Notes for the new exam.

Dr Swamy PLAB courses

Topic 1 Mannequins

Breech Antenatal examination

You are FY2 doctor in the OBG department

Mrs Catherine Anderson, 20 years old lady has come to the hospital with
gestational amenorrhoea of 36 weeks. Midwife suspected breech presentation.
Midwife has checked the vitals and they are normal.

Take a brief history, do the examination – confirm the diagnosis and talk to the
patient about further management.

Dr: Hello Mrs Catherine Anderson, I am Dr … one of the junior doctors in the OBG department.
How are you doing?
Pt: I am OK doctor.
Dr: How is your pregnancy? any problem at all ? Pt: No problems
Dr: I was told that Midwife has examined you and she was bit concerned about the position of
the baby. Is that right ? Pt: Yes that is right.
Dr: How many weeks pregnancy now ? Pt: 36 weeks doctor
Dr: Do you feel your baby kicking ? Pt: Yes
Dr: Did you have any problem before in this pregnancy at all? Pt: No
Dr: Were you pregnant before ? Pt:: Yes, twice before.
Dr: How are the children now? Pt: They are fine
Dr: Was it normal delivery or caesarean section ? Pt: Both were normal delivery
Dr: Was there any problems with the position of the babies during delivery in your
previous pregnancy ? Pt: No
Dr: Mrs Anderson Can I examine your tummy now. This examination involves inspecting
and touching your tummy to feel for the structures and position of baby. The reason it is
performed is to ensure yours and your baby’s wellbeing.
Exposure/ position, privacy and Chaperone: “for the sake of examination I would like
you to lie down and undress below your breasts, keeping your underwear on. For which I
will ensure adequate privacy and have a chaperone.”
Consent: “can I proceed?” (Verbal consent)
Is there any question you would like to ask me or have you got any concerns?
Thank you very much for your cooperation, I will continue the examination on
mannequin.

Ask the examiner: “Where is the head end?” ask this question only if you cannot
make out which is head or foot end. Undress gently from the down side.

Tip: never expose the breast. If examiner didn’t show the head end, undress manikin
gently. If you expose the breast, say sorry and roll down and go back the other side.

Inspection:

• On inspection of abdomen there is a distended abdomen consistent with the days

of amenorrhea.
• I can’t see any cutaneous signs of pregnancy, such as striae gravidarum and
linea nigra.
• There are no visible scars, veins peristalsis, bruises; umbilicus seems to be
inverted inside.
• There are no obvious fetal movements.

Palpation:
I would ask mother if she is tender anywhere on abdomen before touching, and also ask
if she feels discomfort or pain to let me know.

• Temperature: Warm your hands and compare temperature with the other side.
“There is no local rise in temperature.”
• Tenderness: “ I will look for any tenderness by looking at the face of
the patient.”
• Deep palpation: For palpation, start from the middle to up and come back to
down.

• Lie: fix one hand and palpate with the other hand, while checking the sides.

(Lie: relationship of cephalocaudal axis (spinal column) of fetus to c. a. of

mother)
Longitudinal: parallel
Transverse: fetal c.a. is 90° to woman’s spine
Oblique lie: (unstable lie)
Presentation: ( cephalic or breech) palpate upper pole and lower pole separately.
Fundal Grip: Upper pole, hard and globular head “on the upper pole, I can feel hard
globular structure, most likely it is head.”

• Back of the fetus: (either left or right)

One side you will feel irregular structure limbs on the left/right, I can feel
irregular structures, most likely the limbs.”
The other side you will feel a curved structure - back on the right/left, I can feel a
curved structure, most likely is back of fetus.”

Pelvic Grip: Lower pole, round and soft buttocks “on the lower pole, I can feel soft
round structure; most likely it is buttock of fetus.”

Engagement:
• Head is free or engaged in the pelvis
• Insertion of fingers
• Pawlick’s Grip
• “Presenting part is not engaged/ or is engaged.”
[ in the new exam – it will be breach presentation – there will not be any engagement]

Height:
Measure the symphysio-fundal height from pubic symphysis to the maximum of
the fundus with the help of measuring tape.
 The measurement in centimeters and should closely match the fetus gestational
age in weeks, within 1 or 2 cm, e.g., a pregnant woman's uterus at 22 weeks should
measure 20 to 24 cm.

Fetus is clinically normal/ small/ large of dates

If the fundal height is high:
Polyhydramnios
Multiple pregnancies
Wrong date of LMP.
Large baby

Auscultation:
• The fetal heart is best heard in the back of the fetus
• In cephalic or normal fetus, it is on either sides of the umbilicus (below and
lateral to umbilicus) along the back of the fetus.
• In the GMC manikin, there is actual heart sounds that means you should try to
hear any sound on the tummy of the manikin with the help of the fetal
stethoscope provided to you. Wider part of fetal stethoscope should be on the
tummy and smaller part to your ear to listen to the heart of the fetus.
• Let the examiner know if you can hear fetal heart sound.

Thank the patient and ask her to dress up.

Baby in vertex - or 'head' down position.

1. Assessing the height of the fundus
(lower area of the baby) - seeing how
many finger breadths below the 2.
xiphisternum (bottom of the Assessing the size of baby and
woman’s sternum bone). feeling for the baby's back and
limbs.

4.

3.
Pawlik's grip - the lower part of the
uterus is grasped by the midwife to Pelvic palpation to determine the
determine the presenting part. position of the baby's head.
 6. Listening to the baby's heartbeat.

5. Measuring the height of the fundus

which generally corresponds to the
number of weeks of gestation

Baby in breech position - or 'bottom' down position

1. Checking
the height of the fundus (the highest
point of the uterus). At 20 weeks this
measurement is taken from the belly 2.
button. When the pregnancy is at Assessing the baby's position and
term (37-40 weeks), it's taken from size. Feeling for the baby's head,
the lower end of the woman's back and limbs.
sternum bone (the xiphisternum).
 3. Using ‘Pawlik's grip’ to check that
the baby's buttocks are in the pelvis. 4.
Listening to the baby's heartbeat.

Dr: Mrs Anderson – I think your baby is in a breech position? Do you know anything about it ?
Pt: No

Dr: Breech means your baby is lying in a bottom first ie bottom of the baby is facing down
instead of usual head first position. Usually by 36 to 37 weeks of pregnancy babies are ready to
be born in the head down position.

