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Table of Contents

Subject Page Number

1- teaching structure 3

2- Epipen 7

3- Urine Dipstick 13

4- Subcutaneous injection 20

5-ECG 25

6- BLS 30

7- speculum Examination & pap Smear 35

8- Inguinoscrotal Examination 44

9- DRE 52

10- Testicular Examination 62

11- Cancer Pathway 73

12- Toddler Milestones 77

13- informed Consent 82

14- Vaccination refusal 87

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TEACHING STATIONS STRUCTURE

Smile Please it is a happy station

1. Introduction:

• My name is ( ❌ No titles Please ❌ ).

• (Do not address yourself as Dr. eg. I am X, One of your FY2

colleagues here).

2. ID check:

• Met before/ weren’t introduced properly (❌ No titles again ❌ ).

3. Build rapport and acknowledge: ( try to stand out and choose

your own words here to be unique ⭐ ).

• How’s work/ Study/ Rotations/ Encourage/ Wish Luck for exams. (A

maximum of three questions).
• “How is your study ongoing?”

• “How are you liking the ward so far?”

• “How is your rotation ongoing?”

• “Are there any exams coming up soon?”

• “Well, I wish you the best of luck for your exam.”

• “Are you settling well in the ward?”

• “Have you seen any interesting cases here?”

• It is important not to build excessive rapport with your colleague and
at the same time, no rapport building at the beginning will affect the
conversation flow.

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• The rapport must be based on professional relationship.

• Must not be overly friendly, must not be cold emotionless.

4. Acknowledge:

• “I really appreciate that you came to me to learn about xxxx. You are
going to be a great Dr one day.(choose your own words, stand
out).

5. Golden Statement: ( Safety Net In case you run out of time ⌛ )

• I might get bleeped in the middle of this conversation so please do

bear with me and I will arrange another session again if that
happens.

• If I cannot finish this in one go, please do bear with me. I am happy
to arrange another session for you, maybe go a bit deeper next
time. I will also give you NHS link to this (topic) so that you could
read it again at home. What do you think?

6. Open invitation:

• Please come back if want to learn again/ and for example, in case
of EpiPen teaching remind proper dangers to look out for.

7. Main Concern:

• 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).

• If what the student wishes to learn has already been written in the
stem (99% of the time), don’t start with ( how can I help you ? ).
8. 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).

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• When and why we do it? (Brainstorming).

9. +/- Pa ent 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.

10.Teach the sta on: (⭐ Only teach what he/she requested⭐ )

• Before: the procedure: (Tell them)

• Gather Materials
• Checklist
• Do and show: Teach Procedure or Examina on, DO AND SHOW.

▪ Don’t forget to take the colleague with you to the mannequin or

anywhere you go to teach them.

▪ Always remember that anything provided inside the cubicle is for

a reason and for you to use it while Showing the colleague. EX:
Pen and Paper.

• A er: the procedure/ What to do next.

• What to do a er.
• Any other concerns.

🥇 Golden TIPs🥇 that you should apply at all sta ons.

• Don’t ever teach wrong medical informa on or try to
fabricate or invent informa on ( be simple and safe ).
• Don’t over teach or under teach.
• Don’t ask complicated ques ons that you wouldn’t be
able to answer.
•Always assess understanding, and ask the student if you
are going fast or not, or if they want you to repeat
anything.
•Always involve the student in the teaching and ask him

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to repeat or perform the procedure a er showing it to him
if needed.
• Some of the sta ons that will be explained here come in
the exam as teaching and as combined examina on, so
always be ready to tackle them with both approaches.
• Always have your own way of teaching, and avoid
repea ng xed phrases as much as you can ( as we always
say try to stand out and impress the examiner ).
• You can use medical terms as you are dealing with medical
professional, but at the same me try to simplify things as
much as you can.

IMPORTANT NOTE:

DO NOT EVER SAY “How Can I help you?” if what the

student wants to learn is given in the stem

• “I can understand that you are here to learn about xxxxx,

right? I really appreciate that you are coming to me to learn
more about this. You are going to be a great Dr you know?”

• “Of course, I am very happy to teach you about this. I am

very glad that you come to me for this. I can see your
enthusiasm here”

IPS in Teaching

Check understanding:
• pick on the non-verbal cues.
• It is never about knowledge, It is about the way you teach.

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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.

TIP 1: It is really important not to teach the colleague too much or

too little. You have to teach them on precisely what they want to
learn. But it is also important to ask what specific things they want
to learn now and what they want to learn next.

TIP 2: In procedure or examination (especially speculum), it is really

important to complete teaching the procedure that the colleague
wishes to learn. But never skip Intro, ID check, Rapport, Safety Net.

TIP 3: Teaching station is all about being interactive and having a

style of your own in teaching. Never teach in presentation style
teaching.

What else to do to stand out?

• Have your own phrases and languages

• Do not complicate or over simplify them. E.g. right drug means you
will have to give the right medication so that bla bla..

• Involve the student “Do you know what we should be doing?”

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• Be interactive.

• “One way” conversation is presentation not teaching. Teaching is a

two-way street

• Do not believe when someone say “Go with one way teaching”.
No approach is 100% right but one way will not get you two digit
marks in teaching.

• They are simulators and they don’t know anything but in this exam,
they want you to regard them as medical students so you can
check their understanding. They will say NO. IT IS OKAY to go
TWO WAY CONVERSATION! Involve them after saying 4 or 5
facts. DO NOT SAY “What will you do next?” after every
sentence.

• Teach whatever necessary (do not over teach)

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EPIPEN

📜 EXAM SENARIO 📜

Where You Are:

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

📜 APPROACH 📜

😄 Smile 😄
1-Introduction:
Introduce yourself and explain your role.
2-ID check:
of the mother and her son. 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 now?/ How was the hospital stay?/How was the care by
the doctors?… etc.

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4-Main concern:

(she wants to learn about EpiPen💉 ), here you should praise her how
caring as a mom she is. (IPS).
5- Assess her knowledge:
child, attack, and EpiPen.

• Child:
• When he has been diagnosed with Allergy, Allergy regarding
what- food/medications?
• Attack:
• 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).
6- Manage the Panic attack of the mother and encourage her:

• Tell the mother that what she did was brave and that it saved her son’s
life.
• Encourage her to gather strength next time and calm down when
trying to use the EpiPen.

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7- Check / Safety Net:

Check that she knows what she might observe or look for symptoms of
Allergy.
Do you know when you might have to be using the EpiPen?/Do you have any
idea of the signs of severe allergic reaction?.
“Swollen lips, wheeze, rash, difficulty of breathing, fainting… etc”

8-Teach:

• Here it comes the mission of how to teach the EpiPen💉 .

• Again, you can score high in IPS.

• For example, as you said you were afraid to use the EpiPen 💉 (if
she said that to you) to the level that made you panic.
• Manage the panic attack here:Mrs. Winslow, I understand that
being in this kind of situation could have been unimaginable hard
for you.
• But you know that you are doing that to save your son’s life( use
the name for more IPS).

• Please try to take your breath, calm down, and do it 💪 .

• 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 contains a very important medicine ( Adrenaline ) to treat

anaphylactic attacks.

• It has to ends (blue and orange).

• The orange end contains the needle (blue to the sky, Orange to
the thigh ) Needle is covered and retractable so do not worry to
get hurt.

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• Check expiration date ( exchange them at GP if expired or used ).

• Check (this small window) it contains the drug watch for any
changes (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.

