B.P.

1825
UNIVERSITY OF LUBUMBASHI
FACULTY OF MEDICINE

ENGLISH MEDICAL
COURSE (2021 -2022)
Professor Edouard SWANA
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BY PSG & Francas

NB : ce document n’a pas été rédigé pour un but lucratif, mais pour aider les étudiants de
D1 médecine à mieux réviser leur cours d’anglais médical !

BONNE LECTURE ET BONNE CHANCE A TOUS !

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ENGLISH MEDICAL COURS

Plan
Introduction
Patient’s approach
Clinical procedures
How to write a discharge summary

CHAP.1. INTRODUCTION
Students concerned:
- Faculty of Medicine
- Undergraduate Clinical Students of classes 1, 2 and 3 (Doctorate 1,2,3
and 4)
Total number of students and working groups: the number is to subdivide by
10 groups for practical works, making groups of 20 to 30 students
Contact hours
- 15 hours: theoretical teaching hours,
- 15 hours of practical.
Prerequisite
- General criteria of admission to the second cycle at the University of
Lubumbashi, Faculty of Medicine
- Having completed the first part of « Medical English » taught during the
graduate cycle
- Having performed an end of biomedical sciences cycle research work
Course learning outcomes or objectives: Knowledge, Skills, Procedure and
Attitudes
Course main objective
The course is aiming to build up in the future French speaking medical
practitioner the foundation of the principles of the English medical
education and to acclimatise him/her in listening, understanding, reading,
and writing.
Course specific objectives
At the end of his/her undergraduate studies, the end of the current course,
the French speaking medical doctor should be able to perform in English
settings the following

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1. Knowledge objectives
• To describe among others
a) The process of performing medical studies in the DRC
b) Ministry of health organogram
c) The Medical counsel
d) The main morbid condition encountered in Lubumbashi clinical
department (internal medicine, gynaecology-obstetrics, paediatrics,
surgery). How these are diagnosed and treated and how people do to
prevent them
• To explain or discuss among others
a) The causes and mechanisms of epidemic disease
b) The spread of non-communicable diseases: like hypertension,
diabetes mellitus…
c) Diagram for example the layers of the alimentary canal at any of its
components and discuss the role of these structures in digestion and
absorption.
d) The practice of medicine in Lubumbashi
2. Skills and procedure
For each common disease, the medical doctor should able to:
- Take the patient’s history,
- Perform physical examination,
- Chose and interpret lab and imaging results from tests or investigation.
- Prescribe medicine or perform case management
For any systemic organ or tissue, the medical doctor should be able to
perform common procedure
- Vein puncture,
- Insert an IVL (intravenous line),
- Take blood pressure,
- Insert a nasogastric tube.
3. Attitudes
Ethics to the patients,
Ethics to patient’s relatives and to the health personnel,

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Commitment:
- Attendance,
- Punctuality,
- Recognition of limitation: calling for help,
- Lifelong learning attitude,
- Leadership.
Learning methods
Adult learning methods,
Student-centred, self-directed, guided by the facilitator/coach
Including: lecture, tutorials, seminars, workshop clinical practical, bedside
teaching, modern ICT1
resource: audio tapes, video tapes, CD, DVD, scenarios…
Assessment
Based on learning objectives of knowledge, skills and attitude.
Methods
- Continuous assessment or year work assessment (50%),
- Final examination (50%).
HOMEWORK
Main morbid conditions encountered in Lubumbashi clinical departments
(internal medicine, gynaecology-obstetrics, paediatrics and surgery). How
these are diagnosed and treated and how people do to prevent them.
Gynaecology-obstetrics
1. Cervical cancer
2. Endometriosis
3. Ectopic pregnancy
4. Pre-eclampsia
5. Pelvic pain
6. Threat of abortion
7. ovarian cyst
8. Gestational Diabetes
9. Uterine fibrosis
10. Breast cancer
surgery
1. Appendicitis
2. Inguinal hernia
3. Peritonitis
4. bowel instruction
5. gastric perforation
6. tendon rupture