Pt: Is there any problem with this ?

Dr: Unfortunately sometimes this can cause serious problem during delivery because head
of the baby can get caught inside the birth canal and the delivery can be very difficult.
Sometimes we may need to use the instruments to deliver the baby if the head gets caught
inside the birth canal.

Pt: Why is this happening doctor?

Dr: Sometimes it is just a matter of chance but sometimes it may be due to excessive or less fluid
in the womb or the position of the placenta causing this.

Pt: What will happen now ?

Dr: We need to do ultrasound scan of your tummy to check the type of breech and also we need
to check the size of the baby and the size of your birth canal. We can do several things.
Sometimes we may wait for few more days and see whether the baby will turn on its own to the
normal position because most of the times babies do turn to normal position by 37 weeks.
Otherwise my seniors may try to change the position to normal position by manually turning the
baby by moving it over the tummy. If that is not possible then we may do caesarean section. If
the scan shows it is safe to deliver through the vagina then we may deliver the baby through
vaginal route. However if we decide to deliver through the vagina sometimes we may need to
use some instruments to deliver the head of the baby. Caesarean section is safer than vaginal
delivery.
My seniors will discuss with you and you can decide which way you can have the delivery. Are
you following me? Pt: Yes doctor
Dr: Any questions ? Pt; No doctor.
Thank you very much.

Catheter
You are the FY 2 doctor in surgery department.
Mr. Graham Martin a 55 year old male patient presented to the hospital with
pain abdomen and unable to pass urine.
Take brief history
Do the relevant procedure and talk to him about the further management.
Dr : How can I help you. Pt: Doctor I have pain in my tummy
Dr : Since when Pt: Since yesterday.
Dr : Where is the pain ? Pt: Lower part of my tummy
Dr : Any other problem other than pain?
Pt: I could not pass urine since yesterday it is almost 24 hours now
Dr : I am sorry to hear that.
Dr : Did you have this problem before Pt: No
Dr : Did you have any problem passing urine before like burning sensation while
passing urine Pt: No
Dr : Did you have any surgery recently Pt: No
Dr : Were you going to loo more times than usual especially in the night ?
Pt: Yes since last few months Dr : Any dribbling of urine ? Pt: yes
Pt: Any fever – Pt: No
Dr : Do you have back pain ( for secondaries in the vertebra) ? Pt: No
Pt: Weight loss (for cancer prostate)? No
Dr : Did you have any injury to or instrumentation done on urethra Pt: No
Dr: Any kidney stones before ? Pt: No
Dr : How is bowel habits - Pt: That is fine.

Dr : Are you taking any medications ( opiods, antipsychotics CCB)? - Pt: No

Dr: Any medical conditions ( MS, DM, Parkinsons) Pt: No

Examination - I need to examine your tummy and back passage to see what is causing
this problem.
Examiner says – Bladder is distended and prostate is smooth surface and enlarged.

Thank you.

Management: Dr : Mr Martin, Your urine bladder is enlarged because the urine is

collected in the bladder. I think you had this problem because a gland called Prostate
which is present at the base or the urine bladder which surrounds the urine passage is
enlarged and making the urine passage narrow.
We need to do further test to see what type of enlargement is this whether it is cancerous
or non-cancerous. On examination it looks like non-cancerous type of enlargement.
We need to do some blood tests which is specific for prostate gland and also do the scan
for the gland and take some tissue sample from the gland and treat the condition either
with medication or we may need to some surgery to widen the urine passage. We will
keep you in the hospital for all this.

Dr: Do you follow me?

Pt: Yes what will happen to me now ?
Dr: For now I am going to pass a tube to your urine bladder through the penis and drain
the urine out. Take Consent: would that be okay with you?
Pt: OK doctor.

Short history to rule out contraindications:

1.Any injury to the urethra ? No
2.Any bleeding from the urethra ? No
Exposure / chaperone: For the purpose of this procedure I would like you to get undressed
below your waist please, lie comfortably on your back. I will ensure your privacy and
request for a chaperone.

PROCEDURE
Catheter set is kept open and ready – catheter will be kept inside bag opened at the top.

Wash hands, put on apron, clean the trolley you are going to use with wipe.
Collect equipment.

Catheter pack: it includes ( drape, forceps, gauze, cotton wool, fluid container, kidney
tray)
Cleaning solution
2 pairs of sterile gloves
Prefilled syringe with anaesthetic gel

Catheter ( this comes double packed and includes a syringe of water to inflate the balloon.
Urinary bag Clinical waste bin
-----------------------------
Make sure the clinical waste bin is near you before starting

Open the catheter pack without touching the contents and place the inner pack on clean
surface
Wash your hands. Now open the catheter pack by just touching the edges and underside.
This creates your sterile field. Everything in this is sterile and shouldn’t be touched unless
you are wearing sterile gloves.
Open the urinary catheter outer packaging and lubricant without touching the contents.
Place them carefully in your sterile field.
Open the urinary drainage bag and place it between the patients leg for easy access when
needed.
Pour cleaning solution into the container. Open a pair of sterile gloves to the side of your
sterile field.
Wash your hands, put on your gloves, take care not to contaminate them by touching the
outside of the gloves with your hands. Place the drape over your patient to create a clean
area.
One hand ( right ) is now going to be your clean hand, which can be used to pick things out
of the sterile field. The other hand ( left ) will be your dirty hand, which will be used to hold
the penis using gauze. This hand cannot enter the sterile field.
Retract the prepuce ( if the mannequin has it and only if it is possible to retract, most of the
mannequins you won’t be able to retract it, then you will have to clean over the prepuce )
for adequate exposure of the glans and meatus.
Pick up a swab with the help of forceps, dip it in cleaning solution and clean the glans from
centre to periphery in a circumferential manner with single stroke. Repeat the procedure to
clean area around glans also. Discard the swab and plastic forceps in clinical waste bin.
Take the lubricant and inject it down the urethra.