Finishing:

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 just as I showed 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.

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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 EpiPens because it is a
SINGLE USE , from nearest Pharmacy or GP . We can set a reminder
for that.
• 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

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 in Medicine Department.
Who the Student is:
Jaden Smith, a nurse who started his first day in clinical attachment wants
to learn about the urine dipstick test.
Special Note:

There is a Urine Dipstick Test Equipment inside the cubicle.

What you must do:

Please talk to Jaden and teach him about urine dipstick test.

📜 APPROACH 📜

😄 Smile 😄
1-Introduction:
Hey, you must be Jaden if I am not wrong? I am 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.
3- Main concern:

- Copy the concern from the notes ( I understand you are here today
to learn about Urine Dipstick Test ) am I right?.

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- 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).

4- 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?, do you know why we do it?
• And do you know when we do it? (Brainstorming for
colleague).

5- Teach:

Before – Collecting materials:

Remember in the Start (from Equipment in front of you what you
see).
• Gloves and Apron (Be sterile and to prevent cross
contamination).
• 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:
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We check Colour, Clarity, and Odour (But it is outdated), we don’t do
it now, but I want to tell you everything that I know.

Colour🎨 :

• What if we found there is a change in colour❓

• For example.. If it is red what might come in your mind❓

• Red color suggests stones or rarely cancer, etc.

Clarity🕵 :

• So what is normal❓ Yes , to be

clear, What if it is unclear/ cloudy?
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 (Do and Show):

o Wash your hands and wear your gloves, and apron.
o Remove a dipstick from the container without touching the

reagent squares.
o Replace the container lid immediately 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.

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o Lay the dipstick flat on a Paper towel.
o Wait for 30-120 seconds ( According to whatever you look for )
Ex: glucose, leukocytes etc.
o See the urinalysis guide on the side of the testing strip container
to interpret the results.
❆After Analyzing:
o Discard everything in its suitable place, and 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 conjugated bilirubin.

Ketones

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●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 other

conditions.

● 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
● Time at which the reagent square should be interpreted: 60
seconds
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● 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 by haemolysis like 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 any condition that could result in haematuria.

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SUBCUTANIOUS INJECTION

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 in Medicine Department.
Who the Student is:
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.

Special Note:
None.

What you must do:

Teach the student the basics of subcutaneous injection.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern:

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?

• What exactly do you want to know about it?

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• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

🗯 Common route of delivery for medications such as:

insulin, low molecular weight heparin (LMWH), and

palliative medications.

5- Teach:

❆Before we do the test:

Collect Materials
o Gloves & apron to Be sterile and to prevent cross contamination.
o Equipment tray
o Standard Syringe (not prefilled)
▪ Syringe ( smallest syringe that will accommodate the
medication volume).
▪ 2 needles
• Injecting needle (26–30 gauge).
• Drawing-up needle (when drawing up medications
from ampoules).
▪ The medication bottle to be administered ( Heparin)

▪ 1 alcohol pad

⚠ Or sometimes it can come with prefilled syringe. (No need

to collect needles and medication bottles if prefilled).

o Gauze or cotton swab.

o Sharps container/ Bin.
o The patient’s prescription.
o Injection Site chart.
Checks Before the procedure:
• Introduce yourself to the patient including your name and role.
• Briefly explain what the procedure(BBECC).
• Gain consent (Right to refuse‼ ).
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Do check List: (Do not need to over explain)

1) Right person: ask the patient to confirm their details and then
compare this to the patient’s wristband (if present) and the
prescription.
2) Right drug: check the labelled drug against the prescription and
ensure the medication hasn’t expired📆 .
3) Right dose: check the drug dose 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.

❆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. (one swipe clean).
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 the injecting needle.
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.

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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.
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
for a few minutes and mention to avoid rubbing the site.
14) Replace the gauze with a plaster. Dispose of your equipment into an
appropriate clinical waste bin.

❆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 is the preferred site if administering low
molecular weight heparin).
● Upper outer aspect of the arm.
● Outer aspect of the upper thigh.
● Upper buttock.
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● Do NOT use a site that is scarred, inflamed, irritated
or bruised.

Figure below denotes the injection site chart.

Injection Sites

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ECG

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 in Cardiology Department.
Who the Student is:
Jaden Smith, a 5 nth year medical student (or a Nurse) who is undergoing a
rotation in your department has come to you to learn about ECG.

Special Note:
None

What you must do:

Talk with Jaden and teach him ECG.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern:

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?

• What exactly do you want to know about it?

• The basics of interpretation of ECG.
• How to check the Heart rate?

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• What is a normal and an abnormal ECG?
• What is S.T segment elevation?
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

• We use ECG to diagnose if there are any heart related

issues like Arrhythmias, Heart Attack, Coronary Heart
disease and Cardiomyopathy.
5-Teach:

• 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.

TIPS: Always teach what the colleague wishes to know. If the colleague
only wishes to know basics, do not teach him advanced concepts such
as heart block, SVT, VTs, etc.

❆Waves:

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 as waves and are looked at
by a doctor.
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📝 ).

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•Point at 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. (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.
•
• SA Node creates impulse that produces Atrial contraction which
creates P wave.
• when these large chambers (Ventricles) Contract they create QRS
wave (point at it).
• After that it must have time to rest (Ventricular relaxation) that equal
this wave, which is T wave.

❆Rate and Rhythm:

• Before we can calculate rate, we will first have to determine either the
beats of this heart’s tracing are regular or not (rhythm) (Show in ECG
paper).
A. If the distance between each R wave are the same, so it is Regular
and then you can calculate the heart rate, how?

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• 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? between 60-100 bpm.

• What if it is higher and lower than this rate? Do you know what
they are called? Arrhythmia.
• If you see them, please involve your senior because most
probably there is something that may need to be assessed
quickly.
B. 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 8 with
10 you will get 80 that is the HR in
irregular Rhythm.

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If colleague/nurse wishes to learn about MI/ST elevation

Teach: (MI ECG).
Start with assessing if he/she wants to learn about basics (Anatomy/
waves, rate, rhythm). If he wants to know, teach them first quickly. And
Then.
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.

⭐ Only teach what he/she requested⭐

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BASIC LIFE SUPPORT

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 in Accident and Emergency Department.
Who the Student is:
Alex Wilson is a 3rd year medical student who has not attended his
Basic Life Support Class. He came today to you to learn about it now.
Other information:
You will find the BLS mannequin inside the cubicle.
Special Note:
+-Ask the student to perform chest compressions after you teach him.
What you must do:
Talk to Alex and teach him the basics of BLS.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about BLS, Am I right?

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
• The basics of interpretation of BLS.
• Why do you want to know about it any reasons in particular?

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• Do you know Why and When we do it? (Brainstorming for
colleague).

• We do BLS when someone experiences sudden

cardiac arrest (SCA), respiratory distress, or an
obstructed airway.
• Basic life support (BLS) is a level of medical care which is
used for patients with life-threatening illnesses or injuries until
they can be given full medical care by advanced life
support providers (paramedics, nurses, physicians).

5-Teach:

❆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 the mannequin on its side, turn it on its
back.
Call for help • Assign anyone to be next to the patient during the
time
A (Airway) • Head tilt chin life to check for any foreign 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 (Breathing) Come close to his face to:
- Listen his breathing sounds.
- Look for his chest rise.
- Feel his breathing touching your face.
If no breathing, call 999 (or use AED).
Start CPR Immediately.

