Clinical Skills 2018 Big Guide PDF

A GUIDE TO CLINICAL HISTORY
AND EXAMINATION
2018
SCHOOL OF MEDICINE
Contents
Introduction to Practising Medicine .............................................................................................................. 4
Professional Approach ................................................................................................................................. 4
Standards of Appearance for Medical Students ....................................................................................... 4
Clinical Communication Skills......................................................................................................................... 5
Clinical Examination ......................................................................................................................................... 8
Documentation ............................................................................................................................................... 26
Clerking Patients............................................................................................................................................. 27
The OSCE .......................................................................................................................................................... 32
Reading List ..................................................................................................................................................... 33
Appendix .......................................................................................................................................................... 34
Checklists for Clinical Examinations ........................................................................................................... 34
Examination Skills Checklist for Respiratory Examination ..................................................................... 35
Examination Skills Checklist for Cardiovascular Examination............................................................... 37
Examination Skills Checklist for Gastrointestinal Examination ............................................................. 39
Examination Skills Checklist for Rectal Examination .............................................................................. 42
Examination Skills Checklist for Ankle Examination ............................................................................... 44
Examination Skills Checklist for Diabetic Foot, Lower Limb Examination ........................................... 45
Examination Skills Checklist for GALS Examination................................................................................ 46
Examination Skills Checklist for Hand Examination................................................................................ 49
Examination Skills Checklist for Hip Examination ................................................................................... 50
Examination Skills Checklist for Knee Examination ................................................................................ 51
Examination Skills Checklist for Shoulder Examination ......................................................................... 53
Examination Skills Checklist for Haematological Examination General, Lymph Nodes and
Abdominal .................................................................................................................................................... 55
Examination Skills Checklist for Lymph Node Examination of the Neck.............................................. 57
Examination Skills Checklist for Thyroid Gland Examination ................................................................ 58
Examination Skills Checklist for Lower Limb Neurological Examination.............................................. 59
Examination Skills Checklist for Cerebellar Examination ....................................................................... 61
Examination Skills Checklist for Cervical, Thoracic and Lumbar Spine Examination ......................... 63
Examination Skills Checklist for Cranial Nerves Examination................................................................ 65
Procedural Skills Checklist for Nasogastric Tube Insertion ................................................................... 68
Procedural Skills Checklist for Peripheral Venus Cannulation............................................................... 70
Procedural Skills Checklist for Arterial Puncture ..................................................................................... 72
University of Dundee, School of Medicine Reviewed December 2017
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Procedural Skills Checklist for Blood Culture (Adult) .............................................................................. 74
Procedural Skills Checklist for Blood Sugar Testing ............................................................................... 76
Procedural Skills Checklist for Scrubbing for Theatre ............................................................................ 78
Procedural Skills Checklist for Urethral Catheterisation ........................................................................ 80
Procedural Skills Checklist for Urinalysis ................................................................................................. 82
Procedural Skills Checklist for Venepuncture ......................................................................................... 84
Intimate Examination Guidelines ................................................................................................................. 86
Chaperone Guidelines .................................................................................................................................... 87
Medical School Charter .................................................................................................................................. 88
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Introduction to Practising Medicine
 The beginning of wisdom is silence and the next step is listening 
Anon
Professional Approach
As a doctor you have certain responsibilities; appropriate dress, being prepared, respecting colleagues
and patients, being on time, being aware of confidentiality in relation to patients.
The General Medical Council is the governing body for medical practice within the UK and their website
provides detail on your professional responsibilities.
Standards of Appearance for Medical Students

All clinicians should dress in a professional manner, which is likely to inspire public confidence. The
following dress code has been implemented by the Chief Medical and Nursing Officers for Scotland, taking
into account infection and health and safety risks. All staff and students, in hospitals, primary care and
Clinical Skills Centres, within NHS Scotland are required to follow these guidelines.
• Clean clothes should be worn at all times (no ripped clothes, bare midriffs or low cut tops)
• Hair tied back off the collar
• Nails kept short and clean with no nail varnish (coloured or clear) or false nails
• Wear a clear, visible identity badge at all times
• Arms should be bare below the elbow (short-sleeves or rolled up)
• Avoid wearing neck ties when providing patient care
• Students should no longer wear white coats
• No hand or wrist jewellery (other than a wedding ring or band)
• No wrist watches
• Students should not wear excessive jewellery such as necklaces, visible piercings and multiple
earrings
• Make-up must be suitable and appropriate to the profession
• Students should wear soft-soled, closed toe shoes with no heels
• Students should not carry pens or scissors in outside breast pockets
• Tattoos which could be deemed offensive should be covered where this does not compromise
good clinical practice
Additionally the School of medicine has specific dress code guidance relating to religion and beliefs
http://medicine.dundee.ac.uk/dundee-mbchb-medicine-programme
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Clinical Communication Skills
The aims of this section of the booklet are to give you:
- an overview of how you can develop your own clinical communication skills
- a framework for carrying out a consultation which focuses on the patient
Developing your clinical communication skills

There are a number of principles common to all clinical consultations but every doctor has their own
unique way of consulting. The development of your own communication skills will begin at medical school
and continue throughout your working career.
When developing your communication skills think about the following:
The need to be able to apply theory into clinical practice

What you learn in your lectures, from books, from your small group activities needs to be applied in clinical
practice. To become an effective clinician you need to develop and refine your consultation skills from
now until you retire from the profession, while all the time updating your relevant knowledge base in light
of new evidence and innovation.
The patient should always be central to the consultation process

In whatever context you are learning about the practice of medicine, the patient needs to be your central
focus in the consultation process. The patient should also participate in the decision making process in
relation to their care.
The clinical setting and your role will affect the emphasis of the consultation
The emphasis and outcome of the consultation will vary according to the clinical setting, your role and the
nature of the patient’s concern or problem in relation to their health.
Your role within the consultation is important. Depending on the consultation your role may vary as wide
as just gathering information, performing a procedure, to diagnosing and initiating emergency treatment.
This will influence what you do during the consultation and your clinical thinking.
The need to explore the patient’s expectations

Patients have certain concerns, ideas and expectations of illness, health and disease, often related to
experiences they or their friends and relatives have encountered. This can influence how a disease or
illness episode affects them. Discovering the patients’ perspectives can help to determine how you
approach the examination and subsequent management of any illness episode or preventative
programme.
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Consultation Skills
The consultation can be considered to encompass three types of core skills. They are interlinked and
cannot be taught independently of each other.
1. Content Skills
These include what doctors communicate; the substance of their questions and responses; the
information they gather and give; the investigations and management they discuss
2. Process Skills
How they do each of the key tasks of the consultation. This refers to the communication skills used
during the consultation
3. Perceptual Skills
What they are thinking and feeling – their internal decision making, clinical reasoning and problem
solving; their awareness of feelings and thoughts about the patient, their illness and other issues
that may be concerning them; awareness of their own self-concept and confidence in their own
biases, attitudes, intentions and distractions
The Clinical Consultation Process

There are many different structures and approaches to the consultation process. Your teaching at
Dundee Medical School will revolve around the Calgary-Cambridge guide to the medical interview. This is
not to say that other structures are incorrect but this structure is a useful starting point. You are likely to
adjust your structure over your career to suit your own consulting style and the context in which you work.
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The Calgary Cambridge Guide
In i t i a t i n g t h e s e s s i o n
P r o v id in g B u ild in g th e
s tru c tu re G a t h e r in g in fo r m a tio n re la tio n s h ip
P h y s ic a l e x a m in a tio n
E x p l a n a tio n & P l a n n in g
C lo s in g th e s e s s io n
Calgary Cambridge framework full skills list
Initiating a consultation
Greet patient, obtain patient’s name
• Consider how student should introduce themselves.
• Students are taught to obtain the patient’s name and date of birth – is that always appropriate?
e.g. in GP, or in the acute scenario when you’re speaking to a relative of a patient
Introduce self, role, nature of interview and obtain consent

• This is especially important if the student is playing the role of a medical student, some patients
may not consent or mistake the student for a doctor
Attend to the patient’s physical comfort

• The student should have an awareness of the environment and patient’s comfort.
• Is the area sufficiently private?
• Is the patient in pain / hot / cold / anxious / distressed / embarrassed
• The student should learn to recognise and acknowledge non-verbal cues that may point to patient
discomfort
• The student should acknowledge and attempt to alleviate (if possible) any discomfort
Opening questions
• Even if agenda seems obvious (e.g. a COPD review appointment), there is value is an initial “open”
question – the patient may have a different agenda, priority or perspective on the situation.
Assumptions can lead to misunderstandings
Listen attentively to opening statement

• Encourage the student to pick up non-verbal cues associated with the opening statement that
may show clues of what the patient is thinking or feeling
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Confirm list screen for further problems
• This is often missed by medical students and doctors alike
• Consider summarising presenting problem/s to the patient, this will help show the students have
been listening and also provide opportunity to correct misunderstandings
• Screening for further problems – the patient may have more than one problem
• Screening also allows you to be more effective in timekeeping and prioritization of presenting
problems
Gathering information
Listen and show you are doing so
• Encourage patients to tell their story - the patient will often provide the student with a lot of
information without the need for direct questioning, if they are allowed and encouraged to
Clarify details of the story

• Clarify ambiguity or gather more detailed information
• Respond to cues
Explore
• Ask open and closed questions appropriately
• Avoid leading and double questions
• Facilitate responses both verbally and non-verbally
Summarise and invite correction of inaccuracies

• Use language carefully
Clinical Examination
See relevant pages in Appendix for full details of each system examination and clinical skills videos via
the following link.
https://www.youtube.com/channel/UChkNlLd3PbEPueiAQgufCqg
Physical Examination
During any physical examination communication with the patient is important. Clear communication will
facilitate the examination process by ensuring the patient understands what you would like to do and
what you need them to do. Always ask permission before proceeding with an examination
Explanation and Planning

Providing the correct amount and type of information
Aims: to give comprehensive and appropriate information to assess each individual patient’s
information needs to neither restrict nor overload
• Chunks and checks: gives information in assimilated chunks, checks for understanding, uses
patient’s response as a guide to how to proceed
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• Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving
information, discovers extent of patient’s wish for information
• Asks patients what other information would be helpful e.g. aetiology, prognosis
• Gives explanation at appropriate times: avoids giving advice, information or reassurance
prematurely
Aiding accurate recall and understanding 

Aims: to make information easier for the patient to remember and understand
• Organises explanation: divides into discrete sections, develops a logical sequence

• Uses explicit categorisation or signposting (e.g. “There are three important things that I would
like to discuss. 1st…..” “Now, shall we move on to...”)
• Uses repetition and summarizing to reinforce information
• Uses concise, easily understood language, avoids or explains jargon
• Uses visual methods of conveying information: diagrams, models, written information and
instructions
• Checks patient’s understanding of information given (or plans made): e.g. by asking patient to
restate in own words; clarifies as necessary
Achieving a shared understanding: incorporating the patient’s perspective

Aims: to provide explanations and plans that relate to the patient’s perspective
to discover the patient’s thoughts and feelings about information given to encourage an interaction
rather than one-way transmission
• Relates explanations to patient’s illness framework to previously elicited ideas, concerns, and
expectations
• Provides opportunities and encourages patient to contribute: to ask questions, seek
clarification or express doubts; responds appropriately
• Picks up verbal and non-verbal cues: e.g. patient’s need to contribute information or ask
questions, information overload, distress
• Elicits patient's beliefs, reactions and feelings: re information given, terms used; acknowledges
and addresses where necessary
Planning: shared decision making

Aims: to allow the patient to understand the decision-making process to involve the patient in
decision-making to the level they wish to increase the patient’s commitment to plans made
• Shares own thoughts: ideas, thought processes, and dilemmas 46. Involves patient by making
suggestions rather than directives
• Encourages patient to contribute their thoughts: ideas, suggestions and preferences
• Negotiates a mutually acceptable plan 
• Offers choices: encourages patient to make choices and decisions to the level that they wish 
• Checks with patient if plans are acceptable, if concerns have been addressed
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Options in explanation and planning
If discussing options and significance of problems
• Offers opinion of what is going on and names if possible
• Reveals rationale for opinion
• Explains causation, seriousness, expected outcome, short long term consequences
• Elicits patient’s beliefs, reactions and concerns, e.g. if opinion matches patients thoughts,
acceptability, feelings
If negotiating mutual plan of action

• Discusses options e.g. no action, investigation, medication or surgery, non- drug treatments,
preventative methods
• Provides information on action or treatment offered, e.g. name, steps involved, how it works,
benefits and advantages, possible side-effects
• Obtains patient’s views, advocates alternative viewpoint as necessary
• Accepts patients views, advocates alternative viewpoint as necessary
• Elicits patients reactions, concerns about plans and treatment, including  acceptability
• Takes patients lifestyles, beliefs, cultural background and abilities into  consideration
• Encourages patient to be involved in implementing plans, to take  responsibility and be self-
reliant
• Asks about patient support systems, discussed other support available
If discussing investigations and procedures

• Provides clear information on procedures, including what patient might experience and how
patient will be informed of results
• Relates procedures to treatment plan; value and purpose
• Encourage questions about, and discussion of, potential anxieties or negative outcomes
Closing the session

• Summarizes session briefly and clarifies plan of care
• Contracts with patient re next steps for patient and physician
• Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when
and how to seek help
• Final check that patient agrees and is comfortable with plan and asks if any corrections, questions
or other items to discuss
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Building the relationship
Developing rapport
• Demonstrates appropriate non-verbal behaviour (e.g. eye contact, posture & position,
movement, facial expression, use of voice)
• If reads, writes notes, or uses computer, does in a manner that does not interfere with dialogue
or rapport
• Acknowledges patient’s views and feelings; accepts legitimacy; is not judgmental
• Uses empathy to communicate understanding and appreciation of the patient’s feelings or
predicament
• Provides support: expresses concern, understanding, willingness to help; acknowledges coping
efforts and appropriate self-care; offers partnership
• Deals sensitively with embarrassing and disturbing topics and physical pain, including when
associated with physical examination
Involving the patient

• Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now
is...”)
• Explains rationale for questions or parts of physical examination that could appear to be non-
sequiturs
• During physical examination, explains process, asks permission
Providing Structure to the Consultation