Change your gloves, clean hands in between. Remove the outer packaging from syringe of
water, so it is ready to be used, place the kidney tray between the patient’s legs.
Tear off the tip of the bag covering the catheter. Hold the catheter by the bag in your clean
hand and use your dirty hand to hold the penis. Push catheter with no-touch-
technique ( don’t touch catheter or glans with hand ). Push up to Y junction.
Inflate the bulb with distilled water. Inject in about 5ml of it slowly, looking at the patient’s
face. Then inject the rest of distilled water. Give a slight tug to make sure catheter is
properly placed inside. Discard the syringe to clinical waste bin.

Replace the retracted prepuce if possible and Discard the shaft holding gauze piece to
clinical bin and hold Y junction with left hand. Connect the urine bag. (You can leave the bag
on the floor, place it below the mannequin level).
 • Tear the drape. Discard it to clinical waste bin.

• Stick the catheter on the thigh with the help of tape.

• Make sure that the patient is left clean, tidy up equipment, explain the patient
that procedure is over and if they have any pain or discomfort with catheter, to inform the
member of staff.

• Record findings: “I would record the volume and color of urine, size of catheter,
and time and date and put my signature”
• Ask the patient to redress: “ thank the patient and ask him to dress up.”

Dr :Urine is drained out now How do you feel.

Pt: Much better doctor

Pt: How long should I be in the hospital?

Dr : It may take few days to do the tests and also we need to remove the catheter to see
whether you can pass the urine without the catheter [Trial without catheter (TWOC)] .
After that we can discharge you.

Pt: How long should I have this catheter ?

Dr : Most probably for few days only until we find the cause of the retention and treat it.
Very rare chance that you need it for long time.

Paracetamol overdose and blood sampling

( mannequin)

Ms Victoria Jones has taken over dose of some tablets. Take history from her and do
the necessary investigation and then talk to her about the further management.

Dr -Hello Ms Victoria Jones. I am Dr .. one of the junior doctor in the Emergency

department. I understand you took some tablets today, is that right?
Pt - Yes doc. ( If denies - offer confidentiality say – Ms Jones Whatever you say we will
keep that information confidential. We are here to help you).
Dr -What did you take ? ---- Pt - Paracetamol tablets.
Dr - How may did you take ? - -- Pt - About 40 tab.
Dr - When did you take them –--- Pt - 6 hours ago.
Dr - Did you take anything else with that like Alcohol, other Medication of rec drugs? –
Pt - No.
Dr - Did you throw up ( Vomit) after this ?
Pt - Yes or no.
Dr - Any pain in tummy?
Pt - No.
|Dr – Any chance are you pregnant ?
Pt - No.
Dr - Ms Jones you have taken too much of Paracetamol which can be dangerous to your
health as it can damage your liver and kidneys. We need to do some blood tests on you to
check how your liver and kidneys are functioning as well as the level of Paracetamol in the
blood to see if you need any treatment. Is that OK
Pt – OK
Explain the procedure: For the purpose of investigations, I need to draw some blood from
your vein. For that I would introduce a needle in your forearm, you will feel a sharp scratch
but I would be as gentle as possible.
Consent: Will that be okay with you?
Risk : The procedure can sometimes result in bruising but again it is very rare, so please do
not worry about it.
1. Have you got any pain anywhere in your arms?
2. Have you got any blood disorders that you are aware of?
3. Do you use any medications like, warfarin etc
4. From which arm, would you like me to take blood?

PROCEDURE
1. Put on apron, wash hands.
2. Clean the tray with wipe you are going to use.
3. Collect the equipment in tray :
Tourniquet, alcohol wipe, gauze pieces
Vacutainer, vacutainer holder and vacutainer needle
Sharps bin (yellow ),
Waste bin
Pair of non-sterile disposable gloves
Blood request form
Check tourniquet and place it on the arm.

Remove the correct end (smaller, white) of the needle and load vacutainer holder with
needle. throw the cap in clinical waste bin.
Tip: if you open the wrong end of the needle or touch it discard it in the sharps bin and take a
new one.
 6. Palpate the vein. (above Y junction)
7. Fasten tourniquet.
8. Palpate the vein again.
9. Wipe the alcohol sterets, one stroke only, then discard it in the waste bin.
10. Unsheathe the needle (green end) and throw cap in clinical waste bin.
11. Warn the patient before inserting needle “ you will feel a sharp scratch”.
12. Stretch the skin and introduce needle.
Tip: Don’t try to insert the whole needle inside. The moment the resistance has gone,
you’re inside the vein.
13.When you get blood, stabilise vacutainer holder with left hand and insert vacutainer
one by one for collecting blood samples
1. Shake the bottle and put it inside the kidney tray.
2. Loosen the tourniquet.
3. Take gauze piece and press on needle and withdraw the needle. Ask the patient to keep it
pressed to attain adequate hemostasis.
4. Discard the vacutainer holder in sharp’s bin with the needle.
5. Label the samples (patient’s name, DOB and hospital number, procedure, date
and signature) and mention I will send them to lab along with the blood request
form.”
6. Remove the gloves and discard in clinical waste bin.
7. Enquire how the patient feels and thank the patient for his cooperation and ask her to roll
down sleeves”

– Use yellow cap vacutainer for Paracetamol level, LFT and U&Es. If the examiner say
colour does not matter then use any colour vacutainer given.

Once you take the blood, examiner gives the paracetamol level as 94 mg at 6 hours. Plot the
level on the below chart. 94 mg is above the treatment line at 6 hours.
Dr – Miss Jones I got the paracetamol level result back from the lab. It shows the paracetamol
level in the blood is very high and you need treatment with some antidote medication. This
will reduce the harmful effects of Paracetamol tables. This medication is called as N- Acetyl
cysteine. Is that OK?

This is only one dose which will be given as a drip though your vein for 21 hours. We will
admit you in the hospital and keep monitoring you while we treat and once the treatment is
finished and if you are fine we will refer you to our Psychiatric specialist doctors who will help
your further. Are you following me ? Is that Ok?
Pt - Why, am I mad ? ---
Dr - No you may need help if you are feeling low and stressed out and they can help. Dr - Any
questions? Pt: No
Dr ---Thank you.
Post appendicectomy – IV cannulation
Mrs Stevens had appendicectomy operation few hours ago.
His IV cannula has been blocked.
Take a brief history and do the necessary procedure and talk to the examiner about
the further management.

