C-FRC

270
LOGBOOK
C-FRC-2
(YEAR-2)

271
 Table of Contents
Contents Page No.

List of Abbreviations 475

Preamble 477

Miller’s Pyramid 478

GIT & Nutrition-I 478

Renal-I 493

Endocrinology and Reproduction-I 500

Head & Neck, Special Senses 511

Neurosciences-I 519

Inflammation 526

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 LIST OF ABBREVIATIONS
Abbreviations Subjects
A Anatomy
Ag Aging
B Biochemistry
BhS Behavioral sciences
C Civics
CM Community Medicine
C-FRC Clinical-Foundation Rotation Clerkship
CV Cardiovascular
EnR Endocrinology & Reproduction
ENT Ear Nose Throat
F Foundation
FM Forensic Medicine
GIT Gastrointestinal tract
GO Gynecology and Obstetrics
HL Hematopoietic & Lymphatic
HNSS Head & Neck and Special Senses
IN Inflammation
M Medicine
MS Musculoskeletal
NS Neurosciences
O Ophthalmology
Or Orientation
P Physiology
Pa Pathology
Pe Pediatrics

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PERLs Professionalism, Ethics, Research, Leadership
Ph Pharmacology
Psy Psychiatry
QI Quran and Islamiyat
R Renal
Ra Radiology
Re Respiratory
S Surgery

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 PREAMBLE
The Aim of Medical training is to deliver the best possible patient care. This is not possible until
medical students are holistically trained to deliver standardized patient care, with management
and counselling skills. The competencies given by PMDC for a graduating physician include:

1. Skillful

2. Knowledgeable

3. Community Health Promoter

4. Critical Thinker

5. Professional

6. Scholar

7. Leader and Role Model

All the above cannot be accomplished without a robust Clinical clerkship program.
The purpose of this document is to provide an outline to the UHS clinical clerkship program which
will serve as a vertically integrated module throughout the five years of medical college,
transitioning from Clinical Foundation (CF) in the first two years to Clinical Rotations (CR) in the
third and fourth year and finally to a complete clinical clerkship (CC) in final year of MBBS.
Keeping in view the 45 affiliated medical colleges under the umbrella of UHS, we have tried our
best to devise a flexible program which colleges can tailor according to their capacities and
resources. We are hopeful this innovative new step will lead to standardization of patient care
for UHS lead colleges in the best possible way.

How to use this logbook:

 Each clinical skill has an entry in this logbook along with the checklist to be filled by
the supervisor in the ward.
 Number of entries per skill is also mentioned in the modular study guides.
 The Clinical supervisor must tick all boxes deemed fulfilled and give feedback to the
student regarding their performance.

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276
 MILLER’S PYRAMID
The basis to assess clinical skills is the Miller’s pyramid. Different skills throughout the CFR-C
module scale from Knows How (e.g., Interpretation of CXR) to does (administer IM injections
etc.).

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BLOCK-04

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 GIT AND NUTRITION-1 MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Demonstrate steps of
Abdominal Examination Shows
abdominal examination

Demonstrate the procedure of

shifting dullness Shows
shifting dullness

Identify organs on X-ray

X-ray Abdomen Shows
abdomen

Assess dehydration in
infant/young child and explain
Dehydration Does
procedure of making home
made ORS

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR ABDOMINAL EXAMINATION CASES

(Minimum 3
(Some of the following steps/tasks should be performed
Entries)
simultaneously.)

STEP/TASK
GETTING READY:

1. Has performed hand washing

2. Introduces himself/herself to patient

3. Explains Procedure and Asks for consent

SKILL/ACTIVITY PERFORMED SATISFACTORILY

THE PROCEDURE:

GENERAL EXAMINATION:

Examine the following features to check for any pathology related to

the GIT:

i. Facies
ii. Body build
iii. Posture
iv. Color of skin
v. Vital signs
vi. Head
vii. Neck
viii. Upper limbs

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 ix. Lower limbs
x. Chest and heart
xi. Spine

INSPECTION OF THE ABDOMEN:

1. Position the patient in the supine position and drape the patient,
exposing only the areas needed for assessment.
2. Inspect the abdomen for shape/contour, symmetry,
pigmentation/colour, lesions/scars, pulsation, and visible
peristalsis
3. Examination was carried out in good light, looking from either
end of the bed from the side, and finally tangentially
4. Looked for:

i. shape (contour)
ii. sub costal angle
iii. epigastric pulsation
iv. divarication of recti
v. position of the umbilicus
vi. hair distribution
vii. skin(pigmentation, scars)
viii. dilated veins
ix. hernia orifices (ask pt to cough)
x. visible movements
xi. genitalia
xii. back (all back exam at the end)

5. Type of breathing (ask the patient to take deep breath)

PALPATION:

1. Stand by the right side of the patient

2. Relax the abdominal wall by asking the patient to flex his hip
and knees, and ask him to open the mouth and breathe quietly
in and out.
3. Make sure that his/her hand is warm
4. If a painful area or mass is present, palpate that area at the
end.
5. Started by light palpation (superficial palpation):

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 i. Tenderness: Ask the patient to locate the site of
tenderness. If he/she is not able to; ask them to take a deep
breath or to cough.

Elicit Rebound tenderness

ii. Differentiate rigidity from guarding: rigidity is generally a

sign of peritoneal irritation, it is present throughout the
abdominal wall, the wall feels stiff and board like to touch.

Guarding is a protective mechanism usually triggered by

touch or patient’s anticipation to pain.

iii. (Swelling: If there is a swelling; - Ask the patient to contract

his/her abdominal wall muscles by raising his/her head ( to
determine if it is intra or extra abdominal swelling)

Notice the swelling mobility with respiration

iv. Hernia orifices: Examine the anatomical sites of hernia for

swelling and any expansile impulse with cough.

Elicit deep palpation:

i. Start Palpation of normal solid viscera (the liver, the spleen

and the kidneys):

A. Palpation of the liver:

i. Place hand in the right iliac fossa, (hand may either rest
transversely and flat at right angle to the linea semilunaris
and parallel to the costal margin, or placed with fingers
pointing towards the head of the patient). The other hand is
placed in the loin.
ii. Ask the patient to take a deep breath.
iii. Keep hand still during inspiration and during expiration
slide the hand a little nearer to the right costal margin.

When examining a hepatic swelling record:

i. The degree of enlargement in a fingerbreadth below

the costal margin.
ii. The character of the edge (sharp or rounded).
iii. The surface (smooth or nodular)
iv. The consistency (soft, firm, hard or heterogeneous)
v. The presence of tenderness
vi. The degree of movement on respiration.