Make organisation overt
Patients can sometimes side track you in their story and having a framework for the interview to gently
steer them back is important for effective consulting. Summarise the information you have discovered at
the end of each line of enquiry, and allow the patient to fill in any gaps. Signpost the next section that you
would like to cover and explain your reasons for going there.
Attend to flow
Structure the consultation in a logical sequence, this makes it easier for the patient to follow, and gives
you a solid framework to return to. Attend to the timing of the consultation. Initially your consultations
may feel like they are taking a long time, but as you develop your skills, you will become more efficient.
This requires practicing your skills as often as possible, in the clinical skills centre, on the wards and at
every opportunity!
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Types of consultation
The structure of the consultation will vary depending on the context and purpose of the consultation.
There are generally two main groups of consultation; a new problem consultation and a follow-up
consultation
New Problem
The patient presents a new problem to the clinician of that speciality. As each speciality has their own area
of expertise and viewpoints this includes patients that have previously been seen or referred by a clinician
from a different speciality (but NOT the same speciality).
Examples include first presentation of new problem to GP, or referral from GP to cardiology, referral from
Emergency Department to psychiatry.
Presenting complaint
• What is the main problem/s the patient is coming in with?
History of presenting complaint
• Sequence of Events and ICE (ideas, concerns and expectations)
Symptom analysis
Relevant system review
Risk factors and red flags
Other information to support differential diagnosis
Past Medical history
• Other medical problems / surgery
Drug history
• Any medication - prescribed or over the counter
Allergies
• Allergies to medication and non-medication allergies
Family history
• Relevant family history to presenting complaint and other family history
Social history
• Occupation – including risk
Relevant interests - hobby, sports
Home – marital status, pets
Habits – smoking, drinking, drugs
Systemic enquiry
• Where relevant, a full or partial systemic enquiry may be taken
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Follow-up
AIM of follow up consultation
Follow up consultations are further consultations for a problem / problems that the patient has previously
consulted for with clinicians from the same specialty.
These could include:

• Further or second opinions (e.g. GP referral to consultant, A&E referral to psychiatry)
• Review of long term conditions (e.g. diabetes, asthma)
• Attendance for discussion of results
• Attendance for discussion of management options
• Review of acute episode of illness (e.g. follow up following MI, or pneumonia)
Structuring a follow up consultation
When conducting a follow up consultation the following areas should be covered
1. Background – find out the background for the problems – what has happened so far. If you have
seen the patient previously this may be very brief. It may be useful at the end of this enquiry to
consider the patient’s perspective – ie what do they understand is happening today? What do they
think the current issues are? What questions do they have? Linking in with the next area
2. Current problem – what are the current issues, this could be the doctors agenda (e.g. giving results,
clear management plan) or patient’s agenda (e.g. Minimising medication, concern effect on
employment) or both
3. Anticipated problems – in follow up consultations, there may also need to be a focus on future
anticipated problems – the most obvious example in in chronic disease, where part of the
consultation is to screen and reduce the risk of future complications
4. Shared decision making and management plan - at the end of the consultation, shared decisions
have to be made which should result in a clear management plan including further follow up
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Examples of follow up consultations
Here are a couple of examples of follow up consultations you may encounter
Review of long term condition – Diabetes Giving results of MRI Knee
Background Clarify type 1 or 2 and duration Brief history up to this point - mechanism of injury, previous
How has diabetes affected them so far? contact with health services including tests and treatments
History of complications and problems. Patient’s understanding of reason MRI done, anticipated results,
patient’ concerns
Patient’s questions, concerns and perspective about their
diabetes
Current Problems Patient’s current problems with diabetes Brief review of current symptoms – knee pain = locking
Symptom screen for poor controlled disease e.g. thirst, Brief review of current effects on patient’s life / lifestyle – off work,
tiredness can’t go to gym
PMH - Other medical conditions including any new problems Starting with patient’s starting point
DH - Current management of condition including lifestyle, Sharing information (warning shot if appropriate) – chunk and
therapy, and check, give appropriate amount and type of information
Medication – including side effects and compliance Respond appropriately to patient’s emotional reaction to the
SH - Social history – including current effect of chronic disease information, address patient’s concerns and questions
on patient life
Anticipated problems Screen for future diabetic retinopathy, podiatry for feet, renal Consider risk factors such as weight
function Consider effect if going for operation, e.g. who’s at home
Check for other cardiovascular risk factors, blood pressure, Consider effect on future ability to work, hobbies, interests
cholesterol, smoking
Shared decision making Address patients questions and concerns Address patient’s concerns / questions.
and management plan Appropriate changes to current management Share decision making
Arrange additional support as appropriate Clear management plan and follow up
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Context of the consultation
In ALL consultations it is important to consider one question; “What is the context of this consultation?”
This will determine the focus of the consultation
This may be dependent on several factors:

• Your status and role
• Your environment
• Surrounding support from other services / professionals
• The patient
• The clinical problem
• Time available
Note that the context may change in response to information obtained, or changes in the
patient’s clinical condition
Examples include
Clinical context Intended outcome

Medical student in medical ward Obtained enough information for differential diagnosis
and suggested investigation and management
GP telephone call with patient with Triage patient – ambulance, home visit, surgery visit or
chest pain advice
A&E doctor in A&E with patient Check patient is medically treated and stable and
following overdose arrange for psychiatric assessment once safe to do so
Psychiatry on call in A&E with patient Decide whether patient needs further psychiatric input
following overdose and if so is that as inpatient or outpatient (ie are they safe
to go home)
GP with child and purpuric rash Brief history and examination to exclude meningococcal
meningitis, if possible meningitis urgent admission with
antibiotics if has time to administer. If not can take more
time to find alternative diagnoses.
“Focused history” as a medical Gather only history relevant to presenting complaint/s.
student in OSCE Gathering Information that helps with diagnosis or
management of the presenting problem/s. See next page
Specific Communication Skills
During a consultation you may need to employ specific communication skills to help you successfully
conduct certain aspects of the consultation
Complex Communication Needs

This includes any condition where individuals find it difficult to meet their daily communication needs
through their current method of communication (can be for many different reasons). Augmentative and
Alternative Communication is any method or system or device used to support someone to communicate
Top Tips for Communication in these situations
• Find out what type of questions to ask - Open Questions? Yes/No?

• Check your own understanding if unsure
• Don’t be afraid to ask for repetition!
• Watch the person you are speaking to. Body language = 55% of communication
• Use gestures and facial expressions
• Visual aids may be useful – symbols, photos, objects
• Take your time, don’t rush and be patient
• Use clear, understandable terms
• Be comfortable in the silences (goes with taking time)
• Learn from experience
• “Talk to me, not just my carer!”
Dealing with emotion
You may find yourself dealing with many different emotions during your encounter with patients. It can be
challenging to know how to respond. Below are some suggestions that you may find helpful
Response to “bad news” –

• Give time for patient
• Offer support for example getting a friend / relative from the waiting room, a tissue or a glass of
water
• When appropriate, gently encourage patient to verbalise thoughts / feelings / questions
• Acknowledge and, if appropriate address patient’s concerns / questions openly and honestly
Patient reluctant to talk but appear emotionally upset / low

• Acknowledge the patients current state
• Show genuine concern and explain your role (i.e. why you are needing to talk with the patient)
• Be very gentle with questioning, pull back if your questioning is starting to upset the patient
• Consider starting with “neutral” questions – some simple questions can be helpful (“are you
comfortable?”, “can I get anything for you?”)
• Some techniques that may help you to encourage the patient to speak further
- Ask – you can gently enquire directly
- Reflect – reflect how the patient appears to you (“you look upset”)
- Repeat – repeating some of the patient’s words / phrases, (“you’re worried what everyone
thinks of you?”)
- Paraphrase – similar to repeating but rephrasing it to seek further clarification (“so you’re
worried how you appear to others?”)
- Prime – if it is appropriate to do so, and the patient is very reluctant to talk you can
tentatively make your best guess about the underlying issues (“is there a problem with
your relationship with your partner?”)
Dealing with an agitated / angry patient

• Apologise if appropriate to do so (“I’m sorry to keep you waiting so long”)
• If appropriate, move conversation to a private space
• Keep calm, do not raise your voice
• Express a genuine interest in helping the patient
• Explore – rather than react to the agitation or comments, try to explore what the genuine issues
are. Emotions are often a response to an interpretation of events or facts. They can also relate to
the patient’s own emotional wellbeing. Try to discern the facts from the emotional reaction.
(“You’re angry because you’ve been kept waiting ½ hour, and you need to pick up your child from
school”
“You’re agitated because you have had the pain in your right foot for 3 months and none of our
treatments seem to be helping )
• Work with the patient to help signpost / support / resolve problems
Telephone consultations
Telephone consultations are a potentially more time efficient method of consulting
Challenges
• Confirming identity
• Lack of non-verbal cues - 55% of communication is non verbal
• Gathering enough information to make a diagnosis – e.g. lack of examination
• Obtaining the patient perspective on problem – evidence suggests telephone consultations are
more biomedical and often less patient centred
• Patient’s perception- telephone is seen as a “barrier” to health care
• Less time spent on relationship building and social interactions
• Keeping an open mind – evidence suggests doctors are more likely to narrow down diagnoses
quicker and accept information at face value on the telephone
• Recording of consultations – patients entitled to have copy
Suggested framework
Introduction
• Introduce self to patient – name and role (e.g. GP, medical student)
• Obtain name and number of caller – to establish identity and also in case the telephone call gets
interrupted / cut off
• Confirm identity of caller – as much as reasonably possible – especially important when you will
be passing confidential information – DOB can be helpful as in families, different generations in
Scotland may share the same name! Especially important where you are discussing confidential
information
• Check you are speaking to the most appropriate person – where possible and appropriate speak
directly to the patient rather than a proxy
Gather Information
Gather history / information
• Open then more closed questions – note you may need to ask more questions than in a face to
face consultation, to make up for lack of non-verbal cues and to help clarify points
• Watch for verbal cues e.g., hesitation and voice intonation changes
• Verbal active listening – use verbal cues to encourage patients to continue talking – “Go on”, “ok”,
“what happened next?”
• Make sure that you gather enough information to come to a diagnosis / differential diagnosis
• Consider the patient perspective on the problem – again this may require more direct
questioning due to lack of non-verbal cues
• Consider is the telephone the best place to conduct this consultation? – If not, consider whether
to institute more urgent action, continue the telephone call and arrange face to face review, or
negotiate with the patient to continue face to face
Management Plan
Formulate a management plan

• Review required
• Face to face review – who? You, senior, hospital etc.
• Urgency of review – e.g. 999 ambulance
• Consider timescale for plan / review – urgent, soon, routine
• Negotiate the management plan with the patient and ask the patient to repeat the management
plan / information given to check understanding
• Safety net – with clear advice and directions
Concluding the Consultation

• Offer patient opportunity to ask questions
• Try to let the caller disconnect first
• Keep accurate, detailed, and contemporaneous records
Writing a referral letter
Referral letters should contain the following information – they are often electronic now with some of the
demographic data pre populated
1. Demographic data
Patient name, sex, DOB, address, (contact number), hospital number, hospital name, department,
referring doctor name, (department), address, contact number
2. Urgency of referral
Urgent or routine
3. Reason for referral

Reason for referral - The referring doctor should be explicit about why the patient is being referred
to secondary care. This may include a provisional or working diagnosis - E.g. – New onset chest pain
possible angina
Expectation referral outcome - for example, may be ‘assessment, investigation and treatment’, or
‘patient or family request second opinion’
4. Clinical information
History of presenting complaint – relevant clinical information to provide the reading professional
with a clear picture of the clinical situation, including duration, course, severity, examination
findings, investigation results
Past medical history –that is relevant and proportionate to the referral. Be aware to some of more
sensitive medical and psychosocial conditions that are not related to the referral, e.g. sexually
transmitted diseases, or mental health problems
Current and recent medication
Clinical warnings - any factors that may put patient and professionals at risk – including allergies,
blood borne viruses
Smoking and alcohol – smoking and alcohol has such a wide ranging effect on health that this data
should be routinely incorporated in referral letters. Weight and BMI could justified as well
Examination findings – relevant examination findings
5. Additional relevant information

Patient’s issues – e.g. special needs, disabilities, history of aggression, mobility issues.
Relevant social circumstances – e.g. housing, occupation, hobbies, sports
Patient’s perspective - where relevant - including patient’s understanding of their condition,
expectations and concerns
6. Signature referring doctor and date

Explaining risk
Risk is the probability that something unpleasant will happen. Explaining risk to a patient is a very
common, yet not always easy. It is important that information is presented clearly and in an
understandable way to the patient to ensure that the patient can make an informed choice. Here is some
advice on how to achieve this
Absolute risk is always preferable to relative risk

Try to describe in terms of the prevalence within a population and the associated change from the
intervention
e.g. - Not 3rd generation Combined contraceptive pills are twice as likely to cause DVTs
Use – For 100,000 women taking the contraceptive pill for 1 year. 30 women taking 3rd generation pills will
develop DVT compared to just 15 on 2nd generation pills
Use a clear term to reference

NOT there is a 40% risk of developing a sexual problem on this medication
“If 10 men were to start the medication, about four of them will develop a sexual problem”
Use the same denominator (terms of reference throughout)

NOT 89 in every 100 will get better but 1 in 25 will have a bleed
BUT 89 every 100 will get better but 4 in 100 will have a bleed
Framing
Watch how you frame information (which may reflect your biases). This may encourage or dissuade the
patient
e.g. – There’s a 95% chance the surgery will work
OR there is a 1:20 chance of the surgery failing
Avoid by giving a balanced viewpoint – There’s a 95% chance of improvement but this means a 5% chance
of it failing
Take into account your patient’s needs, values and circumstances

Personalise the information and discuss it within the patient’s understanding and situation
Taken from teaching material produced by Jonathan Silverman, Associate Clinical Dean at the School of
Clinical Medicine. University of Cambridge
Buckman’s Six Steps for delivering “bad news”
1. Getting Started - Getting the physical context right. Where? Who should be there? Starting off
2. Finding out how much the patient knows
3. Finding out how much the patient wants to know
4. Sharing the information - Decide on your agenda (diagnosis/treatment plan/prognosis/support).
Start from the patient’s starting point. Give information in small chunks. The warning shot. Use
simple English, not jargon. Check frequently that the patient has understood and clarify any points.
Listen for your patient’s agenda, concerns and anxieties. Try to blend your agenda with the
patient’s
5. Responding to patient’s feelings - Identify and acknowledge the patient’s reaction
6. Planning and follow through - Organising and planning. Making a contract and following through
Case presentation a concise guide
Essence of presenting a case history to a colleague

