inadvertent intravenous administration is
minimal,however, always follow your local
guidelines.

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 12) Remove the needle and immediately dispose of it into a sharps
container.
13) Apply gentle pressure over the injection site
with a cotton swab or gauze and avoidrubbing
the site.

14) Replace the gauze with a plaster. Dispose of your equipment into
an appropriate clinical waste bin.

C. What to do next
- Explain to the patient that the procedure is now complete.
- Thank the patient for their time.
- Discuss post-injection care and Safety Netting
Warn the patient that it is normal for the injection site to be
sore for one or two days.
Advise that if they experience worsening
pain after 48 hours they should seek
medical review.

Reiterate the potential complications of

subcutaneous injections including
haematoma formation, persistent nodules,
local irritation and rarely anaphylaxis.
- Document the details of the procedure and the medication
administered.

Appropriate
injection site:
● Abdomen: avoid injecting within a 2-inch radius
around the umbilicus (this isthe preferred site if
administering low molecular weight heparin).
● Upper outer aspect of the arm
● Outer aspect of the upper thigh

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 ● Upper buttock
● Do NOT use a site that is scarred, inflamed, irritated or bruised.

Figure below denotes the injection site chart.

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 Teaching ECG
Where are you:
You are an FY2 in Cardiology Department.
Who is the Patient:
Jaden Smith, a 5nth year medical student (or a Nurse) who is undergoing a
rotation in your department has come to you to learn about ECG (They might
hold 3-4 ECG in their hands)
What you must do:
Talk with Jaden and teach him ECG.
Special Note:
None

1. Introduction
Hello I am (Your name) A junior Doctor in this department.
You must be Jaden right?
2. ID check
Yes Dr. (Your name) I am Jaden.
3. Build rapport
How are you doing? / Ask about work/ Ask about the weekend/
Studies… etc.
4. Main concern ( how can I help you )
I want to learn about the basics of the ECG can you please teach me?
I can see that you are very much interested in
learning about the ECG. I reallyappreciate it.
(Praising) Positive reinforcement.

5. Assess knowledge ( 4 w )

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 ● What do you know about it ( past )
Can you please tell me how much you know about the ECG?
Doctor I know how to record ECG on a machine but or I don’t know
much about how to read it. Doctor please teach me here I got you
some ECG.
● What do you want to know (future )
What are the Waves?
How are the waves
produced?

How to check the

Heart rate?

What is a normal and an abnormal ECG?

What is S.T segment elevation?
● Why we do it (for colleague )
- We use ECG to diagnose if there are any heart related issues like
Arrhythmias, Heart Attack, Coronary Heart disease and
Cardiomyopathy. Am I clear sofar?
- Yes Doctor.
-
6. Teach the ECG (Now let me tell you how to/What to do next)

 Before:
- Explain the student/Colleague ECG by Drawing Heart and
Waves
- Then tell him to take consent when he has to do ECG
- Then Attach leads
- Ask about patient if he shows you some ECG where did he
get them and did he take consent from the patient or are
they for teaching purpose.
Teach:

Waves

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Ok, so firstly we need to know how ECG is recorded. Sensors are
attached to the skin which are then used to detect the electrical signals
produced by your heart each time it beats
These signals are recorded by a machine and are looked at by a doctor to
see if they're unusual.These signals are waves.
There is a spark that is initiated from this point - SA Node (you will have
a paper and pen to draw a simple figure of the heart)
Show him what the structure of the heart is:
Point to SA Node, These are the Atria and those are the Ventricles
This spark created from the SA Node travel through gates to reach all of
the heart, creating impulse that resemble life (try to choose your own
words, but please choose simple words and to the point)
Hold ECG … and show what everything of the draw can be translated to a
wave in the ECG

This impulse of SAN creates P wave

And when these large chambers (Ventricles) Contract they create QRS
wave (point at it)
After that it must have time to rest (milliseconds) that equal this wave.
Which is T wave
Now you know the unit of the heart and check with the colleague or the
nurse that he understood what you have said

Then, you move to the Next:

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Rate and Rhythm

We will determine either the beats of this heart’s tracing are regular or
not
If the distance between each R wave are the same, so it is regular

And then you can calculate the heart rate, how?

If Regular then you need to count the number of large boxes between 2
R waves and divide it with 300.
So, for example if you get 4 large boxes between 2 R waves then it will be
300/4 = 75 bpm. Which is actually a normal heart rate.

Do you know the normal heart rate?

Yes between 60-100 bpm
What if it is higher and lower than this rate? DO you know what they are
called?
If you see them please involve your senior because most probably there
is something that may need to be assessed quickly.

What if the rhythm of the heart is irregular?

How can we calculate the heart rate then?

But before that I want to highly stress on the point that if you find the
rhythm of the heart is not regular, it is very important also to involve
your senior.

So to calculate irregular heart Rate

You will count 30 large squares and whatever the number of R waves
present in these large 30 squares and then multiply by 10

For example; you found 8 R waves in 30 large boxes, then you multiply
the & with 10 you will get 80 that is the HR in irregular Rhythm

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Now I will teach you about S.T elevation which we use to detect M.I
If you see ST Elevation in any leads when they have symptoms of
sudden severe crushing central chest pain radiating to the left jaw/
neck/ shoulder/ arm then it means the patient might have MI and
needs urgent management calling for help and seniors.

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Only teach what he/she requested

If you finish and still have time

Check understanding and thought retention
Ask do you want to learn anything else / do you want to learn about?
No Doctor this much knowledge is enough for me.
After tracing and reading ECG remember to note it down in the patient
notes and thank the patient. And always look for red flags and safety net,

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 Basic Life Support Teaching
Where are you:
You are an FY2 in Accident and Emergency Department.
Who is the Patient:
Alex Wilson is a 3nd year medical student who has not attended his Basic Life
Support Class. He came today for you to learn about it now.
What you must do:
Talk with Alex and please demonstrate and teach him the BLS, explain him the
steps of BLS.
Special Note:
Do not perform mouth to mouth breathing.