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 B. Palpation of the spleen

There are several clinical methods for the detection of an enlarged

spleen:

a) The standard method or bimanual examination:

Start palpation from the right iliac fossa with the tips of the
examining hand directed towards the left axilla. The left hand is
placed over the lateral aspect of the left costal margin, exerting a
certain amount of compression. Followed the rules of palpation
moving toward the left hypochondrium until feeling the spleen.( If
the spleen is not felt, lift the rib cage forwards as the patient
inspired).

b) The hooking method:

If the spleen is not felt by the bimanual method, ask the patient to
place the fist of the left hand under the lower ribs in order to push
the spleen forward. Then stand on the left side of the patients head
and place the fingers of both hands over the costal margin. The
patient is instructed to take deep breath.

c)The right lateral position:

If the spleen is not felt by the ordinary method ask the patient to turn
to his right side and palpate the spleen by insinuating hand below
the costal margin and ask the patient to take deep breath till feeling
the lower edge of the spleen .

d)Dipping method:

In the presence of tense ascites. Place hand in the left

hypochondrium and push the abdominal wall downwards and wait
for the return impulse to hand

C). The kidneys:

a) The right kidney is examined by the left hand behind the patient's
right loin (between the last rib and the iliac crest) lift the loin and the
kidney forward. Put the right hand on the right lumbar region just
above the anterior superior iliac spine and as the patient to take
deep breath. During expiration push the right hand deeply but gently
and keep it still during inspiration and repeat as patient takes his
breath.

b) The left kidney is examined by the same procedure on the left

side by either standing on the patient's left side or by leaning across

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 the patient, putting the right hand in the left loin and feeling the
kidney with the left hand.

D). Palpation for other abdominal swellings:

Parietal swellings: Swellings of the anterior abdominal wall are

differentiated from the intra-abdominal swellings by three signs:

i. Relation to the costal margin.

ii. Behavior on contraction of the abdomen.
iii. Movement with respiration.

 If abdomen was tense, started percussion before palpation

PERCUSSION:

i. Percuss over the whole abdomen and particularly over any

masses.
ii. light percussion is necessary.
iii. Start from resonant to dull in the midline

A) Percussion of the liver (span of the liver):

i. Determine the upper border of the liver by heavy

percussion. (started from the 2nd intercostal space, opposite
the sternocostal junction)
ii. Percuss down along each interspace and when reaching
the liver dullness of the upper border ask the patient to take
a deep breath and hold it. Percuss again, and then asked
him/her to exhale and re-percuss (tidal percussion).
Percuss onto the abdomen until the liver dullness
disappeared.
iii. Mark the lower border of the liver.
iv. Measure the distance between the upper and lower border
in the right mid- clavicular line.

B) Percussion of the spleen:

The three methods for percussion of the spleen

(a) Percussion in the right lateral position.

Start at the lower border of pulmonary resonance in the posterior

axillary line and carry down obliquely towards the lowest mid-
anterior costal margin.

(b) Percussion in the supine position: start from the right iliac fossa
towards the left costal margin then continue to the mid axillary line.

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 (c) Percussion of the Traube`s space:

Area defined by the left sixth rib superiorly, the left midaxillary line
laterally, and the left costal margin inferiorly.

C)Percussion of the kidney:

Percuss the renal angle.

AUSCULTATION:

i. Intestinal sounds
ii. Bruits
iii. Venous hum
iv. Succussion splash

Examination of the back:

i. Ask the patient to sit

ii. Inspect for any swellings, deformities or scars
iii. Palpate for edema over the sacrum
iv. Palpate for the tenderness in the renal angles, palpate for
tenderness over vertebrae
v. Auscultate the renal angles for bruit

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

285
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR FLUID THRILL/SHIFTING DULLNESS CASES

(Minimum 3
(Some of the following steps/tasks should be performed
Entries)
simultaneously.)

STEP/TASK

GETTING READY:

1. Washed hands/sanitized hands

2. Explained procedure to the patient and take consent

SKILL/ACTIVITY PERFORMED SATISFACTORILY

The Procedure:

1. Percuss from the umbilical region to the patient’s left flank. If

dullness is noted, this may suggest the presence of ascitic fluid
in the flank.
2. Whilst keeping your fingers over the area at which the
percussion note became dull, ask the patient to roll onto their
right side (towards you for stability).

3. Keep the patient on their right side for 30 seconds and then
repeat percussion over the same area.

4. If ascites is present, the area that was previously dull should now
be resonant (i.e. the dullness has shifted).

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SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

287
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR X-RAY ABDOMEN CASES

(Minimum 2
(Some of the following steps/tasks should be performed
Entries)
simultaneously.)

STEP/TASK
Patient Information
1. Verify patient identification (name, date of birth).

2. Confirm the date and time of the X-ray.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Technical Factors
1. Check the X-ray for proper exposure, focus, and positioning.

2. Assess the image for any artifacts or technical errors.

3. Ensure the correct orientation of the X-ray (anterior-posterior or

posteroanterior view).

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Procedure:
1. Identify and evaluate the integrity of the bony structures, including
the spine, ribs, and pelvic bones.
2. Assess the soft tissues, looking for any masses, swellings, or
abnormalities.

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 3. Identify the presence and distribution of gas throughout the
abdomen and bowel loops.
4. Examine the diaphragm for any abnormalities, such as elevation
or flattening.

5. Evaluate the cardiac silhouette for size and shape.

6. Identify abdominal organs:

i.Liver: assess Assess the size, shape, and density of the liver
ii.Spleen: Evaluate the size and contours of the spleen
iii.Stomach: identify the gastric air bubble and its location
iv. Pancreas: look for pancreatic shadow
v. Kidneys: identify both kidneys, assess their size, shape and
density
vi. Bladder: check for presence of urine in bladder

7. Small Bowel: Evaluate for normal loops and check for any signs
of obstruction.
8. Colon: Assess the size and contour of the colon.
9. Vascular structures:
Aorta: evaluate the size and course of the abdominal aorta
Inferior Vena cava: check the patency and size
10. Muscles: examine abdominal wall muscles for symmetry and
abnormalities.
Fat: assess the distribution and amount of intraabdominal fat.

11. Abnormalities: identify any abnormalities such as calcification,

masses, abnormal densities.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

289
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR ORS FORMULATION AND DEHYDRATION

ASSESSMENT CASES
(Minimum
(Some of the following steps/tasks should be performed 2 Entries)
simultaneously.)

STEP/TASK
Introduction
1. Gain consent from parent / child for examination after explaining
procedure

2. Make sure hands are washed and warm

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Procedure:
3. Ask about diarrhea/vomiting and any reduction in urine output

4. Inquire about color of urine (darker indicates dehydration)

5. Look for dry cracked lips, dry mouth

6. Inspect eyes if they appear sunken (sign of dehydration)

7. Notice if child is generally irritable/has an altered mental status

8. Examine for absence of tears

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9. Check pulse (dehydration results in tachycardia)
10. Skin pinch is assessed by pinching the skin of the abdomen between
the thumb and forefinger without twisting. If the skin goes back in <1
second it is normal, if it takes more than that, dehydration is likely

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Formulation of ORS at home

1. Counsel patient regarding rehydration

2. Explain the procedure of adding 6 teaspoons levelled of sugar, ½

teaspoon of salt and exact 1 liter of water (Approx. 5 cups of 200 ml)

3. Mix the ingredients well and make sure the salt and sugar amount
are exact

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

291
 RENAL MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Detail the steps of urinary

*Catheterization Knows how
catheterization in females

Detail the steps of urinary

*Catheterization Knows how
catheterization in males

 These skills are at the ‘Knows how’ level of the miller’s pyramid, meaning thereby that students
need not perform them themselves but may develop a perception regarding them by observing
performance/working on simulated patients/facilitation with video.