Case presentation is a skill which requires time and practice so you can become flexible in the information
you provide to keep it accurate, relevant yet comprehensive where needed.
A good case history presentation relays your findings from history and examination in such a way that the
recipient can come to as accurate differential diagnosis and management plan, as if they had spoken to, and
examined the patient themselves.
Achieving this does not simply mean regurgitating everything you hear, or have found. It does involve some
intelligent gathering and processing of the information. Even at the early stages, you can use whatever
knowledge you have to help you and the recipient make some sense of the information. The following may
help as a guide.
Please note this guidance relates to a new patient clerking. Case presentation may take other forms which
you might consider later in your course for example a review patient or presentation to a colleague for a
specific reason like a radiologist to discuss need for specific imaging.
Guidance for presenting a case history. Where relevant there are good examples green, poor examples red:
Suggested framework
Situation
Introduce yourself and your role (if appropriate) followed by a one sentence summary of the main presenting
complaint (may include mode of admission if in hospital as with this example). Then your thoughts of the most
likely cause
 I’m Jo Brown a 2nd year medical student, this 73 year old man/woman has a 4 day history right pleuritic chest
pain and shortness of breath.
 This lady was admitted with some chest pain and shortness of breath
Background
Presenting complaint
This is a recount of the current problem including relevant positive and negative findings from the history taking.
This include sequence of events, current symptoms, symptom analysis, and relevant system review.
Note this may include other areas of the history that might otherwise be covered later on, but is directly relevant
to the presenting complaint or may aid in determining the differential diagnosis (eg smoking status or
hypertension in someone presenting with possible ischaemic chest pain).
Don’t forget to include significant negative findings. Note this is the same structure as taking a focused diagnostic
history.
 Sudden onset of right pleuritic chest pain associated with shortness of breath which started 4 days ago but got
much worse yesterday. She had a hernia operation 2 weeks ago and has been immobile since then. The pain does
not radiate anywhere, it is non tender to touch, but worse on breathing and coughing…………
 Chest pain worsening over a few days with some shortness of breath for 4 days. Pain in right chest. More
breathless than usual………
Patients perspective
Patient’s view on the condition – eg affect on life, their thoughts on possible causes, any concerns, what they
already know
Past Medical History
Other past medical history not covered so far. All chronic illnesses and important previous illness (eg cancer)
should be included.
Drug History
Current medication and OTC medication not covered so far – generally should be part of any new case
presentation as any may be relevant.
Allergies
Drug and non-drug allergies – vital in pretty much every case and an important negative to include if no
allergies known.
Social history
Any other information not covered so far

 e.g. single parent and concerned as currently struggling to arrange child care
Family history
Any other information not covered so far

 e.g. Mother suffers from asthma and ischaemic heart disease
Systemic enquiry
Only present positive findings (there is rarely time nor need for negatives as significant negative findings relating
to presenting complaint should be added to history of presenting complaint).
Examination findings
General examination findings including NEWS score

Focus on the systems that relate to presenting complaint / differential diagnoses – include relevant negative
findings for these systems
Only present positive findings and relevant negative findings from other systems
 Full Respiratory and cardiovascular system write up
 Normal GI, neurological and locomotor system write up
Assessment
Differential diagnosis
Top 3 differential diagnoses (for 2nd year and above - with justification) – can have more if more than 3 likely.
 Pulmonary Embolism, pneumothorax, pneumonia. Pulmonary embolism is likely because……
 Pulmonary Embolism (with nothing else)

Prioritised problem list (if more than on or the patient has co-morbidities)/summary of the main issues: (Year 2
and above)
This should include presenting problem and anything else relevant to act as a helpful summary to the person you
are presenting to. Remember, they haven’t seen the patient and may have heard other case presentations earlier
in the their ward round so a quick summary is a nice way to finish
Admitted with worsening pleuritic chest pain and shortness of breath with risk factors - recent surgery and also
takes the combined oral contraceptive pill
Likely pulmonary embolism
Social issues - concern around ability to find child care for children if requires admission
Recommendation (2nd year and above)
Investigation and subsequent management (2nd year and above)
Suggested investigations
 FBC, CRP, D-Dimer, Chest Xray, CT PA scan
 Bloods and Xray
Suggested current management (if appropriate)

 Pain relief, oxygen, anticoagulation
Documentation
Patient records are legal documents which record the interactions between a patient and the health care
system, whether it is in primary care or in the hospital. These records serve two purposes; to support safe
and effective patient care and to provide a legal record of events in any legal process relating to patient
care. These records may be paper based but are often now kept on computer data files
Clinical documents you make to formally record your work must be clear, accurate and legible. These
records must include full details of all parties involved in the clinical interaction; the patient (name, address,
identification number), other staff involved (name and position) and the author of the document (name,
position, contact details, signature). You should make records at the same time as the events you are
recording or as soon as possible afterwards. You must keep records that contain personal information about
patients, colleagues or others securely, and in line with data protection requirements
Clinical records should include:

• Relevant clinical findings
• The decisions made and actions agreed, and who is making the decision and agreeing to the
actions
• The information given to patients
• Any drugs prescribed or other investigation or treatment
• Who is making the record and when
At the completion of your written notes you must sign it, date it and give your status. This is a legal
requirement.
GMC guidance on clinical record keeping can be found here; http://www.gmc-

uk.org/guidance/good_medical_practice/record_work.asp. Remember patients have the right to access
these when requested under the Data Protection Act 1998, using agreed guidelines
Clerking Patients
A patient clerking involves a comprehensive history and examination with documentation when a patient
is going to be admitted to hospital.
The prime objective of the clinical clerking

The prime purpose of a patient clerking is to determine the cause or possible causes of the patient’s
problem(s), this process is called forming a differential diagnosis. The differential diagnosis is a list of things
which might be wrong with the patient. This will not only include the most common, or most likely diagnoses
but also possibly less common or less likely problems which have important implications for the patient
The differential diagnosis that you create will be a reflection of your knowledge and your experience of
clinical medicine. At the start of your medical career you already have a great deal of knowledge and
experience, and a degree in medicine will build on this. Junior students might include the organ or system
they feel is involved if they are uncertain of the specific diagnoses. Senior students will be more specific
and only include individual diagnoses. You can still form a differential diagnosis and ask meaningful and
useful questions even if you don’t know all the specific possible diagnoses
Documenting your clerking

In documenting the history and examination you are recording the evidence to support your ideas of what
might be wrong. You are also recording evidence to show why the underlying problem is not caused by
another pathology. It is therefore intimately linked with the formation of your differential diagnosis. The
recording of the history is an essential part of communication as a doctor as you and your senior colleagues
will rely on what you record to determine what to do with the patient
Structure of a Medical Clerking

1. Initiate the session
Establishing rapport and identify the reason for the consultation.
Always introduce yourself to a patient telling them your profession. Ask their permission to take a
history or/and carry out an examination. Summarise what you would like to achieve with them by the
end of your consultation. Ensure that you have the patient’s details (DOB, CHI if possible)
2. Gathering Information
Identify the reason for the consultation (presenting complaint) and illicit the background
information to this problem (history of presenting complaint). This is potentially the most important
part of your interaction with the patient. Most of the work in forming a differential diagnosis is
undertaken when taking a history about their problem. The competent physician will think of the
possible causes of the presenting complaint whilst taking the history. They will listen to the
patient’s story, they will ask questions and they will interpret the patient’s responses to gain
evidence to support these ideas or to refute them
3. Patient’s perspective
It is essential that you identify early in the consultation the patient’s own ideas about their problem;
their concerns in terms of how it will affect their lives and their feelings and expectations of the
health care services. Your patient will often have an emotional reaction to their current problem
which is not always obvious – this is important to explore and record in your history. The five
following headings are often helpful:
• Ideas
• Concerns
• Expectations
• Feelings
• Effects on life
4. Past medical history

A description of illnesses or problems suffered previously. Ask and record if they have had any
illnesses, have ever been in hospital or had any operations
5. Drug history
Ask what tablets, drugs or medicine the patient is taking; remember to ask about injections
and “over the counter” drugs. Ensure you find out the dose of the drug and what it is being
taken for. Ask about immunisations if relevant. Ask about any allergies the patient has. It is
essential to document any allergy, the extent and type of reaction
6. Family history
Ask about the age, health, and cause of death if known for parents, siblings, partner, or children.
Ask specifically about family history of diabetes, heart disease and any diseases of particular
relevance to the presenting complaint. It may be helpful to present this as a family tree
7. Social history and illness context

Occupation, marital status, partner’s job, children, religious or ethnic background, housing, pets,
recent travel abroad, hobbies, smoking and alcohol (drinks per week). Where relevant ask about
social drug use. Cultural aspects and family structure should be documented where appropriate
If relevant ask how the illness affects the patient - what they can’t do. This section is especially
important when taking a history from the elderly - steps and stairs in and around the home, who
does the cooking and shopping, what other support there is from friends, neighbours and family. It
is important to establish how the problem affects their lifestyle and relationships
8. Systemic enquiry
If one or more of the systems have been covered in full within the history of presenting complaint
then you can put “see history of presenting complaint” under the relevant heading
Cardiovascular System
• Chest pain: (Ask them to describe the pain try to record the following - Site, character,
radiation, mode of onset, aggravating/ relieving factors, associated features - sweaty,
nausea etc.)
• Dyspnoea: (breathlessness on exertion, at rest, nocturnal – paroxysmal nocturnal
dyspnoea)
• Orthopnoea: (ask how many pillows they use to prevent this - record e.g. five pillow
orthopnoea)
• Palpitations: (when occurs, duration)
• Ankle oedema: (extent, time of occurrence)
• Intermittent claudication:(when occurs, duration)
• Peripheral circulation problems
Respiratory System
• Cough: (frequency, duration, character)
• Sputum: (colour, quantity, presence of blood)
• Wheeze (constant/intermittent, triggered by exercise)
• Hoarseness
• Chest pain
• Dyspnoea
Gastrointestinal System
• Appetite
• Weight loss/gain
• Indigestion/heartburn
• Nausea
• Vomiting: (frequency, presence of blood)
• Dysphagia: (difficulty swallowing)
• Pain:(nature, site, radiation, duration, onset, severity, relationship to eating,
alleviating/aggravating factors, assoc. features)
• Constipation: establish clearly what the patient means
• Diarrhoea: establish what patient understands by this term
• PR blood/mucous: (fresh, altered)
Genitourinary System
• Dysuria: (during/after micturition)
• Polyuria: (record frequency, association with terminal dribbling/thirst)
• Nocturia: (record frequency)
• Haematuria
• Incontinence (frequency precipitating factors, urgency)
• Hesitancy (Dribbling)
• Urethral discharge
• Vaginal discharge (nature, irritant, offensive)
• Menstrual history: first day of last period, cycle pattern. Clots, pain, flooding, bleeding
between periods, bleeding after intercourse, menarche. Contraceptive history.
Menopause
• Obstetric history: Number of pregnancies, including miscarriages, in correct order.
Exact date where possible or month and year, place of delivery/miscarriage, duration of
pregnancy, estimated duration of labour, method of delivery, weight and sex of child
and a note of any untoward events in mother or child during pregnancy or labour
Central Nervous System

• Headache: (site, character, radiation, mode of onset, aggravating/ relieving factors,
associated features - nausea, diplopia etc.)
• Vision: loss, diplopia, blurring, glasses
• Taste
• Smell
• Hearing
• Tinnitus
• Vertigo: (triggers)
• Speech: Dysphagia, dysarthria
• Loss of consciousness: (onset, duration, twitching, trauma, sphincter control)
• Involuntary movements/tremor
• Weakness
• Paraesthesiae
Psychiatric History
• Depression (mood, loss of interest, fatigue, reduced concentration, self-confidence,
sleep, appetite, ideas of guilt/unworthiness, pessimistic view of future, ideas of self-
harm)
• Anxiety/panic
• History of presenting problem
• Family history
• Personal history
• Childhood, school, occupation history, psychosexual and marital history, children, present
social circumstances and stresses
• Past medical history Physical and psychiatric
• Drug history Alcohol, tobacco and illicit substances
• Personality before illness
• Social relationships, interests, temperament, standards, values, religion
Musculoskeletal System
• Joint pain: (as before for pain also does it move from one joint to another, associated
weakness)
• Joint stiffness: (time of day, effect of exercise, does the joint lock)
• Joint swelling: (one or more joints, effect of exercise)
Skin
• Hair and nail changes
• Lumps
• Pigmentation
• Rash, itch
Endocrine
• Thirst
• Weight loss
• Sweats
• Heat preference
• Impotence
• Tiredness
• Periods
• Breast lump
Dermatology History
Consider the following points.
• When the problem started
• The site and spread
• If it comes and goes
• If there are spots, do they come in crops?
• If it is itchy, painful or burns
• If it blisters and are the blisters fluid filled
• Aggravating and relieving factors
• The effect of sunlight
• What ointments or creams have been used?
• If the patient has contacts with a similar rash
• If there is a past history of skin problems, asthma or hay fever
At the completion of history taking you should have begun to formulate a diagnosis or have begun to
exclude diagnoses before moving on the carry out an examination to either confirm or refute your
hypothesis.
9. Physical Examination
The purpose of the examination is to gain further evidence of the diagnosis and to uncover any
coincidental signs.
Please establish whether you will require a chaperone before you start your examination (see
section on chaperones for details).
When clerking a patient you should conduct a comprehensive examination of the relevant systems
and also examine the remaining systems in case of relevant findings. For checklists on all
examinations see examinations sections of this guide in the appendix.
10. Differential Diagnosis/Problem List

Record a list of possible diagnosis formulated from the information gained by the history and
examination
Specialist Clerkings
Some of the specialities will require certain aspects of the standard history to be looked at in more detail
and may have their own set of questions.
History from a Child

Always take a history and perform an examination of a child in the presence of a parent/guardian or a
qualified doctor. When the patient is an infant or young child the history may mainly be from a parent or
other adult.
The OSCE
The OSCE (objective structure clinical examination) is used to summatively assess your clinical skills. You
will sit an OSCE at the end of each year. The length of the OSCE stations and the number of stations will
vary depending on your year of study
In Dundee the OSCE is marked using a system called ASSESS. This system is a domain marking system
where your ability will be marked from 1-5 in 5 domain areas:
• Accurate – do you do the right thing?
• Skilful – do you do it in a skilful way?
• Supportive – are you patient centred?
• Efficient/structure – are you well organised and timely?
• Safe – first, do no harm, both patient and professional safety
Examiners will be given two pieces of information to guide their assessment of your ability; a list of what
you have been taught relating to the particular station and a standard grid guiding their discrimination
between the 5 marks. This grid can be seen below:
The domain marking system aims to increase the clinical realism of the exam. You should therefore
approach the exam as you would the real clinical environment. The best preparation for an OSCE is
therefore to see lots of patients in order to practice your skills
Reading List
McLeod’s Clinical Examination. Douglas G, Nichol F, Robertson C (2009) 12th Edition, Churchill Livingstone
Communication Skills for Medicine. Lloyd M & Bor R (2009) 3rd Edition, Churchill Livingstone
Clinical Communication Skills. Washer (2009) Oxford University Press
Skills for Communicating with Patients. Silverman J, Kurtz S, Draper J (2005) 2nd Edition Radcliffe
Publishing
Shut up and Listen: A Guide to Clinical Communication Skills. Jackson, C (2007) Dundee UP
These books are recommended, however you may find an alternative clinical examination book suits you
better. All of the main clinical examination books on the market will be suitable for your needs.
Appendix
Checklists for Clinical Examinations

A number of checklists have been included to help guide your examination and procedural skills. These
steps are a guide and what is actually appropriate in clinical practice will vary depending on a number of
factors, for example the patient’s condition. Local protocols for procedures will vary in different areas of
the country and are updated on a regular basis. Students should take responsibility to ensure they are up
to date and following the local guidance
Skills included:
• Arterial Puncture Procedural Checklist
• Blood Culture Procedural Checklist
• Blood Sugar Testing
• Cardiovascular Examination
• Cerebellar Examination
• Cervical, Thoracic & Lumber Spine Exam
• Cranial Nerves Examination
• Diabetic Foot, Lower Limb Examination Guideline
• Direct Observed Procedural Skill
• Gastrointestinal Examination Guide (Abdominal)
• Guide to Rectal Examination
• Haematological Examination – General Lymph Nodes and Abdominal
• Hand Examination
• Hip Examination
• Knee Examination
• Lower Limb Neurological Exam
• Lymph Node Examination of Neck
• Nasogastric Tube Insertion Checklist
• Peripheral Venus Cannulation
• Respiratory Examination
• Scrubbing Assessment Sheet
• Shoulder Examination
• Upper Limb Neurological Examination
• Urethral Catheterisation Procedural Checklist
• Urinalysis
• Venepuncture Checklist
School of Medicine
Examination Skills Checklist for Respiratory Examination
Introduction and identification
check
Explanation
Consent to proceed
Hand washing
Position patient and expose
Inspection Short of breath?