Breathing checking should not last > 10 seconds⌛ .

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C (Circulation) Feel carotid pulse at the same time of checking for

breathing.
C (CPR) • Make your arm straight.
• Your shoulders are perpendicular to patient’s chest.
• Place heel of your dominant hand to 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 chest wall
diameter.
• Rate: 2 compressions/sec or 100 – 200
compressions/min.
• Do the chest compression 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 sign of life.
(30 compressions then giving 2 rescue breaths).
Make sure you are not compressing xiphi-sternum, do
you know why? Because, it can lead to a fracture.

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IMPORTANT TIPS:

“I want to tell you mention a few things about mouth-to-mouth resuscitation during
CPR” – Mention this

• Mouth-to-mouth can be considered if a pocket mask is readily available.

• If no mask is available, and you are not prepared to perform mouth-to-mouth,

perform continuous CPR

• Each ventilation breath should be given over 1 second

• Alternate between providing 30 compressions and 2 rescue breaths so it is 30:2.

DO NOT PERFORM MOUTH TO MOUTH ON MANIKIN!!!!!!

• As soon as the AED arrives, or if one is already available at the site of the cardiac
arrest, switch it on.

• Follow the spoken (and/or visual) prompts from the AED.

• Ensure that nobody is touching the person whilst the AED is analyzing the heart
rhythm.

• Do not delay defibrillation to provide additional CPR once the defibrillator is

ready.

• Do not continue chest compression during shock delivery.

When to stop CPR❓

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• If help arrives 🚑 .

• If you get tired 😮💨 .

• If patient shows any signs of life ❤ .

Mention about switching to advanced life support once the resuscitation team
arrives

Could CPR cause rib fracture?

• Yes, it may happen but the most important thing at that moment will be saving
the person life right?

🗯 Differences between Adult and Children CPR🗯

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

Assess student at CPR and rescue breaths:

• Can you please show me how to do CPR?
If student asks you, could CPR cause rib fracture❓
• Yes, it may happen, but the most important thing
is to save his life.

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PEDIATRIC BLS:

Definition

• A newborn is an infant just after birth.

• An infant is under the age of 1 year.

• A child is between 1 year and 18 years of age.

Note: if the rescuer believes the victim to be a child, then they should use the
Paediatrics guidelines. If a misjudgment is made, and the victim turns out to be a
young adult, little harm will accrue.

• Danger

• Approach carefully & safely

• Don’t move the patient unless you really have to

• Beware any environmental dangers (road traffic, nearby equipment, etc)

• Response

• Tap on his shoulder to check his response – “hello are you alright?” to both
ears

• Shout for help

• dial 999, activate the speaker if you are outside

• Call for 2222 (double two double two) clinical emergency team if
you are in a hospital

A – airway

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• as usual – Inspect the airway and position the airway to secure it using head-tilt
and chin-lift.

B – breathing

• If there are no ‘signs of life’, and the child or infant exhibits abnormal or absent
breathing, CPR should be started immediately.

• The presence or absence of ‘signs of life’, such as

• response to stimuli, normal breathing (rather than abnormal gasps) or

spontaneous movement must be looked for in B.

• If there is still doubt at the end of the rescue breaths, start CPR.
C - circulation

• Feeling for a pulse is not a reliable way to determine if there is an effective or

inadequate circulation, and palpation of the pulse is not the determinant of the
need for chest compressions.

• Rescuers are no longer taught to feel for a pulse as part of the assessment of
need for chest compressions in BLS.

• The location of the pulse check depends on the age of the patient:

• In an infant, check for femoral pulses

• In a child, check for carotid pulses

Give 5 rescue breaths before starting CPR. Use Bag-Mask Devices if
available in the hospital setting.

Infant (Do RB for 5 times)

• Place an infant’s head in the neutral position (as an infant’s head is usually flexed
when supine, this may require some gentle extension but avoid over-extension)

• Take a breath, cover the mouth and nose of the infant with your mouth and blow
steadily for 1 second (ensuring a good seal by looking for chest rise).

Child (Do RB for 5 times)

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• Place a child’s head in the ‘sniffing position’

• Take a breath, cover the mouth of the child with your mouth and pinch the nose.
Blow steadily for 1 second (ensuring a good seal by looking for chest rise).

• CPR rate = 15:2.

• Use one hand if child is > 1 year.

• If child is < 1 year , use 2 fingers or two-thumb encircling technique for chest
compression in infants

• For a small child, place the heel of one hand over the lower half of the sternum.
Do not apply pressure over the child’s ribs; lift your fingers.

• For a larger child, you may use two hands with your fingers interlocked (as per
adult basic life support)

GOOD QUALITY CPR:

• Rate: 100-120 min for both infants and children.

• Depth: depress the lower half of the sternum by at least one third of chest wall
diameter (which is approximately 4 cm for an infant and 5 cm for a child).

• Compressions should never be deeper than the adult 6 cm limit (approx. an adult
thumb’s length).

• Release all pressure on the chest between compressions to allow for complete
chest recoil and avoid leaning on the chest at the end of a compression. (allow
full recoil)

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• After 15 compressions, tilt the head, lift the chin, and give rescue breaths.
Continue compressions and breaths in a ratio of 15:2. (should never be more
than 10 seconds)

WHEN TO STOP?

Continue resuscitation until:

• the child shows signs of life (e.g., normal breathing, cough, movement)

• additional qualified help arrives

• you become exhausted.

• Mention about switching to advanced life support once the resuscitation team
arrives

Don’t teach this, this is for your own information:

• If there is only one rescuer, with a mobile phone, they should call for help (and
activate the speaker function) immediately after the initial rescue breaths.
Proceed to the next step while waiting for an answer. If no phone is readily
available perform one minute of CPR before leaving the child. To minimise
interruptions in CPR, it may be possible to carry an infant or small child whilst
summoning help.

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• In cases where Paediatrics BLS providers are unable or unwilling to start with
ventilations, they should proceed with compressions and add ventilations into the
sequence when able (another provider, equipment available).

• Rescuers who have been taught adult BLS, and have no specific knowledge of
paediatric resuscitation, should use the adult sequence.

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PER SPECULUM PAP SMEAR

🗯 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🗯

📜 EXAM SENARIO 📜
Where you are:
You are an FY2 in Gynecology and obstetric Department.
Who the Student is:
Sam Peterson is a 5th year medical student who is attending a rotation at
your department, and he wants you to teach him about per speculum
examination.
Other information:
None.
Special Note:
None.
What you must do:
Talk to Sam and teach him how to perform per speculum examination.

⚕ Speculum examination stations come as PAP Smear routine test,

Menorrhagia, PID, and follow up test results⚕

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about Per speculum

examination, Am I right?

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4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
• How to perform per speculum examination.
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

⚑ Speculum Examination:
a device is used to look inside in the vagina and observe the cervix.
A speculum examination is often performed alongside a bimanual
examination, as part of a complete gynaecological workup.

⚑ PAP Smear or Cervical screening:

is a test to check the health of the cervix and help prevent cervical
cancer by checking for HBV which is the biggest risk factor for
cervical cancer. It's offered to women and people with a cervix aged
25 to 64.

• a small sample of cells will be taken from the cervix.

• The sample is checked for certain types of human papilloma
virus (HPV) that can cause changes to the cells of your cervix.
These are called "high risk" types of HPV.
• If these types of HPV are not found, you do not need any
further tests.
• If these types of HPV are found, the sample is checked for any
changes in the cells of your cervix. These can be treated
before they get a chance to turn into cervical cancer.
5-Teach:

⚕ now we will talk how to approach if Examination station. And if it

comes as teaching you just need to apply the structure ⚕

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2 4 2

The diagram is for all examination station, as Time management is the key
to pass them.
You should always manage the time of the station properly.

