clinical skills booklet cbm 2013-14-2

8/12/2019 Clinical Skills Booklet CBM 2013-14-2

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Years 1&2/GEC CBM 2013-14 Page 1

CLINICAL SKILLS BOOKLET

Years 1&2 and GEC Community BasedMedicine

2013-2014

Introduction

This booklet of clinical skills for Community Based Medicine should be seen asa set of building blocks for students to add to in their later clinical years.

The emphasis is on using the IPPA (Inspection, Palpation, Percussion andAuscultation) approach.

The templates are not comprehensive and the students should be encouraged tointegrate their basic knowledge as they go through each system. It is alsoimportant that students should read relevant chapters in a clinicalexamination textbook for more detail.

We want students to develop the skill of trying to make sense of informationthey gather. Students are all intelligent young people and should be able towork out what is going on from first principles in many cases. The aim is forthe student to think about what they are doing why so that when they enteryear 3 they can apply basic skills and knowledge to novel situations.


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Abdominal Examination

Wash hands

Introduce self to patient and gain consent

Position the patient correctly lying flat for abdominal examination

Expose the abdomen adequately but preserve patient dignity at phase 1 level this wouldbe ideally from nipple to knee but in practical terms you should expose the abdomen fromthe lower part of the sternum to roughly the level of the top of underpants.

Inspection

Be systematic start by looking from the end of couch comment on:

Nutritional status obese/underweight (how might this affect what you can feel?) Colour jaundice/pallor

Move onto the hands:

Look for finger clubbing (remember why you would be looking for this what might itmean?)

Move onto the head:

Look at the sclera for jaundice Look at the tongue does it look normal? Is it smoother than you would expect? Any

mouth ulcers? If so, what might this mean?

Move onto the abdomen itself:

Look for distension, scars, stomas

Palpation

Examine from the right, ask patient if any pain and start away from site of any pain. Considerif your hands are warm enough.

Mentally divide the abdomen into the 9 regions as per your anatomy teaching. Palpate ineach region superficial first, then deep. Look at the patient to see if they react to pain ortense their abdominal muscles in response.

Feel for masses.

Palpate for the liver, spleen and kidneys. Always bear in mind the underlying anatomy.

Percussion

Percuss the liver and spleen and any masses found.


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Auscultation

Using the diaphragm of the stethoscope

Listen to the right of the umbilicus for at least 1 minute for bowel sounds and any othersounds you may hear.

Thank patient.

Summarise your findings

Cardiovascular Examination

Wash hands


Position patient approximately 45 degrees to the horizontal

Expose patient adequately you need to be able to see as much of the chest as possiblebut preserving patient dignity. At phase 1 level, a female patient would be allowed to leave avest top on but you may have to move this as needed during the examination.

Inspection

Be systematic. Start from the end of the couch. Comment on:

Breathlessness and count respiratory rate (over 30 seconds) Colour pallor, cyanosis Ankles for oedema


Look for finger clubbing (what in the CV system might cause this?) and peripheralcyanosis

Move onto the head:

Look for central cyanosis Observe neck vessels for raised JVP

Palpation examine from the right

Radial pulse describe rate and rhythm

Measure BP

Palpate the apex beat (describe position)

Palpate ankles for pitting oedema (what might cause this?)


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Percussion

Not necessary at this level

Auscultation

Listen with the diaphragm of the stethoscope over the apex, tricuspid, pulmonary and aorticareas for approximately 10 seconds to assess the heart sounds.

Listen with the bell of the stethoscope over the apex.

Listen with the diaphragm of the stethoscope to the bases of the lungs.

Thank patient.

Summarise your findings.

Respiratory Examination

Wash hands


Position patient approximately 45 degrees to the horizontal

Expose patient adequately you need to be able to see as much of the chest as possiblebut preserving patient dignitiy. At phase 1 level, a female patient would be allowed to leave avest top on but you may have to move this as needed during the examination.

Inspection

Be systematic. Start from the end of the couch. Comment on:

The patients environment (any inhalers or oxygen cylinders nearby?) Breathlessness and count respiratory rate (over 30 seconds) Colour normal, cyanosed, pink Respiratory effort symmetrical movements, pursed lips, audible wheezing,

accessory muscles, recession

Chest - size and shape, any scars remember to look at the front and the back


Look for finger clubbing (what in the respiratory system might cause this?) and tarstaining

Move onto the head:

Look for central cyanosis


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Palpation

Feel chest movements for symmetry and expansion place hands around the front of thechest from the ribs and ask them to take a deep breath in and out (keep thumbs free of thesternum and watch the movement of the thumbs).

Feel for the tracheal location

Percussion

Tapping front of chest comparing one side with the other starting at clavicle and workingdown over the upper and middle zones

Tapping back of chest comparing one side with the other over the upper and lower zones.Listening and feeling for difference normal, hyper-resonant, dull, stony dull

Auscultation

Using the diaphragm of your stethoscope

Listen in the same places as you percussed

Listen for breath sounds vesicular, bronchial, absent

Listen for added noises wheeze, crackles

Thank patient.