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7. colon cancer
8. bone fracture
9. burn
10. prostate adenoma
Epidemic diseases in the DRC (5)- causes and mechanisms
1. cholera
2. viral hemorrhagic fevers
3. measles
4. COVID-19
5. H5N1
Non-communicable diseases (4main types, causes and risk factors)
1. Cardiovascular disease,
2. Cancer,
3. Chronic respiratory disease, and
4. diabetes
Layers of the alimentary canal
the GI tract contains four layers:
1. the innermost layer is the mucosa,
2. underneath this is the submucosa,
3. followed by the muscularis propria and
4. finally, the outermost layer-the adventitia or serosa

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CHAP.2. PATIENT’S APPROACH

Content
- History taking
- Physical examination
- How to document a Patient Assessment
- Materials to perform physical examination
2.1. What is history taking?
Asking questions of patients to obtain information and aid diagnostics.
Gathering data both objective and subjective for the purpose of generating
differential diagnoses, evaluating progress following a specific treatment /
procedure and evaluating change in the patient’s condition or the impact of
specific disease process.
Key principals of patient assessment
It is estimated that 80% of diagnoses are based on history taking alone.
Use a systematic approach.
Practice infection control techniques.
Establish a rapport with the patient.
Ensure the patient is as comfortable as possible.
Listen to what the patient says. (Scott 2013, Talley and O’Connor 210,
Jevon 2009) Ensure consent has been gained.
Maintain privacy and dignity.
Summarize each stage of the history taking process.
Involve the patient in the history taking process.
Maintain an objective approach.
Ensure that your documentation (of the assessment) is clear,
accurate and legible.
“Always listen to the patient they might be telling you the diagnosis”
(Sir William Osler 1849-1999)
Assessment (consultation) Models
The use of assessment models is dependent upon the condition of the
patient. e.g.: the ABCDE approach (Styner 1976).
Systematic, structured and suitable model.
Inter-professional (i.e. shared understanding and documentation).
Transactional analysis.
The medical model.
Physical, psychological and social.
Folk model.
The Disease-Ill ness model.
Calgary-Cambridge (kurtz).
Narrative-based medicine (Launer 2002).

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History taking
Major complaint,
Complaint history,
Possible associated events,
Patient’s past medical history,
Patient’s social history,
Patient’s drugs and toxic history,
Patient’s systemic review history,
Summary from the history taking.
2.2. Physical examination (clinical)
In a physical examination, medical examination, or clinical examination,
a medical practitioner (physician) examines a patient for any possible medical
signs or symptoms of a medical condition
It generally consists of a series of questions about the patient’s medical history
followed by an examination based on the reported symptoms/signs

PHYSICAL EXAMINATION CHECKLIST

General appearance, skin, & vital signs
General appearance 1. Observe general appearance
Skin 2. Perform an integrated skin exam during
vital signs entered exam
3. Pulse measure radical pulse for 15 second
measure systolic and diagnostic blood
pressure by auscultation
Perspiratory cite: count the respirators for
30 seconds

HEENT (Head, Eyes, Ears, Nose, and Throat)

General ✓ Inspect size and shape of the head and the scalp
impression ✓ Inspect for symmetry, masses, and signs of
trauma
✓ Inspect the skin as you perform the HEENT
exam
✓ Note any difficulty with breathing or speech

Eyes ✓ Measure visual acuity

✓ Inspect the eyelids, lashes, bulbar & palpebral
conjunctiva, sclera, cornea, anterior chamber,
and iris.
✓ Assess pupils
✓ Perform ophthalmoscopy

Ears ✓ Inspect auricle and mastoid

✓ Examine auditory canals and middle ears
structures

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Nose ✓ Examine the external nose, nares, septum, and

nasal cavities

Mouth ✓ Inspect the lips, buccal mucosa, tongue, floor of

mouth, palate, palatine tonsils, and posterior
pharyngeal wail
✓ Inspect the teeth and gums
✓ Palpate parotid glands
✓ Palpate temporomandibular joints