Dr: Hello Mrs Stevens I am Dr …one of the junior doctor in the surgical department. How are you
doing ?
Pt: I am OK doc
Dr: Do you have any problem like pain ?
Pt: Yes I still have pain over the operation area.
Dr: Ok we will give you some pain killers
Dr: Any vomiting - Pt: yes doctor
Dr: Any pain in Calf or Shortness of breath Pt: - No
Dr: Any fever ? Pt: - No
Dr: Mrs Stevens I need to put a cannula to your hand now because the one what you have now is
blocked. Then I can give medications through your vein. Is that Ok
Ok doctor
Then insert cannula
Explain procedure: It will be a little uncomfortable and you will feel a sharp scratch but I would
be as gentle as possible. Also, I would need to repeat the procedure again, if I do not get blood in
the first attempt.

Consent: Are you happy for me to go ahead with this procedure?

1.Are you allergic to anything?

2. Have you got any pain anywhere in your arms?
3. Which arm would you like me to do the procedure on?

Complications: This procedure also carries a risk of infection (phlebitis) and swelling (haematoma)
but please do not worry about it, we take great care to prevent this from happening.

PROCEDURE
1. Put on apron, wash hands.
2.Clean the tray with wipe you are going to use.
Collect equipment in tray:

• 1 Pair of gloves
• Cannula (pink or blue)
• Alcohol sterets
• Gauze piece
• Tegaderm
• Tourniquet
• 2cc syringes filled with normal saline or syringe and saline vial
• Clinical waste bin
• Sharp bin – yellow

Make sure sharps bin is close by and open the sharps bin.

• Check tourniquet and place it on arm. (loose, don’t tie it yet)

• Check the site and the vein. (below Y junction if the mannequin has Y junction)
• Remove cannula from the sheath with no touch technique and place it back in clean tray.

• Take out stopper; place it on clean area facing upwards.

• Fasten tourniquet.
• Palpate the vein again.
• Clean the area with alcohol sterets in one direction with single stroke. Discard it into
clinical waste bin.
• Take a three point grip of the cannula, with your thumb on the white cap or the projecting
part of the stylet, index finger on the coloured cap, and middle finger on the wing. Apply
countertraction to the overlying skin with your other hand to help anchor the vein during
insertion.
• Before introducing needle you should warn the patient, so say “you will feel a sharp
scratch now”.
• Stretch the skin and insert cannula with bevel end upwards at 30 to 40 degree. Then
reduce to a 15° angle to advance the needle inside the vein.
When blood gushes back, change your grip, so the thumb and middle finger are on the white cap to
withdraw the needle about 5 mm to produce the second flashback. Importantly the index finger
provides countertraction on the wing so that cannula will stay inside and only needle is withdrawn
out, but not fully.
With just the index finger remaining in place at the wing, advance the cannula along the vein.
Release the tourniquet.

Place a gauze between cannula and underlying skin. Press over the vein around the tip of cannula
with the index finger of left hand so that blood does not leak out.
Remove the needle and discard into sharps bin.
Position and stabilise the cannula with left thumb.
Put the stopper at the end of cannula.

Take 2cc syringe with normal saline and flush through third opening (opening in upwards), go slowly,
feel for the flow and see for patient’s comfort and say “I would check any resistance or swelling or
reports of pain from the patient”. Then push all the remaining normal saline in the syringe and close
the opening.

Apply tegaderm: mentioning date and time on the tegaderm.

Inform the patient to please not move his arm.

 Information written on a paper on the table

Patient has been prescribed Morphine 5mg every 4 hours.

Last dose given one hour ago.

Talk to the examiner about the further management.

Since patient was given morphine just one hour ago I cannot give Morphine for the next 3 hours.
Since the patient has pain now – I will give him Paracetamol -1gm IV and
Metaclopramide –10 mg IV for vomiting and also IV fluids – Normal saline.
I will give her IV antibiotics
Since the patient is complaining of pain in her abdomen I will examine her abdomen and check for
any signs of intra-abdominal bleeding. I will check her Haemoglobin for bleeding.

• Aftercare advice: Inform patient the cannula will be checked and flushed 3 times a day
and will be removed after 72 hours. Inform patient to alert staff if:
• The cannula site becomes painful/sore/hot.
• The insertion site looks infected/red/swollen.
• The cannula is knocked
• The dressing is coming loose or is wet
• They feel the cannula is limiting their self care.
•

IV cannulation Post operation ( ruptured appendix)

Stop at 6th minute bell if you did not get the blood.
Check on the table for any paper which may be written – 5 mg Morphine to be given every 4
hours. Last dose was given one hour ago.
Management – talk to the examiner
Check NEWS chart – there may be Hypoxia, Check the pulse and blood pressure also.

I will give her pain killer – Diclofenac 75mg IV for pain ( if she complains of pain abdomen)
since the last dose of Morphine just given one hour ago.
I will give her Cyclizine for vomiting – 50mg IV
I will examiner her for any signs of bleeding because she has hypoxia like pallor and
abdomen for distension generalised tenderness.
I will do blood tests like FBC, U& Es, Group and cross match and clotting screen
I will also examine her chest for any signs of Atelectasis and PE.
I will inform my senior about this.
 Earache
Exam question

21 year old Mr …. Presented to the hospital complaining of earache.

Take history, examine the patient and discuss the further management with the patient.

Dr: Hello Mr …. I am Dr…. How can I help you ?

Pt: Doctor I am having pain in my ear.
Dr: Can you tell me anything more about it?
Pt: It is there for few days now doctor. I took some pain killers it is not going.
Dr: Which ear you have the pain? Pt: Right ear.
Dr: Do you have any discharge from that ear? Pt: No
Dr: Do you have any fever ? ( Otitis media may or may not have fever)
Pt: Yes since the last few days.
Dr: Are able to hear in that ear properly ? Pt: Yes
Dr: Do you hear any sound or noise in the ear ( tinnitus – meniere’s disease) Pt: No
Dr: Do you feel your head is spinning ( meniere’s disease, labyrinthitis) Pt: No Dr:
Do you have any balance problem while walking ( labyrinthitis) Pt: No
Dr: Did you have any injury to the ear? Pt: No
Dr: Any rashes around the ear or face ( Ramsay hunt syndrome) ? Pt: No
Dr: Did you go for swimming recently ( trauma, furunculosis ) Pt: No
Dr: Any recent flight travel ( Barotrauma) ? Pt: No
Pt: Any headache ( GCA, Meningitis, Migraine ) ? Pt: No
Dr: Any problem in the other ear at all? Pt: No
Dr: Did you have any problems in the ear before ? Pt: No
Dr: Do you have any medical conditions ? Pt: No
Dr: Ae you on any medications ? Pt: No
Dr: Are you allergic to anything ? Pt : Yes Penicillin

Examination:
I need to examine your ear. During the examination I will be coming very close to you and
will be touching your ear, cheek and face.