Summarise your findings.

Blood pressure measurement(Input by Dr Panting Consultant Cardiologst)

Practice must supply and student should understand the need for regularly servicedsphygmomanometer.

Meniscus should be zero if disconnected.

Student should understand the necessity to have a bladder cuff 80% of arm circumference.

Patient should rest for three minutes before blood pressure is measured. Explain to thepatient what to expect.

Student should be less than a foot from instrument.

Students should be able to

Identify the brachial artery. Place a cuff of appropriate size (80% of arm circumference) in the correct place (2cm

above the point of maximum pulsation of the brachial artery) so that the cuff lies overthe artery. It does not matter if the tubes of the sphygmomanometer are directed upor down the arm.


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Support the patients arm (e.g. on the table) at the correct height so that the cuff is atthe height of the heart.

Inflate the cuff until the brachial pulse is no longer palpable and then 30 mmHghigher. (This must be done by palpation to avoid erroneous measurement in thesmall number of patients with an auscultatory gap).

Place the diaphragm of the stethoscope over the brachial artery and deflate the cuffslowly, about 2mm per beat or second Record the blood pressure using the 1 st (appearance of sounds) and 5 th

(disappearance of sounds) Korotkov sounds.

Blood pressure should be recorded to the nearest 2 mm Hg (please note on a mercuryspyhgmomanometer the reading will always be in even numbers e.g. 128/72mmHg).

The practice should be supplied with a digital mercury sphygmomanometer. Tutors arehowever encouraged to show the students other electronic devices too.

Here is a link from the British Hypertension Society with guidelines on how to measure bloodpressure electronically

http://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster_-_Electronic.pdf (accessed 30.7.2013)

The Year 2/GEC OSCE BP station will use the digital mercury sphygmomanometers.Students should practise assembling the cuff and sphygmomanometers and befamiliar with the teaching stethoscopes.

Peak Flow Measurement

Students should be able to use a peak flow meter correctly and demonstrate use of a peakflow meter to patient.

The student should use a peak flow meter in the following way; all steps are essential

stand up zero the marker hold peak flow meter horizontal

inhale fully enclose the mouthpiece fully with the lips exhale forcibly without delay through the mouth piece (the exhalation should be as

forceful as possible without excessive straining or coughing) the reading should be noted and the marker zeroed again at least three readings should be taken or until the reading is no longer going up (i.e.

training effect is achieved fully) the reading should be compared with a normogram, allowing for age, gender, and height

and or with the students or patient's previous reading

Peripheral pulses

These are many but first year and second year students should be able to identify the radialand brachial pulses as described. They should know that if they are uncertain whether they
http://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster_-_Electronic.pdfhttp://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster_-_Electronic.pdfhttp://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster_-_Electronic.pdf


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are feeling their own or the patient's pulse (particularly likely with the more difficult pulsesand in their early clinical career) that they should feel their own radial pulse simultaneouslyusing their other hand.

When counting, the student should normally do so for thirty seconds and be able then tocomment on:

rate in beats per minute rhythm: regular [sinus rhythm], irregular [ectopics], irregularly irregular [AF]

Only rate and a basic description of rhythm are requirements for first and second yearstudents

Presence or absence of peripheral pulses and the rate and rhythm of the pulse are ofimportance for the cardiovascular days.

Radial pulse

Palpate the pulse at the wrist using the tips of the fingers of the right hand. Palpate bothpulses. Use first three fingers of one hand placed at approximately 45 degrees whilesupporting the patient's wrist with the other hand.

Brachial pulseThis is usually palpated using the thumb of the same hand i.e. the student's left for thepatient's left etc. It lies just medial to the biceps tendon. Technically more correct is to usethe fingers at the medial side of biceps tendon while supporting elbow with other hand.

Carot id Palpate with the fingers of the right hand. Place fingers or thumb medial to sterno-mastoid.Do not palpate both at the same time.

The dorsalis pedis and posterior tibial pulses can be difficult to feel.

Dorsal is pedis Felt just lateral to the extensor hallucis part way along the dorsal surface of the foot.

Poster ior t ibial Can be easily felt by standing at the foot of the couch and simultaneously placing the firsttwo fingers of both hands behind the medial malleoli, one hand being used for each foot.

Additional resources

Please see below a list of resources from the internet which demonstrate some of the skillsdescribed in this booklet. These are to assist you when you practise your clinical skills.Reading and seeing the skills demonstrated will not enable you to develop these skills youmust practise at every available opportunity.

Blood pressure

http://www.youtube.com/watch?v=Xhhn08FyImw
http://www.youtube.com/watch?v=Xhhn08FyImwhttp://www.youtube.com/watch?v=Xhhn08FyImwhttp://www.youtube.com/watch?v=Xhhn08FyImw


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Ok but doesnt check for auscultatory gap and no explanation to patient. Also representation ofsounds poor and unsteady release of air from cuff after 80mmHg. Aneroid rather than mercuryspyphg. Use in conjunction with your clinical skills booklet.

http://www.youtube.com/watch?v=P-hAp6DItkA

Demonstrates checking for auscultatory gap although with radial pulse. This is ok if you arestruggling to find the brachial but do justify why you are doing it. Ignore the last couple of minutes ofdancing and chat!

http://www.bhsoc.org//index.php?cID=162 British Hypertension Society website- useful links onhow to measure BP and further examples of BP readings.