Respiratory rate, rhythm and associated features such as
wheezing.
Shape of chest
Symmetry
Movement
Scars
Palpation Trachea
Chest expansion
(*Tactile vocal fremitus)
Percussion Lung fields – anterior and posterior
Cardiac dullness
Upper limit of liver dullness
Auscultation Air entry
Character (vesicular or bronchial)
Added sounds (wheeze, stridor, crepitations or rub)
(*whispering pectoriloquy)
Thank and discuss findings
Hand wash
This list is a guide and is not exhaustive. In particular, full respiratory examination includes
general examination (for respiratory distress, cyanosis, clubbing etc.) and examination of the
sputum.
*You should know how to perform tactile vocal fremitus and whispering pectoriloquy and be
aware that the evidence for their usefulness is limited.
School of Medicine
Examination Skills Checklist for Cardiovascular Examination
Introduction Greets patient
Introduction and explanation of role
Confirm patient's identity
Appropriate infection control
Consent Clarifies nature of task & seeks consent to proceed
Manages set up Patient positioned at 45 degrees
General Examination
End of bed inspection Appears well or ill

Anxious. Sweaty. Pale/Grey. Cyanosed
Breathlessness. Obvious deformities or syndromes
Clues in surrounding area
Hands Inspect both hands
Possible signs:
Splinter haemorrhages. Tobacco staining Peripheral cyanosis.
Xanthomata in skin. Finger clubbing
Head/face Inspect the face
Possible signs:
Corneal arcus. Xanthelasma. Malar flush
Pulses Radial
Rate. Rhythm. Character. Volume. R=L?
Check for a collapsing pulse
Carotid
R&L (not simultaneously). Check for character and volume.
Auscultate for bruit
Blood Pressure Bilateral (higher value taken as true BP) and postural if
necessary
JVP Locate JVP. Height – raised?
Examination of the Precordium
Inspection of precordium Deformity. Pulsations. Scars. Dilated vessels
Palpation of precordium Thrills

Heaves
Apex beat – the most lateral and inferior position of the
cardiac impulse
Auscultation of precordium Examine in a logical sequence, auscultating all four areas and
performing the two manoeuvers
Areas for auscultation:

Mitral area – 5th rib space, midclavicular line/apex
Tricuspid area – 4th rib space, left sternal edge
Aortic area – 2nd rib space, right sternal edge
Pulmonary area – 2nd rib space, left sternal edge
Use both diaphragm and bell on ALL areas (or differing

pressure on a tuneable stethoscope)
Two manoeuvers:
Sit patient up and hold breath in expiration while auscultating

over left lower sternal edge for aortic regurgitation
Turn patient to left side and auscultate the apex for mitral
stenosis
Auscultate carotids
Peripheral Examination
Inspection of lower limbs Colour. Skin. Hair. Amputations. Ulcers
Palpation of lower limb pulses Remember to examine both limbs
Palpate for coldness or any temperature difference between

the two limbs
Palpate pulses (work proximal to distal):

Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Capillary refill time

Check for peripheral oedema
Special Tests Buerger’s Test
Close the consultation

School of Medicine
Examination Skills Checklist for Gastrointestinal Examination
Hand wash/use gel

check
Explanation
Consent to proceed with

examination
End of the bed inspection Well or ill

Anxious. Distressed. Sweaty.
Confused. Drowsy
Jaundiced. Pale
Surrounding clues- drugs, iv fluids, oxygen, sticks/walking aids
Inspection of hands Palmar erythema
Clubbing
Leukonychia/kolionychia
Dupuytren’s contracture
Hepatic flap
Coarse tremor
Pulse Assess rate, rhythm and character
Inspection of head Eyes

- Conjunctival pallor
- Jaundice in sclera
- Kayser Fleisher rings
- Corneal arcus
- Xanthelasma
Mouth
- Buccal mucosa for ulcers
- Candida/leucoplakia
- Angular stomatitis
- Quality of dentition
Palpation for lymphadenopathy Examination of all neck nodes

Inspection of legs Bruising
Oedema
Muscle wasting
Position patient supine and expose
Asks patient if in pain
Inspection Scars/symmetry/masses
Abdominal distension: localized or generalized
Skin changes – striae, bruising
Visible veins- spider naevi, caput medusa
Stomas
Drains
Palpation Ensure the student is at appropriate level i.e. kneeling/sitting
beside the patient
Ask the patient if they have any painful areas before beginning
*Palpation should start away from any area of tenderness
Ensure hands are warm
Observe patient throughout for reaction to palpation i.e
pain/distress
Superficial palpation with hand fully on abdomen flexing slightly at
MCPs
Repeated with deep palpation
Students should be encouraged to systematically examine the
abdomen starting in LIF and ending in RUQ ensuring to examine 9
areas
Sequence Abdominal Palpation
3 2
1
Assessment for organomegaly Liver

- Start in RIF, asking the patient to take deep breaths
- Use the edge of the index finger to “scoop” on inspiration
to detect the liver edge
- Move the hand up 2 cm with each breath during expiration
- Palpate over any detected organomegaly
-
Spleen
- Place the right hand in the right iliac fossa
- Use the edge of the index finger to “scoop” upwards on
inspiration
- Move the hand 2 cm each time working from the RIF to the
LUQ
- If the spleen cannot be felt then this should be repeated
with the patient rolled onto their right hand side
Kidneys
- Place one hand over the back at the level of the kidney
- Place the other hand on the anterior abdominal wall (at the
same level as the posteriorly placed hand)
- Hold the anterior hand steady
- “Bounce” the kidney forward using the posterior hand on
deep inspiration
Percussion Liver
- Percuss from the RIF to the right lower coastal margin
mid-clavicular line
- Percuss down from the 5th intercostal space midclavicular
line to upper border of the liver
Spleen
- Percuss from the RIF to the LUQ
Assessment for Ascites Inspection for distension
Percuss with finger pointing towards toes, from midline to
opposite flank, noting when the notes becomes dull
- If dullness detected roll patient towards you, wait 10 secs
and then re- percuss
- Dullness present- no shifting dullness
- Resonance present- shifting dullness present= ascites
Auscultation Bowel sounds- auscultate for up to 2 mins (if bowel sounds heard
then it is acceptable to listen for <2 mins)
Hepatic/renal/aortic bruits
Examine for hernias If appropriate to the context
Hand wash
School of Medicine
Examination Skills Checklist for Rectal Examination
check
Explanation and questions See Intimate examination and chaperone guidance
Discuss chaperone As a medical student you should have an appropriate

chaperone for all intimate examinations
Consent to proceed
Check equipment
Hand washing and gloves
Position patient left lateral with

knees to chest and expose
Inspection Anal tags, fissures, scars, sinuses, fistulae, stool leakage, skin
changes
Palpation – on insertion of Anal sensation
lubricated gloved index finger Assess if painful on penetration of anus
Palpation – internal Stool in rectum?

Bowel wall – 360o
Prostate – size, texture, masses
Cervix – masses?
Tenderness?
Palpation – withdrawal Assess anal tone
Inspection Look at glove for stool, mucus, melaena or blood

Clear up Clean lubricant/stool from patient
Dispose of soiled equipment
Cover patient
Allow to get dressed in privacy
Hand wash
Record in notes Consent for examination

Chaperone – identity
Findings of examination
School of Medicine
Examination Skills Checklist for Ankle Examination
Introduction Greet patient
Consent Clarify nature of task & seek consent to proceed
Manages set up Adequately expose ankles for examination

Check for any pre-existing discomfort
Look Watch the patient walk, look for an antalgic gait

(compare both sides) Deformity
Swelling (diffuse or localized), bruising or oedema
Feel Bone tenderness (consider the Ottawa Ankle Rules)

(one side only) Ligament tenderness: lateral ligament, inferior tibio-fibular
ligament
Achilles tendon: tenderness or palpable gap
Move Plantar-flexion (normal range 550)

(compare both sides) Dorsiflexion (normal range 150)
Inversion (normal range 400)
Eversion (normal range 100)
Special tests Stability tests:

Ankle anterior drawer test
Forced inversion for lateral ligament laxity
Forced eversion for deltoid ligament laxity
Simmonds test (detects Achilles tendon rupture)
Conclusion Thank patient and discuss findings

Hand hygiene
School of Medicine
Examination Skills Checklist for Diabetic Foot, Lower Limb
Examination
1. General Examination Visible problems
Mobility problems
2. Legs - preparation Adequate exposure at least to
above knee
Remove shoes and socks
3. Vascular/skeletal Inspect - amputations

(Always examine both feet and - ulcers
examine all surfaces including - hair
heels, plantar surface & - skin
between the toes) - callous
- bony prominences
4. Palpate Temperature
- cold if ischaemic
Pulses
- dorsalis paedis
- posterior tibial
5. Neurological Inspect Muscle wasting (motor)

Temperature and sweating
(autonomic)
6. Test sensation Vibration – 128Hz to distal bony

prominences
Pressure – 10g monofilament to
metatarsal heads and big toes
7. Footwear Inspect Suitability

Wear patterns
This list is a guide and is not exhaustive. In particular, the students have not been taught the full
neurological examination of the lower limb which will be addressed in Year 3
School of Medicine
Examination Skills Checklist for GALS Examination
Manages set up Expose the patient appropriately, the patient will need to
stand, walk and lie on the couch during the examination.
Screening questions “Do you have any pain or stiffness in your muscles, joints or
back?”
“Can you dress yourself completely without any difficulty?”
Gait Ask the patient to walk a few steps and turn and observe
the patient’s gait for symmetry, smoothness and the ability
to turn quickly
With the patient standing in the anatomical position, observe

from behind, from the side, and from in front for:
• bulk and symmetry of the shoulder, gluteal,
quadriceps and calf muscles
• limb alignment, alignment of the spine, equal
level of the iliac crests
• inspect the spine from behind for evidence of
scoliosis, and from the side for abnormal
lordosis or kyphosis
• ability to fully extend the elbows and knees,
popliteal swelling
• abnormalities in the feet such as an excessively
high or low arch profile, clawing of the toes and/or
presence of hallux valgus
Arms Ask the patient to put their hands behind their head. Assess
shoulder abduction and external rotation, and elbow flexion
With the patient’s hands held out, palms down, fingers

outstretched: observe the backs of the hands for joint
swelling and deformity
Ask the patient to turn their hands over: Look at the palms for
muscle bulk and for any visual signs of abnormality
Ask the patient to make a fist. Visually assess power grip,

hand and wrist function, and range of movement in the
fingers
Ask the patient to squeeze your fingers: assess grip

strength
Ask the patient to bring each finger in turn to meet the

thumb: assess fine precision pinch (this is important
functionally)
Gently squeeze across the metacarpophalangeal

(MCP) joints to check for tenderness suggesting
inflammatory joint disease (watch the patient’s face
for signs of discomfort)
Legs With the patient lying on the couch, assess full flexion and
extension of both knees, feeling for crepitus
With the hip and knee flexed to 90º, holding the knee and
ankle to guide the movement, assess internal rotation of
each hip in flexion (this is often the first movement affected
by hip problems)
Perform a patellar tap to check for a knee effusion. Slide

your hand down the thigh, pushing down over the
suprapatellar pouch so that any effusion is forced behind
the patella. When you reach the upper pole of the patella,
keep your hand there and maintain pressure. Use two or
three fingers of the other hand to push the patella down
gently. Does it bounce and ‘tap’? This indicates the
presence of an effusion
From the end of the couch, inspect the feet for swelling,
deformity, and callosities on the soles
Squeeze across the metatarsophalangeal (MTP) joints to

check for tenderness suggesting inflammatory joint disease
(watch the patient’s face for any sign of discomfort)
Spine With the patient standing, ask the patient to tilt their head to
each side, bringing the ear towards the shoulder. Assess
lateral flexion of the neck (this is sensitive in the detection of
early neck problems)
Ask the patient to bend to touch their toes. Assess lumbar

spine flexion by placing two or three fingers on the lumbar
vertebrae. Your fingers should move apart on flexion and
back together on extension
Give privacy for dressing. Offer help if required
Hand hygiene
School of Medicine
Examination Skills Checklist for Hand Examination
Manages set up Adequately expose hands

Look Wrist / elbow: Swelling (synovitis), rheumatoid nodules,

psoriatic plaques
MCPJs: Ulnar deviation
Digits: Swan neck / Boutonniere deformities / Z- shaped
thumb
Nails: for psoriatic changes/ nail fold infarcts
Skin: for sclerodactyly or signs of steroid use
Muscle wasting: dorsum of hand and thenar/hypothenar
eminence.
Feel Feel for warmth at wrist and MCPs Squeeze MCPs

observing for tenderness.
Bimanually palpate any swollen joints to assess whether
synovitic.
Special tests to assess function Check wrist flexion/extension (make a fist)

Power of pincer grip
Fine pinch (picking up a coin)
Chuck or tripod grip (holding a pen)
Power grip (squeezing your fingers)
Hook grip (resisting decoupling of your hooked
hands when pulling away)

Hand hygiene
School of Medicine
Examination Skills Checklist for Hip Examination
Manages set up Adequately expose the patient’s hips (only underwear below
the waist)
Look Patient standing: Quadricep/hamstring/gluteal muscle mass

(Compare both hips)
Gait: Pace, symmetry, gross gait abnormalities, walking aids
Patient lying on couch: Local inspection of the hip for

erythema or skin changes, swelling over greater trochanter,
bruising, scars, hair changes. Attitude of limb
Feel (one side only) Greater trochanter

Groin (mid-point and medially)
Move Flexion (active and passive)

(Compare both hips) Internal/External rotation (passive)
Adduction/Abduction (passive).
Special Tests Trendelenburg test (abductor power)
Limb lengths (true and apparent)
Conclusion Thank patient and discuss findings.