Neck ✓ Inspect the neck

✓ Palpate the neck, including lymph nodes
(anterior cervical, posterior cervical and
supraclavicular)
✓ Palpate thyroid
Chest
Inspection ✓ Observe respiratory and note and sings of
respiratory distress
✓ Inspect the skin of the posterior chest

palpation ✓ Assess symmetry of respiratory excursion

✓ Assess tactile fremitus

percussion ✓ Percuss the chest posteriorly

✓ Percuss the spine and the costovertebral angles

Auscultation ✓ Auscultate the chest using the diaphragm of

the stethoscope posteriorly, literally, and
anteriorly

Assess tactile fremitus

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Cardiovascular
Inspection ✓ inspect and measure JVP (jugular venous
pressure)
✓ inspect the precordium
✓ inspect the skin of the interior chest and neck
as you perform the CV exam

palpation ✓ palpate the apical impulse

✓ palpate LLSB (lower left sternal border)
✓ palpate the carotid arteries

Auscultation ✓ listen at each location diaphragm all heart

murmurs
✓ listen with the bell cardiac apex
✓ listen for bruits over each carotid artery

Peripheral circulation ✓ palpate each of the following pulses on each

side: radial, femoral etc.

Abdomen
• Right hypochondriac region
• Right lumbar region
• Right ilioinguinal region
• Epigastric region
• Umbilical region
• Hypogastric region
• Left hypochondriac region
• Left lumbar region
• Left ilioinguinal region

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FOUR QUADRANTS

Inspection ✓ Observe the patient for discomfort

✓ Inspect the abdominal contour
✓ Inspect skin as you examine the abdomen

Auscultation ✓ Listen in one place with the diaphragm of the

stethoscope

Percussion and ✓ Percuss all four quadrants

palpation ✓ Palpate all four quadrants
✓ Percuss the liver
✓ Palpate the lower liver edge
✓ Palpate for an enlarged spleen
✓ Palpate for inguinal lymphadenopathy

Once you complete the physical examination, our next steps are:
Working diagnosis and differential diagnosis
Decision and chose further investigations:
• Laboratory testing
• Imaging or morphological investigations
• General or specific
• Noninvasive or invasive
• Endoscopy +/-biopsy
• Biopsy: types, techniques
• Definite diagnosis
• Treatment: methods, indication, applications
• Follow-up, prognosis

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COMMON LAB TESTS

• Complete blood count (CBC)
• Prothrombin time (PT)
• Basic metabolic panel: glucose, Sodium, potassium, calcium, chloride,
carbon dioxide, blood urea nitrogen and creatinine
• Lipid panel; cholesterol and triglyceride levels
• Liver panel; albumin, total protein, ALP (alkaline phosphatase), ALT
(alanine transaminase), AST (aspartate aminotransferase), and gamma-
glutamyl transferase (GGT), Bilirubin, lactate dehydrogenase (LD)
• Thyroid stimulating hormone
• Hemoglobin A1C: This test is used to diagnose and monitor diabetes
• Urinalysis

MRI (magnetic resonance imaging) scanner

CT Scan (computed tomography)

2.3. How to document a Patient Assessment

SOAP framework for the follow up of inpatients or patients seen previously
(outpatients)
- Subjective
- Objective
- Assessment
- Plan
Subjective
The subjective section should include how the patient is currently feeling and
how they have been since the last review in their own words
As part of your assessment, you may ask:
- How are you today?
- How have you been since the last time I reviewed you?
- Have you currently got any troublesome symptoms?
- How is your nausea?
- Etc…

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If the patient mentions multiple symptoms, you should explore each of them,
having the patient describe them in their own words
You should document the patient’s responses accurately and use quotation
marks if you are directly quoting something the patient has said

