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Introduction

Basic Patient
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Acute Patient
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Medication
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The Unofficial Guide to


Practical Skills
Paediatrics

Step-By-Step Illustrated Guides to Over 50 Core Practical Skills,


with Accompanying Mark Schemes, and Typical Exam Questions

FIRST EDITION
General Skills

Emily Hotton and Zeshan Qureshi

Join Our Medical Book Writing Project (details inside)


THE UNOFFICIAL GUIDE TO
PRACTICAL SKILLS
FIRST EDITION
Emily Hotton
Zeshan Qureshi
Introduction

ISBN 978-0957149960
Text, design and illustration © Zeshan Qureshi 2014

Edited by Emily Hotton and Zeshan Qureshi

Published by Zeshan Qureshi. First published 2014

All rights reserved; no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form,
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of
the publishers.

Original design by Zeshan Qureshi and Emily Hotton. Front cover design by Zeshan Qureshi, Emily Hotton, and Tom Green.
Page make-up by Anchorprint Group Limited

Illustrated by Anchorprint Group Limited, Peter Gardiner: medical illustrations (clinical skills limited) and Martin Burnett:
clinical photographs (UK Media Solutions)

A catalogue record for this book is available from the British Library.

Publisher and Chief Editors’ Acknowledgements:


We would like to thank all the authors for their hard work, and our distinguished panel of expert reviewers for their specialist
input. We are extremely grateful for the support given by medical schools across the UK. We would also like to thank the
medical students that have inspired this project, believed in this project, and have helped contribute to, promote, and
distribute the book across the UK.

Thank you to Matt Harris, Andrew Strain, Baldeep Sidhu, Kyle Gibson, and Reza Jarral for their contributions to the Practical
Skills chapter of the Unofficial Guide to Passing OSCEs upon which this book has been developed.

Thank you to Ruth Harrison, Srikant Ganesh, Abiola Adeogun for acting as models. Particular thanks go to Natalie Blencowe,
for her constant advice and support. We also want to make a special mention to Dr and Mrs Hotton, who have been truly
invaluable in providing energy and support to see this project through. Thanks also go to the Bath Academy, at the University
of Bristol for the equipment and facilities for the images.

The authors and publishers would like to thank the following for permission to reproduce their images:
Reproduced by the kind permission of the Resuscitation Council (UK): Fig 3.7, 3.10, 3.13
Dr David Pothier (www.earatlas.co.uk): 3.70, 3.71, 3.72, 3.73, 3.74, 3.75
Pamela Gulland/Hannah Collinson: ECG 1-6 (Station 3.9)
Dr Richard Mansfield: Fig 3.56, 3.60, 3.61
Dr Ed Friedlander: Fig 3.66
NHS Lothian: Fig 3.65, 3.68
NHS Fife: Fig 3.64, 3.67
CME Medical UK Ltd: Fig 4.16

Commissioned photographs by:


Katrina Mason: All images: station 5.13
Martin Burnett (www.martinburnettphotography.co.uk): All other photographs

Commissioned medical illustrations by:


Peter Gardiner (petergardiner@clinicalskills.net)

Although we have tried to trace and contact copyright holders before publication, in some cases this may not have been
possible. If contacted we will be pleased to rectify any errors or omissions at the earliest opportunity. Knowledge and best
practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always
rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products
identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property that may occur as a result of any person acting or
not acting based on information contained in this book

Printed and bound by Cambrian Printers in UK

2
Introduction
Introduction
‘The Unofficial Guide to Practical Skills’ follows on from the huge success of ‘The Unofficial Guide to Passing OSCEs’.
This book covers the core clinical competencies for new graduates, as well as additional practical procedures that are
expected to be performed by junior doctors. Written by recently qualified foundation doctors, with review by senior
clinicians, we have ensured that all procedures follow current guidelines.

This book has detailed explanations of over 50 practical skills stations. Each station includes a corresponding mark
scheme, associated questions and answers as well as further areas to explore. The aim is to give you a comprehensive
overview of all procedures, even if you have yet to witness them in your training. Covering both basic and more
advanced practical skills, we hope this book will prove to be a handy study companion for your undergraduate and
postgraduate training.