Examine the affected ear first ( In real life examine normal ear first).

Inspection : ( on the patient)

Pre auricular : There are no scars, sinus, discharge , redness, swelling , previous marks
of surgery

Auricular : No swelling, obvious haemotoma, deformity , vesicles, bleeding discharge

Post Auricular : Same as pre auricular + no mastoid bruises / discolouration.

Palpation : ( On the patient)

Temperature
Tenderness -> looking at patient’s face
 Pre auricular –> pulp of finger - no obvious swelling or tenderness
Auricular -> thumb +index finger
Post auricular –pulp of finger – no obvious swelling or mastoid tenderness.

Tragus Test: ( if positive – Contraindication to otoscopy).

Tragus negative – proceed with Otoscopic examination on the mannikin.

Explain Procedure : I am need to examine the inside of your ear with a special instrument
called an Otoscope .

Right examination Left ear examination

Position : Sitting with head and neck slightly tilted to the other side .

Check Instrument - Check the Otoscope working

Use the large size speculum. Hold the Otoscope in pen holding position
External auditory Canal –Throw Light
Comment on – No discharge, bleeding, inflammation, wax, FB
Tympanic Membrane
Left hand on head, pull pinna upward +backwards with thumb and index finger.-

LOOK AT THE SLIDE

Withdraw the instrument, Look at speculum, comment on bleeding, discharge or wax over
speculum. Remove and dispose it in clinical waste bin.

DESCRIPTION OF SLIDE:
Comment on:
• Cone Of Light
• Handle of Melleus
• Umbo
• Annulus
• Pars Flaccida/Pars Tensa (Any Findings In Tympanic
Membrane)

SLIDE OF AOM WITHOUT EFFUSION

I can see the TM which is red, inflamed, congested, edematous and tense
There is no air fluid level
Cone of light, handle of malleus and umbo cannot be appreciated Annulus
can be appreciated.
Therefore diagnosis is AOM without effusion

Ideally, I will do Rinne’s and Weber’s test to check for any hearing loss.
( no need to do these test in the exam as the tuning forks were not kept in the cubicle).

Check the hearing with finger clicking sound.

Examine the Lymph nodes ( if you have time)

• Sub mental
• Submandibular
• Pre – auricular
• Post Auricular
• Cervical
• Occipital

[ stop the examination by 6 minutes]

Diagnosis

Mr… You have infection in the right ear. This could be due to Bacteria type of bugs.
Pt: Ok

Treatment:

We will give you antibiotic called Erythromycin ( since the patient allergic to Penicillin)
which you need to take for 5 days.
We will also give you some pain killer medication.
Usually this condition subsides in about 5 to 7 days.

Pt: Any complications doctors?

Dr: Rarely this can cause infection in the nearby ear area like infection in the bone
( mastoiditis) and also infection of the covering layer of the brain called meningitis.

Warning signs:
You can take this medication at home. If the condition is getting worse, or if you develop
headache, rashes on the body – these signs of meningitis - please call the ambulance and
come to the hospital.

[ No need to do – Rhombergs and Marching test because there is no hearing loss and
balance problem].

For information only

SLIDE OF TYMPANIC MEMBRANE (NORMAL)
Cone of Light- Directed downwards and anteriorly
Handle of Malleus- antero superior
Umbo - Central portion which joins handle with cone of light
rd
Upper 1/3 Pars Flaccida
Lower 1/3rd Pars Tensa
Annulus Outer fibrous ring around TM joining TM to surrounding
bony

Structure

• Pearly grey in colour

• Semi transplant
• Normal Tissue
Can appreciate cone of light in antero inferior quadrant, handle of malleus in antero
superior quadrant and umbo at the junction of cone of light and handle of malleus.
Pars flaccida, Pars tensa and annulus appear normal
No retraction, no bulging, no air fluid level, no per formation, no bleeding, no discharge,
no wax over TM
Therefore diagnosis is Normal Tympanic Membrane.

SLIDE OF WAX
I can see the TM
Colour in transition from pale yellow-golden yellow-yellow brown – finally brown or
cannot see TM , obscured by golden material.
Cone of light, handle of malleus and umbo cannot be appreciated.
Can appreciate annulus.
Therefore my diagnosis is cerumen over TM.
Treatments to remove earwax:
The main treatments are:
eardrops – drops used several times a day for a few days to soften the earwax so that it
falls out by itself
ear irrigation – a quick and painless procedure where an electric pump is used to push
water into ear and wash the earwax out
microsuction – a quick and painless procedure where a small device is used to suck the
earwax out of ear
aural toilet – where a thin instrument with a small hoop at one end is used to clean the ear
and scrape out the earwax.

SLIDE OF ACUTE OTITIS MEDIA WITH EFFUSION

I can see the TM which is red, inflamed, congested, edematous and tense
Can appreciate an air fluid level in antero superior and postero superior quadrants.
Cone of light, handle of malleus and umbo cannot be appreciated
Annulus can be appreciated.
Therefore diagnosis is AOM with effusion.

SLIDE OF AOM WITHOUT EFFUSION

I can see the TM which is red, inflamed, congested, edematous and tense
There is no air fluid level
Cone of light, handle of malleus and umbo cannot be appreciated Annulus
can be appreciated.
Therefore diagnosis is AOM without effusion

SLIDE OF AOM WITH BULGING

I can see the TM which is red, inflamed, congested, edematous and tense
Can appreciate an bulge in TM which is in the postero inferior quadrant due to pus or fluid
behind TM.
Cone of light, handle of malleus and umbo cannot be appreciated
Annulus can be appreciated.
Therefore diagnosis is AOM with bulging which may progress to perforation or it is an
impending perforation.