Hand hygiene
School of Medicine
Examination Skills Checklist for Knee Examination
Manages set up Adequately expose the knees

Look Patient standing: Limb alignment, quadricep/hamstring

(Compare both knees) muscle mass, popliteal fossae
Gait: Pace, symmetry, gross gait abnormalities, walking aids
Patient lying on couch: Local inspection of the knee for

erythema or skin changes, bruising, scars, hair changes,
swelling (generalised or joint effusion)
Feel Temperature
Tibial tuberosity
Patella tendon
Medial and lateral joint line.
Medial and lateral collateral ligaments
Move Flexion (active and passive)

(compare both knees) Extension (passive +/- heel height testing for locked knee)
Special Tests Straight leg raise (confirm extensor mechanism intact)
Effusion tests: medical gutter sweep test (positive with a

small effusion) or patella tap (positive with a large effusion)
Patella tests: Patella apprehension tests (patella instability).

Patella grind test (patella-femoral OA)
Steinman’s test – meniscal provocation test (meniscal tear)
Collateral ligament testing: Stressing of medial (valgus) and

stressing of lateral (varus) ligaments
Cruciate ligament testing: Posterior drawer test (PCL).

Lachman’s test (ACL)
Hand hygiene
School of Medicine
Examination Skills Checklist for Shoulder Examination
Manages set up Adequately expose the patient (only underwear above the
waist)
Look Anterior:
(compare both shoulders) • Contour of the shoulder
• Deltoid and trapezium muscle bulk
• Sterno-clavicular and acromio-clavicular joints joint
for deformity Clavicle for deformity
• Scars
Laterally:
• Shoulder contour
• Sterno-clavicular and acromio-clavicular joints
Posteriorly:
• Supraspinatus and infraspinatus fossae for
muscle wasting
• Scapula for evidence of asymmetry
Axilla:
• Swellings
• Scars
Feel Sterno-clavicular joint Clavicle

(one side only) Acromio-clavicular joint Acromion
Long head of biceps Scapula (spine and body)
Move External rotation

(Compare both shoulders). Forward flexion
Active followed by passive ONLY if Abduction
active movement is limited: Internal rotation
distinguishes between + - Scapula winging
weakness/ stiffness
Special tests Impingement/Rotator cuff pathology:

• Painful arc on abduction (impingement)
• Hawkins-Kennedy test (impingement)
• Scarf test (ACJ pathology)
• Rotator cuff power: Supraspinatus (Jobe’s test),
Infraspinatus and Subscapularis
Instability:
• * Sulcus sign
• Anterior and posterior drawer tests
• Anterior apprehension and relocation test
• * Posterior apprehension test

Hand hygiene
*Sulcus sign and Posterior apprehension test: You should be aware of these
and they are demonstrated for you on the clinical skills videos, but it will
not be assessed in an undergraduate OSCE
School of Medicine
Examination Skills Checklist for Haematological Examination
General, Lymph Nodes and Abdominal
Introduction Greets patient
Consent Clarifies nature of task & seeks consent to proceed
Manages set up Check patient comfort

Pulls curtain round for privacy
General Examination
End of bed inspection Inspection of surrounding area, general condition, body

habitus
Hands and general skin inspection Hands - koilonychia, pallor of palmar creases.
Skin - petechiae, purpura, jaundice, infections
Head/face Eyes – conjunctival pallor, jaundice
Mouth – angular stomatitis, smooth or beefy tongue, oral
candidiasis, inspect tonsils and tonsillar bed
Examination of the neck and
axillary lymph nodes
Neck Inspect -
Masses, asymmetry
Swallow (ask patient to take a mouthful of water, hold it and
then swallow whilst observing neck)
Palpate lymph node groups -

(from behind, comparing right and left)
Submental
Submandibular
Anterior triangle
Posterior triangle
Pre auricular
Posterior auricular
Occipital
Supraclavicular
Axillary lymph nodes Apply gloves, palpate the medial, anterior and posterior walls
of the axilla and towards the axillary apex.
Examination of the abdomen with
haematological focus - inguinal
lymph nodes, liver and spleen
Set up and inspection Lie the patient flat
Inspect (including the inguinal regions) for any scars, swelling,
distension or dilated vessels
Inguinal lymph nodes Inguinal lymph node examination:

Palpate for horizontal and vertical inguinal lymph nodes
Abdominal palpation General abdominal palpation. Superficial and then deep

(masses, tenderness)
*Palpation should start away from any area of tenderness.
Students should be encouraged to systematically examine
the abdomen starting in LIF and ending in RUQ i.e.
Sequence Abdominal Palpation
3 2
1
Palpate the liver

Palpate the spleen (if you do not feel the spleen repeat with
the patient on their right side)
Percussion Percuss the liver
Percuss the spleen
Auscultation Listen for bowel sounds and bruits
NB complete abdominal examination would also include

kidney palpation, percussion for ascites, hernia examination
and PR examination
Conclusion
Close the consultation Thank the patient & explain your findings
Wash your hands
Document your findings
School of Medicine
Examination Skills Checklist for Lymph Node Examination of the
Neck
Wash hands Use gel

Confirm patient’s identify
Explain examination
Check understanding
Consent Clarify nature of task and seek consent to proceed
Examination sequence: Include:

Inspection
Palpation
From Front
From Behind
Compare Left with Right
Lymph node groups Submental

Submandibular
Anterior Triangle
Posterior Triangle
Pre Auricular
Posterior Auricular
Occipital
Supraclavicular
Always remember patient comfort when examining the neck

School of Medicine
Examination Skills Checklist for Thyroid Gland Examination
Introduction Hand washing, explanation, consent to proceed
General examination • Affect

• Clothing
• Hair
• Skin
• Pulse
• Tremor
• Sweatiness
• Eye disease: exophthalmos and lid lag
Slow relaxing reflexes
Inspection Neck from the front and the sides- symmetry or

asymmetry; movement of the thyroid on swallowing
water; deep breathing to check for stridor
Palpation From behind- thyroid and cervical nodes.
• Thyroid
o Size: (a)symmetry of lobes
o Tenderness
o Movement
o Texture: hard, soft
o Presence of nodules: multiple, solitary
• Cervical lymph nodes

o Submental
o Submandibular
o Pre-auricular
o Post-auricular
o Occipital
o Deep cervical
o supraclavicular
Auscultate For bruits

School of Medicine
Examination Skills Checklist for Lower Limb Neurological
Examination
Equipment Tendon hammer
128Hz tuning fork
Neurotips
Cotton wool


Consent Clarify nature of task & seeks consent to proceed
Manages set up Position patient on supine and reclined on couch with legs
exposed appropriately
General Inspection Inspect for a catheter and possible signs: skin lesions such as
neurofibromas, scars, fasiculations, tremor, muscle wasting
Tone Examine tone slowly and quickly by:

- Rolling each leg
- Flexing and extending the knee
CLONUS: dorsiflex ankle with knee flexed
COMPARE BOTH SIDES
Power Examine against resistance:

Grade Power (MRC Scale): - HIP flexion and extension
0 No contraction - KNEE flexion and extension
1 Flicker of contraction - ANKLE plantar flexion, dorsiflexion, eversion and
2 Slight movement with gravity inversion.
eliminated - GREAT TOE flexion and Extension
3 Movement against gravity
4 Movement against resistance COMPARE BOTH SIDES
5 Normal Power
Reflexes KNEE (L3/4)

ANKLE (S1/2)
Grade reflex: Predominant nerve route in bold
- Absent
+/- present only with reinforcement Reinforcement if necessary (ask the patient to interlock their
+normal fingers and pull one hand against the other on your command
++ brisk as you as you strike the tendon)
+++ very brisk
PLANTAR Response (S1/2)
COMPARE BOTH SIDES
Sensation Always first test on the skin of upper chest wall or sternum
(for vibration)
Note the hemi-sensory, dermatomal
or peripheral distribution of any Test PAIN (neurotips), TEMPERATURE (cold touch of tuning
abnormality found. fork), LIGHT TOUCH (cotton wool) in the following
dermatomes:
The pattern in which you test
sensation will depend on the L2 – anterior, lateral thigh
history, the example given on the L3 – anterior, medial thigh
right is for dermatomal testing. L4 – anterior, medial calf
L5 – anterior, lateral calf or base of 1st and 2nd toe web space
To identify the level of a peripheral on dorsal aspect of foot
neuropathy test pain sensation of S1 – lateral aspect of foot
the anterior limb, moving from distil
to proximal, comparing left with If necessary based on history:
right until you find the level where S2 – popliteal fossa
sensation changes. S3 – central buttock
S4/5 – Perianal area
VIBRATION – place 128Hz tuning fork interphalangeal joint of

great toe, if sensation impaired move proximally to malleolus,
knee and anterior superior iliac spine
PROPRIOCEPTION – test by holding the sides of distil

interphalangeal joint of great toe. Test after initial eyes open
demonstration
COMPARE BOTH SIDES

Hand hygiene
Note: Gait, Romberg’s test and co-ordination are covered in the Cerebellar Examination.
This check list complements the clinical skills lower limb neurological examination video
available on Medblogs
School of Medicine
Examination Skills Checklist for Cerebellar Examination

Manages set up You will need to ask the patient to walk, stand, sit and lie
supine on the couch at different points
Gait Observe gait for stance (note wide based) stability (note if
unsteady, slow, staggering) and symmetry (note if falling to
one side)
Heel to toe walking test (note any unsteadiness)
Romberg’s test (note a positive test if patient fails to maintain

balance). The examiner should stand ready to support the
patient if needed
Eyes Test for impaired smooth pursuit/nystagmus/saccadic eye

movements
Speech Test for dysarthria by simply by talking to the patient– note

slurred, jerky, explosive, staccato speech
Ask patient to repeat the following phrases ‘42 West Register

street’ and ‘British constitution’
Upper Limbs CO-ORDINATION

- Finger nose tests (note past pointing and intention
tremor)
- Test rapid alternating hand movements (note
dysdiadochokinesis)
- Rapid supinating hand movements
Test for rebound phenomenon (note if arms shoot up past

original position)
TONE (note hypotonia)
REFLEXES (note pendular reflex or hyporeflexia)
COMPARE BOTH SIDES
Lower limbs CO-ORDINATION

- Heel to shin test (note if unable to keep heel on the shin).
Ideally perform on a couch
- Rapid alternating foot movements
TONE (note hypotonia)
REFLEXES (note pendular reflex or hyporeflexia)
COMPARE BOTH SIDES

Hand hygiene
Note: Tone and Reflex examination are covered in more depth in the upper and lower limb checklists. All
reflexes can be examined, but a pendular reflex would be most obvious at the knee.
This check list complements the clinical skills co-ordination and cerebellar video available on Medblogs
School of Medicine
Examination Skills Checklist for Cervical, Thoracic and Lumbar
Spine Examination
Manages set up Adequately expose the spine

Look From Behind: Posture of the head, neck and shoulder

Thoraco-lumbar scoliosis (standing, bending forward)
From the side: Cervical lordosis, thoracic kyphosis (+/- gibus),

lumbar lordosis
Feel Supraclavicular: feel for cervical ribs or enlarged lymph nodes
mid-line: spinous processes (cervical to lumbar vertebrae)
Para-spinal muscles (muscle bulk and note any spasm)
Iliac crest heights (asymmetry or excessive pelvic tilt)
Sacroiliac joints
Chest expansion
Move Cervical Spine: Flexion/extension Rotation (left/right) Lateral

(All active) flexion (left/right)
Lumbar Spine: Flexion, Extension. Lateral flexion (left/right)
Special Tests Schober’s test (to assess lumbar flexion)

Hand hygiene
Note: patients presenting with spinal problems may present with neurological symptoms affecting the
upper limbs (cervical spine) or lower limbs (lumbar spine). In these patients, full assessment would
include the mechanical back examination detailed above combined with a neurological examination of the
arms or lower limbs and perineum (dermatomal sensations, myodermal power and reflexes). This is not
included in the sessions or the list above as students have not had any neurology teaching yet (this will be
covered in Year 3). In Year 4, students should practice integrating the mechanical and neurological
examinations
School of Medicine
Examination Skills Checklist for Cranial Nerves Examination
Red topped pin
Ophthalmoscope
512Hz tuning fork
Torch
Tongue depressor
Neurotips
Cotton wool
Eye cover
Ischihari chart
Schnellen chart

Manages set up Position yourself sitting opposite the patient
General Inspection Possible signs: muscle wasting, facial asymmetry, ptosis, lack
of expression
CN I Olfactory Ask about any change to sense of smell

Smell identification test (if necessary)
CN II Optic Ask if any trouble with their vision and if they wear glasses or
contact lenses
Test visual acuity (Snellen chart) and colour vision (Ishihara

chart +/- red pin moved through visual fields)
Test visual fields
Map blind spot
Perform opthalmoscopy (darkened room)

- Red reflex
- View optic disc, blood vessels and retinal background
Test pupillary response:

- Direct light reflex (pen torch)
- Consensual reflex (pen torch)
- Accommodation (use pin)
-
Note pupil size, regularity and compare both sides
CN III Oculomotor Ask about double vision

CN IV Trochlear
CN VI Abducens Observe resting gaze, look for ptosis or nystagmus
Test eye movements (pin moved in ‘H’ formation and then

test for sacaddic movements)
CN V Trigeminal Test light touch (pain, temperature and vibration can be

tested for if necessary)
- ophthalmic
- maxillary
- mandibular
Test muscles of mastication:

- Palpate contracted temporalis and masseter muscle
(instruct patient to clench teeth)
- Push jaw open against pressure to test power
Corneal reflex (if necessary) test with a wisp, damp cotton

wool at lateral edge of cornea
Jaw jerk – with a loose open jaw. Gently tap your finger
(placed between the lip and chin) with a tendon hammer
CN VII Test facial muscles:

- Frontalis (Raise eyebrows)
- Orbicularis oculi (open eyes widely, blink and screw eyes
closed)
- Orbicularis Oris (smile, show teeth and whistle)
- Buccinators (puff out cheeks)
Ask about any change in sense of taste or test taste using

sweet, sour, or bitter solutions on anterior 2/3 of tongue
CN VIII Simple hearing test - whisper in ear while occluding hearing in

contralateral ear
Rinne’s test (specifically identifies conductive deafness,

which is not testing a cranial nerve, but this test can help
differentiate conductive versus sensorineural hearing loss
when performed with Weber’s test)
Weber’s test – place a vibrating tuning fork in the middle of

the forehead and ask the patient to identify where they hear
the sound (both ears or louder in left or right)
Vestibular tests (if necessary):