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 FEMALE CATHETERIZATION

Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

(Minimum 1
CHECKLIST FOR FEMALE CATHETERIZATION (Some of the following
Entry)
steps/tasks should be performed simultaneously.)

1. Identification of patient

2. Washed hands/ sanitized hands

3. Preparation: gloves, in place, Foley catheter kit, extra pair of sterile

gloves, VelcroTM catheter securement device to secure Foley catheter to
leg, wastebasket, and light source

SKILL/ACTIVITY DESCRIBED SATISFACTORILY

4. Explain procedure to the patient and obtain consent, and explain the
need of a chaperone ( for male students)

5. Assess for latex/iodine allergies, GYN surgeries, joint limitations for

positioning, and any history of previous difficulties with catheterization.

6. Position the female patient in a dorsal recumbent position. Uncover the

patient, exposing the patient’s groin, legs, and feet for positioning and
sterile field (female = dorsal recumbent; may need assistance to position
patient and help support legs). Drape the patient with a bath blanket,
exposing only the necessary area for patient privacy.

7. Create a sterile field on the over-the-bed table.

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8. Open the outer package wrapping. Remove the sterile wrapped box with
the paper label facing upward to avoid spilling contents and place it on
the bedside table or, if possible, between the patient’s legs. Place the
plastic package wrapping at the end of the bed or on the side of the bed
near you, with the opening facing you or facing upwards for waste.

9. Open the kit to create and position a sterile field:

a. Open the first flap away from you.
b. Open the second flap toward you.
c. Open side flaps.
d. Only touch within the outer 1” edge to position the sterile field on
the table.

10. Carefully remove the sterile drape from the kit. Touching only the
outermost edges of the drape, unfold and place the touched side of
drape closest to linen, under the patient. Vertically position the drape
between the patient’s legs to allow space for the sterile box and sterile
tray.

11. Wash your hands and apply sterile gloves.

12. Empty the lubricant syringe or package into the plastic tray. Place the
empty syringe/package on the sterile outer package.

Simulate application of iodine/antimicrobial cleanser to cotton balls.

13. Carefully remove the plastic catheter covering, while keeping the
catheter in the sterile box. Attach the syringe filled with sterile water to
the balloon port of the catheter; keep the catheter sterile.

14. Lubricate the tip of the catheter by dipping it in lubricant and place it in
the box while maintaining sterility.

15. Tell the patient that you are going to clean the catheterization area and
they will feel a cold sensation.

16. With your nondominant hand, gently spread the labia minora and
visualize the urinary meatus. Your nondominant hand will now be
nonsterile. This hand must remain in place throughout the procedure.

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 17. With your dominant hand, use an antiseptic swab or pick up a sterile
antiseptic soaked cotton ball with plastic forceps to clean the labia
minora farthest from you using a downward stroke, then discard the
swab or cotton ball. Repeat for the labia minora closest to you. Use
another antiseptic swab or antiseptic soaked cotton ball to clean the area
between the labia minora. Discard the cotton ball after use into the
plastic bag, not crossing the sterile field. Repeat for a total of three times
using a new cotton ball each time. Discard the forceps in the plastic bag
without touching the sterile gloved hand to the bag

18. Pick up the catheter with your sterile dominant hand. Instruct the patient
to take a deep breath and exhale or “bear down” as if to void, as you
steadily insert the catheter maintaining sterility of the catheter until urine
is noted.

19. Once urine is noted, continue inserting the catheter 2-3″ farther.” Do not
force the catheter.

20. With your dominant hand, inflate the retention balloon with the water-
filled syringe to the level indicated on the balloon port of the catheter.
With the plunger still pressed, remove the syringe and set it aside. Pull
back on the catheter until resistance is met, confirming the balloon is in
place.

21. Remove your gloves and perform hand hygiene.

22. Apply new gloves. Secure the catheter with securement device, allowing
room as to not pull on the catheter.

23. Place the drainage bag below the level of the bladder, attaching it to the
bed frame.

24. Remove your gloves and perform hand hygiene. Assist patient to a
comfortable position.

SKILL/ACTIVITY DESCRIBED SATISFACTORILY

Signatures of Supervisor

295
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR MALE CATHETHERIZATION (Minimum 1

(Some of the following steps/tasks should be performed simultaneously.) Entry)

1. Identification of patient
2. Collect the equipment required for the procedure and place it within reach
on the clean trolley. Check the expiry date on the catheter, sterile water, normal
saline and lidocaine gel. Ensure a clinical waste bin is placed nearby

SKILL/ACTIVITY OBSERVED AND DESCRIBED SATISFACTORILY

1. Wash hands

2. Introduce yourself to the patient, explain the procedure and take consent

3. Explain the need for a chaperone (for female students)

4. Setup up the sterile field by first removing the outer packaging from the
catheter pack and then opening the catheter pack from the corners without
touching the inner surface of the field.
5. Using aseptic non-touch technique (ANTT) empty the catheter, lidocaine gel
syringe, sterile water syringe and sterile gloves onto the field.
6. Pour the 0.9% sodium chloride solution over the cotton balls which should
already be located within the gallipot of the catheter pack

7. With the patient lying supine, ensure the bed is at an appropriate height for
you to comfortably carry out the procedure
8. Wash your hands again and don a pair of sterile gloves
9. Ask your chaperone to remove the sheet covering the patient’s genitals to
allow you to maintain sterility
10. Place a sterile absorbent pad underneath the patient’s genital region,
ensuring you maintain sterility

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11. With your dominant hand pick up a cotton ball and use a single stroke
moving away from the urethral meatus to clean an area of the glans. Dispose
of the first cotton ball into the clinical waste bin and continue to repeat this
process with a new cotton ball each time until all areas of the glans have
been cleaned
12. Discard your used gloves, wash your hands again and don a new pair of
sterile gloves
13. Place the sterile drape over the patient’s penis, positioned such that the
penis remains visible through the central aperture of the drape. Some
drapes come with a hole already present for this purpose, whereas others
will require you to create one
14. Place the sterile urine collection bowl below the penis but on top of the sterile
drape
15. Warn the patient that the anesthetic gel might initially sting, but then should
quickly cause things to become numb with your dominant hand place the
nozzle of the syringe of anaesthetic gel into the urethral meatus. Empty the
entire 10mls of anaesthetic gel into the urethra at a slow but steady pace .
Continue to hold to the penis in the vertical position to ensure the gel
remains within the urethra and allow 3 to 5 minutes for the lidocaine gel to
reach its maximum effect
16. Pick up the catheter which should be on your sterile field in its wrapper.
Remove the tear-away portion of the wrapper near the catheter tip, making
sure not to touch the catheter. Clean away any urine spillage or excess
lubricating gel and cover the patient with the sheet. Dispose of your
equipment into a clinical waste bin 46 Provide the patient with privacy to get
dressed