Treating middle ear infection:

Most middle ear infections (otitis media) clear up within three to five days and don't need any
specific treatment.
Paracetamol or Ibuprofen to relieve pain.
Antibiotics aren't routinely used to treat middle ear infections as there's no evidence that
they speed up the healing process. Many cases are caused by viruses, which antibiotics
aren't effective against.If antibiotics are needed, a five-day course of an antibiotic called
amoxicillin is usually prescribed.An alternative antibiotic such as erythromycin or
clarithromycin may be used for people allergic to amoxicillin.

SLIDE OF CENTRAL PERFORATION WITH TYMPANOSCLEROSIS

can see the TM
Cone of light, Umbo be appreciated but can appreciate handle of malleus which is
distorted.
Can appreciate a large central perforation in anteroinferior and postero inferior quadrants,
Can also appreciate few white calcified plagues over TM
Therefore diagnosis is AOM without effusion

SLIDE OF TYMPANOSCLEROSIS
Can see TM
Cone of light, handle of malleus and umbo can be appreciated
Annulus can be appreciated.
Can appreciate white calcified plagues in antero superior quadrants,
Most probably diagnosis is tympanosclerosis.

Treatment is only required if there is hearing loss.

Hearing aids can be beneficial, as with any form of conductive hearing loss.
Surgery for tympanosclerosis involves excision of the sclerotic areas and reconstruction of
the ossicular chain.

SLIDE OF GROMMET
Can see TM
Cone of light, handle of malleus and umbo cannot be appreciated
Annulus can be appreciated.
Can appreciate a foreign body in postero inferior quadrant, most probably a grommet. Most
probable diagnosis is grommet in TM.

A grommet is a very small tube that's inserted into ear during surgery. It can help drain away
fluid in the middle ear and maintain air pressure.It will help keep the eardrum open for
several months. As the eardrum starts to heal, the grommet will slowly be pushed out of the
eardrum and will eventually fall out.

SLIDE OF SECRETOARY OTITIS MEDIA

I can see the TM which is red, inflamed, congested, edematous and tense
Cone of light, handle of malleus and umbo cannot be appreciated Annulus
can be appreciated.
No air fluid level, bulge etc seen
Most probably diagnosis is secretory otitis media.

TURNING FORK TESTS

Check tuning fork 512Hz or 256 Hz

Do Rinne’s or modified Rinne’s test

Interpretation of tests
AC>BC Rinne’s Positive – Normal or sensori neural deafness
BC>AC Rinne’s Negative – Conductive deafness

Do Weber’s
Interpretation
CSSO Conductive Same side Sensorineural Opposite side
Conductive lateralized to SAME side
Sensorineural lateralized to OPPOSITE side.
Sensorineural

Hearing Loss – Acoustic neuroma

50 years old Mrs... presented to the hospital complaining of hearing loss for last 3
weeks. Take history, examine the patient and discuss the further management with the
patient.

Dr: Hello Mr …. I am Dr….  How can I help you ?Pt: Doctor I am losing hearing.

Dr: I am so sorry to hear about that. Can you tell me anything more about it?
Pt: It is there for quite some days now doctor. It is not getting any better.
Dr: Which ear are you loosing the hearing from?Pt: Left ear.
Dr: Any problem in the right ear ? No
Dr: When did it start? Pt: Almost 3 weeks doctor.
Dr: How did it start? Was it sudden or gradual?Pt: (Sudden/gradual?)
Dr: Do you have pain in this ear?Pt: No doctor.
Dr: Do you have any fever ?(Otitis Media)Pt: No.
Dr: Do you have any discharge from that ear? (Otitis Media)Pt: No.
Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus - Meniere’s
disease/Acoustic Neuroma )Pt: No.
Dr: Have you been feeling dizzy lately? (Meniere’s disease)Pt: Yes doctor.
Dr: Do you feel that your head is spinning? (Vertigo - Meniere’s disease)Pt: Yes.
Dr: How long do these episodes last? (>20 min in Vertigo - Meniere’s disease)
Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s
disease/Acoustic Neuroma)Pt: (No )
Dr: Do you feel any fullness in your ear (Aural Fullness-Meniere's Disease)? No
Dr:  Have you been feeling any painor numbness on your face? (Acoustic Neuroma)Pt:
No
Dr: Have you been feeling any headaches lately? (Acoustic Neuroma)Pt: No.
Dr: Did you have injury to this ear or head recently? (Trauma)Pt: No.
Dr: Were you exposed to any sudden loud noise when it start? (Noise induced)No.
Dr: Did you go for swimming recently? ( Trauma)              Pt: No.
Dr: Any recent flight travel? (Barotraumas)                Pt: No.
Dr: Did you have any medical conditions in the past ?Pt: No
Dr: Are you taking any medications now? Pt: No
Dr: Have you received any IV antibiotics or salicylates or diuretics or chemotherapy?
(Ototoxic HL)Pt: No.

Examination:

I need to examine your ear. During the examination I will be coming very close to you and
will be touching your ear, cheek and face.Examine the affected ear first ( In real life
examine normal ear first).

Inspection : (on the patient)

There are no scars, discharge, redness, swelling , previous marks of surgery or
discolouration over the ear and around the ear.

Palpation : (On the patient)

Tragus Test:( if positive – Contraindication to otoscopy).

I need to examine the inside of your ear now with a special instrument called an Otoscope.

Right examination Left ear examination

Position : Sitting with head and neck slightly tilted to the other side .

Check Instrument - Check the Otoscope  working

Use the large size speculum. Hold theOtoscope in pen holding position
External auditory Canal –Throw Light
Comment on – No discharge, bleeding, inflammation, wax, FB
Tympanic Membrane
Left hand on head, pull pinna upward +backwards with thumb and index  finger.-

LOOK AT THE SLIDE

Withdraw the instrument, Look at speculum, comment on bleeding, discharge or wax over
speculum. Remove and dispose it in clinical waste bin.