1. Introduce yourself:
 Hello, are you Alex?
 I’m Dr. ……, one of the junior doctors here.
2. Rapport :
 I can see you come here today to learn …….
 That’s very good.
 In which year, are you in?
 How do you find your studies?
 Very soon, you will be here teaching.
 If you need any help, please let me know.
 Best of luck in your exams.
3. Assess knowledge:
 How much do you know about ……?
 Have you seen chest compression before?
 That’s very good, you read before you came that shows how a good
student you are!
 Do you know why we do CPR?

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  When the heart or lung stops, we do CPR to restore their function.
Simply it’s a lifesaving technique, so you need to know it exactly very
well because you can save patient’s life.
4. Start teaching :
 Before we go ahead, at any time, if you think I’m going too fast or I
can’t express myself very well , You can stop me and I’ll be more than
happy to explain it again.
 Involve the student:
- Are you following me?
- Am I clear so far?
- Do you know what we are looking for?
Steps of BLS
Safety  Ensure the place is safe.
 Not in work place, main road or wet area.
Check response  Tapping on his shoulder
 Hello, Are you alright?
Note: If mannequin on its side, turn it on its
back.
Call for help  Assign anyone to be next to the patient
during that time.
A  Head tilt chin lift to check for any foreign
Airway body
 What to do if you find any foreign body?
 Make sure that you make your little finger
like a hook to remove the FB to pull it (not
pushing).
 If you suspect there is spinal cord injury then
check the airway by Jaw Thrust method.
B  Come close to his face to
Breathing  Listen his breathing sounds
 Look for his chest rise
 Feel for his breathing touching

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 your face
 If no breathing → call 999 ( or use AED).
 Start CPR immediately.
 Checking for breathing should not last > 10
sec.
C  Feel carotid pulse at same time of checking
Circulation for breathing.

C  Make your arm straight.

CPR  Your shoulders are perpendicular to patient’s
chest.
 Place heel of your dominant hand on lower
1/3 of his chest but not on xiphi-sternum.
 Interlock or cross your fingers of both hands.
 Start to press
 Depth should be 5-6 cm or 1/3 of the chest
diameter.
 Rate: 2 compressions / sec or 100-120
compressions /min
 Do the chest compressions for 2 minutes and
then reassess patient by checking his breathing
and circulation but no more than 10 seconds
 Then repeat compressions again and so on
until no improvement or signs of life
(30 compressions then giving 2 rescue breaths.
– This is now obsolete according to the new
NHS and WHO guidelines in adults)
 Make sure you are not compressing xiphi-
sternum , do you know why? Because, it can
lead to a fracture.

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Important Notes
1. If student asks you , when to stop ?
 If ambulance arrives.
 If you can see signs of life.
 If you get tired.

2. In paediatrics BLS → same as adult ,

Differences are:
 Give 5 rescue breaths before starting CPR.
 CPR rate = 15:2.
 Use one hand if child is > 1 year.
 if child is < 1 year , use 2 fingers.

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3. If the student start to yawning:
 Are you ok ?
 I can see you are yawning , are you tired ?
 Should I carry on ?

4. Assess student at CPR and rescue breaths :

 Can you please show me how to do CPR ?

5. If student asks you, could CPR cause rib fracture ?

 Yes , it may happen , but the most important thing is to save his
life.

6. In any teaching station :

 Use medical terms.
 Check for understanding along the station.

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Per Speculum Examination/ Pap Smear Procedure
Teaching (Mixed Station)

Note: This Station can come as a teaching station or a procedure/

examination station in the exam, so learn it in both ways following the
structure of the either way.

Where are you:

You are an FY2 in GP Surgery.
Who is the Patient:
Mrs. Michelle Aylesbury, aged 31, presented to the clinic today for her routine
cervical screening test.
What you must do:
Talk with the patient, perform the pap smear and address the patient’s
concerns
Special Note:
None

1. Introduction / Pt ID
2. Brief History of her general health and sexual health
3. Patient Safety for any symptoms and complaints and how was her
previous procedure if she had
4. Rule out any contraindications for the procedure
 Active vaginal bleeding
 Active menstruation
 Recent sexual intercourse
 Recent use of spermicidal gel
 Pregnancy

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5. Do the procedure/ examination or teach it
Before we can do the procedure I need to check your (Vitals) Blood
Pressure, Body temperature, Pulse rate, Respiratory rate.

Before the examination/ Procedure

Explain the procedure (PEPCC)

● Procedure/ Purpose: This will involve me
inserting a Lubricated instrument called
speculum into you r vagina to visualize +/-
(take a sample of cells from the) neck of you
womb
● It shouldn't be painful, but it will feel a little
uncomfortable. I will be as gentle as possible,
but you can ask me to stop at any point.
● Exposure For the purpose of this exam I need you to be bare
below the waist ,
● Position: you need to remove your
underwear, lie down on your back, Bring your
heels towards your bottom and then let your
knees fall to the sides making it wide apart”

● Chaperone: “One of the female ward staff

members will be present throughout the
examination, acting as a chaperone, would
that be ok?”

● Consent to proceed with the examination/

procedure: “Do you understand everything
I’ve said? Doyou have any questions? Is it ok
for me to carry out the

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 Examination/Procedure?”

