Introduction

Introduce yourself

Wash Hands

Ask if patient has any pain anywhere before you begin

Explanation

Describe what you are going to do

Gain consent

Get a chaperone!!

Inspection

Position patient to the supine position

Expose abdomen from xiphisternum to the pubic symphysis

Inspect the abdomen

Asymmetry

Foetal Movements

Surgical Scars

Cutaneous Signs of Pregnancy:

• Linea Nigra
• Striae Gravidarum
• Striae Albicans

Palpation

Ask about tenderness before starting!

Measure symphyseal-fundal height

• Palpate using ulnar border of left hand moving from sternum downwards
• Locate the fundus of the uterus (firm feeling)
• Locate upper border of pubic symphysis
• Measure distance in cm
• The distance should correlate with gestational age (+/- 2cm)

Determine foetal lie

Fundal Palpation

Do this with both hands to identify which pole of foetus is at fundus

Lateral Palpation

Palpate either side of uterus, moving down to determine where the fetal back lies

.

Pelvic Manoeuvre

Turn to face patients feet

Press down on either side of lower uterus to determine presenting part

The head will be ballotable (be gentle)

How many 5th’s palpable?

Foetal head is divided into fifths in the coronal plane

If you are able to feel the entire head in the abdomen it is 5/5th’s palpable (not engaged)

If you are not able to feel the head at all abdominally it is 0/5th’s palpable (fully engaged)

Auscultation

Use a Pinard’s stethoscope

You have already identified the fetuses back

Place over anterior fetal shoulder (scapulae)

To complete the examination

Re-cover patient - allow patient to re-dress in privacy

Thank Patient

Wash Hands

Summarise Findings - “fundal heigh is 36cm which is in keeping with the current gestation.  The foetus is in a longitudinal lie, with cephalic presentation, 2/5th’s palpatable with a regular heart rate”

Introduction

Introduce yourself

Wash Hands

Ask if patient has any pain anywhere before you begin

Explain procedure

Gain Consent

Chaperone – “I’m required to have a female chaperone by law, is that ok?”

Position patient at 45 degrees on bed

Ask patient to undress down to waist behind the curtain – provide sheet

General Inspection

Patient comfortable at rest?

Obvious masses, scars or asymmetry?

Close Inspection

Arms by side

Scars

Asymmetry

Masses

Deformity

Skin changes - puckering, peau d’orange, rashes

Nipple changes - retraction, discharge, eczema (Paget’s disease)

Arms above head

Repeat inspection

Look in particular for masses & puckering

Hands on Hips

Quickly repeat inspection again
Look for masses & signs of tethering

.

Palpation

Breast

Start with the normal breast

Ask to place hand behind head

Palpate 4 quadrants of breast - use flat of palm in circular motion

Palpate centrally around nipple

Assess any mass describing

• Size
• Shape
• Texture
• Tenderness
• Mobility

Nipple

Ask patient to squeeze nipple if discharge suspected

Axilla

Take the weight of the patients arm

Examine the 5 axillary areas - medial, lateral, anterior, posterior, apical

Other lymph nodes

• Cervical
• Supraclavicular
• Infraclavicular

Repeat all steps on the other breast

To complete the examination

Thank patient

Cover patient up

Wash Hands

Summarise Findings

Say you would…

• Do mammography if appropriate

Introduction

Introduce yourself

Wash Hands

Explain the examination

Gain Consent

Position patient sat on chair facing you

Inspection

Behaviour

Agitated

Anxious

Fidgety?

Hands

Dry/Sweaty

Thyroid Acropatchy -phalangeal bone overgrowth – Graves disease

Palmar Erythema

Peripheral Tremor – arms straight out in front of them with paper across back of hands

Pulse

Rate - Tachycardia – thyrotoxicosis

Rhythm – Atrial fibrillation – thyrotoxicosis

Face

Dry skin

Eyebrows - loss of outer third – hypothyroidism

Eyes

Exopthalmos – look from front, side & above – forward displacement of the eye

Visual Fields

Eye Movements

Lid Lag - hold finger high & ask patient to follow it, then quickly move it downwards – upper eyelid lags behind eye

Thyroid

Masses

Ask patient to swallow some water - watch for masses movement

Protrude tongue -if mass moves it is likely a thyroglossal cyst

Palpation

Cervical nodes

Feel for lymphadenopathy

Thyroid

Symmetry

Nodular?

Size, Shape & Mobility of any masses

Ask patient to swallow some water whilst you feel masses movement

Trachea

Percussion

Percuss downwards from sternum – Retrosternal Mass

Auscultation

Auscultate each  lobe of the thyroid for a bruit - Graves Disease

Special Tests

Reflexes - Biceps & Ankle – Hyporeflexia common in hypothyroidism

Proximal Myopathy – Tell patient to stand from a sitting position with arms crossed

Look for pre-tibial myxodema - associated with Grave’s Disease

To complete the examination

Thank patient

Wash Hands

Summarise Findings

Say you would…

• Do TFT’s
• FNA any masses found

Introduction

Introduce yourself

Wash Hands

Explain the examination

Gain Consent

Position patient on bed at 45°

Expose patients lower legs & feet

Inspect

Colour – pallor, cyanosis, redness

Skin – dry, eczema, shiny, hair loss, haemosidrin staining

Ulcers – look between toes & behind legs

Calluses - incorrectly fitting shoes?