Practical procedures can be nerve-wracking to perform, both under the close scrutiny of OSCE examiners and
pressures of daily clinical practice. The following simple measures are central to performing practical skills proficiently
and effectively:

... take time to prepare yourself for the procedure


... ensure you are familiar with the method and equipment you need
... make sure that correct infection control measures are undertaken, from hand washing to use of personal
protective items
... always identify the patient you are about to perform a procedure on and obtain the appropriate consent
... check the patient understands your explanation and allow time for them to ask any questions
... be confident in your ability
... use the experience of your peers
... if you are having difficulty, seek help

With this textbook, we hope you will become more confident and competent in these skills both in exams and in
clinical practice, but we hope that this is just the beginning. We want you to get involved, this textbook has been
written by junior doctors and students just like you because we believe:

... that fresh graduates have a unique perspective on what works for students. We have tried to capture the
insight of students and recent graduates to make the language we use to discuss this complex material more
digestible for students.
... that texts are in constant need of being updated. Every student has the potential to contribute to the
education of others by innovative ways of thinking and learning. This book is an open collaboration with you.

You have the power to contribute something valuable to medicine; we welcome your suggestions and would love for
you to get in touch. A good starting point is our facebook page, which is growing into a forum for medical education,
search for “The Unofficial Guide to Medicine” or enter the hyperlink below into your web browser.

Please get in touch and be part of the medical education project

Emily: emily.j.hotton@gmail.com
Zeshan: zeshanqureshi@doctors.org.uk, @DrZeshanQureshi
Facebook: http://www.facebook.com/TheUnofficialGuideToMedicine?fref=ts

The Unofficial Guide To Practical Skills Introduction 3


Introduction

foreword
This book is the latest addition to ‘The Unofficial Guide to…’ series, giving high quality advice and guidance to medical
students through their transition into doctors. Previous books in the series have focused on tackling the nuances of OSCE
stations. However, ‘The Unofficial Guide to Practical Skills’ aims to reflect the recent emphasis, by the General Medical Council
(GMC), on practical skills.

Approaching practical stations in exams can be challenging. Many medical students struggle to get hands-on experience of
practical procedures during time on the wards. In addition, doctors have their own methods for a given skill and contrasting
advice can be given. Although a breadth of opinion is good to allow you to develop, it can be a hurdle under exam pressure.
This book provides an interactive framework from which to hang this array of knowledge. Directing you through a wide range
of scenarios, from knee joint aspirations and ascitic taps to administering oxygen, with skill specific mark schemes, it gives
you a clear structure from which to hone and perfect your practical skills.

The once daunting prospect of approaching practical skills can now be overcome by using this refreshingly comprehensive
and user-friendly guide. Including both skills focused upon by the GMC and an array of additional skills essential in the
armoury of a junior doctor, this book really is the must have!

Best of luck with all your practical skills!

Robert Miller, Final Year Medical Student, University of Bristol

4 Introduction
Introduction
how to use this book
This book has been created for you. We aim to ease the stress of studying and assist in making learning enjoyable to help
you become a better clinician. The book is split into eight chapters, following a logical order from simple procedures to those
that are more challenging.

Each practical skill station has a method outlining how to perform the skill as well as detailed objectives, general advice and
facts dispersed throughout. This is followed by a matched mark scheme and a series of questions. This format allows for
individual study or group work. There are three roles that may be adopted: the patient; the examiner and the candidate. The
roles of the patient and examiner can be combined if working in pairs.

Scenario
These are real life instructions that would be found in OSCEs or on the wards. Take your time to read the passage and note any
salient points. In OSCE scenarios you will not be able to ask the examiner any questions regarding the passage, so carefully
reading it before starting is paramount.

Mark Scheme
This is a checklist of points that are important to cover in each station. It is not based on any specific
university mark scheme, but covers principles we believe are important to address. The examiner can
tick off points in the boxes as they are covered. These mark schemes can be used several times to
gauge progress over a period of time.

Questions and Answers for Candidate


These questions can be asked to the candidate with model answers provided. Q&A
Additional Questions to Consider
These are other questions surrounding the theme of the station. They are ones to consider, discuss and
think through further to those provided.