Gather materials / equipment:

● Gloves
● Lubricant
● Speculum
● Light source for the speculum
● Paper towels
● A pot of cytology preservative solution : Sure path/Thin prep
● Cervical brush
● Clinical waste bin

Do the Examinations/Procedure
1. Give time for the Patient to undress/change herself.
2. Provide the patient with the opportunity to pass urine to empty her
bladder before the examination procedure.
3. Ask the patient if they have any pain before doing the clinical
examination
4. Make sure you adjust the light before proceeding to the procedure.
5. Don an apron, and a pair of non-sterile gloves if gloves are available.
(Assume I am gloved if gloves not available).
(Make sure the Lubricant bottle or Packet is kept open before you
start the procedure/ examination)
● On inspection/Palpation
- Warn the patient that you are going to touch
and inspect their front passage. Verbalize these:
There is no redness, swelling, bleeding,, Ulcers,
vaginal discharge, Scarring, Vaginal atrophy,
White lesions, Masses, Varicosities, Female
genital mutilation/ Injury
- Separate the labia gently with your left index and left thumb and
inspect the inside of the labia.

34
 - Ask the patient to cough and inspect for prolapse
● Instrumentation

● Speculum ( Go in )
- Apply some lubricant to the blades of the speculum.
- Warn the patient you are about to insert the speculum.
- Gently insert the speculum sideways (blades closed, angled
downwards).
- Once inserted, rotate the speculum 90° so that the handle is
facing upwards.
- Open the speculum blades until an optimal view of the cervix
is achieved.
- Tighten the locking nut to fix the position of the blades.
1) Verbalize vaginal canal examination
- fix the position of the blades. Hold the
speculum with your hand and makesure
that you do not leave it
- Verbalize “ I am Inspecting the cervix and vaginal walls: -
- External os: Open/Closed
- Cervical erosion /Masses /Ulcers/ Discharge / Bleeding
2) +/- PAP Smear
- Verbalize “I am inserting the brush deep into
the endocervical canal to reachthecervix,
- brushing carefully around the
external os, 5 times, 360 degrees, in a
clockwise direction to obtain a
sample of cells.
- Gently removing the brush, avoid touching

35
 the speculum or the vaginal wallswith the
brush.
- SurePath: Drop the detachable brush end into
the SurePath sample pot and discard the rest
into the clinical waste bin. Place the cap on the
pot and tighten.
- ThinPrep: dip the brush into the ThinPrep
sample pot 10 times. Then discard it into the
clinical waste bin. Place the cap on the pot
and tighten.
● Speculum ( Go out )
- Warn the patient you are about to Withdraw the speculum
- Loosen the locking nut on the speculum and partially close
the blades.
- Rotate the speculum 90°, back to its original insertion
orientation, while gentlyremoving the speculum, inspecting
the walls of the vagina as you do so. Do not completely close
the speculum (to avoid pinching/damaging the vaginal walls.)

- Inspect the Speculum for any blood or Discharge

After the Procedure/Examination
- Document the procedure in the medical notes
- Thank the patient for their time.
- Summarise your findings. ( mention only positive )
- Explain to the patient that her smear results will be sent to her GP in
approximately 2 to 3 weeks and that she may experience some
bleeding over the next few days

OSCE Checklist: Per Speculum examination/ PAP Smear

Introduction

36
1 Introduce yourself to the patient including your name and role
2 Confirm the patient's name and date of birth
3 Explain what the examination will involve using patient-friendly language
4 Explain to the patient (Position)
5 Explain the need for a chaperone

6 Gain consent to continue with the clinical examination

Preparation

7 Ask the patient to remove their underwear for the examination and provide
themwith privacy whilst they get undressed
8 Ask the patient if they have any pain before continuing with the examination
9 Gather equipment
10 Don a pair of non-sterile gloves
Inspection
11 Separate the labia.and inspect the region for any relevant clinical signs
12 Ask the patient to cough

Palpation

13 Lubricate the speculum

14 Warn the patient you are about to insert the speculum
15 Insert speculum: Once inserted, rotate the speculum back 90° (so that the
handle is facing upwards).
16 Open the speculum blades until an optimal view of the cervix is achieved
17 Tighten the locking nut to fix the position of the blades
18 fix the Speculum in position ( do not let go )

+/- PAP Smear

A I am inserting the brush deep into the endocervical canal to reach the cervix,
B Verbalize brushing carefully around the external os, 5 times, 360 degrees, in a
clockwise direction to obtain a sample of cells.
C Gently removing the brush,
D Dip in SurePath OR ThinPrep:

37
19 Loosen the locking nut on the speculum and partially close the blades.
20 Rotate the speculum 90°, back to its original insertion orientation.
21 Warn the patient you are about to remove the speculum
22 Withdraw Speculum and inspect for blood or mucous
23 Clean the patient using paper towels
24 Cover the patient with the sheet, explain that the examination is now complete
and provide the patient with privacy so they can get dressed
25 Dispose of the used equipment into a clinical waste bin
26 Thank the patient for their time
27 Document the examination in the medical notes
28 Explain to the Pt that smear results will be sent to her GP in approx (2 to 3 w )
29 Explain to the Pt she may experience some bleeding over the next few days.,

38
 Inguinoscrotal Examination Teaching

Where are you?

You are an FY2 working in Surgery Department.
Who is the Patient:
Sammy Wilson, a 5th year medical student in clinical rotation in your
department wanted to seek help regarding learning about inguinoscrotal
examinations
What you must do:
Talk to him and teach him inguinoscrotal examinations. Do not ask him to
repeat the steps of examination.
Special Note:
None
The Medical student can ask you to teach the anatomy or the examination only
sometimes so ask and understand your task properly at the start.
1. Intro/ID Check/ Rapport:
 Hi, I‘m Dr. ….. , are you …..?
 How are you doing? (Be smile and friendly)
 How are you doing today?
 Which year are you in?
 How do you find the studies?
 Is there anything difficult?
2. Main Concern/ Assess knowledge :
 I can see that you are coming to learn about hernia, how much do you
know about it?
 What do you want me to explain about it?
3. Start teaching :

39
 If you have any question or I am not clear, please let me know.
 Before we start teaching, do you know what hernia is? - It is a swelling
that occurs when internal organ like small or large intestine pushes
through a weakness in the anterior abdominal wall and it comes like
swelling.
 Do you know what causes hernia?
- When there is an increased intra-abdominal pressure like constipation,
chronic cough, etc.

