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Introduction

Basic Patient
Assessments
13

H19
15

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


with Accompanying Mark Schemes, and Typical Exam Questions
FIRST EDITION
Emily Hotton and Zeshan Qureshi

Join Our Medical Book Writing Project (details inside)

Blood Tests
Paediatrics

Practical Skills

General Skills

The Unofficial Guide to

Urology

Medicine
and Surgery

Medication
Administration

Acute Patient
Management

Hosp

No.

Tim
e

Dat
e

AU
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THE UNOFFICIAL GUIDE TO


PRACTICAL SKILLS
FIRST EDITION
Emily Hotton
Zeshan Qureshi

Introduction

ISBN 978-0957149960
Text, design and illustration Zeshan Qureshi 2014
Edited by Emily Hotton and Zeshan Qureshi
Published by Zeshan Qureshi. First published 2014
All rights reserved; no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form,
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of
the publishers.
Original design by Zeshan Qureshi and Emily Hotton. Front cover design by Zeshan Qureshi, Emily Hotton, and Tom Green.
Page make-up by Anchorprint Group Limited
Illustrated by Anchorprint Group Limited, Peter Gardiner: medical illustrations (clinical skills limited) and Martin Burnett:
clinical photographs (UK Media Solutions)
A catalogue record for this book is available from the British Library.
Publisher and Chief Editors Acknowledgements:
We would like to thank all the authors for their hard work, and our distinguished panel of expert reviewers for their specialist
input. We are extremely grateful for the support given by medical schools across the UK. We would also like to thank the
medical students that have inspired this project, believed in this project, and have helped contribute to, promote, and
distribute the book across the UK.
Thank you to Matt Harris, Andrew Strain, Baldeep Sidhu, Kyle Gibson, and Reza Jarral for their contributions to the Practical
Skills chapter of the Unofficial Guide to Passing OSCEs upon which this book has been developed.
Thank you to Ruth Harrison, Srikant Ganesh, Abiola Adeogun for acting as models. Particular thanks go to Natalie Blencowe,
for her constant advice and support. We also want to make a special mention to Dr and Mrs Hotton, who have been truly
invaluable in providing energy and support to see this project through. Thanks also go to the Bath Academy, at the University
of Bristol for the equipment and facilities for the images.
The authors and publishers would like to thank the following for permission to reproduce their images:
Reproduced by the kind permission of the Resuscitation Council (UK): Fig 3.7, 3.10, 3.13
Dr David Pothier (www.earatlas.co.uk): 3.70, 3.71, 3.72, 3.73, 3.74, 3.75
Pamela Gulland/Hannah Collinson: ECG 1-6 (Station 3.9)
Dr Richard Mansfield: Fig 3.56, 3.60, 3.61
Dr Ed Friedlander: Fig 3.66
NHS Lothian: Fig 3.65, 3.68
NHS Fife: Fig 3.64, 3.67
CME Medical UK Ltd: Fig 4.16
Commissioned photographs by:
Katrina Mason: All images: station 5.13
Martin Burnett (www.martinburnettphotography.co.uk): All other photographs
Commissioned medical illustrations by:
Peter Gardiner (petergardiner@clinicalskills.net)
Although we have tried to trace and contact copyright holders before publication, in some cases this may not have been
possible. If contacted we will be pleased to rectify any errors or omissions at the earliest opportunity. Knowledge and best
practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always
rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products
identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property that may occur as a result of any person acting or
not acting based on information contained in this book
Printed and bound by Cambrian Printers in UK