Objective
The objective section needs to include your objective observation, which are
things you can measure, see, hear, feel or smell
Objective observation includes the following;
1. Appearance
Document the patient’s appearance
e.g. “the patient appeared to be very pale and in significant discomfort”
2. Vital signs
Document the patient’s vital signs
- Blood pressure (BP)
- Pulse rate (PR)
- Respiratory rate (RR)
- SpO2 (also document supplemental oxygen if relevant)
- Temperature (including any recent fevers)
3. Fluid balance
An assessment of the patient’s fluid intake and output including:
- Oral fluids
- Nasogastric fluids/feed
- Intravenous fluids
- Urine output
- Vomiting
- Drain output/stroma output
4. Clinical examination findings
Some examples of clinical examination findings may include:
- “widespread expiratory wheeze on auscultation of the chest”
- “the abdomen was soft and non-tender”
- “The pulse was irregular”
- “There were no cranial nerve deficits noted”
5. Investigation results
Some examples of investigation results include:
- Recent lab results (e.g. blood tests/microbiology)
- Imaging results (e.g. chest X-ray/CT abdomen)
Assessment
The assessment section is where you document your thoughts on the salient
issues and the diagnosis (or differential diagnosis), which will be based on the
information collected in the previous two sections
Summarize the salient points:
- Productive cough (green sputum)
- Increasing shortness of breath
- Tachypnoea (respiratory rate 22) and hypoxia (SpO2 87% on air)
- Right basal crackles on auscultation
- Raised white cell count (15) and CRP (80)
- Chest X-ray revealed increased opacity in the right lower zone, consistent
with consolidation

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Document your impression of the diagnosis (or differential diagnosis):

Impression: community-acquired pneumonia
If the diagnosis is already known and the findings of your assessment remain in
keeping with that diagnosis, you can comment on whether the patient is
clinically improving or deteriorating:
- On day 3 of treatment for community-acquired pneumonia
- Reduced shortness of breath and improved cough
- Oxygen saturation 98% on air, respiratory rate 15
- CRP decreasing (20), white cell count decreasing (11)
- Impression: resolving community-acquired pneumonia
Plan
The final section is the plan, which is where you document how you are going
to address or further investigate any issues raised during the review
Items you have to include in your plan may include:
i. Further investigations (e.g. laboratory tests, imaging)
ii. Treatments (e.g. medications, intravenous fluids, oxygen, nutrition)
iii. Referrals to specific specialities
iv. Review date/time (e.g. “I will review at 4 pm this afternoon)
v. Frequency and monitoring of fluid balance
vi. Planned discharge date (if relevant)

2.4. Materials to perform physical examination

The physical assessment includes:
- Audio scope
- Examination light
- Laryngeal mirror
- Nasal speculum
- Otoscope
- Ophthalmoscope
- Penlight
- Percussion hammer
- Sphygmomanometer
- Stethoscope
- Thermometer
- Tuning fork
Additional Supplies
- Cotton balls
- Cotton-tipped applicators
- Disposable needles
- Disposable syringes
- Gauze, dressing and bandages
- Gloves
- Paper tissue
- Specimen containers
- Tongue depressors

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Clinical waste bins and sachets

Clinical personal protective equipment (PPE)

1. glovers
2. face mask
3. gown
- surgical gown
- disposable
gown
4. apron
5. doctor coat

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CHAP.3. CLINICAL PROCEDURES

Content
Basic Procedures: a collection of guides to common clinical procedures such as
venepuncture, cannulation, blood pressure, measure and more
1) Intravenous access
2) Injection procedures
3) Catheterization
4) Gynaecological procedures
5) Surgical procedures
3.1. Intravenous access
Here we discuss venepuncture (venepuncture) using vacutainer bottles, so steps
may differ if you are using different equipment (e.g. a needle and syringe)
A. Gather equipment
Collect all equipment needed for the procedure and place in within reach on a
tray or trolley, ensuring that all the items are clearly visible
- Clean procedure tray
- Non-sterile gloves
- Tourniquet
- Blood sampling device (e.g.
butterfly needle and barrel): the
size should be appropriate to the vein and sample
requirements
- Blood specimen bottles
- Sharps container
- Alcohol swab (2% chlorhexidine
gluconate in 70%
isopropyl)
- Gauze or cotton wool
- Sterile plaster
- Laboratory forms, labels and transportation bag