⭐ 2 mins History + 4 mins Examination or Procedure + 2

mins Management.⭐
❆History Taking: ( 2mins ):
• Take history according to the case and the presenting complaint.
• Explore presenting complaint properly.
• Ask about other associated symptoms.
• Ask 4Ps.
• Ask about previous PAP Smear or speculum, what was the outcome? Any
complications? The results?

• Ask about the contraindications of PAP Smear and Speculum Examination.

⚑PAP Smear contraindications:

• Active menstruation.
• Active vaginal bleeding.
• Recent sexual intercourse.
• Recent use of spermicidal gel.

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• Pregnancy.
⚑Speculum Examination contraindications:
uterine prolapse.
cysts.
❆Do the procedure or examination: ( 4 mins ).

⚕ we can do the procedure I need to check your Vitals

Blood Pressure, Body temperature, Pulse rate, Respiratory
rate.

⚑Before the examination / Procedure:

1-Explain the procedure (PEPCC)

● Procedure/Purpose: This will involve
me inserting a Lubricated instrument called speculum
into your 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, including your
undergarment.
● 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, and I will ensure your privacy.

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● Consent: to proceed with the examination/
procedure: “Do you understand everything I’ve said?
Do you have any questions?

● Do I have your consent to proceed? Can I proceed

with my examination?

2-Gather materials / equipment:

• Gloves.
• Lubricant.
• Speculum.
• Light source for the speculum.
• Paper towels.
• A pot of cytology preservative solution: Sure path
or 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🫧

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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.
- Ask the patient to cough and inspect for prolapse.

Speculum ( Go in ):
- Apply some lubricant to the blades of the
speculum.
- Verbalise about the light source.
- 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.
- fix the position of the blades. Hold the speculum
with your hand and make sure 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.

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+/- PAP Smear

- Verbalize “I am inserting the brush deep into the
endocervical canal to reachthe cervix.
- 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
the speculum or the vaginal walls
with 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 gently removing 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

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⚑After the Procedure/Examination:
- Document the procedure in the medical notes, and
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.

⛔ Safety Netting:
• It is normal to have some vaginal spotting after the
examination for a few hours.
• If the spotting persists or it turn into heavy bleeding, go to
see the GP or go to the hospital immediately.

❆Management: ( 2 mins ).

⚕ Pelvic In ammatory Disease:

• Pain Killer.
• Antibiotics.
• If diagnosed at an early stage, PID can be treated with a course of
antibiotics, +/- 14 days.
• Remind the patient of the importance of completing the whole course.
• Avoidance of sexual intercourse during treatment.
• Sexual health clinic will help with partner noti cation, contact tracing,
STI screening, swab test (swab test can be done at GP).

⚕ menorrhagia ( Fibroid ):
• Medicines are available that can be used to reduce heavy periods,
but they can be less effective the larger your fibroids are.

• Levonorgestrel intrauterine system (LNG-IUS).

• Tranexamic acid.

• Anti-inflammatory medicines ( IPUPRUFEN).

• Surgery to remove your fibroids may be considered if your symptoms

are particularly severe and medicine has been ineffective.

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• Hysterectomy is a surgical procedure to remove the womb.

• Myomectomy is surgery to remove the fibroids

from the wall of your womb. It may be
considered as an alternative to a
hysterectomy if you'd still like to have
children.

Plastic Speculum
Metal Speculum

Brush
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INGUINOSCROTAL EXAMINATION

📜 EXAM SENARIO 📜

Where you are?

You are an FY2 working in Surgery Department.
Who the Student is:
Sammy Wilson, a 5th year medical student in clinical rotation in your
department wanted to seek help regarding learning about inguinoscrotal
examination.
What you must do:
Talk to him and teach him inguinoscrotal examination.
Special Note:
Do not ask him to repeat the steps of examination.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

• 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?
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⚡︎

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4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?

• What exactly do you want to know about it?

• Anatomy of ingunoscrotal region..
• How to perform Inguinoscrotal Examination?
• Types of Inguinal hernias?
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

• Inguinoscrotal Examination is Part of Abdominal

Examination
• We perform Inguinoscrotal Examination when
someone is presenting with Inguinal hernia.

5-Teach:
• Do you know what is hernia?
Hernia is a swelling that occurs when an internal part of the body
pushes through a weakness in the muscle or surrounding tissue
wall.
• Do you know the causes of hernia?
Increased intra abdominal pressure in cases if chronic cough
or chronic constipation.

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⚑Explain the Anatomy:

• Always remember the most important structure is Pubic Tubercle.
• If you draw imaginary line between Pubic Tubercle and Anterior
Superior Iliac Spine (ASIS), this line is called the inguinal ligament.
• Superficial ring → ½ inch on top of pubic tubercle.
• Deep ring → ½ inch on top of mid point of inguinal ligament.
• Inguinal canal → mid-way between ASIS and symphysis pubis.
⚑Types of inguinal hernia:
• 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.

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Indirect → enters from deep ring and passes into the inguinal canal
→ exits from superficial ring.

⚑Steps of Examination: ( Remember two words,

COUGH, AND RED FLAGS ).
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:

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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,

Shape, Skin on top, Unilateral/bilateral”.
• If you cannot see swelling, ask the patient to cough:
if the swelling comes out, comment as before.
• Ask the pt to lie down and reduce the hernia and
locate the deep inguinal ring. Then ask pt to cough.
o If hernia comes out from superficial ring →
Direct.
o If feel impulse below your finger → Indirect.

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Palpation • Temperature: by back of your hand – Touch it and

compare with anything above.

• Tenderness: Touch it and look at pt’s face.

• Deep palpation:

1) Site – Inguinal → above and medial pubic tubercle.

Femoral → below and lateral pubic tubercle

Testicular (if your fingers cannot touch each other).

2) Consistency → touch the swelling and see if it is

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.
● Results – Impulse felt under index → indirect.

Impulse felt under middle finger → direct.

Impulse felt under ring finger → femoral.

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Percussion ● Looking for the content.

● Resonant → Intestine.
● Not resonant → Omentum.
Auscultation ● Looking for the content.
● Peristaltic sound → intestine.
● No sound → Omentum.

❆After the Examination:

• Make sure you cover the pt. Ideally, I should cover the pt.
• Ideally I should examine the abdomen, scrotum, testicles and
L.Ns of the abdomen.
❆Management:
• Explain hernia and its risk factors.
• 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:
Surgery:
Elective repair → if hernia is reducible.
- Emergency urgent laparotomy → if strangulated.
- Open or laparoscopic repair → if irreducible.

🆘 Tell the student to always watch out for the RED FLAGS 🚩 and
to escalate to seniors and the surgical team if he finds any of them
as this is a Surgical Emergency🆘

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PER-RECTAL EXAMINATION

🗯 This Station can come as a teaching station or a procedure/

examination station in the exam, so learn it in both ways and
follow the structure of the either way🗯

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 working in GP Surgery.
Who the Student is:
Mr. Jason Roy, aged 57, presented to the clinic requesting PSA
Special Note:
None
What you must do:
Talk to the patient and take focused history and do relevant examinations and
discuss appropriate further management with him.