Explain the Anatomy

 Superficial ring → ½ inch on top of pubic tubercle.

 Deep ring → ½ inch on top of mid inguinal ligament.
 Inguinal canal → mid-way between ASIS and symphysis pubis.
 There are 2 types of inguinal hernia (different entrance but same exit)
– Direct → enters through wall weakness in inguinal canal, then passes
through Hassel Bach’s triangle → exits from superficial ring .
- Indirect → enters from deep ring and passes into the inguinal canal →
exits from superficial ring.

40
Steps of Examination
1. Before you do any examination, you need to do PPCCE ( explain them
to the student)
 You have to ensure patient privacy.
 Explain examination to the patient and Take consent
 Tell the patient about the adequate exposure, from mid-chest to
mid-thigh, because, you need to examine abdomen, testicles,
scrotum and mid-thigh due to there might be a femoral hernia.
 You need to check his genital area to see if this swelling is coming
from abdomen (inguinal) or from scrotum (femoral).
2. How to examine hernia?
 Position: Ideally, I should examine the patient in standing position,
but for the purpose of the exam, I‘ll examine the patient while lying
down. (As the mannequin used can be a lying down)
Inspection  If you can see swelling, comment on: - Site. - Size.
- Skin on top. - Unilateral or bilateral.
 If you cannot see swelling, ask the pt. to cough, if
swelling come out, comment as before.
 Ask pt. to lie down and reduce the hernia and
locate the deep inguinal ring. Then, ask pt. to
cough: - If hernia comes out from superficial ring →
Direct. - If feel impulse below your finger →
Indirect.
Palpation  Temperature - by back of your hand - Touch it
and compare with anything above.
 Tenderness - Touch it and look at pt. face.
 Deep palpation :
1. Site - Inguinal →above and medial pubic
tubercle. - Femoral → below and lateral pubic
tubercle. - Testicular (if your fingers can not touch
each other
2. Consistency → touch the swelling and see if it: -
41
 Doughy → omentum or fat. - Elastic (like tube) →
intestine. - Very tender → strangulation ( the pt.
will have constipation and vomiting in this case )
3. Cough impulse: (ask pt. to cough twice)
 In inspection → if there is no swelling.
 In palpation → while you are touching the
swelling, ask Pt. to cough:
a) Feel impulse → Good (no strangulation)
b) No impulse → may be strangulation.
c) If I am palpating + there is no swelling → ask pt.
to cough + do Zieman’s test.
4. Zieman’s test (3 fingers test )
 Indication: done when there is no apparent
hernia by palpation.
 Steps: - Block deep ring by your index finger -
Block superficial ring with your middle finger -
Block saphenous opening with your ring finger. -
Ask pt. to cough
 Result: - Impulse felt under index → indirect -
Impulse felt under middle finger → direct - Impulse
felt under ring finger → Femoral
Percussion  Looking for the content.
 Resonant → intestine.
 Not resonant → omentum
Auscultation  Looking for the content.
 Peristaltic sound → intestine.
 No sound → omentum
After the examination
(Verbalize)
 Make sure you cover the pt. → Ideally, I should cover the pt.
42
 Ideally. I should examine the abdomen, scrotum, testicles and L.Ns
of the abdomen.
Management
 Explain hernia and its risk factors.
 Alex, we should do some investigations:
- To see its content as US.
- To check for check for risk factors (as CXR for cough if present).
 Treatment is surgical - Elective repair → if hernia is reducible.
- Emergency urgent laparotomy → if strangulated.
- Open or laparoscopic repair → if irreducible.

This is the mannequin you will be given in the exam for examination
and teaching purposes.

43
 Per- Rectal Examination/ Teaching
Where are you:
You are an FY2 working in GP Surgery.
Who is the Patient:
Mr. Jason Roy, aged 57, presented to the clinic requesting PSA
What you must do:
Talk to the patient and take focused history and do relevant examinations and
discuss appropriate further management with him.
Special Note:
None
Per Rectal Examination Stations usually come as a combined examination
stations than teaching station, but rarely teaching do come, so make sure you
learn it in both the structures, i.e. teaching and examination structures.

1. Introduction / Pt ID
2. Brief History
D: How can I help you?
P: I want to do a PSA test.
D: Why do you want to do the PSA test?
P: My friend died of Prostate Cancer (empathize the patient)

Pt safety , any symptoms or complaints History

Positive history for frequency of urine, nocturia, urgency
Positive History for DESA

D/D Rule Out: BPH, UTI & Cancer

3. Rectal Examination:
Now I need to check your Blood Pressure, Body Temperature, Pulte rate,
Respiration rate and I would like to perform a rectal examination.