The Unofficial Guide To Practical Skills How to use this book 5


Introduction

Abbreviations and symbols


⁰ degrees kPa kilopascal(s) pressure
ABPI ankle brachial pressure index L litre
AMD age-related macular degeneration LA local anaesthetic
ß beta LFTs liver function tests
BE base excess LP lumbar puncture
BiPAP bilevel positive airway pressure m metres
BMI body mass index MC&S microscopy, culture and sensitivity
BP blood pressure mg milligram(s)
cm centimetre(s) MI myocardial infarction
cmH2O centimetre of water min minute(s)
CO2 carbon dioxide mL millilitre(s)
COPD chronic obstructive pulmonary disease mmHg millimetres of mercury pressure
CPAP continuous positive airway pressure mmol millimoles
CPR cardiopulmonary resuscitation MRSA methicillin-resistant Staphylococcus aureus
CRP C reactive protein NPDR non-proliferative diabetic retinopathy
CSF cerebrospinal fluid NTT non touch technique
CT computed tomography O2 oxygen
CVP central venous pressure OP oropharyngeal
DKA diabetic ketoacidosis PaCO2 arterial partial pressure of carbon dioxide
DLCO diffusion capacity of the lung for carbon PaO2 arterial partial pressure of oxygen
monoxide
PCI primary coronary intervention
ECG electrocardiogram
PEA pulseless electrical activity
EDTA ethylenediaminetetraacetic acid
PICC peripherally inserted central catheter
FBC full blood count
PPE personal protective equipment
FEV1 forced expiratory volume in one second
PT prothrombin time
FiO2 inspired oxygen concentration
SaO2 arterial oxygen saturation
FVC forced vital capacity
SAAG serum-ascites albumin gradient
GCS Glasgow Coma Score
SBP spontaneous bacterial peritonitis
Hb haemoglobin
STEMI ST elevation myocardial infarction
HCO3- bicarbonate
TB tuberculosis
HAS human albumin solution
TLCO transfer factor of the lung for
ICP intracranial pressure carbon monoxide
ID identification U&E urea and electrolyte
IJV internal jugular vein USS ultrasound scan
INR international normalised ratio VF ventricular fibrillation
IV intravenous VT ventricular tachycardia
kg kilograms WCC white cell count

6 Introduction
Introduction
Contributors
Editors
Emily Hotton Foundation Doctor (University of Bristol)
Zeshan Qureshi Academic Clinical Fellow - Paediatrics (University of Southampton)

Senior Advisor
Dr Natalie Blencowe NIHR Doctoral Research Fellow and Honorary Specialty Registrar, Surgery, University of Bristol

Practical Skills Authors


Andiran Anduvan Core Medical Trainee (Charles University, Prague)
Diagnostic Ascitic Tap
ECGs

A.Anduvan
Otoscopy
Spirometry
Therapeutic Paracentesis

Srikant Ganesh Foundation Doctor (University of Bristol)


Chest Drain
Diagnostic Ascitic Tap
Diagnostic Pleural Tap
Instruments

S.Ganesh
Proctoscopy
Surgical Gowning and Gloving
Suturing

Nikki Hall Opthalmology Trainee (University of Edinburgh)


Fundoscopy

N.Hall

Ruth Harrison Foundation Doctor (University of Bristol)


Death Certification
ECGs
Female Urethral Catheterisation
R.Harrison

Fundoscopy
Inhaler Technique
Local Anaesthetic Administration
Male Urethral Catheterisation
Peak Flow

James Hayward Foundation Doctor (University of Bristol)


Administering Oxygen
Airway Management
Central Venous Lines
J.Hayward

Immediate Life Support


Intravenous Cannulation
Lumbar Puncture
Setting Up a Giving Set

The Unofficial Guide To Practical Skills Contributors 7


Introduction

Practical Skills Authors Continued


Emily Hotton Foundation Doctor (University of Bristol)
Ankle Brachial Pressure Index
Arterial Blood Gas
Blood Cultures

E.Hotton
Blood Glucose
Blood Pressure
Blood Gas Interpretation
Blood Transfusion
Body Mass Index
Choking
Drug Administration via Nebuliser
Hand Washing
Heart Rate and Respiratory Rate
Infection Control
Intradermal Injections
Intramuscular Injections
Intravenous Drugs
Knee Joint Aspiration
Lying and Standing Blood Pressure
Manual Handling
MRSA Swab
Nasogastric Tube Insertion
Nutritional Assessment
Operating a Syringe Driver
Oxygen Saturation
Phlebotomy
Preparing Baby Formula Milk
Simple Dressing Change
Sizing and Fitting a Hard Collar
Subcutaneous Injections
Suprapubic Catheterisation
Urinalysis

Katrina Mason Core Surgical Trainee (University of Bristol)