- Gait
- Heel to toe walking
- Romberg’s test
- Vestibular ocular reflex
CN IX Glossopharyngeal Ask patient to cough, swallow and say “Ah”

CN X Vagus while viewing soft palate movement, mouth and gums
Gag reflex, using tongue depressor (if necessary)
CN XI Accessory Test Sternocleidomastoid - Turn head to each side (against

resistance)
Test Trapezius - Shrug shoulders (against resistance)
CN XII Hypoglossal Observe tongue for:

- wasting/fasciculations
- passive movement (move protruded tongue right to left)
Test intrinsic muscle of tongue:

- push tongue against inside of cheek against external
pressure of your hand

Hand hygiene
This checklist compliments the clinical skills cranial nerves examination video available on Medblogs
School of Medicine
Procedural Skills Checklist for Nasogastric Tube Insertion
Equipment
• Apron
• Gloves
• NG tube
• NO drainage bag
• Glass of water
• Gauze swabs
• Lubricating gel
• 50ml (catheter tip)
• Syringe
• pH testing strips
• Tape to secure tubing
Preparation
• Hand hygiene
• Introduce self
• Identify patient
• Explain procedure
• Gain consent
• Patient comfort?
• Appropriate positioning and exposure of patient
Procedural Pause
• Equipment ready?
• Patient ready?
Cleaning & Anaesthetising

• Decontaminate hands
• Put on apron and gloves
Perform Procedure
• Sit patient upright with chin slightly forward and in line with sternum
• Measure approximate length of tube, take proximal end tubing:
- Bridge of nose to tragus of ear to xiphisternum
- Select appropriate marker on the tube from the patient’s measurements
• Explain to patient that they will need to swallow when specified to help the tube go down
• Lubricate tube and insert into patient nostril. Gently advance tube towards the occiput
• Ask patient to swallow when they feel the tube at the back of their throat
• The tube is advanced during swallowing: getting the patient to sip water at this stage may help
• Advance the tube through the pharynx until the predetermined mark has been reached
• To assess position, aspirate a few ml of gastric contents and check pH or check chest x-ray
• Secure tube. Attach drainage bag
• Ensure the patient is left comfortable
• Dispose of waste in clinical waste bag
Post Procedure Care

• Provide required information to patient
• Ensure patient covered and comfortable
• Dispose of equipment safely
• Hand hygiene
• Communicate procedure to appropriate team members
Documentation
• Document procedure in patients’ notes
School of Medicine
Procedural Skills Checklist for Peripheral Venus Cannulation
Equipment
• Gloves, gauze swabs/cotton wool, tourniquet and syringe, vial of sodium chloride, dressing and
sharps container. Take to bedside
• Check expiry dates on all packaging
• Select appropriate venous cannula for procedure
Preparation
• Hand hygiene
• Introduce self
• Gain consent
• Establish whether the patient has any allergies
Procedural Pause
• Patient ready?

• Put on gloves and apron
• Identify if the patient requires local anaesthetic cream
Perform Procedure
• Select appropriate vein and apply tourniquet
• Swab skin with antiseptic wipe (70% isopropyl alcohol, 2% chlorhexidine) for 30 secs and allow to
dry for 30 secs
• Avoid any contamination of cleaned cannulation site
• Secure the vein with the fingers of one of your hands
• Ensure bevelled edge of cannula is uppermost
• Enter vein with cannula at an angle of approximately 10-45° to the skin
• Avoid contamination of needle or cannulation site with hands
• Advance needle and cannula for a few mm after flashback is seen
• Release tourniquet prior to removing needle
If cannula fails to advance:
• Release tourniquet
• Place a swab over the cannula
• Remove cannula
• Dispose of cannula in sharps bin
• Apply pressure to vein for 2 mins or until bleeding stops
• Explain to patient and try again at a different site
• Apply pressure to vein above tip of cannula

• Remove and dispose of needle safely into sharps bin
Apply and secure a needle-free system

• Secure appropriately with sterile dressing
• Flush cannula with 0.9% sodium chloride
• Label cannula dressing with the date of cannula insertion
• Dispose of waste into clinical waste bag
Post Procedure Care

• Hand hygiene
Documentation
• Document procedure in patients’ notes:
- Date
- Reason for cannula
- Site
- Size / colour
- Number of attempts taken
- Signature – print name and grade
School of Medicine
Procedural Skills Checklist for Arterial Puncture
Equipment
• ABG Syringe Pack
• Equipment tray with attached sharps bin
• *Gloves
• Gauze swabs/cotton wool
• Request form and ice if indicated
• Consider use of topical local anaesthetic
Preparation
• Hand hygiene
• Introduce self
• Gain consent
Procedural Pause
• Patient ready?

• Put on gloves (disposable non-powdered latex not vinyl)
• Choose and palpate appropriate artery with fingers
• Perform Allen’s procedure
• Swab skin with antiseptic wipe (70% isopropyl alcohol) and allow to dry 30s
Perform Procedure
• Draw back the needle to at least 0.5ml/1.6ml to set the space required
• Palpate artery with two fingers
• Enter artery with needle at an angle of approximately 45° to the skin directed into the proximal
part of the artery
• Ensure the bevel edge is upmost
• Avoid contamination of needle with hands*
• Allow syringe to fill with arterial blood
If no blood appears
• Slowly withdraw needle and re-advance until flash back seen
• If no flashback is seen place a swab/cotton wool over entry site
• Withdraw needle and apply pressure to artery for 5 mins or until bleeding stops
• Dispose of needle and syringe in sharps bin*
• Explain to patient and try again at another site
• Remove needle and syringe and apply pressure to the artery for 5 mins or until bleeding stops
• Remove needle from syringe, safely disposing of needle into sharps bin*
• Remove any air bubbles from the syringe
• Put cap on syringe
• Dispose of gloves into clinical waste bag
• Decontaminate hands*
• Put patient details on syringe at bedside
• Send on-ice to lab immediately or take to analyser
Post Procedure Care

• Hand hygiene
Documentation
School of Medicine
Procedural Skills Checklist for Blood Culture (Adult)
Equipment
• Obtain trolley and clean surfaces with Clinitex wipe
• Obtain sharps box and tray and clean with Clinitex wipe
• Organise gloves, disposable tourniquet, gauze swabs, tape, Clinell Wipes, winged blood
collection set and blood culture bottles
Preparation
• Hand hygiene
• Introduce self
• Gain consent
• Ask about any allergies
Procedural Pause
• Patient ready?

• Take sharps bin to the bedside on a clean trolley
• Decontaminate hands* - either hand wash or alcohol gel if hands visibly clean
• Put on apron, then gloves
• After removing caps clean rubber septum (30 seconds) and allow to air dry
• Attach winged blood collection set to blood collection adapter cap (securely)
Perform Procedure
• Apply tourniquet and select appropriate vein
• Apply Clinell wipe to 5cm radius with friction to ensure good clean
• Ensure bevelled edge of butterfly needle is upmost
• Enter vein with needle at an angle of approximately 15° to the skin
• Avoid contamination of needle with hands – no touching “critical” sterile parts
• Secure butterfly with tape if necessary
• Place adapter cap over blood culture bottle (aerobic first) and pierce septum. Make sure the
bottles are below the patient’s arm and hold bottle upright
• Distribute 5-10mls of blood into each culture bottle
• For further blood samples insert adaptor inside blood culture cap
• Release tourniquet, remove butterfly and engage safety device by sliding the safety shield
• Discard complete winged blood collection set to sharps container
• Cover area with saw/cotton
• Apply pressure to site for 30-60 seconds or until bleeding stops
• Keep arm extended and elevated
• Write patient details on sample containers
• Place blood sample(s) into sealed polythene bag (one bag per patient)
• Dispose of gloves into clinical waste bag and then dispose of apron (pull and break ties) and
finally decontaminate hands before leaving patient zone
If blood collection fails
• Place a swat/cotton wool over the needle
• Remove needle
• Dispose of needle in sharps bin*
• Apply pressure to vein for 30-60 seconds or until bleeding stops
• Explain to patient and try again at a different site / side
Post Procedure Care

• Hand hygiene
Documentation
School of Medicine
Procedural Skills Checklist for Blood Sugar Testing
Equipment
Collect all equipment required:
• Blood glucose monitor
• Testing strips (check date and compatibility with monitor)
• Automatic lancing device
• Clean cotton wool/tissue
• Disposable gloves and apron
• Sharps disposal bin
Preparation
• Hand hygiene
• Introduce self
• Gain consent
Procedural Pause
• Patient ready?

• Wash and dry your hands
Perform Procedure
• Ensure chip in side of glucose monitor has the same LOT number as the testing strips
• Put on disposable gloves and apron
• Wash the patient’s hands with soap and water, rinse and dry thoroughly (alcohol swabs or
solutions should not be used as these may effect operation of the sensor/results obtained)
• Remove one test strip from container and reseal lid
• Hold test strip with grey electrode facing upwards and insert this electrode into the monitor. The
monitor will ask you to apply a drop of blood to the exposed end of the test strip
• Using the lancing device, obtain a drop of blood from the patient (using sides of fingers rather
than pads or tips is less painful)
• Place lancing device directly into a sharps bin
• Bring the end of the test strip to lightly touch the drop of blood. Hold until the meter indicates a
sufficient sample (insufficient samples can lead to false low readings)
• The meter will display the blood sugar measurement
• Remove the test strip and dispose of this in a clinical waste bag (orange)
• Apply clean tissue or cotton wool to the patient’s finger
• Wipe over all external surfaces of meter with an Alcowipe
Post Procedure Care

• Hand hygiene
Documentation
• Record the results immediately on the patient’s record, report results out with normal
parameters to your senior
School of Medicine
Procedural Skills Checklist for Scrubbing for Theatre
Equipment
• Face mask and eye protection
• Appropriate theatre attire is worn
Preparation
• No jewellery, nail polish or false nails are worn
• All hair is covered within theatre headwear (either a hat or a hood)
• Skin should be intact and free from breaks or lesions. Small breaks should be covered with a
waterproof dressing after scrubbing
• Face mask and eye protection fitted securely and comfortably
Procedural Pause
Scrubbing
• Sleeves are rolled up past the elbows
• Water is running at a steady rate and comfortable temperature
• Rinses always from finger tips to the elbows
• Hands are wet before applying microbial solution
• First wash (Approx. 2 MINUTES) is above the elbows using an antimicrobial wash of choice.
Approximately 5mls of scrub solution used. Uses the opposite elbow to hand to administer the
solution. Holds arm away from the body at all times and make sure the hands and arms are not
contaminated on the surrounding areas
• Uses a nail brush on finger nails in a downward motion
• Second wash (Approx. 1 MINUTE) rinse as above to the elbows but this time concentrating on
the wrist and hands
• Uses the six steps to hand-washing:
- Palm to palm
- Right palm over left dorsum and left palm over right dorsum
- Palm to palm with fingers interlaced
- Rotational rubbing of right thumb clasped in left palm and vice versa
• Third wash (Approx. 2 MINUTES) final application of scrub solution from the hand to mid forearm
and again concentrating on the wrist and hands and rinse as above
• Pushes off taps using the elbows
Gowning
• Stands a safe distance from opened gown packs
• Dries hands by placing one hand behind the folded hand towel and patting dry the skin of the
opposite hand and forearm in a corkscrew action. Towel is discarded
• Process is repeated using the opposite hand
• On completion, both hands are held higher than the elbows and away from theatre attire
Closed glove technique

• Keep hands inside the sleeves of the gown (approximately one inch from the cuff edge)
• Using the right thumb and forefinger, take hold of the right glove cuff
• Flip the glove over so that it rests on the right forearm. Line the glove up with the thumb
• With the left hand (which remains inside the gown sleeve), pull the double edge over the back of
the right hand
• Then pull the cuffed edge down to the wrist
• Ease the gown downwards at the front and the back until the fingers start to emerge within the
glove
• Wriggle the fingers and thumb into position then gently pulling the glove and gown
NB: the gown cuff should remain well within the glove
• Pick up the left glove using the left hand. Flip the left glove over so that it rests on the left
forearm
• Using the already gloved right hand, pull the double edge of the left glove over the back of the
left hand
• Then pull the cuffed edge down to the wrist
• Ease the gown downwards at the front and the back until the fingers start to emerge within the
glove
• Wriggle the fingers and thumb into position then gently pulling the glove and gown. NB: the
gown cuff should remain well within the glove
Documentation
• N/A
School of Medicine
Procedural Skills Checklist for Urethral Catheterisation
Equipment
• Catheterisation pack
Preparation
• Hand hygiene
• Introduce self
• Establish patient allergies (especially latex)
• Gain consent
• Ensure patient privacy
• Appropriate positioning and exposure of patient, ensuring not unduly exposed
Procedural Pause
• Patient ready?
Cleaning and Anaesthetising

• Place protective sheet under the patient’s buttocks and adjust lighting as necessary
• Put on apron
• Open catheterisation pack and apply both pairs of gloves
Perform Procedure
• Retract the foreskin (if present) and cleanse the glans and urethral meatus with saline solution,
swabbing away from the urethral orifice
• Hold the penis gently and laterally behind the glans with a gauze swab
• Before applying anaesthetic gel, check with patient regarding any previous allergies/reactions
• Anaesthetise the urethra with 11ml of local anaesthetic lubricating disinfecting gel, instilling
slowly
• Gently squeeze the end of the penis (or apply a penile clamp) to prevent the anaesthetic from
escaping the urethra
• Using saline, cleanse the vulval area swabbing from above downwards
• Identify the urethral meatus
• Insert 5mls of local anaesthetic lubricating disinfecting gel into urethra
• Allow 5 minutes to elapse

• Remove outer gloves
• Apply the sterile drapes appropriately over the patient
• Position receptacle for urine
• Pick up catheter in dominant hand and remove packaging
• Using the gauze swab, hold the penis at a 90 degree angle from the pelvis
• Introduce catheter into meatus and continue to insert until urine flows
• If resistance is felt, increase traction on the penis slightly and apply steady, gentle pressure on
the catheter
• Insert into urethral orifice for about 6-8cm until urine flows
• Once urine flows insert the catheter a further few centimetres

• Inflate the balloon with sterile water as per manufacturer’s instructions
• Withdraw the catheter slightly until resistance is felt
• Attach catheter to drainage systems
• Ensure the foreskin (if present) is placed back over the glans
• Collect urine samples if required
Post Procedure Care

• Hand hygiene
Documentation
• Document procedure in patient’s notes/care plan/fluid chart, including reason for procedure,
catheter used (size, type, batch number, volume in balloon), anaesthetic gel used, any problems
and signature of practitioner
If any difficulties are experienced contact Urology Team
Key: Male Female

School of Medicine
Procedural Skills Checklist for Urinalysis
Equipment
• Container with testing strips
Preparation
• Hand hygiene
• Introduce self
• Gain consent
Procedural Pause
• Patient ready?
Cleaning and Anaesthetising

• Put on disposable apron
• Put on disposable gloves
Perform Procedure
• Collect sample
• Note the colour and clarity of the urine
• Note the odour of the urine
• Check that container contains the correct testing strips
• Check the expiry date on the container
• Open container and remove one strip
• Remove test strip without touching reagent pads
• Replace container top immediately
• Dip test strip in urine ensuring that all reagent pads are immersed
• Tap strip on side of specimen container to remove excess urine
• Immediately commence timing of strip, using a watch with a second hand
• Commence reading strip at correct time
• Read strip accurately against bench marker only
• Record results at correct times
Post Procedure Care

• Hand hygiene
Documentation
• Record results on correct form
School of Medicine
Procedural Skills Checklist for Venepuncture
Equipment
• Containers
• Needles
• Vacu-barrel
• Gloves
• Tourniquet
• Gauze
• Swabs/tape
• Sharps bin
Preparation
• Hand hygiene
• Introduce self
• Explain procedure and ask about preferred site /side
• Gain consent
•
Procedural Pause
• Patient ready?