44
Before the examination

Explain the procedure

1. Purpose: This will involve me inserting a gloved and
lubricated finger into your back passage tofeel for any
abnormalities.
It shouldn't be painful, but it will feel a little uncomfortable,
but you can ask me to stop atany point.
2. Exposure: For the purpose of this exam I need you to be bare below the
waist ,
3. Position: you need to lie down on your left side, with
your knees lifted up towardsyour chest and the botox at
the edge of the table.
4. Chaperone: “One of the other staff members will be
present throughout theexamination, acting as a
chaperone, would that be ok?”
5. Consent: to proceed with the examination: “Do you
understand everything I’ve said? Doyou have any questions?
Is it ok for me to carry out the examination?”
If the patient refuses, ask why in a polite way; He will say if
you’re doing the PSA test why do you need Per Rectal exam?
The Answer is; as the PSA test can often also be false result
as there are many exceptions where the test shows a
positive result but the patient doesn’t have any problem
with the prostate, therefore examining the prostate gland
can avoid such confusions as it might be or might not be
enlarged growing a tumor.

45
 Gather Materials / Equipment:

● Non-sterile gloves / Apron

● Lubricant
● Paper towels

Do it (explain and do)

6. Give time to Pt to change
7. Ask the patient if they have any pain before doing the clinical examination
8. Don an apron and a pair of non-sterile gloves (assume I am gloved )
On inspection/Palpation :
Separate the buttocks and inspect the peri-anal region
Warn the patient that you are going to touch and inspect their back passage.
Verbalize: There is no redness, swelling, bleeding,, Skin tags,
haemorrhoids, Analfissure or fistula

Ask the patient to cough and inspect for rectal prolapse and or internal
haemorrhoid

Finger Insertion

● PR ( go in )
- Lubricate the examining finger.
- Place finger at anus
- Warn the patient you are about to insert your finger.
- Insert your finger gently into the anal canal.
1) Verbalize Anal canal examination
- Rotate your finger 360 degrees to assess the entirety of the
rectum:
- Feel for any hard stool or any rectal lumps

46
 2) Verbalize Prostate examination
- prostate gland is palpated anteriorly,
- 2 lobes :- assess and verbalize the symmetry , size (
normal/enlarged), Surface and texture
- Midline sulcus.
- Anterior Rectal Mucosa over the prostate Fixed or not
3) Verbalize Anal tone assessment.
- Asking the patient to bear pressure down on your finger (couple
of Sec) and then relax

Note the location of any tenderness, which may

indicate an anal fissure or thrombosed internal
haemorrhoids.

● PR ( go out )
- Warn the patient you are about to withdraw your finger.
- Withdraw your finger and inspect for blood or mucous:
● Dark sticky (melaena)
● Fresh red blood
● Excess mucous
What to do next
Clean the patient using paper towels/ or tell them to clean themselves with
paper napkin.
Cover the patient with the sheet, explain that the
examination is now complete and provide the patient
with privacy so they can get dressed.

Dispose of the used equipment into a clinical waste bin.

Document the procedure in the medical
Thank the patient for their time.

47
Summarize your findings. ( mention only Positive findings )
Suggests appropriate further investigations and Management according
to your finding.

If there is prostate enlargement:

Dx Best case it can be a BPH and in worst case something sinister

Involve senior and do PSA, and other routine investigations

Urgent referral to Urologist/ Specialist

Treatment options if cancer/ sinister can be surgery, chemotherapy and

radiotherapy And if BPH then medication to reduce the size and ease
out problems of urination.

Safety net for FLAWS, worsening symptoms of urination and UTI.

48
DR. MO SOBHY [TEACHING STATIONS]

Per Rectal Examination Mannequin

49
 DR. MO SOBHY [TEACHING STATIONS]

Testicular Examination
Where are you:
You are an FY2 working in GP Surgery.
Who is the Patient:
Mr. Robert Frost, aged 25 years, came to you today with some concerns
What you must do:
Talk to the patient and take focused history and do relevant examinations and
discuss appropriate further management with him.
Special Note:
None
Testicular Examination Station scenarios:
1. Epididymal Cyst
2. Testicular Tumor
3. Hydrocele
4. Mumps Orchitis
5. Epididymo Orchitis

Greet and introduce yourself and check Identity

Build proper rapport and use proper IPS –
- How may I address you Mr. Robert Frost?
- How are you doing Robert?
- I can see that you came with some concerns today, how can I help
you?
History/Data Gathering

Scenarios History
Epididymal Cyst Main Concern: Swelling in the scrotum
Focussed History
Incidental finding of painless swelling while shower,
2 days-2 weeks,
Round in touch,

50
 DR. MO SOBHY [TEACHING STATIONS]

Not increasing in size, shape, no fever, discharge,

trauma,
Age middle aged mostly
Testicular Tumor Main Concern: One of the testis is swollen/heavy
Focussed History
One of the testis is growing bigger,
2-3 weeks,
Painless,
Growing bigger,
Hard on touch,
Increasing/or not increasing in size,
No trauma, discharge,
Age young in his 20s
History of undescended testis,
History of Childhood surgery for the same,
+/- FLAWS
+/- Family History
+/- Smoking
Hydrocele Main Concern: One of the testis is swollen
Focussed History
One of the testis is feeling heavy and discomforting,
1-2 weeks,
Growing bigger,
Cystic on touch,
No FLAWS,
No Trauma,
No Family History,
+/- Smoking
Mumps Orchitis Main Concern: Painful swelling/Pain in the testis

51
 DR. MO SOBHY [TEACHING STATIONS]

Focussed History
One of the testis is swollen and painful,
2 days,
Fever, History of Cold/Flu/Mumps,
No urinary symptoms,
No FLAWS,
No Trauma,
No Sexual History,
Epididymo Orchitis Main Concern: Painful swelling/Pain in the testis

Focussed History
One of the testis is swollen and painful on touch,
2 days,
Fever,
Positive sexual history of unprotected sex with
multiple partners,
No urinary symptoms,
No FLAWS,
No Trauma,
+/- Smoking
+/- Travel history