Introduction

Introduction
The Unofficial Guide to Practical Skills follows on from the huge success of The Unofficial Guide to Passing OSCEs.
This book covers the core clinical competencies for new graduates, as well as additional practical procedures that are
expected to be performed by junior doctors. Written by recently qualified foundation doctors, with review by senior
clinicians, we have ensured that all procedures follow current guidelines.
This book has detailed explanations of over 50 practical skills stations. Each station includes a corresponding mark
scheme, associated questions and answers as well as further areas to explore. The aim is to give you a comprehensive
overview of all procedures, even if you have yet to witness them in your training. Covering both basic and more
advanced practical skills, we hope this book will prove to be a handy study companion for your undergraduate and
postgraduate training.
Practical procedures can be nerve-wracking to perform, both under the close scrutiny of OSCE examiners and
pressures of daily clinical practice. The following simple measures are central to performing practical skills proficiently
and effectively:
... take time to prepare yourself for the procedure
... ensure you are familiar with the method and equipment you need
... make sure that correct infection control measures are undertaken, from hand washing to use of personal
protective items
... always identify the patient you are about to perform a procedure on and obtain the appropriate consent
... check the patient understands your explanation and allow time for them to ask any questions
... be confident in your ability
... use the experience of your peers
... if you are having difficulty, seek help
With this textbook, we hope you will become more confident and competent in these skills both in exams and in
clinical practice, but we hope that this is just the beginning. We want you to get involved, this textbook has been
written by junior doctors and students just like you because we believe:
... that fresh graduates have a unique perspective on what works for students. We have tried to capture the
insight of students and recent graduates to make the language we use to discuss this complex material more
digestible for students.
... that texts are in constant need of being updated. Every student has the potential to contribute to the
education of others by innovative ways of thinking and learning. This book is an open collaboration with you.
You have the power to contribute something valuable to medicine; we welcome your suggestions and would love for
you to get in touch. A good starting point is our facebook page, which is growing into a forum for medical education,
search for The Unofficial Guide to Medicine or enter the hyperlink below into your web browser.
Please get in touch and be part of the medical education project
Emily: emily.j.hotton@gmail.com
Zeshan: zeshanqureshi@doctors.org.uk, @DrZeshanQureshi
Facebook: http://www.facebook.com/TheUnofficialGuideToMedicine?fref=ts

The Unofficial Guide To Practical Skills

Introduction

Introduction

foreword
This book is the latest addition to The Unofficial Guide to series, giving high quality advice and guidance to medical
students through their transition into doctors. Previous books in the series have focused on tackling the nuances of OSCE
stations. However, The Unofficial Guide to Practical Skills aims to reflect the recent emphasis, by the General Medical Council
(GMC), on practical skills.
Approaching practical stations in exams can be challenging. Many medical students struggle to get hands-on experience of
practical procedures during time on the wards. In addition, doctors have their own methods for a given skill and contrasting
advice can be given. Although a breadth of opinion is good to allow you to develop, it can be a hurdle under exam pressure.
This book provides an interactive framework from which to hang this array of knowledge. Directing you through a wide range
of scenarios, from knee joint aspirations and ascitic taps to administering oxygen, with skill specific mark schemes, it gives
you a clear structure from which to hone and perfect your practical skills.
The once daunting prospect of approaching practical skills can now be overcome by using this refreshingly comprehensive
and user-friendly guide. Including both skills focused upon by the GMC and an array of additional skills essential in the
armoury of a junior doctor, this book really is the must have!
Best of luck with all your practical skills!

Robert Miller, Final Year Medical Student, University of Bristol

Introduction

Introduction

how to use this book


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

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

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

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

Questions and Answers for Candidate


These questions can be asked to the candidate with model answers provided.

Q&A

Additional Questions to Consider


These are other questions surrounding the theme of the station. They are ones to consider, discuss and
think through further to those provided.

The Unofficial Guide To Practical Skills

How to use this book

Introduction
6

Abbreviations and symbols

degrees

kPa

kilopascal(s) pressure

ABPI

ankle brachial pressure index

litre

AMD

age-related macular degeneration

LA

local anaesthetic

beta

LFTs

liver function tests

BE

base excess

LP

lumbar puncture

BiPAP

bilevel positive airway pressure

metres

BMI

body mass index

MC&S

microscopy, culture and sensitivity

BP

blood pressure

mg

milligram(s)

cm

centimetre(s)

MI

myocardial infarction

cmH2O

centimetre of water

min

minute(s)