17. Hold the penis again using sterile gauze with your non-dominant hand

18. Warn the patient you are about to insert the catheter. Insert the exposed
catheter tip into the urethral meatus using your dominant ‘clean hand’
19. Advance the catheter slowly whilst gradually removing more of the wrapper
to expose more of the catheter. You should continue to advance the catheter
until it is fully inserted into the penis
20. Once the catheter is fully inserted, inflate the catheter balloon with the 10ml
syringe of sterile water to secure it within the bladder

21. Once the balloon is fully inflated, remove the syringe and gently withdraw
the catheter until resistance is noted, confirming the catheter is held securely
within the bladder
22. Attach the catheter bag tubing to the end of the catheter securely. Position
the catheter bag below the level of the patient to facilitate effective drainage
of urine
23. Clean away any urine spillage or excess lubricating gel and cover the patient
with the sheet Dispose of your equipment into a clinical waste bin. Provide
the patient with privacy to get dressed

24. Dispose of your equipment into a clinical waste bin.

25. Provide the patient with privacy to get dressed

297
SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

BLOCK-05

298
 ENDOCRINOLOGY & REPRODUCTION-1 MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Examination of the thyroid gland Thyroid examination Shows

Examination for Acromegaly Examination for acromegaly Shows

Measurement of blood glucose

Blood sugar measurement Shows
levels

Suturing Suturing *Knows how

 These skills are at the ‘Knows how’ level of the miller’s pyramid, meaning thereby that students
need not perform them themselves but may develop a perception regarding them by observing
performance/working on simulated patients/facilitation with videos.

299
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR THYROID EXAMINATION CASES

(Some of the following steps/tasks should be performed (Minimum 3 Entries)

simultaneously.)

STEP/TASK

GETTING READY:

1. Wash your hands and don PPE if appropriate

2. Introduce yourself to the patient including your name and role
3. Gain consent to proceed with the examination
4. Ask the patient to sit on a chair for the assessment
5. Adequately expose the patient’s neck and upper sternum
6. Ask if the patient has any pain before proceeding

SKILL/ACTIVITY PERFORMED SATISFACTORILY

THE PROCEDURE:
7. Inspect the patient whilst at rest, looking for clinical signs
suggestive of underlying pathology
8. Inspect the patient’s face for clinical signs suggestive of thyroid
pathology (dry skin, excessive sweating, eyebrow loss)
9. Inspect the patient's eyes for evidence of lid retraction,
inflammation and exophthalmos

10. Assess for eye movement abnormalities

11. Assess for lid lag

300
 12. Inspect the midline of the neck for evidence of thyroid
enlargement, lumps or scars

13. Ask the patient to protrude their tongue and repeat inspection

14. Palpate the patient's thyroid gland assessing size, symmetry

and consistency. Also note any masses present in the thyroid
tissue.

15. Ask the patient to protrude their tongue whilst you palpate

16. Palpate local lymph nodes to assess for lymphadenopathy

17. Inspect for tracheal deviation

18. Percuss downwards from the sternal notch for evidence of

retrosternal dullness

19. Auscultate each lobe of the thyroid for a bruit

20. Thank the patient

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

301
Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR ACROMEGALY CASES

(Some of the following steps/tasks should be performed (Minimum 3 Entries)

simultaneously.)

STEP/TASK
THE PROCEDURE:
1. Wash your hands and gain consent from the patient
2. Ask the patient if he/she has any pain in any region

3. Perform a brief general inspection of the patient, looking

for clinical signs suggestive of acromegaly such as:
a. Facial features: coarse features, such as prominent
supraorbital ridges and prognathism, may be
indicative of acromegaly.
4. Hands and feet: may be enlarged.
5. Skin: may display thickening in the hands and face and
excess sweating or oiliness in acromegaly.
6. Posture: patients with acromegaly can present with signs of
osteoarthritis, especially in the weight-bearing joints (knees
and hips).

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7. Hair growth: hirsutism in women and hypertrichosis may
occur.
8. Skin tags: acromegaly can cause an increase in the number
of skin tags.
9. Gait: acromegaly can cause a rolling gait or varus deformity.
10. Clothes: clothes or jewellery may appear tight if significant
weight gain has occurred.

11. Hands:
Inspect for:
a. Enlargement: grossly increased size of the hands
may be assessed by comparing your hands to the
patient are, accounting for natural size differences.
b. Wasting: thenar wasting can indicate untreated
carpal tunnel syndrome.
c. Scars: carpal tunnel release scar may indicate
previous median nerve compression.
d. Skin changes: skin thickening and excess sweating
can occur in acromegaly.
e. Finger pricks: finger prick marks on the tips of the
fingers may indicate diabetes, which is linked to
acromegaly
f. Palpation
g. Assess for thickening of the patient’s skin by
pinching the skin overlaying the third
metacarpophalangeal joint. This can be compared
with your own hand’s skin to detect any differences.

12. Axillae: Whilst supporting the patient’s

arm, inspect each axilla for the following:
a. Acanthosis nigricans: darkening
(hyperpigmentation) and thickening (hyperkeratosis)
of the axillary skin which can be benign (most
commonly in dark-skinned individuals) or associated
with insulin resistance (e.g., type 2 diabetes mellitus)
as a complication of acromegaly.
b. Hypertrichosis: increased hair growth can occur as a
result of the effects of growth hormone.

13. Palpate for thyroid gland

14. Look for raised JVP

15. Face:
a. General features:

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 b. Inspect the general appearance face for coarse
features associated with acromegaly:
c. Frontal bossing: a prominent or protruding brow can
occur with excess GH.
d. Large nose, ears, and lower lip: aspects of soft-tissue
overgrowth.
e. Prognathism: overgrowth of the jaw can lead to a
mandibular protrusion

16. Mouth: Inspect the inside of the mouth for the following:

a. Macroglossia: tongue enlargement may cause the

tongue to appear large for the mouth or even cause
visible partial airway obstruction in extreme cases.
b. Wide spaced teeth: growth of the soft palate may
cause interdental separation of the lower jaw.
c. Prognathism: overgrowth of the jaw may only be
discernible on closer inspection.

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR EXAMINATION OF BLOOD GLUCOSE LEVELS CASES

(Some of the following steps/tasks should be performed (Minimum 3 Entries)

simultaneously.)

STEP/TASK
THE PROCEDURE:
1. Explain the procedure to the patient and get a verbal consent
to proceed.
2. Gather the relevant equipment and place in a clean tray:

i. Non-sterile gloves
ii. Blood glucose reader (a.k.a. glucometer): calibrate
using calibration fluid if required.
iii. Spring-loaded lancet: to obtain the blood sample.
iv. Testing strips: make sure the expiry date is valid.
v. Gauze
vi. Tape

3. Ensure the patient’s finger is cleaned prior to measuring

capillary blood glucose:

i. It’s important that the skin over the site being tested has
been cleaned, as substances on the skin can affect the
accuracy of capillary blood glucose results (e.g.
substances containing sugar).
ii. Ask the patient to wash their own hands or alternatively
you can clean the site with an alcohol swab (70%
isopropyl).

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 iii. Make sure the skin over the testing site has dried
completely before performing capillary blood glucose
measurement.