Testicular Examination
 Before the Examination - Preparation: PPECC
1. Identify and Explain the procedure
2. Explain the purpose of the examination
3. Explain that it will involve undressing fully from the abdomen to
the thighs.
4. Gain consent and offer a chaperone
Also verbalize about checking his vitals and General head to toe
examination
 Inspection:

52
DR. MO SOBHY [TEACHING STATIONS]

Inspection of Genital region and the surrounding areas (penis, groin

& lower abdomen)
Verbalize: There are no skin changes (rash, bruising, erythema, and
swelling), scars and any obvious masses.
Inspection of the scrotum: Ask the patient to hold their penis out of
the way to allow easier inspection of the scrotum (they will make you
do it for assuming).
Inspect the scrotum from the front and posterior sides.
Verbalize: There are normal scrotal rugosities, no skin changes, scar,
obvious masses, swelling, sinuses and necrotic tissue. I don’t see any
scar mark, any discharge.
 Palpation: (T,T,D)
Temperature: compare both the testicles with the thigh, check the
normal side first
Palpation: (Palpate with thumb and index finger)
Superficial: check for Tenderness in both the testicles.
If Tender then only do:
Phren’s Test:
If testicular pain is relieved by elevating the testes, this is
suggestive of epididymitis.
Testicular torsion (if pain is not relieved)
If No Tenderness then do:
Deep Palpation: palpate for spermatic cord, epididymis, course of
the testis, course of the swelling.
Feel for any mass (site, size, shape, surface, consistency, contour,
tenderness, mobile, attached to underlying structure or not)
Special Tests

Get Above the Swelling (if no pain)

Try to grab above the swelling with your thumb and index finger
If able to get above it, likely to be scrotal swelling: if not able to
get above it, likely groin swelling.

53
 DR. MO SOBHY [TEACHING STATIONS]

Fluctuation Test: (if no pain)

Cystic, fluid filled masses fluctuate. Fluctuation is elicited by
holding the mass firmly with thumb and two fingers of both
hands. Firmly press the mass with one finger while observing for
displacement of the other finger.

Trans-illumination Test: (if no pain)

Place a pen torch behind the scrotal swelling (trans-illumination
suggests the mass is fluid where there will be red glow-hydrocele),
verbalize to dim the lights of the room.

Cremasteric Reflex: (In all scenarios)

Stroke the patient’s medial thigh which leads to stimulation to
cremaster reflex and elevate the testicles (loss of cremaster reflex
may suggest testicular torsion)
After the Examination
Thank the patient for letting you examine
Summarize your findings. ( mention only Positive findings )
Suggests appropriate further investigations and Management according
to your finding.

Management:

Give the proper diagnosis and discus the appropriate management with
the patient.

Scenarios Management
Epididymal Cyst Main management is reassurance, that it will go away on
its own and doesn’t need any further interventions.
Involve senior, offer routine tests
Referral to urologist if needed.

54
 DR. MO SOBHY [TEACHING STATIONS]

Might consider surgical removal if growing bigger and

bigger.
Safety Net: about FLAWS, getting bigger and painful.
Testicular Give Dx with best case and worst case scenario approach.
Tumour
Involve senior, offer routine tests
Urgent Referral to urologist/Specialist
Treatment plan will be surgery followed by
chemotherapy and or radiotherapy
Safety Net: about FLAWS, getting bigger and painful.

Hydrocele Main management is reassurance, that it will go away on

its own and doesn’t need any further interventions.
Involve senior, offer routine tests and imaging such as
USG and referral to urologist if needed.
Might consider surgical removal if growing bigger and
bigger.
Safety Net: about FLAWS, getting bigger and painful.
Mumps Orchitis Main Management is bed rest, scrotal support bandages,
Pain killers for few days
Involve senior, offer routine tests and imaging such as
USG and referral to urologist/specialist if needed.
Safety Net: about of worsening of symptoms, and FLAWS
Epididymo Main Management is Antibiotic treatment, bed rest,
Orchitis scrotal support bandages, Pain killers for few days
Involve senior, offer routine tests and imaging such as
USG
Referral to Genito-Urinary Medicine Clinic or Sexual
Health Clinic for further assessment.
Advice about Safe sex and abstain from sex until total
recovery which will be few days
Safety Net: about worsening of symptoms, and FLAWS

55
DR. MO SOBHY [TEACHING STATIONS]

Testicular Examination Mannequin

56
DR MO SOBHY NOTES

Teaching Cancer Pathway

Where are you:

You are FY2 in a Teaching centre.

Who is the Patient:

A final year medical student, Max Hilton, wants to learn about the diagnosis and
management of a cancer patient.

Task:

Teach him and address his concerns.

Concerns:

1. What are the cancer referral pathways?

2. How to diagnose and manage a cancer patient.

● Introduction:
Hey, You must be Max if I am not wrong? I am XYZ,one of the FY2 doctor
working in this teaching centre.

● ID check :
Already done in intro part.

.
● Build Rapport:
Ask couple of questions for rapport.

R
Have we ever met before?
How's the study going?
Any exams coming up?
How are you finding the teaching centre?

● Main Concerns:
Max,How can I help you? Or I understand that you are here to learn
something,is that correct?
-Yes,could you please teach me the cancer referral pathways,how to diagnose
and Manage any cancer?

-Yes,definitely I would love to teach you about that and I really appreciate that
you are already filled with so much enthusiasm…(Acknowledge and IPS)
DR MO SOBHY NOTES

● Assess knowledge:
-So before we start could you tell me What do you know about cancer?
: abnormal proliferation of various types of cells in the body
-What exactly you want to know in particular?
-Why do you want to know about it,any reasons in particular?