Deformities - charcot’s joints (due to loss of proprioception)

Palpate

Temperature

Pulses – dorsalis pedis, posterior tibial, popliteal

Capillary Refill – should be < 2 seconds

Soft touch sensation – use cotton wisp

Sharp / Dull Sensation – use neurotip

Vibration Sense – 128hz tuning fork on base of toe – no need to check further if sensation intact

Monofilament – place in 5-6 areas across the foot – ensure to do the same spots on each foot

Proprioception – assess using the big toe – ensure to hold sides of toe, avoiding the nail-bed

Ankle Jerk Reflex – slightly dorsiflex the foot & tap tendon hammer over the achilles tendon

Gait

Smoothness

Symmetry

Turning - quick, slow, staggered, poor balance

Abnormalities – broad based gait, foot drop, antalgia (may suggest ongoing Charcot joint)

Examine Shoes – pattern of wear on soles - holes, asymmetrical wearing, incorrect size

To complete the examination

Thank Patient

Wash Hands

Say you would do…

Introduction

Introduce yourself
Confirm patient details
Explain procedure
Gain consent
Wash hands

Equipment

Gather the following items:

• Needle
• Barrel
• Vacutainer bottles
• Tourniquet
• Alcohol swab
• Cotton wool
• Tape

It’s often wise to bring 2 needles, barrels, bottles & swabs in case you fail first time

Procedure

1. Ensure the patient is lying or sitting comfortably - place a pillow under the arm if possible

2. Apply tourniquet – avoid nipping the patients skin

3. Palpate a vein:

• The antecubital fossa is usually the best place to go
• Go for a straight vein you can feel – ideally should have a springy feeling
• Avoid areas where veins are joining together

.

4. Put on gloves

5. Clean the area with an alcohol swab in a circular motion – 30 seconds

6. Screw the needle into the barrel

7. Unsheathe the needle

8. Anchor the vein from below with your non-dominant hand

9. Warn the patient of a “sharp scratch”

10. Insert the needle through the skin at 20-40 degrees - ensure bevel is upwards

11. You should feel a slight “give” as the needle enters the vein

12. Lower the needle & anchor the barrel firmly to the skin

13. Attach the required amount of vacutainer bottles

14. It’s essential to keep the barrel held firm & still whilst changing bottles!

15. Remove the tourniquet - this is very easy to forget, make sure you don’t!

16. Remove the needle carefully & place immediately in a sharps bin

17. Once the needle is out press down on the site with some cotton wool

18. Tape the cotton wool to the patients arm

19. Dispose of the equipment in the clinical waste bin

To complete the procedure…

Thank the patient
Wash hands
Fill out patient details on the vacutainer bottles at the bedside
Send the vacutainer bottles to the lab for testing

What if I fail my first attempt?

Don’t panic! – this is common and not the big deal you’ll feel it is

Try again:

• Get some new equipment
• Try another part of the vein, or another vein entirely

If you fail again ask someone else to try - don’t let it get you down, it’s not a big deal
.
DO NOT

Continue trying to get blood
Re-use the same equipment
.

Introduction

Introduce yourself
Wash hands
Check patient details
Explain procedure
Gain consent

Gather equipment

Non sterile gloves
Apron
Cannula Dressing
Gauze
Cannula - the standard size is 20g (pink)
Tourniquet
Saline - 10ml
Syringe – 10ml
Alcohol swab

Prepare equipment

Put on gloves & apron

Open cannula:

• Open wings
• Check top cap is working
• Slightly withdraw & replace needle – this will make it glide easier
• Unscrew the cap at the back of the cannula & place upright

Palpate a vein

Apply tourniquet - avoid nipping the patients skin

Feel for a vein:

• Go for a vein you can feel – it’s best if they feel “springy”
• It should be straight
• Tapping the vein & asking the patient to pump their fist can make it easier to see & feel veins
• It’s often easier to feel veins without gloves on
• Avoid placing the cannula where there will be lots of movement - e.g. antecubital fossa
• Avoid areas where two veins are joining (valves present)