4. Turn on the capillary blood glucose monitor and ensure it is

calibrated.

5. Load a test strip into the glucose monitor.

6. Don a pair of non-sterile gloves.

7. Pick up the lancet and carefully remove the protective cap.

8. Prick the side of the patient’s finger with the lancet and gently
squeeze the finger from proximal to distal to produce a droplet
of blood. Some guides advise cleaning away the first drop of
blood, however, there is no evidence that this significantly
impacts the reliability of blood glucose results.
9. Gently touch the tip of the test strip against the droplet of blood
to allow it to be absorbed into the strip.

10. Apply gauze or cotton wool to the puncture site to stop the
bleeding and ask the patient to maintain pressure over the site
11. Safely dispose of the lancet into a sharps bin.

12. Dispose of the test strip and the cotton wool/gauze into a
clinical waste bin. If the patient’s finger is still bleeding, keep
the cotton wool or gauze in place and secure with some tape.

POST PROCEDURE:

1. ‘Wash your hands, thank the patient’

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines
Date Observed: _______________

CHECKLIST FOR SIMPLE INTERRUPTED SUTURE (Some of the following CASES

steps/tasks should be performed simultaneously.) (Minimum 2 Entries)

STEP/TASK
EQUIPMENT:
Collect a procedure trolley, and clean the top surface using an alcohol surface
disinfectant wipe. Next obtain a plastic tray, and clean it in a similar manner. You
will then need to collect a number of items.

For cleaning:

i. A pair of non-sterile gloves.

ii. Five 10mL sachets of 0.9% sodium chloride (saline) solution.
iii. Gauze.
For anaesthesia:

i. A pair of sterile gloves.

ii. Alcohol wipe (2% chlorhexidine in 70% alcohol).
iii. 20mL 1% lidocaine solution (with or without adrenaline.
iv. Drawing up needle (≤18 gauge).
v. Subcutaneous needle (25-27 gauge) and syringe (20mL).
vi. Sharps bin.
For suturing:

i. Suture pack (containing needle holder, scissors, toothed forceps,

non-toothed forceps).
ii. A pair of sterile gloves.
iii. Suture material.
iv. Sterile drape.
v. Sharps bin.

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THE PROCEDURE:
i. Explain the procedure to the patient and take consent
Inspection:

ii. Assess the size and depth of the wound as well as the state of its
border. Inspect for any pus inside which may suggest infection.
Ensure that there are no foreign bodies present, such as glass.
Finally, check the surrounding skin for
any bruising or erythema which may suggest a cellulitis infection.

Cleaning

iii. To clean the wound, take the gauze and soak it in saline solution.
Carefully wipe the area starting from the centre of the wound and
continuing outwards.

Anaesthesia

iv. Before injecting the anaesthetic, confirm with the patient that they
have had no previous reactions to local anaesthetic. Once this has
been confirmed, clean the surrounding area using an alcohol wipe.
Whilst waiting for the skin to dry, draw up the lidocaine solution into
the syringe.

a) Once ready to inject, switch the needle on the syringe and don
some sterile gloves. Using proper technique, inject 2mL of
lidocaine solution subcutaneously into the surrounding skin.
After doing so, manoeuvre the needle and continue to inject
small amounts of anaesthetic such that all of the surrounding
skin is anaesthetised. For medium to large wounds, you will
need to withdraw the needle and reinject at another area.
v. Wash and dry both your hands and the distal third of your forearms
and then put the sterile gloves on using correct sterile technique.
Allow the anaesthesia at least 5 minutes to work.
vi. Carefully position the part of the body with the wound and apply the
sterile drape over it. At this point, explain to the patient that it is very
important for them to keep still and not touch anything on the sterile
field to avoid contamination.

a) Using the toothed forceps, pinch the sides of the wound to test
for numbness, and ask the patient whether they can feel any
pain. Be sure to warn the patient before you do this. The patient
may be able to feel a sense of pressure but should not feel any
pain.
vii. Use the forceps to position the needle in the needle holder so that
the needle holder is two-thirds of the way up from the tip of the
needle.
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 viii. Hold the needle holder in your dominant hand and the toothed
forceps in the other. Starting from the middle of the wound, use the
forceps to pull the skin up on the wound side closest to your
dominant hand. Insert the needle into the skin on the same side at
a 90° angle, at least 5mm from the wound edge.
ix. Push the needle through the skin, supinating your forearm to follow
the curvature of the needle as you do so. Remove the needle from
the needle holder and pull the needle through that side of the wound
using the forceps.

a) Position the needle back into the needle holder and insert it into
the dermis of the other side of the wound, around 5mm below the
skin surface. Again, supinate your wrist such that the needle
emerges to the skin surface. Pull the needle through such that
only 15cm of thread remains on the other side.

x. To secure the suture in place, you will need to tie a surgical knot.
This is achieved by tying three smaller “throw” knots.
xi. 1st throw: Hold the needle holder directly above and parallel to the
wound. Wrap the longer end of the thread around the needle
holder twice in a clockwise direction and then use the tip of the
needle holder to grasp the shorter end of the thread and pull in
opposite directions, tying the first throw.
xii. 2nd throw: Once again wrap the longer end of the thread around the
needle holder, however this time, do so only once and in
an anticlockwise direction. Then, as before, use the tip of the needle
holder to grasp the shorter end of the thread. Pull the suture
material through, tying another throw.
xiii. 3rd throw: Tie this throw in a clockwise direction in a similar manner
to the 1st. However, only wrap the thread once around the needle
holder.

xiv. Once you have completed the three throws, you should have a
strong surgical knot. Try to position the knot on one side of the
wound. Next, cut both ends of the suture such that there is 5mm of
thread on either side. This is so that it is easy to identify the suture.
Insert more sutures as required about 5-10mm apart.
xv. Once you are finished, dispose of the needle in the sharps bin.

xvi. Press lightly on the sides of the wound to stop any bleeding. Once
satisfied, remove the drape and your gloves. Arrange for the wound
to be dressed using a non-adherent dressing.

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 HEAD AND NECK, SPECIAL SENSES MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Examination of the nose Nasal examination Shows

Examination of neck lumps Neck lump examination Shows

 These skills are at the ‘Knows how’ level of the miller’s pyramid, meaning thereby that students
need not perform them themselves but may develop a perception regarding them by observing
performance/working on simulated patients/facilitation with videos.

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR EXAMINATION OF THE NOSE
CASES
(Some of the following steps/tasks should be performed
(Minimum 3 Entries)
simultaneously.)

STEP/TASK
THE PROCEDURE:
1. Explain the procedure to the patient and get a verbal consent
to proceed.
Inspection:

2. Inspect the external surface of the nose from

the front, side and behind the patient to identify any
abnormalities.
3. Skin changes:
I. Inspect for skin lesions:

i. Basal cell carcinoma: pearly lesions with

telangiectasia and rolled edges.
ii. Squamous cell carcinoma: scaly lesions,
sometimes with associated ulceration and
hyperpigmentation.
iii. Keratoacanthoma: raised lesions with a core of
scaly keratin.