● Teaching:
Max, now i will start with cancer pathway. It is the patients journey from the
initial suspicion of cancer through clinical investigatons,diagnosis and
treatment.
This could be done by :
-Initial referral to a hospital by the GP
-Assessment in the emergency department
-Identification through screening programme

Max,do you know what are the most common cancer in the UK ?
Breast,lung,prostate and bowel cancer

Do you know the symptoms of cancer, max?

- It Could be specific for different types of cancer - like blood in
sputum,shortness of breath for lung cancer, blood in stool/black stool in bowel

O
cancer,lump in breast in breast cancer etc
- Or could be non-specific which we can remember as FLAWS: Fever,Loss of
appetite/Lumps and bumps,Anaemia,Weight loss,night Sweats

Are you following me ?(Check for understanding-IPS)

.
Approach can be divided as :
History taking:
Max, whenever someone comes with above mentioned symptoms, we will take a
history of symptoms(ODPARA) including red flags- FLAWS

Examination:
After taking history, we need to examine. Do you know how do we examine the
patient?
We take observations, do general physical examination and do specific systemic
examination ( Inspection,palpation,percussion,Auscultation) depending on the
system involved.

Diagnosis:
Diagnosis can be done by :
-Labs : includes routine blood tests,tumor markers
DR MO SOBHY NOTES

-Scans : Xrays,USGs,CT scans/MRI,camera tests etc.

-Tissue sampling-which we call Biopsy(confirmatory)

So, when we suspect any cancer in primary setting like GP clinic, we will refer them
to cancer specialist and it is urgent referral (Patient should see the specialist within
2 weeks). - Very Important

How do we tell the diagnosis of cancer to the patient?

Max, its really important to know that we will tell the diagnosis of cancer only after
the confirmatory tests like biopsy but if we are only suspecting the cancer, we will
always follow best case-worst case scenario.(could be a harmless growth or as
sinister as cancer)

Management:
Once we diagnose the cancer, the treatment should be started in less than 31 days.
Treatment options for cancer are :
-Chemotherapy : medications to kill the cancer cells
-Surgery : removal of cancer/ cancer containing organ by surgery
-Radiotherapy: using radiation to kill the cancer cells

S
Do you have any questions so far Max?(Check for concerns)

Alright Max, this pretty much sums up the approach to a cancer patient.I hope i am

O
able to meet your expectations regarding the teaching.

Could you please summarise briefly whatever we’ve discussed today?(Check for
retention of knowledge)

.
If you have any further questions,you can always come back and ask me, i would be
happy to answer that.(Open return)
DR MO SOBHY NOTES

Teaching Toddler Milestone

Where are you:

You are FY2 in a paediatric department.

Who is the Patient:

A final year medical student, Robert Johnson, wants to perform a toddler

development assessment.

Special information:

You can find a chart for toddlers' development inside the cubicle.

Task:

Teach him how to perform toddler development assessment.

● Introduction:

.
Hi there, I am XYZ , one of the FY2 working in the paediatric
department.(Dont introduce yourself as a Dr. XYZ to your colleague,just
say your name)

● ID check :
Is this Robert? Could you please confirm your full name please? (Not
DOB,Not Age)

● Build Rapport:
Ask couple of questions for rapport.
Have we ever met before?
How's the study going? any difficulties?
Any exams coming up?
How are you finding the paediatric department?

● Main Concerns:
DR MO SOBHY NOTES

Robert,How can I help you? Or I understand that you are here to learn
something,is that correct?
-Yes,could you please teach me how to assess the toddler developmental
milestone?
-Yes,definitely I would love to teach you about that and I am glad that you are
here to learn about it.I really appreciate that.(Acknowledge and IPS)

● Assess knowledge:

-So before we start, could you tell me What is developmental milestone

(things most children can do by a certain age)/toddler(children in between 1-3
year)?
-What exactly do you want to know in particular?
-Why do you want to know about it,any reasons in particular?
-Do you know Why do we do toddler development assessments?
: it helps to identify possible developmental problems and the need for further
diagnostic evaluation.

● Teaching:

Alright Robert, now i am going to teach about toddler’s milestone but if i am

.
going too fast or if you are having problem in understanding anything,you can always
stop me and ask me ,i would be happy to explain it again. Would that be okay with
you?

While assessing the developmental milestone, basically we look for 4 domains:

Gross motor,Fine motor,Language and social/cognitive.
Now, explain all these criteria one by one from the chart: pick any one of the
milestones from each domain and explain it.
DR MO SOBHY NOTES

● Check for understaning and concerns in between while explaining the

milestone by saying:
-Are you following me?
-Should i move forward?
-Any questions so far?
DR MO SOBHY NOTES

Robert, once you know about the normal milestone,its really important to know about
red flags/developmental delay like:
-If the child is not following commands,inability to walk, poor eye contact by 2 years
-If the child is unable to make sentences,frequently falling,lack of interaction with
other children by 3 years

If we find any of these red flags/delay in development,we have to refer them to

specialist for furthur assessment and management.

We can complete the assessment by assesing the overall development by using

growth chart where we can measure,weight,height,head circumference.

-Answer questions and cross check understanding.

Okay Robert,this is how we do the assesment of toddler developmental

milestone,hope this session is fruitful for you.

O
I can provide you some reading materials from pediatric and child health NHS
websites as well, you can go through them and if you find any difficulties,you can
always come back.
DR MO SOBHY NOTES

Teaching Informed Consent

Where are you:

You are FY2 in the Surgery department.

Who is the Patient:

A 3rd year medical student, Harrold Foster, wants to learn about the informed
consent.

Task:

Teach him and address his concerns.

Concerns:

1. How do we get consent before any surgical procedure?

2.Should it be in written form?

● Introduction and ID Check:

M
Hey, You must be Harrold, right? Could you please confirm your full name? I
am XYZ,one of the FY2 doctor working in the surgery department.