DESCRIPTION OF SLIDE only if the examiner wants you to

Comment on:
Cone Of Light
Handle of Melleus
Umbo
Annulus
Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane)

SLIDE OF TYMPANIC MEMBRANE (NORMAL)

Cone of Light- Directed downwards and anteriorly
Handle of Malleus- Antero superior
Umbo - Central portion which joins handle with cone of light
Upper 1/3rd Pars Flaccida
rd
Lower 1/3 Pars Tensa
Annulus Outer fibrous ring around TM joining TM to surrounding
bony

Structure

Pearly grey in colour, Semi transplantNormal Tissue

Can appreciate cone of light in antero inferior quadrant, handle of malleus in antero
superior quadrant and umbo at the junction of cone of light and handle of malleus.
Pars flaccida, Pars tensa and annulus appear normal
No retraction, no bulging, no air fluid level, no per formation, no bleeding, no discharge,
no wax over TM

Therefore, is Normal Tympanic Membrane.

I will now do Rinne’s and Weber’s test to check for any hearing loss.

Rinne Weber

no
AC > BC lateralizes to left lateralizes to right
lateralization

lef
right left ear right ear both ears left ear right ear
t

⊕ ⊕ Normal Sensorineural Normal Sensorineural Normal

loss loss

Sensorineural
 loss

Conductive Combined
⊖ ⊕ Normal Normal
loss loss

Combined Conductive
⊕ ⊖ Normal Normal
loss loss

Conductive Combined Conductive Combined Conductive

⊖ ⊖
loss loss loss loss loss

Combined loss = conductive and sensorineural loss

Patient will show following results:

Rinne's Test: AC>BCWeber's Test: Lateralization to Right Ear.

(Indicating that patient has SNHL in Left Ear.)

Examine the  Lymph nodes (if you have time otherwise verbalise)
Do Rhomberg's Test ( only if you have time).

[ stop the examination by 6 minutes]

Diagnosis:

Pt: From the information I have gathered, I suspect you have a problem called
Sensorineural Hearing Loss. This is actually a problem of the inner ear and the nerves
that supply this part of the ear. Are you following?Pt: Yes doctor.

Dr: This problem could be due to conditioncalledAcoustic Neuroma. Do you know what
it is?Pt: No doctor.
Dr: Well, it is growth (tumour) in the brain. This is a non - cancerous type of growth. This
tumour grows on a nerve in the brain near to the ear. It can cause problems with hearing
and balance.
Pt: Are you sure that I have it doctor?
Doctor: This what I am suspecting now. We need to do some tests like MRI scan of the
brain to confirm that.Pt: Okay
Dr: Another test is Audiometry. This is a test which will enable precise understanding of
the degree of hearing loss.
Pt: Why did I get it doctor?Dr: In most cases, the cause is unknown.

Management:

Dr: We will refer you to Ear Nose and Throat specialist.

Pt: How are you going to treat me?
Dr: If tests show that you have a very small acoustic neuroma, then it does not require
 any treatment but we will monitor it closely by regular scans. This is because these
growths are very slow-growing and may not cause any problems for a long time. If it is big
then we may do surgery or radiotherapy.

Dr: Also, for the hearing loss we can give you Hearing aids. Is that OK? Pt: OK

[ Patient need to inform the DVLA if they drive]

Pt: Will I never get my hearing back?

Dr: I am sorry to tell you that even if the tumour is removed with surgery or destroyed
with radiotherapy unfortunately a degree of hearing loss will be permanent.

Dr: Do you have any concerns?Pt: No, you have been very kind. Dr: Thank you

Teach a final year medical student about Per

Speculum Examination.

Introduce yourself to the medical student; build a rapport with

him/her. Ask how his/her studies are going, offer any help with
regards to studies.
Assess his/her knowledge about Per Speculum Examination,
Remember to make sure that the student is following what you
are teaching and praise the student.
Explain why we do PS examination.
 Bivalve (cusco) speculum is the instrument most commonly
used to inspect the vagina.
 The purpose of the examination is to look at the size and
shape of external and internal reproductive organs.
The external examination will
involve:

 examination of anatomy
 looking for any lesions, ulcers,
discharge or other signs of
disease
 palpation of the abdomen

 
The internal examination will
involve:

 palpation of the vulva and vaginal walls

 examination of the cervix
 Assessing the size and position of the uterus.
 palpating for any adnexal tenderness
 location of the cervix using the speculum
 performing any appropriate swabs or smears using the
speculum

Preparation and Introduction

1. Introduce yourself to Patient – (GRIPS – Greet, Rapport,

Introduce and Identify and Explain Procedure) and wash your
hands
2. Ask the patient whether they are experiencing any symptoms
and explain the purpose of the examination
3. Explain that it will involve undressing fully from the lower half
and the examination may be a bit uncomfortable but should
not be painful
4. Gain consent and offer a chaperone
5. Before the patient undresses, perform a general examination,
looking for signs of hormonal disorders for example hirsutism
and acne
6. Explain to the patient that the position they should be lying in is
supine, with knees bent, heels brought up towards bottom, and
then letting legs fall to either side of the bed. Let the patient
undress in privacy behind the curtain and provide them with a
blanket to maintain their dignity.  
7. Prepare trolley and equipment: flexible light source, gloves,
lubricating jelly, speculum.
8. Allow the patient to become comfortable before starting
Inspection

1. Begin with a general abdominal examination

2. Inspect the external genitalia for hair distribution, swelling,
scarring, signs of infection for example warts or ulcers
3. Ask the patient to cough looking for signs of prolapse.

Speculum Examination

1. Think about the size of the speculum needed and use

lubrication
2. Explain to the patient what you are going to do before
proceeding
3. Expose the introitus by spreading the labia from below using
the index and middle finger
4. Gently insert the speculum at a 45 degree angle and pointing
slightly downward
5. Gently rotate the speculum
to a horizontal position and
gently open the blades until
the cervix is in view (the
blades may not need to be
fully opened)
6. Secure the speculum by
turning the thumb nut
7. Visualise the cervix and
vaginal walls for any
abnormalities, such as
ectopy, cysts or polyps
8. Comment on whether the cervical os is open or closed?
(parous or nulliparous)
9. Perform any necessary tests, obtaining samples for culture
and cytology (below)
10. Withdraw the speculum slightly to clear the cervix and gently
loosen the speculum to close the blades
11. Continue to withdraw whilst rotating the speculum to 45
degrees, avoiding contact with the vaginal walls
12. Tell the patient that you have finished, give a towel to the
patient to wipe herself.
 Breast Examination
You are the FY2 doctor in the surgical department.
Mrs .. Moulton 44 year lady presented to the hospital because she is concerned about
lump in her breast.
Take history examine the patient and talk to her about the further management.