CO2

carbon dioxide

mL

millilitre(s)

COPD

chronic obstructive pulmonary disease

mmHg

millimetres of mercury pressure

CPAP

continuous positive airway pressure

mmol

millimoles

CPR

cardiopulmonary resuscitation

MRSA

methicillin-resistant Staphylococcus aureus

CRP

C reactive protein

NPDR

non-proliferative diabetic retinopathy

CSF

cerebrospinal fluid

NTT

non touch technique

CT

computed tomography

O2

oxygen

CVP

central venous pressure

OP

oropharyngeal

DKA

diabetic ketoacidosis

PaCO2

arterial partial pressure of carbon dioxide

DLCO

diffusion capacity of the lung for carbon


monoxide

PaO2

arterial partial pressure of oxygen

ECG

electrocardiogram

PCI

primary coronary intervention

EDTA

ethylenediaminetetraacetic acid

PEA

pulseless electrical activity

FBC

full blood count

PICC

peripherally inserted central catheter

FEV1

forced expiratory volume in one second

PPE

personal protective equipment

FiO2

inspired oxygen concentration

PT

prothrombin time

FVC

forced vital capacity

SaO2

arterial oxygen saturation

GCS

Glasgow Coma Score

SAAG

serum-ascites albumin gradient

Hb

haemoglobin

SBP

spontaneous bacterial peritonitis

HCO3-

bicarbonate

STEMI

ST elevation myocardial infarction

HAS

human albumin solution

TB

tuberculosis

ICP

intracranial pressure

TLCO

transfer factor of the lung for


carbon monoxide

ID

identification

U&E

urea and electrolyte

IJV

internal jugular vein

USS

ultrasound scan

INR

international normalised ratio

VF

ventricular fibrillation

IV

intravenous

VT

ventricular tachycardia

kg

kilograms

WCC

white cell count

Introduction

Introduction

Contributors
Editors
Emily Hotton
Zeshan Qureshi

Foundation Doctor (University of Bristol)


Academic Clinical Fellow - Paediatrics (University of Southampton)

Senior Advisor
Dr Natalie Blencowe

NIHR Doctoral Research Fellow and Honorary Specialty Registrar, Surgery, University of Bristol

Srikant Ganesh Foundation Doctor (University of Bristol)


Chest Drain
Diagnostic Ascitic Tap
Diagnostic Pleural Tap
Instruments
Proctoscopy
Surgical Gowning and Gloving
Suturing

S.Ganesh

Andiran Anduvan Core Medical Trainee (Charles University, Prague)


Diagnostic Ascitic Tap
ECGs
Otoscopy
Spirometry
Therapeutic Paracentesis

A.Anduvan

Practical Skills Authors

James Hayward Foundation Doctor (University of Bristol)


Administering Oxygen
Airway Management
Central Venous Lines
Immediate Life Support
Intravenous Cannulation
Lumbar Puncture
Setting Up a Giving Set

The Unofficial Guide To Practical Skills

J.Hayward

Ruth Harrison Foundation Doctor (University of Bristol)


Death Certification
ECGs
Female Urethral Catheterisation
Fundoscopy
Inhaler Technique
Local Anaesthetic Administration
Male Urethral Catheterisation
Peak Flow

R.Harrison

N.Hall

Nikki Hall Opthalmology Trainee (University of Edinburgh)


Fundoscopy

Contributors

Emily Hotton Foundation Doctor (University of Bristol)


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

E.Hotton

Introduction

Practical Skills Authors Continued

K.Mason

Katrina Mason Core Surgical Trainee (University of Bristol)


Suturing

Senior Reviewers
Dr Steven Alderson
Dr James Andrews
Ken Arber
Dr Patrick Byrne
Frances Haig
Elizabeth Hotton
Dr Chris Lang
Sophie Macadie
Tracey Murphy
Dr David Tate
Mr Jonathan Wyatt