II. Deformity
i. Inspect for any deviation in
the nasal bones or cartilage suggestive of
a fracture. This is best performed by standing
behind the patient with their head tilted slightly
backwards.

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 III. Palpation:
i. Warn the patient that you will be applying some
pressure to their nose and ask them to let you
know if they experience any pain.
4. Palpate the nasal bones assessing:

i. Alignment
ii. Tenderness
iii. Irregularity (suggestive of fracture)
5. Palpate the nasal cartilage assessing:

i. Alignment
ii. Tenderness

6. Palpate the infraorbital ridges and assess eye movement if

there is a history of trauma to screen for an orbital blowout
fracture.

*An orbital blowout fracture is a fracture of

the orbital floor or medial wall resulting from blunt trauma to
the eye socket (e.g., tennis ball). Typical findings on clinical
examination include infraorbital tenderness, epistaxis and restricted
eye movement (usually on vertical gaze).

7. The correct method for using a nasal speculum is slightly

counter-intuitive, however, it does allow the best
visualization of the nasal mucosa:

i. Insert your index finger into the bend of the speculum

and support it above with the thumb.

ii. The middle and ring fingers are used to manipulate

the prongs of the speculum.

iii. You will be aiming to look at the gap between these

two fingers.

iv. Press the prongs of the speculum together to allow

them to be placed within the nostril and then reduce
your grip on the speculum to widen the prongs until
an optimal view of the nasal cavity is achieved.

a) Nasal vestibule: inspect for inflammation,

ulceration or oedema affecting the nasal mucosa.
b) Nasal septum: note any polyps, deviation,
perforation, haematoma, superficial vessels or
areas of cautery.

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 c) Inferior turbinates: note any asymmetry,
inflammation or polyps.

8. Place a cold shiny surface, such as a metal tongue

depressor under the nose.

9. Observe for misting of the metal surface as the patient

breathes and compare the misting pattern of the two nostrils.

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR EXAMINATION OF NECK LUMPS CASES

(Some of the following steps/tasks should be performed (minimum 2 entries)

simultaneously.)

STEP/TASK

THE PROCEDURE:
1. Explain the procedure to the patient and get a verbal consent to
proceed.
2. Inspect the patient, looking for clinical signs suggestive of
underlying pathology:

i. Scars: may indicate previous neck surgery (e.g. thyroidectomy,

lymph node biopsy/excision, radiotherapy related scarring).
ii. Cachexia: ongoing muscle loss that is not entirely reversed with
nutritional supplementation. Cachexia is commonly associated
with underlying malignancy.
iii. Hoarse voice: caused by compression of the larynx due to
thyroid gland enlargement (e.g. thyroid malignancy).
iv. Dyspnoea or stridor: may indicate compression of the upper
respiratory tract by a neck mass.
v. Behaviour: anxiety and hyperactivity are associated with
hyperthyroidism (due to sympathetic overactivity).
Hypothyroidism is more likely to be associated with low mood.
vi. Clothing: may be inappropriate for the current temperature.
Patients with hyperthyroidism suffer from heat intolerance
whilst patients with hypothyroidism experience cold
intolerance.
vii. Exophthalmos: bulging of the eye anteriorly out of the orbit
associated with Graves’ disease.

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 3. Ask the patient to point out the neck lump’s location if relevant.

i. Inspect the neck lump from the front and side, noting
its location (e.g. anterior triangle, posterior triangle, midline).

4. If a midline mass is identified during the initial inspection, perform

some further assessments to try and further narrow the differential
diagnosis.

Swallowing

Ask the patient to swallow some water and observe the movement of the
mass:

i. Thyroid gland masses (e.g. a goitre) and thyroglossal cysts

typically move upwards with swallowing.
ii. Lymph nodes will typically move very little with swallowing.
iii. An invasive thyroid malignancy may not move with swallowing
if tethered to surrounding tissue.

Tongue protrusion

Ask the patient to protrude their tongue:

i. Thyroglossal cysts will move upwards noticeably during

tongue protrusion.
ii. Thyroid gland masses and lymph nodes will not move during
tongue protrusion.

Further Assessment

i. If you identify a midline neck lump or systemic signs indicative

of thyroid disease, ask the examiner if a full thyroid status
examination should be performed.

5. Palpate the neck lump assessing the following:

i. Site: assess the lump’s location in relation to other anatomical

structures (e.g. anterior triangle, posterior triangle, midline).
ii. Size: assess the size of the lump.
iii. Shape: assess the lump’s borders to determine if they feel
regular or irregular.
iv. Consistency: determine if the lump feels soft (e.g. cyst), hard
(e.g. malignancy) or rubbery (e.g. lymph node).
v. Mobility: assess if the lump feels mobile or is tethered to other
local structures. Asking the patient to turn their head as you
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 palpate, the mass can reveal if it is tethered to the underlying
muscle (e.g. malignant tumour).
vi. Fluctuance: hold the lump by its sides and then apply
pressure to the centre of the mass with another finger. If the
mass is fluid-filled (e.g. cyst) then you should feel the sides
bulging outwards.
vii. Temperature: increased warmth may suggest an
inflammatory or infective cause (e.g. infected epidermoid
cyst).
viii. Overlying skin changes: note any overlying skin changes
such as erythema (e.g. inflammatory/infective aetiology) or a
punctum (a pore in the epidermis indicative of an underlying
epidermoid cyst).
ix. Pulsatility: suggests vascular origin (e.g. carotid body tumour,
aneurysm).
x. Tenderness: may indicate infective and/or inflammatory
aetiology (e.g. ruptured epidermoid cyst, infected cyst).

Other characteristics of the lump may include:

i. Transillumination: apply a light source to the lump, if it is

illuminated it suggests the lump is fluid-filled (e.g. cystic
hygroma).
ii. Vascular bruit: auscultate the lump to listen for a bruit
suggestive of vascular aetiology (e.g. carotid artery
aneurysm).

6. Assess cervical lymph nodes and thyroid gland as explained in

previous checklists
7. Assess the submandibular gland if a swelling is found in that area.
Each submandibular gland can be
palpated inferior and posterior to the body of the mandible.
Move inwards from the inferior border of the mandible near
its angle with the patient’s head tilted forward. To assess the gland
thoroughly, you should perform bimanual palpation with one
gloved finger palpating the floor of the mouth whilst the other
palpates externally underneath the mandible.

 Submandibular gland swellings are usually singular, whereas

lymphadenopathy typically involves multiple nodes). Salivary duct
calculi are relatively common and may be felt as a firm mass within
the gland.
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BLOCK-06

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 NEUROSCIENCES-1 MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Assess Glasgow Coma Scale GCS Shows

Interpretation of Normal CT
CT scan interpretation Knows how
brain

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR GLASGOW COMA SCALE CASES
(Some of the following steps/tasks should be performed simultaneously) (Minimum 3 Entries)

STEP/TASK

THE PROCEDURE:

The Glasgow Coma Scale (GCS) allows healthcare professionals to

consistently evaluate the level of consciousness of a patient. It is commonly
used in the context of head trauma, but it is also useful in a wide variety of
other non-trauma related settings. Regular assessment of a patient’s GCS can
identify early signs of deterioration.