• Identify if the patient requires local anaesthetic cream
• Organise gloves, tourniquet, gauze swabs/tape
• Take sharps bin to the bedside
• Put on disposable gloves and apron
Perform Procedure
• Select appropriate container(s), needle and vacu-barrel for procedure
• Apply tourniquet and select appropriate vein
• Swab skin with antiseptic wipe (70% isopropyl alcohol) for 30 secs and allow to dry for 30 secs
• Avoid any contamination of venepuncture site
• Ensure bevelled edge of needle is upmost
• Enter vein with needle at an angle of approximately 15° to the skin and avoid contamination of
needle or insertion site with hands
• Collect blood in appropriate containers as per order of draw
If blood collection fails:
- Release tourniquet
- Place a swab/cotton wool over the needle
- Remove needle
- Dispose of needle in sharps bin
- Apply pressure to vein for 30-60 seconds or until bleeding stops
- Explain to patient and try again at a different site/side
• Remove needle and cover area with swab/cotton wool
• Dispose of needle safely into sharps bin
• Apply pressure to site for 30-60 seconds or until bleeding stops, with swab/cotton wool
• Keep arm extended and elevated
• Ensure bottles are mixed as per manufacturer’s guidelines
• Apply pre-printed labels or write details (name, DOB, CHI, ward, time, initial and date) on blood
bottles at the side of the patient
• Place blood sample(s) into sealed polythene bag (one bag per patient)
• Check that bleeding has ceased
Post Procedure Care

• Hand hygiene
Documentation
• Record results on correct form
Intimate Examination Guidelines
(Taken from GMC guidelines – Intimate examinations and chaperones
Retrieved from http://www.gmc-uk.org/guidance/ethical_guidance/30200.asp on 19th December 2016)
Intimate examinations
Any examination which involves touching or even being close to a patient could be thought of as intimate
and therefore you should be considerate to your patients’ perception of the situation. Examinations of
breasts, rectum and genitalia are particularly intimate and as such should always be treated with respect.
The GMC have clear guidance around intimate examinations which is detailed below
“You must follow this guidance and make detailed and accurate records at the time of the examination, or
as soon as possible afterwards”
Before conducting an intimate examination, you should:
a) explain to the patient why an examination is necessary and give the patient an opportunity to ask
questions
b) explain what the examination will involve, in a way the patient can understand, so that the patient
has a clear idea of what to expect, including any pain or discomfort
c) get the patient’s permission before the examination and record that the patient has given it
d) offer the patient a chaperone
e) if dealing with a child or young person:
- you must assess their capacity to consent to the examination
- if they lack the capacity to consent, you should seek their parent’s consent
f) give the patient privacy to undress and dress, and keep them covered as much as possible to
maintain their dignity; do not help the patient to remove clothing unless they have asked you to, or
you have checked with them that they want you to help
During the examination, you must follow the guidance in Consent: patients and doctors making decisions
together. In particular you should:
a) explain what you are going to do before you do it and, if this differs from what you have told the
patient before, explain why and seek the patient’s permission
b) stop the examination if the patient asks you to
c) keep discussion relevant and don’t make unnecessary personal comments”
Chaperone Guidelines
A chaperone for intimate examination can provide comfort and support for the patient and protection for
the doctor. The General Medical Council provide clear guidance on the use of chaperones. Please follow
the link below:
https://www.gmc-uk.org/guidance/ethical_guidance/30200.asp
Intimate examinations should be regarded as teaching opportunities by students and therefore they
should not be undertaken without a clinician supervising. Students should not perform an intimate
examination without a chaperone being present. A medical student should not act as the chaperone for
another medical student. The name and position of the chaperone should be documented in the patient’s
notes.
School of Medicine
Medical School Charter
Reviewed July 2016

Introduction
This document defines the expectations and responsibilities of both yourself as a medical student
and your University.
It has been developed from the principles set out in the Medical School Charter developed by the
Council of Heads of Medical Schools and BMA Medical Students and should be read in conjunction
with the General Medical Council’s document Good Medical Practice:
http://www.gmc-uk.org/guidance/good_medical_practice.asp
The Medical School Charter is not a fixed standard but contains a core of issues designed to
promote a good awareness on both our parts of our responsibilities and commitments.
For your own part it is important that your choice to enter medicine is made in the full awareness
of the duties and expectations that studying for a degree in medicine entails.
As a medical student you will be studying both for a University degree and a professional
qualification. On successful completion of your training you will be qualified to practise as a
doctor. You will also be coming into contact with members of the public in sometimes vulnerable
and distressed circumstances and will be placed in a position of trust and expected to behave with
the utmost integrity from the very start of your studies.
So that you may have a clear understanding not only of the standards laid down by the guidance
of the General Medical Council for the medical profession but also the University’s expectations of
you throughout your training, the University sets out these duties and responsibilities in terms of
its Medical School Charter. In the first section of the Charter the expectations of you as a medical
student are presented and in the second section we detail our responsibilities as a Medical School
to you as they relate to education provision, privacy and equal opportunity, administration and
support and student representation.
While it is subject to the University’s own Charter, Statutes, Ordinances and approved policies, the
Charter is designed to inspire high standards and quality delivery. The issues raised here are not
exhaustive nor are they prescriptive but they do represent the route to best practice and a way to
develop that. Together that is what we are setting out to achieve by signing up to this Charter.
Part 1: The responsibilities of the medical student
Medical students undertake a degree in medicine with the aim of becoming medical practitioners.
Whilst students do not yet have the full duties and responsibilities that go with being a registered
medical practitioner, they are already in a privileged position with regards to patients and those
close to them. In recognition of this, students must maintain a good standard of behaviour and
show respect for others. By awarding a medical degree, a university is confirming that the graduate
is fit to practise to the high standards that the GMC has set in its guidance to the medical
profession, Good Medical Practice. The GMC outlines the standards expected of a qualified doctor
in Good Medical Practice and other guidance. Many of those standards apply to you as a medical
student. Those of particular relevance are set out below.
1. The student will treat every patient politely and considerately
As a student, you will:
1.1 treat each patient with respect
1.2 make sure that the patient understands that you are a student and not a qualified doctor
1.3 make sure the patient has agreed to your presence and involvement
1.4 not continue interaction if the patient indicates a wish to stop
1.5 dress in an appropriate professional manner that enables good communication with your
patients
1.6 acknowledge that patients have the right to expect that all health care workers and students
should both appear and be professional
During your training you will come into contact with many patients from a variety of backgrounds.
Usually, your contact with patients will be for your benefit and not theirs. It is important that you
approach each patient with respect. As a minimum, this means that you should make sure that
patients understand that you are a student and that they have agreed to your presence and
involvement with them. Be sensitive to their reactions and do not continue your interaction with
them if they indicate that they have had enough
Students as well as doctors must be prepared to respond to a patient’s individual needs and take
steps to anticipate and overcome any barriers to communication. In some situations this may
require you to set aside your personal and cultural preferences in order to provide effective
patient care
Consideration for your patients affects how you choose to appear. Your dress and appearance
should not interfere with your ability to communicate with your patients and their supporters.
Fashion changes but patients have the right to expect that all health care workers and students
appear professional. Dress which is too informal or is at the extremes of fashion may offend some
patients. Good personal hygiene and grooming is essential
Be aware that you are going to be in very close contact with patients. General appearance, facial
expression and other non-verbal signals are important components of good communication in
the wider UK community. Any form of dress which interferes with this (such as covering the face
or wearing excessive jewellery) should be avoided
2. The student will respect patients’ dignity and privacy
The student will:
2.1 address patients in professional way
2.2 endeavour to preserve the patient’s dignity at all times
2.3 attempt to ensure the patient’s privacy at all times
Remember, patients are human beings not museum exhibits. Always ensure that the patient’s
dignity is preserved in the manner in which you address them. Err on the side of formality rather
than familiarity unless the patient gives you specific permission to be more informal. Take care
when examining a patient not to embarrass them by over-exposure. The level of acceptable
exposure varies from individual to individual. Be aware of the wishes of your patient in this regard.
3. The student will listen to patients and respect their views
It is easy to turn history taking into an interrogation, but a consultation is a two way process. Do
not allow yourself to ignore what the patient has to say
4. The student will respect and protect confidential information
The student will not:
4.1 intentionally divulge information concerning a patient to anyone not directly involved in the
patient’s care
4.2 discuss his/her patients in a public place and will take other precautions to ensure that
she/he does not inadvertently pass on information regarding a patient
As a medical student you will have access to information about patients, which they will expect
to be kept confidential. Some of this you will obtain directly from patients or their relatives when
you take histories. Other information will be available to you because you are given access to the
patient’s medical records as part of your training. This information should not be deliberately
divulged to anyone not directly involved in the patient’s care. You should also take care not to
inadvertently pass on information about a patient. Think about who else may see your report or
hear your conversations. You should not discuss your patients in a public place
5. Students must not allow their personal beliefs to prejudice their patients’ care
Students will care for patients irrespective of their views about patients’ lifestyles, culture,
religion and beliefs, race, colour, gender, sexuality, disability, age, nationality, or social or
economic status
You are entitled to hold any beliefs that you wish but you must not allow these to interfere with
your care of patients. This corresponds to the requirements in paragraph 5 of Good Medical
Practice, GMC
6. Students will act quickly to protect patients from risk if they have good reason to believe
that they or a colleague may not be fit to practise
6.1 The student will immediately report any concerns using the procedures for voicing concern
which are in force in the medical school
You may see a health professional or a fellow student behaving in a way that is likely to lead to
harm to patients. You should discuss this immediately with a senior person such as a tutor whom
you trust. It is uncomfortable to be a “whistle-blower” but it is important and your professional
duty not to ignore behaviour if you know it to be dangerous or reckless. Where necessary you
should contact a professional organisation, or the GMC for advice
6.2 Medical students should strive for high standards in their professional lives and their
conduct should reflect this
7. The student will take all of the opportunities provided to develop his/her professional
knowledge and skills
The student will be expected to:
7.1 attend all of the compulsory teaching sessions
7.2 inform the medical school as soon as possible of the reason if s/he is unable to attend a
compulsory session
7.3 complete and submit course work and assignments on time
7.4 be conscientious in his/her approach to self-directed learning
7.5 endeavour to contribute effectively to any learning group of which he/she is a part
7.6 respond positively to reasonable feedback on his/her performance and achievements
7.7 immediately inform the medical school of factors that might affect his/her performance so
that appropriate action can be taken
7.8 carry out examinations (including intimate examinations where necessary and when a
chaperone is present) on patients regardless of gender identity
This corresponds to the requirement in Good Medical Practice. Keep your professional
knowledge and skills up to date
At this stage you are acquiring knowledge and skills rather than maintaining them but the
principle is the same. Learning is a professional duty. Reading up on the patients you have seen
and practising your clinical skills is an essential part of your life as long as you remain within the
medical profession. Failure to attend compulsory teaching sessions is a breach of professional
standards
8. The student will recognise the limits of his/her professional competence
8.1 The student will not hesitate to ask for help and advice when needed
This may appear obvious to you but there is a temptation to undertake tasks or give advice
beyond your level of competence. If in doubt ask for help
9. The student will be honest and trustworthy in all matters
9.1 All forms of academic cheating and plagiarism are unacceptable and may result in
disciplinary proceedings
9.2 This corresponds to the requirement in Good Medical Practice. The University has a Code
of Practice on Plagiarism and Academic Dishonesty
(http://www.dundee.ac.uk/academic/plagiarism.htm )
9.3 Be honest and trustworthy
This applies to your clinical encounters and has wider implications. If you are not trustworthy in
your academic life it will be difficult to be trustworthy in the clinical setting
10. The student will work with colleagues in the ways that best serve patients’ interests
Students will:
10.1 acknowledge that health care is dependent on effective co-operation between all members
of the team
10.2 attempt to ensure that they maintain good relationships with the other health professionals
caring for the patient
10.3 treat other healthcare professionals, staff and other members of the university and fellow
students with respect
Health care is dependent on effective co-operation between all members of the team. Even as a
student you must ensure that you maintain good relationships with the other health professionals
caring for the patient
11. The student undertakes to provide feedback on the usefulness, significance and
effectiveness of all aspects of the course, including teaching
11.1 The student will complete such evaluation tools as are agreed between the medical school
and the student body
The medical school makes every effort to ensure that the course you are undertaking is of the
highest quality by a process of continuous quality enhancement. If this is to be effective, the
medical school needs timely and honest feedback on the course highlighting what worked well
and what needs to be changed. Your opinion is important
12. The student will use social media in a way that is fitting with the standard expected from a
medical professional
12.1 Social media is widely used and medical students are expected to maintain their professional
standards both on and off line. The use of social media has blurred the boundaries between
public and private life, and online information can be easily accessed by others. When
considering your use of social media you should consider the following;
Social media sites cannot guarantee confidentiality whatever privacy settings are in place.
Patients, your medical school and potential employers may be able to access your personal
information
When you make a statement using social media it can be almost impossible to delete it as
other users may have distributed it further or made comment
Medical students should treat everyone fairly and with respect. This also applies to
communications using social media. You must not bully, harass or make gratuitous,
unsubstantiated or unsustainable comments about individuals online. The medical school
will not tolerate this kind of behaviour
The GMC have published a Doctors’ use of social media guide that is available from the GMC
website
13. Data Protection
The University of Dundee does process the personal information of students during the
normal course of University business. Your personal details are never shared with a third
party with the exception of approved organisations who are carrying out work on behalf of
the University of Dundee such as Occupational Health (OHSAS). We also pass information
about you to the General Medical Council (GMC) that is required for the identification check
that is carried out early in fifth year. The GMC will also receive personal information about
you upon graduation in order for you to complete your GMC registration
Part 2: The responsibilities of the medical school
In accepting a place at medical school or university, you are expected to comply with certain
responsibilities, which are outlined in Part 1 of the Medical School Charter. These responsibilities
accord with GMC standards and take into consideration the requirement that medical schools are
expected to graduate students who are fit to practise medicine. The responsibilities of the medical
school relate to:
• Education
• Privacy and Equal Opportunity
• Administration and Support
• Student representation
In identifying these goals the Medical School seeks to obtain the highest possible standard and work
with students to ensure that this is consistently achieved.
1. Education
The Medical School shall always strive to:
1.1 Provide high quality teaching and training in clinical and non-clinical settings
Medical schools are under an obligation to comply with the GMC’s Tomorrow’s Doctors, therefore
this objective simply requires continuation of providing the good quality education demanded by
the GMC. This is assessed via the GMC’s quality assurance visiting process but it is also a proactive
duty of the school. Where applicable students should be involved in quality assurance processes in
order to aid the provision of consistent and high quality training by the Medical School
1.2 Ensure assessment and examinations are based upon the required learning
objectives/outcomes
To ensure continuity and fairness, assessment and examinations will be based upon the standards
laid down by the GMC and medical school syllabus.
1.3 Provide learning experiences that are challenging and stimulating
1.4 Ensure that staff and students understand their responsibilities with respect to gaining
consent from patients prior to examinations by students
1.5 Provide a level of training whereby, upon an individual’s satisfactory completion of the
course, the minimum standards attained comply with the professional expectations of the
regulating body
All courses and course changes must have approval from the GMC
1.6 Make clear the responsibilities and expectations of the regulating body and how they relate to
the curriculum. The professional duties of the regulating body must be made known to the
students
Fitness to practise and professional duties are important features of the curriculum, therefore it is
imperative that medical schools make clear to students the implications of these issues, if they are
to expect students to comply with the regulations and professional duties bestowed upon them.
1.7 Ensure that the course is relevant and led by suitably qualified individuals
1.8 Give impartial, timely and constructive feedback on individual student progress and
performance, including explanations for failure
If a student is failing to meet academic standards at any point of the course they should be offered
constructive feedback and support. A reasonable time is within 2 weeks of a problem being
established.
1.9 Where necessary provide access to extra support and advice from teachers and tutors
It is imperative that students who require support get it from the teachers and tutors who can
facilitate the successful completion of exams and modules
1.10 Inform, regularly update and provide access to full information about the course, module
contents and course objectives
Ease of access to information about the course is a necessity. Clear communication of changes
and dissemination of information should be a priority of the medical school. Involving student
representatives may make this easier
1.11 Give clear and timely information about assessment/submission dates and the preferred or
required format of assessments/submissions
Assessment dates and format should be made clear to all students and a minimum time period of
one month prior warning should be afforded to students
1.12 Provide timetabled information about the academic year ahead at least one month before
commencement of the year
It is increasingly important for medical schools to have clearly timetabled academic sessions and
clinical placements so that students can ensure they adequately plan travel, accommodation and
other arrangements, such as childcare. A minimum notice period of one month before
commencement of the placement is desired
1.13 Ensure that students are well informed about the question types to be presented in
examinations
1.14 Where requested give due consideration to extenuating circumstances which may affect
academic and clinical progress and performance in any aspect of the medical course
Family pressures, illness and personal circumstances may cause significant problems for students
and they should be considered if a student’s studies are affected. The medical school should make
every effort to accommodate students and their needs in an open and supportive environment.
Medical schools must be aware of their requirements under the Disability Discrimination Act and
make reasonable adjustments where necessary
1.15 Wherever possible, provide students with the opportunity to study and practise abroad as part
of the medical degree
ERASMUS and other international schemes allow students to attain modules and SSCs. The medical
school should be open to such schemes and have a clear policy regarding the availability of these
opportunities
1.16 Respect the intellectual property rights of the medical student. Any work undertaken by the
student remains the property of the student subject to locally agreed arrangements discussed
in advance with student representatives, subject to the normal policy of the individual medical
school or university
The intellectual property rights of any individual’s work must be respected. Therefore, work
undertaken by a medical student should not be passed off as somebody else’s and there must be
clear acknowledgement of the ownership of this work
1.17 Provide students with the opportunity to give the medical school or university feedback on the
usefulness, significance and effectiveness of all aspects of the course, including teaching
Feedback is a key element of the improvement process and the school should take the opportunity
to survey students about the course on a regular basis. This exercise should not be limited to just
teaching, but to other areas of educational delivery such as support, assessment, organisation and
communication
1.18 Give due consideration to feedback provided in accordance with 1.17 above and inform the
student of any positive action that is possible to take with respect to the feedback
For various reasons changes to a course or its provision may not be possible and where possible the
student should be given feedback on those reasons
1.19 Inform the student within a reasonable time period of any changes to the curriculum, structure
of the course and any other significant alterations other than minor timetabling changes, which
will affect the student
Any substantial changes made to the course should be made known to the students well in advance
and ideally with one year’s notice. Changes that would require significant expenditure or
inconvenience on the student’s behalf must be made known as soon as practicably possible
1.20 Ensure that all staff with responsibilities to medical students are made aware of the Medical
School Charter
The Charter should be advertised to students and staff alike
1.21 Ensure responsible allocation of available resources in order to facilitate delivery of the
provisions of Parts 1 and 2 of this Charter
2. Privacy and equal opportunity
The Medical School is obliged to:
2.1 Respect the fundamental Human Rights of students as set out by the Human Rights Act 1998
as far as they do not impact on the rights and freedoms of others for whom the Medical School
has an equal duty of care, including patients and the general public
2.2 Ensure that learning, both at the medical school and on clinical placements, is undertaken in a
safe and secure physical environment
Medical schools must maintain strict health and safety regulations. The school is also
responsible for providing a safe and secure environment for medical students to learn both
clinical and academic skills
2.3 Provide a diverse environment which takes positive action to protect students from bullying,
discrimination, victimisation, intimidation or harassment of any kind and promote equality and
value diversity
Students and staff alike must be treated respectfully, and not be subject to any form of
discrimination. The medical school must ensure that they have policies which are compliant
with relevant equal opportunities legislation. The school must actively encourage diversity and
accommodate as best possible the participation of all students
Any report of bullying, discrimination, victimisation, intimidation or harassment will be followed