⚕ DRE examination Stations come as PSA demanding patient,

suspected prostate cancer, BPH, and Prostatitis⚕

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about DRE examination, Am I

right?

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4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
• How to perform DRE examination.
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

⚑ DRE Examination:
A rectal examination is where a doctor or nurse uses their finger to
check for any problems inside your bottom (rectum). It's usually very
quick and you should not feel any pain.

⚑ Prostate specific antigen (PSA):

⛔ There's currently no screening programme for prostate cancer in the

UK. This is because it has not been proved that the benefits would
outweigh the risks⛔

Routinely screening all men to check their prostate-specific antigen (PSA)

levels is a controversial subject in the international medical community. There
are several reasons for this.

PSA tests are unreliable and can suggest prostate cancer when no cancer
exists (a false-positive result).

Offer PSA if the patient is > 50 years, but explain about the risks and benefits
first, and tell him about FAULSE POSITIVE AND NEGATIVE.

Most men are now offered an MRI scan before a biopsy to help avoid
unnecessary tests, but some men may have invasive, and sometimes
painful, biopsies for no reason.

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Furthermore, around 1 in 7 of those with normal PSA levels may have
prostate cancer (a false-negative result), so many cases may be missed.

Although screening has been shown to reduce a man's chance of dying from
prostate cancer, it would mean many men receive treatment unnecessarily.

5-Teach:

⚕ now we will talk how to approach if Examination station. And if it

comes as teaching you just need to apply the structure ⚕

2 4 2

The diagram is for all examination station, as Time management is the key
to pass them.
You should always manage the time of the station properly.

⭐ 2 mins History + 4 mins Examination or Procedure + 2

mins Management.⭐
❆History Taking: ( 2mins ):

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 (show empathy).

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Any symptoms or complaints?
Positive history for frequency of urine, nocturia, urgency, and
hesitancy.
Positive History for DESA.
D/D Rule Out BPH, UTI, and Cancer.
FLAWS.

❆Do the procedure or examination: ( 4 mins ).

⚕ we can do the procedure I need to check your Vitals

Blood Pressure, Body temperature, Pulse rate, Respiratory
rate.

⚑Before the examination / Procedure:

1-Explain the procedure (PEPCC)

● Procedure/Purpose: This procedure will
involve me inserting a gloved and lubricated finger
inside your back passage to feel for any
abnormalities, and to check your male gland.
It shouldn't be painful, but it will feel a little
uncomfortable, 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, including your
undergarment.
● Position: you need to lie down on your left side, with
your knees lifted up towards your chest and the botox
at the edge of the table.

● Chaperone: “One of the ward staff members will be

present throughout the examination, acting as a
chaperone, and I will ensure your privacy.

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● Consent: to proceed with the examination/
procedure: “Do you understand everything I’ve said?
Do you have any questions?

● Do I have your consent to proceed? Can I proceed

with my 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 that 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‼

⚑Gather Materials / Equipment:

● Non-sterile gloves / Apron.

● Lubricant gel.
● Paper towels.

⚑Do it (explain and do):

1. Give time to Pt to change.
2. Ask the patient if they have any pain before doing the clinical
examination.

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3. Wear 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(if teaching): There is no redness, swelling, bleeding, Skin

tags, haemorrhoids, Anal fissure or fistula.

• Ask the patient to cough and inspect for rectal prolapse and or
internal haemorrhoids (contraindications of the PR Examination).

⎻Insert your finger PR ( go in ):

- Lubricate the examining ( Index) finger.
- Place finger at anus and leave it for
sometime to relax the sphincter.
- Warn the patient you are about to insert
your finger.
- Insert your finger gently into the anal
canal.
1) Anal canal examination:
- Rotate your finger 360 degrees to assess the entirety
of the rectum.
- Feel for any hard stool or any rectal lumps.
2) Prostate examination:
- prostate gland is palpated anteriorly.
- 2 lobes separated by sulcus.
- Assess and verbalize the symmetry , size (normal/
enlarged), Surface and texture -
- Midline sulcus.
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- Anterior Rectal Mucosa over the prostate Fixed or
not.

3) 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 hemorrhoids.

⎻Remove your finger (go out):

- Warn the patient you are about to withdraw your finger.
- Withdraw your finger and inspect for blood or mucous on
the finger:
• 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 that they can get
dressed.
Dispose of the used equipment into a clinical waste bin.
Document the procedure in the medical note.

Thank the patient for their time.

Summarize your findings. (Mention only positive findings).

❆Management:
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Suggests appropriate further investigations and Management

according to your finding.

1- Benign Prostatic hyperplasia (BPH):

• Involve senior and do PSA, and other routine investigations.
• referral to Urologist/ Specialist.
• The treatment for an enlarged prostate gland will depend on
how badly the symptoms are affecting your qualify of life.

1-Lifestyle changes:

• Avoid drinking coffee and fizzy drinks, drink

less water at evening.

Mumps Epididymo Cancer E.Cyst Hydrocele

orchitis orchitis

Undescended Small Large painless

Face swelling +ve unprotected sex
Testis + surgery painless Lump growing
swelling
• Remember to
empty your
bladder, and do double voiding.

2-bladder training:

• Bladder training is an exercise programme that aims to help

you last longer without peeing and hold more pee in your
bladder.

• You'll be given a target, such as waiting 5 to 15 minutes

when you feel the urge to pee. You'll then gradually increase
how long you wait.

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3-Medicine (Alpha Blocker):

• Alpha blockers relax the muscle in your prostate gland and at

the base of your bladder, making it easier to pee.

• Commonly used alpha blockers is tamsulosin.

• Safety net for FLAWS, worsening symptoms of urination and

UTI.

2- Prostate Cancer:
• Do best case worst case scenario approach.
• Involve senior and do PSA, and other routine investigations.
• Urgent referral (2weeks)to Urologist/ Specialist.
• According to the test results the specialist will decide the treatment
plan.
1. Surgery to remove the Prostate gland.
2. Chemotherapy to kill the cancer cells.
3. Radiotherapy to kill the cancer cells.

• Safety net for FLAWS, worsening symptoms of urination and

UTI.

2- Prostatitis:
In this case pt will present with perianal pain +- urinary
symptoms, and fever.
• Involve senior and do PSA, and other routine investigations.
• referral to Urologist/ Specialist.
• Acute prostatitis (where symptoms are sudden and severe) is
usually treated with:
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• painkillers.

• 2-4 week course of antibiotics.

• Hospital treatment may be needed if you're very ill or unable

to pee.

• Safety net for FLAWS, worsening symptoms of urination and

UTI.
🗯 So to summarize if any patient > 50 years old asks for PSA, even if there
are no symptoms offer the test but first explain the risks and benefits of
having the test, and the need to perform Per Rectal exam, and the further
tests they will need to go through if the PSA is positive🗯

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TESTICULAR EXAMINATION

🗯 This Station can come as a teaching station or a procedure/

examination station in the exam, so learn it in both ways and
follow the structure of the either way🗯

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 working in GP Surgery.
Who the Student is:
Mr. Robert Frost, aged 25 years, came to you today with some concerns.
Special Note:
None.
What you must do:
Talk to the patient and take focused history and do relevant examinations and
discuss appropriate further management with him.

❆Testicular Examination Station scenarios:

• Epididymal Cyst.
• Testicular Tumor.
• Hydrocele.
• Mumps Orchitis.
• Epididymo Orchitis.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

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I understand that you came today to learn about Testicular
examination, Am I right?