B. Introduction
Wash your hands using alcohol gel. If your hands are visibly soiled, wash them
soap and water
Don PPE if appropriate.
Introduce yourself to the patient including your name and role
Gain consent to proceed with venepuncture
C. Choosing an arm
Choose an arm to perform venepuncture on:
- You should ask the patient if they have a preference

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- Pre-existing medical conditions may prevent particular limbs from being

used (e.g. arterio-venous fistula, lymphoedema, a stroke affecting the
movement of a limb)
- Do not perform venepuncture on an arm that has intravenous infusion in
progress as this may alter blood test results
Place a pillow under the relevant arm.
D. Choosing a vein
- Inspect the patient’s arm for an appropriate venepuncture site
- Position the patient’s arm in a comfortable extended position that provides
adequate access to the planned venepuncture site
- Apply the tourniquet approximately 4-5 fingers-widths above the planned
venepuncture site
- Palpate the vein you have identified to assess if it is suitable
- Once you have identified a suitable vein, you may need to temporarily
release the tourniquet, as it should not be left on for more than 1-2 minutes
at a time
- Wash your hands again
- Don gloves (gloves don’t need to be worn for cleaning the site, but they
should always be donned prior to performing venepuncture itself)
- Clean the site with an alcohol swab for 30 seconds and then allow to dry
completely for 30 seconds
You should start cleaning from the centre of the venepuncture site and work
outwards to cover an area of 5cm or more
Do not touch the cleaned site afterwards at any points, otherwise, the cleaning
procedure will need to be repeated prior to venepuncture
E. Insertion of the needle
- Re-apply the tourniquet if removed previously
- Attach the needle to the barrel (some blood collection systems come pre-
assembled, such as the butterfly needle with barrel)
- Unsheathe the needle
- Anchor the vein from below with your non-dominant hand by gently pulling
on the skin distal to the insertion site
- Warn the patient that they will experience a sharp scratch
- Insert the needle through the skin at a 30° angle or less, with the bevel
facing upwards. You should see flashback into the needle’s chamber and
feel a sudden decrease in resistance as the needle enters the vein
- Advance the needle a further 1-2 mm into the vein after flashback is noted
to ensure you are within the lumen
- Lower and anchor the needle to the patient’s skin using the wings of the
butterfly needle
- Attach each blood bottle, in the correct order of draw, to the barrel and
allow them to fill to the appropriate level. Make sure to continue to anchor
the needle to the skin as you remove each bottle from begins to flow into
the bottles, try slightly withdrawing or adjusting the angle of the needle
- Release the tourniquet
- Withdraw the needle and then apply gentle pressure to the site with some
gauze of cotton wool
- Ask the patient to hold the gauze or cotton wool in place whilst you dispose
of the needle into a sharp’s container.

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- Apply a dressing to the patient’s arm (e.g. cotton wool, gauze, plaster)
- Invert each of the blood bottles the suggested number of times based on its
colour
- Discard the used equipment into the appropriate clinical waste bin
Intravenous access summary
• Gather equipment
• Introduce yourself to the patient
• Choose an arm
• Choose a vein
• Insert a needle
NB Blood tests and order of draw
Below is a list of the common blood bottle types and the associated blood tests:
- Blood culture: these bottles should always be attached first,
with the aerobic sample preceding the anaerobic one
- Light blue: coagulation screen, INR and D-dimer. D-dimer and
international normalized ratio (INR) are correlate with
tumour markers and disease stage in colorectal cancer
patients
- Gold/yellow: U&Es (urea and electrolytes), CRP, LFTs (liver
function tests), amylase, calcium, phosphate, magnesium,
TFTs (thyroid function tests), lipid profile and troponins
- Purple: FCB (full blood count), blood film, ESR (erythrocyte sedimentation
rate) and HbA1c (this is a form of haemoglobin, a blood pigment that carries
oxygen, that is bound to glucose. HbA1c level routinely performed in people
with type 1 and type 2 diabetes mellitus
- Pinks: group and save allowing for cross matching
- Grey: glucose and lactate
Content
Basic procedures: A collection of guides to common clinical procedures such as
venepuncture, cannulation, blood pressure measurement and more