up and investigated. If the complaint is about a staff member then action will be taken under
the policy relevant to staff members and if the allegation is proven then appropriate
disciplinary action will be taken. If the complaint is about a student then action will be taken
under the appropriate policies relevant to students and which might include both the School's
disciplinary and fitness to practise policies
2.4 Provide the student with information and advice on how to make a complaint. Complaints shall
remain confidential to those involved at all times and the complainant shall be protected from
any form of victimisation following such a complaint
There must be clear policies in place to empower medical students and the medical school to
take complaints seriously. The treatment of complaints against either a member of staff or
student should be treated in a uniform manner and confidentially
2.5 Provide the student with information and advice on procedures for voicing concerns.
Disclosures shall be strictly anonymous. Such procedures will be made freely available and
taken seriously. See my Dundee under Regulations and Policies
2.6 Those making complaints or disclosures that are proven to be malicious and/or untruthful will
be subject to the School's disciplinary procedures
The University upholds the right of each member of the University community to be treated
with dignity and respect (http://www.dundee.ac.uk/hr/equality/dignity.htm)
3. Administration and support
3.1 In so far as resource allows, ensure that the medical students have adequate access to modern
IT equipment that is appropriate to the demands of the course
3.2 In so far as resource allows, ensure that the student has access to high quality facilities and
resources required to achieve the academic and professional goals set by the GMC and the
school
Technical facilities such as anatomical models, professional computer programmes and other
resources should be made available to students
3.3 Provide assistance for students who might require accommodation whilst on placements
It is recognised that the increase in student numbers and the growth in Independent Treatment
Centres has restricted the availability in clinical placements in some areas. This has put pressure
on students who might now have to travel significant distances. Medical Schools should try to
minimise and alleviate such pressures
3.4 Endeavour to facilitate a high standard of teaching facilities whilst on placement
3.5 Provide access to a student centred support service within the medical school and ensure that
contact with the support service shall be treated in confidence
Given the personal nature of some problems that students encounter, the medical school must be
able to direct the student to facilities that offer them suitable support
3.6 Ensure that the student has access to both identifiable academic tutors responsible for
overseeing education, and identifiable pastoral tutors, to oversee general welfare and assist
with personal problems
Both the academic and pastoral welfare of the student must be catered for and where a ‘conflict of
interest’ ’might exist there should be alternative services open to the student
3.7 Ensure that, in order to avoid any potential conflict of interest, if the pastoral tutor has any
academic responsibilities for the student, then either the student or the pastoral tutor can
make alternative arrangements for the pastoral role to be carried out by another member of
staff
Due to potential for a conflict of interest the medical school should ideally ensure that the pastoral
tutor does not have academic responsibility for the student. Should a pastoral tutor have academic
responsibility for a student, a scheme must be in place by which the students can seek pastoral
care from another member of staff who does not carry out this dual function at that time
3.8 Ensure that issues disclosed to the pastoral tutor remain confidential or alternatively the tutor
must advise the student that in some circumstances he/she will be required to disclose
information which affects the student's fitness to practise
The student-tutor relationship should have the same status as the patient-doctor relationship
unless the issue being discussed becomes a matter of fitness to practise. This should be made clear
to the student at the start of the student-tutor relationship and whenever a matter of fitness to
practise is discussed. The tutor must make the student aware of the potential ramifications of
disclosing information relating to his/her fitness to practise
3.9 Make arrangements for the provision of external support services should these be necessary.
It should ensure that the student is aware of these external support mechanisms (including
those available through local government and health service providers)
Due to the nature of the medical degree programme the student may be embarrassed or concerned
about seeking assistance from some health services, such as genito-urinary clinics or psychiatric
support. The medical school will seek to ensure that there are services which can be independently
accessed by the student outside the medical school catchment area. This could be achieved by a
reciprocal arrangement with other schools. As such issues are of a sensitive nature, the school
should advertise these external facilities to all medical students in case access to these services is
required. Students must not allow their own health or condition to put patients and others at risk
3.10 Ensure that the university provides advice about internal and external sources of funding
including access to hardship funds
The medical school will ensure that funding arrangements are clearly signposted. Local and
national funding arrangements should be well advertised, as well as information about travel and
hardship funding
3.11 Ensure that all students have easy access to medical school regulations and policy
3.12 Ensure that careers advice is given to students throughout their degree
Careers advice is an essential element of a degree programme. The school must ensure that advice
is given at a suitable time during the course and this should be done through whatever medium is
felt appropriate. It should however be reviewed and updated on a regular basis to ensure it is fit for
purpose. Where students do not wish to pursue a medical career, the medical school should ensure
that the student has access to appropriate careers advice, provided by the school, or other
university departments
3.13 To ensure that in conjunction with the Postgraduate Dean, the transition between medical
school and foundation training is as seamless as possible. This includes providing information
about the process for applying to F1, suitable levels of careers advice and relevant and timely
information as required by any application process. It also includes the transfer of information
about you to Foundation School in order that you can be supported in your on-going education
and training
Any ranking information provided by the Medical School must be arrived at by means of a
transparent process, which will be clearly communicated to the students
In the interests of public safety, in accordance with Tomorrow’s Doctors, and in your own best
interests, information pertinent to your educational achievements and to your fitness to practise
may be shared by the Medical School with training providers, employers, regulatory organisations
and other medical schools
4. Student representation
4.1 Ensure that fair student representation exists on all decision-making bodies, which directly
affect medical students
4.2 Facilitate the ability of students to participate in all activities of the medical school and
university students’ unions and external bodies related to education, including trade unions
and professional bodies
Representation is a key right and this should be respected by the medical school. Fair
representation should be actively pursued on all key bodies within the medical school, which
includes the students’ union or political organisations. As well as this, medical schools should
respect a student’s right to sit on external bodies in a national or local representative

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A GUIDE TO CLINICAL HISTORY

University of Dundee, School of Medicine Reviewed December 2017

University of Dundee, School of Medicine Reviewed December 2017

Standards of Appearance for Medical Students

University of Dundee, School of Medicine Reviewed December 2017

Developing your clinical communication skills

The need to be able to apply theory into clinical practice

The patient should always be central to the consultation process

The need to explore the patient’s expectations

University of Dundee, School of Medicine Reviewed December 2017

The Clinical Consultation Process

University of Dundee, School of Medicine Reviewed December 2017

Calgary Cambridge framework full skills list

Introduce self, role, nature of interview and obtain consent

Attend to the patient’s physical comfort

Listen attentively to opening statement

University of Dundee, School of Medicine Reviewed December 2017

Clarify details of the story

Summarise and invite correction of inaccuracies

Explanation and Planning

University of Dundee, School of Medicine Reviewed December 2017

Aiding accurate recall and understanding

• Organises explanation: divides into discrete sections, develops a logical sequence

Achieving a shared understanding: incorporating the patient’s perspective

Planning: shared decision making

University of Dundee, School of Medicine Reviewed December 2017

If negotiating mutual plan of action

If discussing investigations and procedures

Closing the session

University of Dundee, School of Medicine Reviewed December 2017

Involving the patient

Providing Structure to the Consultation

University of Dundee, School of Medicine Reviewed December 2017

University of Dundee, School of Medicine Reviewed December 2017

These could include:

Structuring a follow up consultation

When conducting a follow up consultation the following areas should be covered

University of Dundee, School of Medicine Reviewed December 2017

Review of long term condition – Diabetes Giving results of MRI Knee

University of Dundee, School of Medicine Reviewed December 2017

This may be dependent on several factors:

Clinical context Intended outcome

Complex Communication Needs

• Find out what type of questions to ask - Open Questions? Yes/No?

Response to “bad news” –

Patient reluctant to talk but appear emotionally upset / low

Dealing with an agitated / angry patient

Formulate a management plan

Concluding the Consultation

3. Reason for referral

5. Additional relevant information

6. Signature referring doctor and date

Absolute risk is always preferable to relative risk

Use a clear term to reference

Use the same denominator (terms of reference throughout)

Take into account your patient’s needs, values and circumstances

Essence of presenting a case history to a colleague

Past Medical History

Any other information not covered so far

Any other information not covered so far

General examination findings including NEWS score

 Pulmonary Embolism (with nothing else)

Likely pulmonary embolism

Aiding accurate recall and understanding 