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
• How to perform Testicular examination.
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

• We do it when someone is presenting with pain or swelling in

testicles.

5-Teach:

⚕ now we will talk how to approach if Examination station. And if it

comes as teaching you just need to apply the structure ⚕

2 4 2

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The diagram is for all examination station, as Time management is the key
to pass them.
You should always manage the time of the station properly.

⭐ 2 mins History + 4 mins Examination or Procedure + 2

mins Management.⭐
❆History Taking: ( 2mins ):

Tips for testicular stations history taking ‼

•Proper ODIPARA or SOCRATES for
the presenting complaint.
•Ask sexual history(Epididymo
orchitis).
•Ask contact history and vaccination
history (Mumps Orchitis).
•Ask about other Swellings in body
esp face (Mumps Orchitis).
•Ask Flaws (Testicular cancer).
•History of undescended testis and
surgery when was young (testicular
Cancer).
•Ask other symptoms like discharge
and urinary symptoms.

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🗯 Follow the below tables for history🗯

Scenarios History
Epididymal Cyst Main Concern: Swelling in the scrotum.
Focussed History:
Incidental nding of painless swelling while shower,
2 days to 2 weeks.
Round in touch, Not increasing in size, shape, no fever,
discharge, trauma.
Age middle aged mostly.

Tes cular Tumor Main Concern: One of the tes s is swollen/heavy

Focussed History:
One of the tes s 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 tes s.
History of Childhood surgery for the same.
+/- FLAWS.
+/- Family History.
+/- Smoking.

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Hydrocele Main Concern: One of the testes is swollen.

Focussed History.
One of the testes is feeling heavy and discomfor ng.
1-2 weeks.
Growing bigger.
Cys c on touch.
No FLAWS.
No Trauma.
No Family History.
+/- Smoking.
Mumps Orchi s Main Concern: Painful swelling/Pain in the tes s.
Focussed History:
One of the tes s is swollen and painful, 2 days,
Fever, History of Cold/Flu/Mumps
MUST NOT MISS to ask Cheek swelling, contact
history, MMR vaccina on history.
No urinary symptoms.
No FLAWS.
No Trauma.
No Sexual History.
Epididymo Orchi s Main Concern: Painful swelling/Pain in the tes s.
Focussed History:
One of the tes s is swollen and painful on touch.
2 days.
Fever.
Posi ve sexual history of unprotected sex.
mul ple partners.
No urinary symptoms.
No FLAWS.
No Trauma.
+/- Smoking.
+/- Travel history.

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⚑This history should no take more than 2 minutes at any

station of them.

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Testicular Scenarios

Swelling
Swelling
+- Pain

❆Do the examination: ( 4 mins ).

⚑Before the Examination

- Preparation: PPECC
1-Explain the procedure (PEPCC)
● Procedure/Purpose: This procedure will
involve me looking, touching and putting some
pressure on your testicles and performing special
tests.

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● Exposure: For the purpose of this exam I need you
to be bare below the waist, including your
undergarment.
● Position: you need to be standing during the
examination.

● Chaperone: “One of the ward staff members will be

present throughout the examination, acting as a
chaperone, and I will ensure your privacy.

● Consent: to proceed with the examination/

procedure: “Do you understand everything I’ve said?
Do you have any questions?

● Do I have your consent to proceed? Can I proceed

with my examination?

Also verbalize about checking his vitals and General head

to toe examination.
Inspection:
• Inspection of Genital region and the surrounding areas (penis,
groin & lower abdomen).
• Verbalize ( if teaching or any Positive findings):
• 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 ( if teaching or any Positive findings):
• There are normal scrotal rugaes, no skin changes, scar, obvious
masses, swelling, sinuses and necrotic tissue. I don’t see any scar
mark, any discharge.

Palpation: (T,T,D):

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• Temperature: compare both the testicles with the thigh, check the
normal side first.
• Superficial Palpation: (Palpate with thumb and index
finger):
• check for Tenderness in both the testicle sand look
at PT face.
⚑If Tender then only do:
• Phren’s Test.
⚑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:
1-Phren’s Test:
• Ask the pt to elevate the testicles or do it.
• If testicular pain is relieved by elevating the testes →this is
suggestive of Epididymitis (Mumps or Epididymo Orchitis).
• If the Pain is not relieved → Torsion.

2-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 (testicular) swelling.

3-Fluctuation Test: (if no pain):

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

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4-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, as in case of Hydrocele.
• verbalize to dim the lights of the room.

5-Cremasteric Reflex: (In all scenarios)

• Stroke the patient’s medial thigh with your finger or a pen.
• This will lead to stimulate the cremaster reflex and elevate the
corresponding testicle.
• 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 interven ons.
o er rou ne tests Referral to urologist if
needed.

Might consider surgical removal if growing bigger and

bigger.
Safety Net: about FLAWS, ge ng bigger and painful.

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Tes cular Give Dx with best case and worst case scenario
Cancer approach.
Involve senior, o er rou ne tests like ultrasound and
HCG and LDH markers.
Urgent Referral cancer pathway to urologist/Specialist.
Treatment plan will be surgery.
followed by chemotherapy and or radiotherapy.
Safety Net: about FLAWS, ge ng bigger and painful.

Hydrocele
Main management is reassurance, that it will go away on
its own and doesn’t need any further interven ons.
Involve senior, o er rou ne tests and imaging such as
USG and referral to urologist if needed.
Might consider surgical removal if growing bigger.
Safety Net: about FLAWS, ge ng bigger and painful.

Mumps Orchi s Main Management is self isola on for 5 days.

suppor ve management (bed rest, scrotal support
bandages, Pain killers for few days).
O er rou ne tests and imaging such as USG and referral
to urologist/specialist if needed.
Men on to track down MMR vaccine record and o er
MMR vaccine a few weeks a er mumps orchi s se les
down if not vaccinated.
No fy public health since MMR is a no able disease,
and contacts should be checked and self isolated.
If pa ent raises fer lity concern: can happen but
reassure and regular follow-up with senior.
Safety Net: about of worsening of symptoms, and FLAWS.

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Epididymo Main Management is An bio c treatment.

Orchi s bed rest, scrotal support bandages, Pain killers for few
days.
Involve senior, o er rou ne tests and imaging such as
USG .
Referral to Genito-Urinary Medicine Clinic or Sexual
Health Clinic for further assessment and inves ga ons.
Advice about Safe sex and abstain from sex un l total
recovery which will be few days.
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CANCER PATHWAY

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 working in teaching centre.
Who :
A final year medical student, Max Hilton wants to learn about the
diagnosis and management of a cancer patient.
Special Note:
None.
What you must do:
Teach him and address his concerns.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about Cancer Pathway, Am I

right?

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
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i. What are the cancer referral pathways?
ii. How to diagnose and manage a cancer patient?
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

• We do it when we have a patient presenting with any cancer

symptoms and we suspect that they have cancer.

5-Teach:

• now I will start with cancer pathway.

• It is the patients journey from the initial suspicion of cancer through
clinical investigations, diagnosis and treatment.
• This could be done by :
1) Initial referral to a hospital by the GP.
2) Assessment in the emergency department.
3) Identification through screening programs.

⭐ 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:
• lung cancer → blood in sputum, shortness of breath.
• Bowel cancer → bloody or black stool, abdominal pain, and
vomiting.
• Breast cancer → lump in breast for.
- it could be non-specific common cancer symptoms:
• such as Fever, Loss of appetite, Lumps and bumps, Anemia,
Weight loss, night Sweats.
• We have a good nemonic to remember them FLAWS.