Suturing

K.Mason

Senior Reviewers
Dr Steven Alderson National Medical Director’s Clinical Fellow to Health Education England
Dr James Andrews Medical Registrar, Wellington Regional Hospital, NZ
Ken Arber Clinical Education Facilitator, University Hospitals Southampton
Dr Patrick Byrne Consultant Physician and GP, Belford Hospital Fort William
Frances Haig Clinical Education Facilitator, University Hospitals Southampton
Elizabeth Hotton Sister and Unit Manager, Mount Edgcumbe Hospice, Cornwall
Dr Chris Lang Consultant Cardiologist, Edinburgh Royal Infirmary, Edinburgh
Sophie Macadie Clinical Education Facilitator, University Hospitals Southampton
Tracey Murphy Clinical Education Facilitator, University Hospitals Southampton
Dr David Tate Gastroenterology Registrar, Royal United Hospital, Bath
Mr Jonathan Wyatt Emergency Department Consultant, Royal Cornwall Hospital, Truro

Student Reviewers
Alexander Curtis University of Bristol
Vanessa Hayter University of Bristol
Amelia Holloway Peninsula Medical School
Katherine Lattey Brighton and Sussex Medical School

8 Introduction
Introduction
contents
1. Basic Patient Assesments 5. Medicine and Surgery
1.1 Heart Rate and Respiratory Rate .............................. 12 5.1 Simple Dressing Change.......................................... 122
1.2 Oxygen Saturation..................................................... 14 5.2 Spirometry.............................................................. 125
1.3 Blood Pressure.......................................................... 15 5.3 Knee Joint Aspiration............................................... 128
1.4 Lying and Standing Blood Pressure........................... 18 5.4 Nasogastric Tube Insertion...................................... 130
1.5 Ankle Brachial Pressure Index................................... 20 5.5 Diagnostic Pleural Tap............................................. 133
1.6 Blood Glucose........................................................... 22 5.6 Chest Drain............................................................. 137
1.7 MRSA Swab............................................................... 24 5.7 Diagnostic Ascitic Tap.............................................. 144
1.8 Body Mass Index....................................................... 26 5.8 Therapeutic Paracentesis......................................... 147
1.9 Nutritional Assessment............................................. 28 5.9 Lumbar Puncture..................................................... 152
5.10 Proctoscopy............................................................ 156
2. Blood Tests
5.11 Instruments............................................................ 159
2.1 Phlebotomy............................................................... 32
5.12 Suturing.................................................................. 163
2.2 Blood Cultures.......................................................... 36
5.13 Surgical Gowning and Gloving................................. 168
2.3 Arterial Blood Gas..................................................... 39
2.4 Blood Gas Interpretation........................................... 42 6. Urology
6.1 Urinalysis................................................................ 176
3. Acute Patient Management
6.2 Male Urethral Catheterisation................................. 180
3.1 Immediate Life Support............................................. 48
6.3 Female Urethral Catheterisation.............................. 184
3.2 Choking..................................................................... 54
3.3 Sizing and Fitting a Hard Collar................................. 56 6.4 Suprapubic Catheterisation .................................... 187
3.4 Airway Management................................................. 59
3.5 Administering Oxygen............................................... 63 7. Paediatrics
3.6 Intravenous Cannulation........................................... 66 7.1 Peak Flow............................................................... 192
3.7 Setting up a Giving Set.............................................. 72 7.2 Inhaler Technique.................................................... 194
3.8 Blood Transfusion...................................................... 75 7.3 Preparing Baby Formula Milk.................................. 197
3.9 ECGs.......................................................................... 80
3.10 Fundoscopy............................................................... 91 8. General Skills
3.11 Otoscopy................................................................... 95 8.1 Hand Washing......................................................... 202
3.12 Central Venous Lines................................................. 97
8.2 Infection Control..................................................... 204

4. Medication Administration 8.3 Manual Handling..................................................... 206


4.1 Intramuscular Injections.......................................... 102 8.4 Death Certification.................................................. 208
4.2 Subcutaneous Injections......................................... 105
4.3 Intradermal Injections............................................. 107
4.4 Local Anaesthetic Administration............................ 109
4.5 Intravenous Drugs ................................................. 112
4.6 Drug Administration via Nebuliser........................... 115
4.7 Operating a Syringe Driver....................................... 117

The Unofficial Guide To Practical Skills Contents 9


Introduction

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