● Build Rapport:
Ask couple of questions for rapport.
Have we ever met before?
How's the study going?
Any exams coming up?
How are you finding the teaching centre?

● Main Concerns:
Max,How can I help you? Or I understand that you are here to learn
something,is that correct?
-Yes,could you please teach me about the informed consent?
DR MO SOBHY NOTES

-Yes,definitely I would love to teach you about that and I really appreciate that
you are already filled with so much enthusiasm…(Acknowledge and IPS)

● Assess knowledge:
-So before we start could you tell me What is consent ?
: permission before any time of medical treatment,test or examination.
-What exactly you want to know in particular?- Informed consent before any
surgical procedure
-Why do you want to know about it,any reasons in particular?

● Teaching :

H
Harrold, as we already mentioned consent is a permission before any medical
treatment,tests or examination, but do you know who gives consent to whom
?

Consent is given by patient to any health care personnels eg. Nurse arranging
a blood test,surgeon planning an operation etc.

S
For a consent to be valid,it must be voluntary and informed, and the person
consenting must have the capacity to make the decision.

-Voluntary : the decision to either consent or not to consent to treatment must

be made by the person and must not be influenced by pressure from medical
staff,friends or family.

-Informed : the person must be given all of the information about what the

.
treatment involves, including the benefits and risks,whether there are
reasonable alternative treatments and what will happen if treatment doesnot
go ahead.

-Capacity : the person must be capable of giving consent,which means they

understand the information given to them and can use it to make an informed
decision.

If an adult has the capacity to make a voluntary and informed decision to

consent to or refuse a particular treatment,their decision must be
respected.This is still the case even if the refusing treatment would result in
their death.

-If a person doesn’t have the capacity to make a decision about their treatment and if
they haven’t appointed the lasting power of attorney(LPA) : decision to treatment
should be in person’s best interest.
DR MO SOBHY NOTES

Harrold, Do you know how do we take consent in Child and young people?
-If they are able to,consent is usually given by patients themselves.
-But someone with the parental responsibility may need to give consent for a child
upto 16 years age.

How consent is given?

Verbal: for minor tests and examinations: eg a person saying they’re happy to have
an Xray, blood sampling

Written: for surgical procedures: eg signing a consent form for surgery

When consent is not needed:

-emergency treatment to save patient’s life,but they are incapacitated eg if they are
unconscious)- reasons can be explained once they have recovered
-when there is an additional emergency procedure during an operation : eg tear in
major blood vessel like aorta during abdominal operation
-treatment of severely ill patient living in unhygienic condition

-Adress the concerns

-pause and check for the understanding
-offer links to NHS website for more information
-offer him to come back if he has any furthur question.
 Vaccination/ immunization teaching

Where are you:

You are an FY2 in the pediatrics department.

Who is the Patient:

Anna presented having some concerns regarding her child’s vaccines, John Adam who is
8 weeks old.
Task:
Talk to her and address her concerns.
Introduce yourself and ID check:

Hello, I am Dr. …one of the doctors here.

You must be Anna, can I confirm John’s name and age.

Confirm purpose:
I Can see that you have some concerns regarding Johns Vaccination.
Build rapport:

Child history: can I just ask you few questions about John’s health.

BIRDDD MAM especially allergy as it’s a contraindication of vaccination.

Patient concerns: can it cause autism? is it safe?

4 w questions: what you know about Vaccines? do you know what is it?
Why do we give it?
When we give it?
What are your main concerns about vaccines and why are you worried? Do you know
anyone who had the vaccine and had a bad reaction? Where did you get information
about vaccines? (Explore and acknowledge)
1) What is a Vaccine: It’s a substance that we administer to make our immune
system familiar with viruses or bacteria, so when we get infected our bodies
can fight the infection better and cause less complications.
Usually, vaccines are made of small amount of bacteria or viruses that have been
weakened or destroyed in the lab.
2) Why do we give it:

A) to protect vulnerable groups: young age (children) and

old age as they have weak immune system.

B) to protect the whole community (herd immunity):

as when more people get vaccinated then less people.
get infected and thus the spread of the infection is significantly reduced in the whole
community, protecting both vaccinated and non-vaccinated individuals as well.

C) Eradication of diseases: because of vaccines some diseases completely

disappeared from the UK like polio.

3) When do we give it:

8 weeks 6 in 1
(Diphtheria, Hepatitis b, Hib, polio,
Tetanus, Pertussis)
Rota virus
Meningitis B
12 weeks 6 in 1 (2nd dose)
Pneumococcal vaccine
Rota (2nd dose)
16 weeks 6 in 1 (3rd dose)
Meningitis B (2ND dose)
1 year Hib
Meningitis C (1st dose)
MMR (1st dose)
Pneumococcal (2nd dose)
Meningitis (3rd dose)

Can it cause Autism or any complications?

Many studies and research have been conducted, and it was proven that there is
no link between Vaccines and Autism.
I can also provide you with some reliable sources of information, like NHS website
or Patientinfo.co.uk, and in case you have any doubts you can ask any healthcare
professional as well.
Side effects and complications:
Sometimes vaccines can cause some side effects such as
1) Mild fever within 48 hrs. of taking the vaccine.
2) Swelling, pain or redness at site where vaccine was given.
3) Very rarely it can cause an allergic reaction to one of the ingredients of the
vaccine, however it can be managed immediately by the medical professionals
administering the vaccine.

Parent refusing vaccination:

Give the parents time to think about it.
You have the right to refuse vaccines, as they are NOT compulsory in the UK, it’s
totally up to you to decide.
Whenever you have any questions or you changed your mind, you can always
come back, and we can discuss it.

NB:
DON’T be pushy give them time to think.
Your task is to address concerns and correct any false information.
Not convince them with the vaccine