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⛔ it is so important to know about cancer symptoms, and how to

identify them, as the earlier we detect them the better the prognosis and
treatment outcomes for the patients ⛔

❆History taking:

• whenever someone comes with above mentioned symptoms, we will

take history.
• ODIPARA for the presenting complaint.
• Ask about any other Specific Symptoms for this cancer type.
• Ask about general symptoms or red flags (FLAWS).

❆ Examination:

• After taking history, we need to examine.

• Do you know how we examine the patient?
• We take observations, do general physical examination and do
specific systemic examination.
• examination ( Inspection, palpation, percussion, Auscultation)
depending on the system involved.

❆Diagnosis:

Diagnosis can be done by:

• Labs: includes routine blood tests, tumor markers
• Scans: Xrays, USGs, CT scans/MRI, camera tests etc.
• Tissue sampling: which we call Biopsy to confirm the diagnosis.

❆Referral:

• 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).

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⛔ We should Safety Net about the Acute Symptoms of the cancer,

worsening of symptoms, and about not seeing the specialist within two
weeks, and if any of this happens to come back to us immediately ⛔

❆How to tell the diagnosis of cancer to the patient?

• 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).
• But if we are certain of the diagnosis, of course, we have to break the
bad news in layers.
• We must show empathy and sympathy to the patient all the time,
explain the diagnosis to them in a simple language, offer all the
support needed, and make sure they understand everything about
their condition.

⛔ When cancer is confirmed, pt should not have to wait more than 31

days from the decision to treat to the start of treatment ⛔

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Two weeks referral pathway:

• Q1 What is two-week referral pathway?

• Q2 How can we catch the cancer in the first place?

• Q3 As an FY2 in GP, how can we suspect cancer?

• Q4 What reasons could GP have to refer a patient to the specialist?

• Q5 What do we do as GP FY trainees?

• Q6 What will happen if you refer urgently?

• Q7 What if the appointment is more than two weeks after the referral?

• Q8 How do we share the news with patient before referral?

• Q1 What do you think two-week referral pathway means?

• It is part of the cancer pathway from suspicion of cancer to be seen by the

specialist for the first time. It is the right of all patients to be seen by the
specialist in two weeks time if cancer is suspected. We also call it simply as
"two-week pathway“

• Q2 How can we catch the cancer in the first place?

• Suspicion by GP (two week referral is done here)

• Suspicion at A&E

• Screening programmes

• Q3 As an FY2 in GP, how can you suspect cancer?

• From proper history taking

• Symptoms of specific cancer - Bowel (alternating bowel habits,

tenesmus, bleeding per rectum)

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• Some subtle ones like ovarian cancer - Abd bloating, fullness, N&V

• They all have in common - FLAWS

• From proper examination

• From Invx - routine, basic imaging scans

• Q4 What reasons could GP have to refer a patient to the specialist?

• The GP feels symptoms need further investigation

• Treatment offered by GP has not been effective

• Investigations your GP has already arranged have shown some unusual

results.

• Q5 What do we do as GP FY trainee?

• refer them to the specialist to be seen urgently in two weeks time via
hospital e-referral system.

• Most patient referred to this pathway may not have cancer but it is
important to exclude a cancer diagnosis.
• Q6 What will happen if you urgently refer?

• send patients details urgently to the appropriate department at a local

hospital, and that department will contact the patient with an appointment

• they will do further special tests including scopy, imaging, biopsies to

confirm/exclude diagnosis

• Q7 What if the appointment is more than two weeks after the referral?

• Patients have the legal right to be seen by specialist in two weeks if the
cancer is suspected.

• The clinically appropriate alternatives must be offered to the patient that

may include a different specialist at the same hospital or an appointment at
another hospital.

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• You safety net about if the hospital does not contact the patient in two
weeks time, ask them to contact the GP back again.

• Q8 How do we share the news with patient before referral?

• We tell the news with “giving provisional diagnosis”. (Give your own example)

• Best case-Worst case scenario is used for giving treatment outcome

especially in surgery setting. It is not used in sharing news

• We cannot break the news yet

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TODDLER MILESTONES

📜 EXAM SENARIO 📜

Where you are?

You are an FY2 working in Pediatric Department.
Who the student is:
Jackie Min, a final year medical student in clinical rotation in your department
wants to perform toddler development assessment.
Special Note:
You can find a chart for toddlers’ development inside the cubicle.
What you must do:
Teach him how to perform toddler development assessment.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about Toddler development

Milestones, Am I right?

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
i. What are the Toddler Milestones?
ii. Why it is important to know Toddler Milestones?

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• Why do you want to know about it any reasons in particular?

• Do you know Why and When we do it? (Brainstorming for
colleague).

⚑Developmental Milestones:

• things or skills most children can do when they reach a certain

age.
• It can be Simple skills such as taking a first step, smiling for the
first time, waving hands.
• It can be more complicated skills like eating or writing or drawing.
• Each age group has different Milestones.

⚑Toddler Milestones:

• Toddler is coming from the word toddling, which means walking

unsteady.
• It is the age group from 1 year to 3 years.

⚑Importance of assessing developmental milestones:

• Reaching milestones at the typical ages shows a child is

developing as expected.

• Reaching milestones much earlier means a child may be

advanced compared with his or her peers of the same age.

• Not reaching milestones or reaching them much later than

children, and that is a Red Flag🚩 that we should watch out for
and escalate immediately.

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5-Teach:

• now you know what is toddler’s milestone, when to use them and why they
are important.

• While assessing the developmental milestone, basically we look for

4 domains:

Gross motor:
• this is how well a child can coordinate using large muscles eg.
walking, and running.
Fine motor:
• This is how well a child can use small muscles such as those at
fingers, hands eg. writing, and gripping things.
Language:
• this is communication domain.
• This is how they talk and understand us.
Social/cognitive:
• This is how the child experience, express and manage their
emotions and how they interact with those around them.

• Now, explain all these criteria one by one from the chart, pick any one of the
and start explaining it.

• milestones from each domain and explain it by paraphrasing and giving

your own examples.

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What if you don’t get the chart in the exam ❓

Remember the table below

Gross Fine
AGE Language Social
Motor Motor
• Stairs one • Turn one • 2-3 word • Parallel Play
step at time book page phrases
2 YEARS • Independence
• Run without • Draw a line • States Name
falling
• Stairs • Draw a circle • 3-4 word • Associative
Alternating phrases play
• Feed himself
3 YEARS • Rides a without help • States Age • Toilet trained
Tricycle but cant wipe
himself

• Milestones assessment is done through history taking, examination,

and the chart.
• We can complete the assessment by assessing the overall
development by using growth chart where we can measure weight,
height, head circumference.

Red Flags 🚩 of Developmental Milestones:

- 2 years →If a child is not running nor walking, no words, poor
eye contact or not following commands.
- 3 years → If a child is unable to 3-word sentences like “I see a
dog”, frequently falling, lack of interaction with other children.
🚩 If we find any of these Red Flags (delay in development), we have to refer
them to specialist for further assessment and management 🚩

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INFORMED CONSENT

📜 EXAM SENARIO 📜

Where you are?

You are an FY2 working in Surgery Department.
Who the Student is:
Harold Thaw, a 3rd year medical student in clinical rotation in your
department wants to learn about the informed consent.
Special Note:
None.
What you must do:
Teach him and address his concerns.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about Informed Consent, Am I

right?