Cardiovascular examination

http://www.youtube.com/watch?v=q_Vap7O-VnI

from macleods more detail than required, use in conjunction with your clinical skills booklet

http://www.youtube.com/watch?v=XiM2fnVDg9A

A lot of detail. Again use in conjunction with your clinical skills booklet to pitch at right level for year2.

http://www.youtube.com/watch?v=-8Hi1PjZam4

Again in more detail than for year 2 but is a mock up of an OSCE station. At the end also includes asummary of the findings.

Peripheral pulses

http://www.youtube.com/watch?v=k27S5j48IZw

not great and on a model not a real patient not a lot of anatomical detail

http://www.youtube.com/watch?v=QQIiB51IWMU

Posterior tibial and dorsalis pedis. Where he says distal to the medial malleolus we would saybehind or posterior to the medial malleolus.

Respiratory examination

http://www.youtube.com/watch?v=0rEvNtNjOSs

from macleods more detail than required, use in conjunction with your clinical skills booklet

http://www.youtube.com/watch?v=L19PVsD--KA
http://www.youtube.com/watch?v=P-hAp6DItkAhttp://www.youtube.com/watch?v=P-hAp6DItkAhttp://www.bhsoc.org/index.php?cID=162http://www.bhsoc.org/index.php?cID=162http://www.youtube.com/watch?v=q_Vap7O-VnIhttp://www.youtube.com/watch?v=q_Vap7O-VnIhttp://www.youtube.com/watch?v=XiM2fnVDg9Ahttp://www.youtube.com/watch?v=XiM2fnVDg9Ahttp://www.youtube.com/watch?v=-8Hi1PjZam4http://www.youtube.com/watch?v=-8Hi1PjZam4http://www.youtube.com/watch?v=k27S5j48IZwhttp://www.youtube.com/watch?v=k27S5j48IZwhttp://www.youtube.com/watch?v=QQIiB51IWMUhttp://www.youtube.com/watch?v=QQIiB51IWMUhttp://www.youtube.com/watch?v=0rEvNtNjOSshttp://www.youtube.com/watch?v=0rEvNtNjOSshttp://www.youtube.com/watch?v=L19PVsD--KAhttp://www.youtube.com/watch?v=L19PVsD--KAhttp://www.youtube.com/watch?v=L19PVsD--KAhttp://www.youtube.com/watch?v=0rEvNtNjOSshttp://www.youtube.com/watch?v=QQIiB51IWMUhttp://www.youtube.com/watch?v=k27S5j48IZwhttp://www.youtube.com/watch?v=-8Hi1PjZam4http://www.youtube.com/watch?v=XiM2fnVDg9Ahttp://www.youtube.com/watch?v=q_Vap7O-VnIhttp://www.bhsoc.org/index.php?cID=162http://www.youtube.com/watch?v=P-hAp6DItkA


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an OSCE guide by medical students, again use in conjunction with the clinical skills booklet as you donot need more detail than given in the booklet

http://www.youtube.com/watch?v=WXhvKwEw3qs

a demonstration of percussion technique, some clinicians would have the fingers closer together onthe hand that is touching the patient.

Peak flow measurement

http://www.youtube.com/watch?v=DxBDfqPmaZU

from asthma UK, simple and clear

Abdominal Examination

http://www.youtube.com/watch?v=gRDeZhOj220

ok, a lot of detail. Level of exposure may not be quite accurate

http://www.youtube.com/watch?v=jqQ4U_DXKf8

from macleods more detail than needed, again use in conjunction with your clinical skills booklet

http://www.youtube.com/watch?v=QO8r_xqamyc

an OSCE guide by medical students. Again use in conjunction with your clinical skills booklet to getthe correct level of detail.
http://www.youtube.com/watch?v=WXhvKwEw3qshttp://www.youtube.com/watch?v=WXhvKwEw3qshttp://www.youtube.com/watch?v=DxBDfqPmaZUhttp://www.youtube.com/watch?v=DxBDfqPmaZUhttp://www.youtube.com/watch?v=gRDeZhOj220http://www.youtube.com/watch?v=gRDeZhOj220http://www.youtube.com/watch?v=jqQ4U_DXKf8http://www.youtube.com/watch?v=jqQ4U_DXKf8http://www.youtube.com/watch?v=QO8r_xqamychttp://www.youtube.com/watch?v=QO8r_xqamychttp://www.youtube.com/watch?v=QO8r_xqamychttp://www.youtube.com/watch?v=jqQ4U_DXKf8http://www.youtube.com/watch?v=gRDeZhOj220http://www.youtube.com/watch?v=DxBDfqPmaZUhttp://www.youtube.com/watch?v=WXhvKwEw3qs

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