National Medical Directors Clinical Fellow to Health Education England


Medical Registrar, Wellington Regional Hospital, NZ
Clinical Education Facilitator, University Hospitals Southampton
Consultant Physician and GP, Belford Hospital Fort William
Clinical Education Facilitator, University Hospitals Southampton
Sister and Unit Manager, Mount Edgcumbe Hospice, Cornwall
Consultant Cardiologist, Edinburgh Royal Infirmary, Edinburgh
Clinical Education Facilitator, University Hospitals Southampton
Clinical Education Facilitator, University Hospitals Southampton
Gastroenterology Registrar, Royal United Hospital, Bath
Emergency Department Consultant, Royal Cornwall Hospital, Truro

Student Reviewers
Alexander Curtis
Vanessa Hayter
Amelia Holloway
Katherine Lattey

Introduction

University of Bristol
University of Bristol
Peninsula Medical School
Brighton and Sussex Medical School

Introduction

contents
1. Basic Patient Assesments

5. Medicine and Surgery

1.1 Heart Rate and Respiratory Rate .............................. 12

5.1 Simple Dressing Change.......................................... 122

1.2 Oxygen Saturation..................................................... 14

5.2 Spirometry.............................................................. 125

1.3 Blood Pressure.......................................................... 15

5.3 Knee Joint Aspiration............................................... 128

1.4 Lying and Standing Blood Pressure........................... 18

5.4 Nasogastric Tube Insertion...................................... 130

1.5 Ankle Brachial Pressure Index................................... 20

5.5 Diagnostic Pleural Tap............................................. 133

1.6 Blood Glucose........................................................... 22

5.6 Chest Drain............................................................. 137

1.7 MRSA Swab............................................................... 24

5.7 Diagnostic Ascitic Tap.............................................. 144

1.8 Body Mass Index....................................................... 26

5.8 Therapeutic Paracentesis......................................... 147

1.9 Nutritional Assessment............................................. 28

5.9 Lumbar Puncture..................................................... 152

2. Blood Tests
2.1 Phlebotomy............................................................... 32
2.2 Blood Cultures.......................................................... 36
2.3 Arterial Blood Gas..................................................... 39
2.4 Blood Gas Interpretation........................................... 42

3. Acute Patient Management


3.1 Immediate Life Support............................................. 48
3.2 Choking..................................................................... 54
3.3 Sizing and Fitting a Hard Collar................................. 56
3.4 Airway Management................................................. 59
3.5 Administering Oxygen............................................... 63
3.6 Intravenous Cannulation........................................... 66
3.7 Setting up a Giving Set.............................................. 72
3.8 Blood Transfusion...................................................... 75
3.9 ECGs.......................................................................... 80
3.10 Fundoscopy............................................................... 91
3.11 Otoscopy................................................................... 95
3.12 Central Venous Lines................................................. 97

5.10 Proctoscopy............................................................ 156


5.11 Instruments............................................................ 159
5.12 Suturing.................................................................. 163
5.13 Surgical Gowning and Gloving................................. 168

6. Urology
6.1 Urinalysis................................................................ 176
6.2 Male Urethral Catheterisation................................. 180
6.3 Female Urethral Catheterisation.............................. 184
6.4 Suprapubic Catheterisation .................................... 187

7. Paediatrics
7.1 Peak Flow............................................................... 192
7.2 Inhaler Technique.................................................... 194
7.3 Preparing Baby Formula Milk.................................. 197

8. General Skills
8.1 Hand Washing......................................................... 202
8.2 Infection Control..................................................... 204

4. Medication Administration

8.3 Manual Handling..................................................... 206

4.1 Intramuscular Injections.......................................... 102

8.4 Death Certification.................................................. 208

4.2 Subcutaneous Injections......................................... 105


4.3 Intradermal Injections............................................. 107
4.4 Local Anaesthetic Administration............................ 109
4.5 Intravenous Drugs ................................................. 112
4.6 Drug Administration via Nebuliser........................... 115
4.7 Operating a Syringe Driver....................................... 117

The Unofficial Guide To Practical Skills

Contents

Introduction
10

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