4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
• What exactly do you want to know about it?
i. What is the Informed Consent?
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ii. Why it is important to take Informed Consent?
• Why do you want to know about it any reasons in particular?
• Do you know Why and When we do it? (Brainstorming for
colleague).

⚑Informed Consent:

• Consent to treatment means a person must give

permission before they receive any type of medical treatment,
test or examination.

• This must be done on the basis of an explanation by a medical

staff.

• Consent from a patient is needed regardless of the procedure,

whether it's a physical examination or something else.

⚑why do we take consent:

• The principle of consent is an important part of medical ethics

and international human rights law.

5-Teach:

• Consent is given by patient to any health care personnels e.g. Nurse

arranging a blood test, surgeon planning an operation etc.

• 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:
• he decision to either consent or not to consent to treatment must
be made by the person.
• Decisions must not be influenced by pressure from medical
staff, friends or family.

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– 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 does not 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.
• e.g. in case of Jehovah’s witness, patient might refuse blood and
blood products transfusion. If they have capacity to make
voluntary and informed decision, then we have to respect their
wishes and offer alternative plans.
• 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) nor have advanced directives, decision to treatment
should be in person’s best interest.

⚑How is consent given?

Verbal:
• for minor tests and examinations: e.g. a person saying they’re happy to
have an Xray, blood sampling.
Written:
• for surgical procedures: e.g. signing a consent form for surgery.

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⚑When consent is not needed:

• emergency treatment:
• to save patient’s life, when they are incapacitated eg if they
are unconscious, and reasons can be explained once they have
recovered.

• Additional emergency procedure during an operation, eg tear in

major blood vessel like aorta during abdominal operation.

• severely ill patient living in unhygienic condition.

• severe mental health condition.

• such as schizophrenia, bipolar disorder or dementia, lacks
the capacity to consent to the treatment of their mental health
(under the Mental Health Act).

⚑how do we take consent in Child and young people:

• Children under the age of 16 can consent to their own treatment if

they're believed to have enough intelligence, competence and
understanding to fully appreciate what's involved in their treatment.
This is known as being Gillick competent.
• Otherwise, someone with parental responsibility can consent for them.

• This could be:

• the child's mother or father.

• the child's legally appointed guardian.
• a person with a residence order concerning the child.
• a local authority designated to care for the child.
• a local authority or person with an emergency protection order for
the child.

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⚑Consent and life support:

• A person may be being kept alive with supportive treatments, such as lung
ventilation, without having made an advance decision, which outlines the
care they'd refuse to receive.

• In these cases, a decision about continuing or stopping treatment needs to

be made based on what that person's best interests are believed to be.

• To help reach a decision, healthcare professionals should discuss the issue

with the relatives and friends of the person receiving the treatment.

• They should consider:

• what the person's quality of life will be if treatment is continued.

• how long the person may live if treatment is continued.
• whether there's any chance of the person recovering.
• If a young person refuses treatment, which may lead to their death or
a severe permanent injury, their decision can be overruled by the
Court of Protection.
• This is the legal body that oversees the operation of the Mental
Capacity Act.
⚑Important definitions:
1-Lasting Power of attorney:
• Is to choose someone, often a close family member, to have lasting
power of attorney (LPA) if someone wish to anticipate their loss of
capacity to make important decisions at a later stage.
• Someone with LPA can make decisions about your health on your
behalf, although you can choose to specify in advance certain
treatments you'd like them to refuse.
2-Advance directive (living will):

• An advance decision (sometimes known as an advance decision to

refuse treatment, an ADRT, or a living will) is a decision you can make
now to refuse a specific type of treatment at some time in the future.

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Vaccination Refusal

📜 EXAM SENARIO 📜

Where you are:

You are an FY2 working in pediatric department.
Who the student is:
Mike James, a final year medical student in clinical rotation in your
department wants to learn about vaccination.
Special Note:
None.
What you must do:
Teach him and address his concerns.

📜 APPROACH 📜

😄 Smile 😄
1- Introduction/ ID check:
2- build rapport:
3- Main concern: ( Always copy from the notes ).

I understand that you came today to learn about Vaccination refusal, Am

I right?

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4- Assess knowledge (4 W):

So before we start could you tell me❓

• What do you know about it in particular?
i. sometimes student will say “I already know about what
vaccines are and when to give them”.
• What exactly do you want to know about it?
i. I wish to learn about how to handle a vaccination refusal?
• Why do you want to know about it any reasons in particular?
ii. because I have seen my senior handling a vaccination
refusal , and want to know What happened after?
• Do you know Why and When we do it? (Brainstorming for
colleague).

5-Teach:

❆What is vaccine:

• 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.
• They are inactive viruses and bacteria that are sufficient to induce the
immune system but not sufficient enough to cause the disease.

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🫧 Most likely that there will not be a vaccination chart in the cubicle. Please
memorize 🫧

❆Time table of vaccines:

❆Start with an outline:

• Okay, now I understand why you wish to know. In these kind of

situation, parents might have a reason to decline vaccination for
their child”

• Whatever the reason may be, it is our duty that:

1) We should give them a good reason (Advantages) to get their child
vaccinated.

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2) At the same time, we should be transparent about Disadvantages
too (side effects).
3) And we should also be addressing any concern they have as well.

❆Then go detail for each outline.

advantages their child can get from vaccination:

• Individual level:
• Help to protect them and their child from many serious and
potentially deadly diseases.
• Community level:
• herd immunity through vaccination: - Protect other people in
their family and community – by helping to stop diseases
spreading to people who cannot have vaccines, such as babies
too young to be vaccinated and those who are too ill to be
vaccinated
• Sometimes, reduce or even get rid of some diseases – if enough
people are vaccinated. Eg: polio in the UK

what they should be looking out for? (side effects):

• Local side effects:

• pain, swelling, redness
• Systemic side effects:
• fever, lymph glands enlargements.
Safety Net: Of course, we will have to tell the parents that they are
temporary side effects and if they usually resolve in a few days and
offer PCM in case they persist and causing trouble.
• Rare side effect:
• anaphylaxis (Severe allergic reaction)
Safety Net: Of course, we will have to tell the parents that we have a
team of Drs, who will be watching over your child for a certain period of
time after vaccination to make sure that nothing happens and they will
be ready to take action in case something rare as anaphylaxis happens.

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❆Common concerns:

⚑Concern by the Parents:

MMR and Autism: (Explain about no connection).
• “Parents do have concerns about MMR being related to autism,
do you know how we should address the concern?” [Brainstorm]
• “We tell the parents that MMR vaccine is given around the time
autism is diagnosed, so parents tend to make false connection to
it but in fact it has been proven that there is no foundation or link
to the connection. We will have to make sure that they understand
that”.

Safety Concern:
• Vaccines have undergone rigorous safety testing before being
introduced – they’re also constantly monitored for side effects
after being introduced.

Still refusing after explain advantages, disadvantages and addressing

their concern?

We have to:
1. Respect their decision.
2. They have the right to decide what is best for their child.
3. We should not force them.

Welcome them back in case they have change of mind.

“But we have to welcome them with open arms and give them a proper
channel to contact us back in case they have a change of mind, for whatever
the reason, right?”

⚑Concern by the student:

• What form do we need the parent to sign? → Immunization Refusal
Form.
• Do we need to inform school about vaccination status? → As
vaccination is not mandatory in UK, it is not usually required to
inform the school about vaccination status. But individual school
policies may vary with school.
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