There are three aspects of behaviour that are independently measured as part
of an assessment of a patient’s GCS – motor responsiveness, verbal
performance and eye-opening. The highest response from each category
elicited by the healthcare professional is scored on the chart.
The highest possible score is 15 (fully conscious) and the lowest possible
score is 3 (coma or dead).

1. Eye Opening:

To assess eye response, initially observe if the patient is opening their eyes
spontaneously.

i. If the patient is opening their eyes spontaneously, your assessment of

this behaviour is complete, with the patient scoring 4 points. You would
then move on to assessing verbal response, as shown in the next
section. If, however, the patient is not opening their eyes
spontaneously, you need to work through the following steps until a
response is obtained.

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ii. If the patient doesn’t open their eyes spontaneously, you need
to speak to the patient “Hey Mrs Smith, are you ok?”

iii. If the patient’s eyes open in response to the sound of your voice, they
score 3 points.

iv. If the patient doesn’t open their eyes in response to sound, you need
to move on to assessing eye-opening to pain.
v. There are different ways of assessing response to pain, but the most
common are:

a. Applying pressure to one of the patient’s fingertips

b. Squeezing one of the patient’s trapezius muscles (known as a
trapezius squeeze)
c. Applying pressure to the patient’s supraorbital notch
d. If the patient’s eyes open in response to a painful stimulus, they
score 2 points.

e. If the patient does not open their eyes to a painful stimulus, they
score 1 point.

f. If the patient cannot open their eyes for some reason (e.g., oedema,
trauma, dressings), you should document that eye response could
not be assessed (NT).

2. Verbal responses:

i. If the patient is able to answer your questions appropriately, the

assessment of verbal response is complete, with the patient scoring 5
points.

ii. If the patient is able to reply, but their responses don’t seem quite
right (e.g. they don’t know where they are, or what the date is), this
would be classed as confused conversation and they would score 4
points.

iii. Sometimes confusion can be quite subtle, so pay close attention to

their responses.

iv. If the patient responds with seemingly random words that are
completely unrelated to the question you asked, this would be classed
as inappropriate words and they would score 3 points.

v. If the patient is making sounds, rather than speaking words (e.g.,

groans) then this would be classed as incomprehensible sounds, with
the patient scoring 2 points.

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 vi. If the patient has no response to your questions, they would score 1
point.

vii. If the patient is intubated or has other factors interfering with their
ability to communicate verbally, their response cannot be tested, and
for this, you would write NT (not testable).
3. Motor Response:

i. The final part of the GCS assessment involves assessing a

patient’s motor response.

ii. You should score the patient based on the highest scoring
response you were able to elicit in any single limb (e.g., if they were
unable to move their right arm, but able to obey commands with their
left arm, they’d receive a score of 6 points).

iii. Ask the patient to perform a two-part request (e.g. “Lift your right arm
off the bed and make a fist.”).

a. If they are able to follow this command correctly, they would

score 6 points and the assessment would be over.

iv. This assessment involves applying a painful stimulus and observing

the patient for a response.

There are different ways of assessing response to pain, but the most common
are:

a. Squeezing one of the patient’s trapezius muscles (known as a

trapezius squeeze)
b. Applying pressure to the patient’s supraorbital notch

If the patient makes attempts to reach towards the site at which you are
applying a painful stimulus (e.g. head, neck) and brings their hand above their
clavicle, this would be classed as localising to pain, with the patient scoring 5
points.

This is another possible response to a painful stimulus, which involves the

patient trying to withdraw from the pain (e.g. the patient tries to pull their arm
away from you when applying a painful stimulus to their fingertip).

This response is also referred to as a “normal flexion response” as the patient

typically flexes their arm rapidly at their elbow to move away from the painful
stimulus.

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It differs from the “abnormal flexion response to pain” shown below due to the
absence of the other features mentioned (e.g., internal rotation of the shoulder,
pronation of the forearm, wrist flexion).

Withdrawal to pain scores 4 points on the Glasgow Coma Scale.

Abnormal flexion to a painful stimulus typically involves adduction of

the arm, internal rotation of the shoulder, flexion of the elbow, pronation of
the forearm and wrist flexion (known as decorticate posturing).

Decorticate posturing indicates that there may be significant damage to areas

including the cerebral hemispheres, the internal capsule, and the thalamus.

Abnormal extension to a painful stimulus is also known

as decerebrate posturing.

In decerebrate posturing, the head is extended, with

the arms and legs also extended and internally rotated.

The patient appears rigid with their teeth clenched.

The signs can be on just one side of the body or on both sides (the signs may
only be present in the upper limbs).

Decerebrate posturing indicates brain stem damage. It is exhibited by people

with lesions or compression in the midbrain and lesions in the cerebellum.

Progression from decorticate posturing to decerebrate posturing is often

indicative of uncal (transtentorial) or tonsilar brain herniation (often referred to
as coning).

The complete absence of a motor response to a painful stimulus scores 1

point.

If the patient is unable to provide a motor response (e.g., paralysis), this

should be documented as not testable (NT).

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR INTERPRETATION OF CT BRAIN CASES
(Some of the following steps/tasks should be performed (Minimum 2
simultaneously) Entries)
STEP/TASK

THE PROCEDURE:

1. Orientation and Windowing:

a. Check the patient's information, including name, age, and
date.
b. Confirm that the images are properly oriented (anterior is at
the top, and the left side corresponds to the patient's right
side).
c. Adjust window settings to optimize visualization of soft
tissues and bone.
2. Overall Assessment:
a. Begin by observing the overall appearance of the brain for
symmetry and any obvious abnormalities.
b. Look for signs of mass effect, midline shift, or other gross
abnormalities.
3. Ventricles:
a. Assess the size and symmetry of the lateral ventricles.
b. Look for any signs of ventricular enlargement or obstruction.
4. Sulci and Gyri:
a. Evaluate the sulci and gyri for normal patterns and
symmetry.
b. Ensure there are no signs of cortical atrophy or abnormal
folding.

5. Cisterns and Cisternal Spaces:

a. Examine the major cisterns (e.g., suprasellar cistern,
ambient cistern) for appearance.

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 b. normal Check for any compression or effacement of cisternal
spaces.

6. Basal Ganglia and Thalamus:

a. Evaluate the basal ganglia (caudate nucleus, putamen, and
globus pallidus) and thalamus for symmetry and density.
b. Look for any signs of calcification or hemorrhage

7. Brainstem:
a. Assess the midbrain, pons, and medulla for normal anatomy.
b. Look for any signs of midline shift or compression.

8. Pineal Gland:
a. Check the size and symmetry of the pineal gland.
b. Assess for calcification, which is a common finding.
9. Fourth Ventricle:
a. Evaluate the size and symmetry of the fourth ventricle.
b. Look for any signs of obstruction or enlargement.

10. Subarachnoid Spaces:

a. Assess the subarachnoid spaces for normal distribution and
density of cerebrospinal fluid (CSF).
b. Check for signs of subarachnoid hemorrhage.