Dr: Hello Mrs… Moulton, Pt: Hello

Dr: I am Dr … one of the junior doctor in the surgical department. How can I help you Mrs
Moulton?
Pt: Doctor I noticed some lump in my breast. I am really worried doctor.
Dr: Mrs Moulton, Do not worry about it because most of the lumps are not any serious
condition. Can you tell me anything more about it please ?
Pt: I noticed it today morning when I was having shower.
Dr: Anything more can you tell me about it?
Pt: like what doctor?
Dr: Is it painful at all ( mastitis) ? Pt: No
Dr: Which side breast is that ? Pt: Right side doctor.
Dr: Have you noticed any swelling on the left side ? Pt: No
DR: How many lumps have you felt? Pt: One/two doctor.
Dr: Do you have fever ( mastitis) ? Pt: No
Dr: Did you notice any discharge ( intra ductal papilloma), or blood discharge (
cancer) from the nipple ? Pt: No
Dr: Do you get your menstrual period now? Pt: Yes / No
Dr: If yes - Do you have your menstrual period now ( Fibroadenosis – lumps are felt during
the menstrual period) ? Pt: No
Dr: Have you noticed any lumps on your arm pits? Pt: No
Dr: Have you injured your breast ? Pt: No
Dr: Are you currently breastfeeding, or have done in the past? Pt: Yes/ No
Dr: Did you have any such swellings in the breast before ? Pt: No
Dr: Any of your family members had breast lumps ? Pt: No/ Yes.

Mrs Moulton I need to examine your breasts now.

Pt : Ok doctor.

Examine the breast.

Explain the procedure “ while examining, I will be asking you to do some manoeuvres
and will be looking at you and touching your breast and arm pits to feel for any lumps.
If you feel uncomfortable on any point please let me know I will stop the examination.

Exposure: Can you please undress above your waist.

I will ensure privacy and have a chaperone with me. Is that OK?

[Position: 3 different position will be used during examination. Sitting, Lying down at 45
degrees and Standing. Ask for exposure by saying ]
• Both the breasts are symmetrical.
• The level of nipples is on the same line.
• There are no skin changes or any pigmentation.
• I cannot see any obvious lump.
• There is no redness, scar, swelling or sinuses

2. Sitting, hands on sides and bending forward. Ask “Could please place your
hands on your hips and lean a bit forward?”
• I cannot see any lump or swelling becoming obvious on bending forward.

3. Sitting, Inframammary region. Ask “Can you lift your breasts with two
fingers?”
• There is no eczema or fungal infection in infra-mammary region.

4. Nipples. Ask “Can you squeeze your nipple with your two fingers?” ( You
(doctor) must not squeeze).
• There is no bleeding or discharge expressed from the nipples.
 5. Lymph Nodes. Ask “Please raise your hands and put behind the head
please?”
• I cannot see Axillary fullness or supra clavicular fullness .

• Palpation:

Palpation is in lying position and 45 degree. If it is not 45 degrees ask the

examiner.
Tell the patient: “Could you please lie down on the couch?”

Warn the patient: “I am going to touch your breasts now. If you feel discomfort
or tenderness please let me know.”

During palpation you should not poke with fingers. Feel with the fingers kept close
together, providing a flat surface.
Temperature: Warm your hands and check for the local rise of temperature comparing
with the opposite breast of each quadrant and say: “There is no rise in temperature.”

Tenderness: Start with the superficial palpation. Do an anti clockwise palpation. Check
the patient’s face for tenderness. “There is no tenderness in superficial palpation.”

Deep palpation: Warn the patient: “this time I am going to touch your breast deeper.”

• Palpate axillary tail of spence

• Check for peri-areolar region for any swelling.
• Then check all the quadrants moving anti-clockwise.

If a lump present, describe the lump.

• Site: e.g. upper outer quadrant of right breast
• Size: e.g. 2X2 cms
• Surface: smooth / irregular
• Consistency: soft / firm / hard
• Margins: well defines/ill defined
• Relation to overlying skin and underlying structures
• Mobility
• Tenderness

Summarise your findings: eg-

“In deep palpation, there is a mass of about 2cm in 2 cm, present in right upper
outer quadrant, which is not tenderness in palpation, not attached to over lying skin,
attached to deep structure and it is mobile.”

C. Axillary Lymph nodes: In standing position

Inform the patient that: “I will be examining the few nodes or swellings in your arm
pit. Could you stand up for me please? ”

For checking patient’s right side, say: “Can you please put your right hand on my
right shoulder? Put your right hand on her right shoulder and examine axilla with
left hand. Examine all groups of Axillary lymph nodes; apical, medial, anterior

Ask the patient: “can you please cross your hands in front of you?”
Go to the back with permission and examine lateral and posterior lymph nodes.
You can examine both sides together.

“Ideally I finish my examination by examining supraclavicular lymph nodes.”

Thank the patient. “Thank you very much, you can dress up now.”
Talk to the patient:

Mrs Moulton, I have found a ( one or two) swelling on your right/left breast.
Do you have any idea what it could be ?
Pt : Is it cancer doctor ?
Dr: Mrs Moulton, please do not be worried now because as I already told you before
most of the time lumps in the breast are non cancerous type. Very rarely only they can be
cancerous. At this moment we cannot say what exactly it is.
We will refer you to the breast specialist. They may do investigations like what we call
triple assessment – that the specialist will examine you and then he may do some tests
like Ultra sound scan ( type of gel test what they do on pregnant ladies) or
Mammography a type of special X Ray of the breasts. Thirdly they may do another test
where they take a small tissue sample with the needle from the breast.

Pt: What is the treatment doctor?

Dr: Specialist will tell you depending on the investigation result. Is that OK? Pt : OK.

Dr: Once again Mrs please do not be worried too much about it.
-----------------------------------------------------------------------------------------------------------
-
Do not give the diagnosis of cancer or fibroadenoma even if you are sure of
Fibroadenoma.

Breast Examination is the same even if the patient had breast augmentation. Breast
lump will be more prominent if the patient had breast augmentation because the
breast implant will be inserted behind the breast tissue.