3.2. Injection procedure

- Subcutaneous (SC) injections
- Intramuscular injection
3.2.1. Subcutaneous (SC) injections
Subcutaneous (SC) injections pierce the epidermis and dermis of the skin to
deliver medication to the subcutaneous layer. It is a common route of delivery for
medications such as insulin and low molecular weight heparin (LMWH).
This is a step-by-step approach to performing a subcutaneous injection.
This should not be used as a guide to administering injections to actual patients
without first consulting what you learned at the faculty of medicine of the UNILU
and undertaking the necessary training
Table of contents
• Gather equipment
• Introduction
• Final steps
• Performing the subcutaneous injection

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A. Gather equipment
- Non-sterile gloves
- Apron
- Equipment tray
- Syringe (the smallest syringe that will accommodate the medication volume)
- Injecting needle (26-30 gauge); a standard length is 13-16mm
- Drawing-up needle (also known as a blunt filter needle)
- Gauze or cotton swab
- Sharps container
- The medication to be administered
B. Introduction
- Wash your hands using alcohol gel. If your hands are visibly soiled, wash
them soap and water
- Don PPE if appropriate.
- Introduce yourself to the patient including your name and role
- Gain consent to proceed with subcutaneous injection
C. Final checks
Before proceeding, check the seven rights of medication administration
❖ Right person
❖ Right drug
❖ Right dose
❖ Right time
❖ Right route
❖ Right to reduce
❖ Right documentation of the prescription and allergies
Once all of the above have been confirmed, prepare the medication
D. Performing the subcutaneous injection
Please, refer to the specific technique learned at the faculty of medicine of the
university of Lubumbashi.
3.2.2. Intramuscular injection
This intramuscular injection guide provides a step-by-step approach to
performing an intramuscular injection
This should not be used as a guide to administering injections to actual patients
without first consulting what you learned at the Faculty of medicine of the UNILU
and undertaking the necessary training
Table of contents
• Gather equipment
• Introduction
• Final steps
• Performing the subcutaneous
injection
Gather equipment
Alcohol wipe, gauze, syringe, drawing up the needle, injection needle, the
medication to be administered
Other steps please follow the same guidelines as above

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3.3. Catheterization
This is the step-by-step guides to male and female catheterization
• Female catheterization
• Male catheterization
3.3.1. Female catheterization
Table of contents
• Gather equipment
• Introduction
• Equipment preparation
• Positioning the patient
• Cleaning the genital region
• Inserting the local anaesthetic
• Inserting the catheter
A. Gather equipment
- Clean the top of a procedure trolley using a disinfectant wipe
- Collect the equipment required for the procedure and place it within reach on
the clean trolley:
• Plastic apron
• Two pairs of sterile gloves
• Sterile water-filled syringe (10ml) for inflation of the catheter balloon
• 0.9% sodium chloride (10mls)
• Lidocaine (1%) anaesthetic lubricating gel for insertion into the urethra
• Male urinary catheter (12/14 French): these are also used for females in
most cases
• Catheter pack: including cotton wool bails, sterile gauze, sterile drapes…
• Catheter bag
• Urine collection bowl
- Check the expiry date on the catheter, sterile water, normal saline
- And lidocaine gel
- Ensure a clinical waste bin is placed nearly
B. Introduction
- Wash your hands using alcohol gel. If your hands are visibly soiled, wash
them soap and water
- Don PPE if appropriate.
- Introduce yourself to the patient including your name and role
- Gain consent to proceed with catheterization
C. Equipment preparation
Setting up the sterile field
D. Positioning the patient
- With the patient lying supine, ensure the bed is at an appropriate height for
you to comfortably carry out the procedure
- Wash your hands again and don a pair of sterile gloves.
- Ask your chaperone to remove the sheet covering the patient’s genitals to allow
you to maintain sterility
- Place a sterile absorbent pad underneath the patient’s genital region, ensuring
you maintain sterility
E. Remaining steps
- Cleaning the genital region