11. Skull and Scalp:

a. Inspect the skull for fractures, abnormalities, or signs of
trauma
b. Assess the scalp for any soft tissue swelling or abnormalities.

12. Sinuses and Mastoids:

a. Check the paranasal sinuses and mastoid air cells for normal
aeration.
b. Look for signs of sinusitis or mastoiditis.

13. Blood Vessels:

a. Evaluate major intracranial blood vessels for patency and
any signs of vascular abnormalities.
b. Look for signs of intracranial hemorrhage.
14. Soft Tissue Structures:
a. Soft tissue structures, including the eyes and extraocular
muscles, for any abnormalities.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

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 INFLAMMATION MODULE

Objectives Skill Miller’s Pyramid

Level Reflected

Learn how to do history taking History Taking Shows

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Place a “✓” in case box if step/task is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines

Date Observed: _______________

CHECKLIST FOR HISTORY TAKING CASES

(Some of the following steps/tasks should be performed simultaneously.) (Minimum 3 Entries)

STEP/TASK
INTRODUCTION (WIIPP)
1. Wash your hands
2. Introduce yourself: give your name and your job (e.g. Dr. Louise Gooch,
ward doctor)
3. Identity: confirm you’re speaking to the correct patient (name and date
of birth)
4. Permission: confirm the reason for seeing the patient (“I’m going to ask
you some questions about your cough, is that OK?”)

Positioning: patient sitting in chair approximately a metre away from you.

Ensure you are sitting at the same level as them and ideally not behind a desk.
PRESENTING COMPLAINT
1. Ask the patient to describe their problem using open questions (e.g.
“What’s brought you into hospital today?”)
2. The presenting complaint should be expressed in the patient’s own
words (e.g. “I have a tightness in my chest.”)
3. Do not interrupt the patient’s first few sentences if possible
4. Try to elicit the patient’s ideas, concerns and expectations (ICE) e.g.
“I’m worried I might have cancer.” or “I think I need some antibiotics.”

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HISTORY OF PRESENTING COMPLAINT

1. Ask the patient further questions about the presenting complaint

2. A useful mnemonic for pain is “SOCRATES“
i. Site
ii. Onset
iii. Character
iv. Radiation
v. Alleviating factors
vi. Timing
vii. Exacerbating factors
viii. Severity (1-10)

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PAST MEDICAL HISTORY
1. Ask the patient about all previous medical problems.
2. They may know these medical problems very well or they may forget
some. Top ensure none are missed ask about these important
conditions specifically (mnemonic: “MJTHREADS Ca”)

i. Myocardiac infarction
ii. Jaundice
iii. Tuberculosis
iv. Hypertension
v. Rheumatic fever
vi. Epilepsy
vii. Asthma
viii. Diabetes
ix. Stroke
x. Cancer (and treatment if so)

3. If the patient is unsure of their medical problems, ask them further

clarifying questions, for example “What do you usually visit your doctor
for?”. Remember you can add to past medical history if any of the
medication later mentioned don’t match the medical problems listed.
4. Risk factors

i. As part of medical history ask about specific risk factors

related to their presenting complaint.
ii. For example, if the patient presents with what maybe a
myocardial infarction, you should ask about associated risk
factors such as:

a. Smoking, cholesterol, diabetes, hypertension, family

history of ischemic heart disease.
5. Clarification of past medical history

i. Some medical conditions require clarification of the severity.

For example:

a. COPD

i. Ask about when the patient was diagnosed, their current and
previous treatments, whether they have ever required
noninvasive ventilation (“a tight-fitting face mask”), whether
they have been to intensive care

b. Myocardial infarction

ii. Ask about angina, previous heart attacks, any previous

angiograms (“a wire put into your heart from your leg or from
your arm”), previous stenting

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 c. Diabetes

iii. Duration of diagnosis, current management including insulin

and usual control of diabetes i.e. well- or poorly-controlled

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DRUG HISTORY

1. All medications that they take for each medication ask them to specify:

i. Dose, frequency, route and compliance (i.e whether they regularly

take these medication).
ii. If they take medication weekly ask what day of the week they take
it.
iii. If they take a medication with a variable dosing (e.g. Warfarin) ask
what their current dosing regimen is

2. Recreational drugs
3. Intravenous drug use (current or previous)
4. Over the counter (OTC) medications

ALLERGIES

1. Does the patient have any allergies?

i. If allergic to medications, clarify the type of medication and the

exact reaction to that medication.
ii. Specifically ask about whether there’s been a history of
anaphylaxis e.g. “throat swelling, trouble breathing or puffy face”

FAMILY HISTORY

1. Ask the patient about any family diseases relevant to the presenting
complaints (e.g. if the patient has presented with chest pain, ask about
family history of heart attacks).
2. Enquire about the patient’s parents and sibling and, if they were
deceased below 65, the cause of death

i. If relevant and a pattern has emerged from previous history sketch

a short family tree

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SOCIAL HISTORY

3. Alcohol intake
4. Tobacco use

i. Quantify the number of pack years (number of packs of 20

cigarettes smoked per day multiplied by the number of years
smoking)

5. Employment history

i. Particularly relevant with exposure to certain pathogens e.g.

asbestos, where you need to ask whether they have ever been
exposed to any dusts

6. Home situation

i. House or bungalow
ii. Any carers
iii. Activities of daily living (ability to wash, dress and cook)
iv. Mobility, and immobility aids
v. Social/family support
vi. Do they think they’re managing?

7. Travel history
8. Further social history maybe required depending on the type of
presenting complaint for example:

vii. Respiratory presenting complaint

a. Ask about pets, dust exposure, asbestos, exposure

to the farms, exposure to birds or if there are any
hobbies

viii. Infectious to disease related

b. Ask for a full travel history including all occasions

exposure to water, exposure to foreign food,
tuberculosis risk factors, HIV risk factors, recent
immunisations

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SYSTEMS REVIEW

1. Run through a full list of symptoms from major systems:

2. Cardiovascular: chest pain, palpitations, peripheral oedema, paroxysmal
nocturnal dyspnoea (PND), orthopnoea
3. Respiratory: Cough, shortness of breath (and exercise tolerance),
haemoptysis, sputum production, wheeze
4. Gastrointestinal: Abdominal pain, dysphagia, heartburn, vomiting,
haematemesis, diarrhea, constipation, rectal bleeding
5. Genitourinary: Dysuria, discharge, lower urinary tract symptoms
6. Neurological: Numbness, weakness, tingling, blackouts, visual change
7. Psychiatric: Depression, anxiety
8. General review: Weight loss, appetite change, lumps or bumps (nodes),
rashes, joint pain

SUMMARY

1. Provide a short summary of the history including:

a. Name and age of the patient, presenting complaint, relevant

medical history

2. Give a differential diagnosis

3. Explain a brief investigation and management plan

SKILL/ACTIVITY PERFORMED SATISFACTORILY

Signatures of Supervisor

Developed by
Dr Komal Atta
Director Medical Education
University Medical and Dental College
Faisalabad

Lt. Col. (R) Dr. Khalid Rahim Khan TI (M)

Director Medical Education & International Linkages
University of Health Sciences
Lahore

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