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- Inserting the local anaesthetic

- Inserting the catheter into the urethral meatus and inflate the catheter
balloon. Then, attach the catheter bag tubing to the end of the catheter
securely
F. Final steps
- Clean away any urine spillage or excess lubricating gel and cover the
patient with the sheet
- Dispose of your equipment into a clinical waste bin
- Provide the patient with privacy to get dressed

3.3.2. Male catheterization

Table of contents
• Gather equipment
• Introduction
• Equipment preparation
• Positioning the patient
• Cleaning the penis
• Inserting the local anaesthetic
• Inserting the catheter
A. Gather equipment
- Clean the top of a procedure trolley using a disinfectant wipe
- Collect the equipment required for the procedure and place it within reach
on the clean trolley:
• Plastic apron
• Two pairs of sterile gloves
• Sterile water-filled syringe (10ml) for inflation of the catheter balloon
• 0.9% sodium chloride (10mls)
• Lidocaine (1%) anaesthetic lubricating gel for insertion into the urethra
• Male urinary catheter (12/14 French): these are also used for females in
most cases
• Catheter pack: including cotton wool bails, sterile gauze, sterile drapes…
• Catheter bag
• Urine collection bowl
- Check the expiry date on the catheter, sterile water, normal saline
- And lidocaine gel
- Ensure a clinical waste bin is placed nearly
B. Introduction
- Wash your hands using alcohol gel. If your hands are visibly soiled, wash
them soap and water
- Don PPE if appropriate.
- Introduce yourself to the patient including your name and role
- Gain consent to proceed with catheterization
C. Equipment preparation
Setting up the sterile field
D. Positioning the patient
- With the patient lying supine, ensure the bed is at an appropriate height
for you to comfortably carry out the procedure
- Wash your hands again and don a pair of sterile gloves.

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- Ask your chaperone to remove the sheet covering the patient’s genitals to
allow you to maintain sterility
Place a sterile absorbent pad underneath the patient’s genital region, ensuring
you maintain sterility
E. Cleaning the penis
- Hold the penis with your non-dominant hand using some sterile gauze and
ensure the patient’s foreskin is retracted (if present)
- With your dominant hand, pick-up a cotton ball and use a single stroke
moving away from the urethral meatus to clean an area of the glans. Dispose
of the firs cotton ball into the clinical waste bin and continue to repeat this
process with z new cotton ball each time until all areas of the glans have been
cleaned
- Discard your used gloves, wash your hands again and don a new pair of sterile
gloves
- Place the sterile drape over the patient’s penis, positioned such that the penis
remains visible through the central aperture of the drape. Some drapes come
with a hole already present for this purpose, whereas other will require you to
create one
- Place the sterile urine collection bowl below the penis but on top of the sterile
drape.
G. Finals steps
- Replace the patient’s retracted foreskin (if present) failure to do so can
result in the development of paraphimosis
- Clean away any urine spillage or excess lubricating gel and cover the
patient with the sheet
- Dispose of your equipment into a clinical waste bin
- Provide the patient with privacy to get dressed
3.4. Gynaecological procedures
These include speculum and bimanual examination
- Vaginal swabs
- Speculum examination
- Cervical screening test
3.5. Surgical procedures
- Deep dermal suture
- Surgical gowning technique
- Surgical gloving technique
- Surgical scrubbing, gowning and gloving
- Simple interrupted suture and other sutures (subcuticular and vertical
mattress sutures)

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Chap.4: HOW TO WRITE A DISCHARGE SUMMARY

Content
1. Introduction
2. Demographics
3. Clinical details
4. Future management
5. Medications
6. Allergies and adverse reactions
7. Information for the patient
8. Person completing
9. Other sections that may be included

4.1. INTRODUCTION
• Discharging patients from a hospital is a complex tack, an essential part of
this process is the documentation of a discharge summary.
• A discharge summary is a clinical report prepared by a health professional
at the conclusion of a hospital stays or series of treatments.
• It is often the primary mode of communication between the hospital care
team and aftercare provider.
• It is considered a legal document and it has the potential to jeopardize the
patient`s care if errors are made.
• Delays in the completion of the discharge summary are associated with higher
rates of readmission highlighting the importance of successful transmission of
a document in as timely fashion.
• This chapter will help you to understand what`s necessary to included and
give you a structure to effectively write discharge summaries.
• It gives a detailed description of each section that may be included in a
tropical discharge summary.
• Each section illustrates key pieces of information that should be included
and aims to explain the rationale being each part of the document.
• In practice each summary is adapted to the clinical context. As such not all
information included in this chapter is relevant and needs to be mentioned in
each discharge summary.
• In addition, different hospitals have different criteria to be included and you
should always follow your hospital`s guidelines for documentation

4.2. DEMOGRAPHICS-PATIENT DETAILS

Important information to included regarding the patient includes:
• Patient name: full name of patient (also the patient’s preferred name if
relevant)
• Date of birth
• Unique identification number
• Patient address: the usual place of residence of the patient
• Patient telephone number
• Patient sex: sex at birth
• Next of kin/emergency contact details

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GP details
This section should be completed with whom the details of the General
practioner whom the patient is registered:
• GP Practice details: name, address, email, telephone
• GP practice identifier: a notional code which identifies the practice
(CNOM)
Hospital details
This section should encompass the salient aspects of the patient’s discharge:
• Discharging specialty/department: the specialty/department
responsible for the patient at the time of discharge.
• Date and time of admission and discharge
• Discharge destination: destination of the patient on discharge from
hospital (e.g. home, residential care home)
4.3. Clinical details
1. History and examination findings
2. Investigations
3. diagnoses
Be as specific as possible when documenting diagnoses. Some examples:
• Diabetes: type 1, type 2, steroid-induced, gestational
• Myocardial infection
• Pneumonia: bacterial, viral
• Septicemia: causative organism and source (e.g. E. coli urosepsis)
• Gastroenteritis: viral, bacterial.
• Management
• Complications
• Procedures: this section include all operations or procedure that the
patient underwent.
4.4. Future management
Included details of the current plan to manage the patient and their condition’s)
after discharge from hospital:
• Treatments (e.g. Medication, surgery, etc.)
• Hospital follow-up
• Referrals made by the hospital (e.g. Referral to chronic pain team)
4.5. Medications
Summarize any changes to the patient’s regular medication and provide an
explication as to why the changes were made if possible:
• You should include a list of all medications that the patient currently
taking.
4.6. Allergies and adverse reactions
This section should outline any allergies or adverse reactions that the patient
experienced. It should be a specific as possible and include the following:
• Causative agent: the agent (food, drug or substance that caused an allergic
reaction or adverse reaction
• Description of the reaction of reaction: this may include the
manifestation (e.g. Rash), type of reaction (allergic, adverse, intolerance)
and the severity of the reaction
• Date first experienced

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4.7. Information for the patient

• Most discharge letters include a section that summarizes the key
information of the patient’s hospital stay in patient-friendly language,
including investigation results, diagnoses, management and follow up.
• This is often given to the patient at discharge or posted out the patient’s
home.
4.8. Person completing record
This section includes personal information about the healthcare provider
completing the discharge summary:
• Name
• Designation or role
• Grade
• Specialty
• Date completed.
4.9. Other sections that may be included
• social context
• special requirements
• legal information
• safety alerts

- END -

Unlocking greatness

Rédigé par : Géorges SHERIA Franck KAKUDJI