Inserting the Cannula

1. Once you have found an ideal vein it’s time to cannulate!
2. Put gloves back on if you took them off to palpate the vein
3. Clean the area with an alcohol swab for 30 seconds - outward circular motion
4. Check with the patient that its ok to proceed
5. Remove the cannula sheath
6. Ensure needle’s bevel is pointing upwards
7. Secure the vein with your non-dominant hand from below
8. Warn them of a sharp scratch
9. Insert cannula at 20-40º – do it in a smooth firm motion & don’t hesitate
10. When you enter the vein you’ll see flashback – blood filling cannula
11. Advance the needle a further 1mm after flashback to ensure it’s in the veins lumen
12. Hold the needle still & advance the cannula forwards slightly
13. Withdraw the needle slightly so that it’s sharp point is inside of the plastic tubing
14. Advance cannula fully into vein – the needle inside the tube will stop the plastic from kinking
15. Release the tourniquet – this will reduce bleeding
16. Place some gauze directly underneath the cannula - this will prevent blood dripping
17. Apply pressure over the vein from above - this should occlude the vein & reduce bleeding
18. Remove the needle
19. Get the cap you unscrewed at the beginning & quickly screw back onto the cannula
20. Ensure you dispose of the needle into a sharps bin as soon as possible
21. Put some sticky strips on the cannula wings to steady before you flush it

There are many different methods of cannulation, this is just one example
What’s important is that you find a method you are comfortable with, and practice lots

Securing the Cannula

Place the sticky dressing over the cannulated area
Remove the sticky covering to reveal the clear plastic dressing - this can be fidgety!

Flushing the Cannula

Set up flush:

• Open 5-10ml syringe
• Get 10ml bottle of saline
• Confirm type of fluid & date of expiry
• Withdraw fluid from saline bottle into syringe
• Remove any air bubbles within syringe

Ask them to tell you if they feel any pain or discomfort
Remove the top cap from the cannula port & insert syringe

Inject the fluid into the cannula:

• It should go in smoothly with little resistance
• Watch for signs of swelling around the site – stop immediately if you see this!
• If the patient complains of pain you should also stop immediately!

Close the cannula port

To complete the procedure…

Thank the patient

Document the following;

• Patient details
• Date & time of cannulation
• Reason for cannulation
• Type of cannula used - e.g 20 gauge
• Date the cannula should be removed or replaced
• Your name

What if I fail my first attempt?

Don’t panic! – this is common and not the big deal you’ll feel it is

Try again:

• Get some new equipment
• Try another part of the vein, or another vein entirely

If you fail again ask someone else to try - don’t let it get you down, it’s not a big deal
.

DO NOT
Relentlessly continue trying to cannulate a patient - ask for help
Re-use the same equipment

Collecting the initial blood sample

1. Ask patient their name & D.O.B & compare this to their identity bracelet to ensure they match

2. Collect blood sample into the bottles used for blood transfusion in your particular hospital

3. Copy the patient details from the identity bracelet onto the bottle AT THE BEDSIDE!

4. Complete the corresponding blood transfusion form, indicating how many units you require

5. Send or take the bloods to the lab for analysis of blood type & preparation of units

How to prescribe the blood transfusion

1. Each unit of blood needs to be prescribed separately

2. This will need documenting accurately:

• The way in which this is done varies between hospitals
• Usually there is an area on the prescribing chart for IV infusions
• You should document time & date of infusion as well as the reason for transfusing

3. Generally a unit of blood is transfused over a 4 hour period (in a non-urgent scenario)

4. You should arrange to have the blood delivered to the ward (or get it yourself)

5. Blood needs to be given within 30 minutes of leaving the refrigerator – so avoid any delay!

How to check the blood transfusion

1. Request another nurse/doctor to go through the checking procedure with you

2. Ensure patient details on bracelet, notes & blood compatibility report all match EXACTLY!

3. Check blood group & serial number on blood bag  matches the compatibility report

4. Check the expiry date & time on the unit of blood to ensure it has not expired

5. Inspect blood bag for:

• Signs of tampering
• Leaks
• Discolouration 
• Clots
• Do not administer blood if any of these are seen!

Administering the blood

1. The patient obviously will require a cannula – see our how to cannulate article here

2. Attach the giving set to the blood bag & run some blood through the tubing to expel any air

3. Once sure all air has been expelled, attach other end of giving set to the cannula port

4. Set the drip rate to match the amount of time you want to give the blood over

5. You & a colleague should document the time/date the transfusion was started & sign to confirm all checks were carried out

Monitor the patient!

Monitoring the patient is an incredibly crucial part of the transfusion process

The patients baseline observations should be taken at 0, 15, 30 mins from onset of transfusion

They can then be done on an hourly basis and again when the transfusion has finished

Regular observations allow early detection of transfusion related reactions such as:

• Acute haemolytic transfusion reaction - ABO group mismatch – occurs soon after transfusion¹
• Delayed haemolytic reaction - Usually due to Rhesus Ab²
• Transfusion Related Acute Lung Injury - donor plasma containing antibodies against host³
• Non-haemolytic Febrile Reaction ⁴
• Anaphylaxis – recipient is allergic to protein components in donor transfusion

References

Click to show

Introduction

Wash hands
Introduce yourself
Explain examination
Gain consent
Achieve appropriate exposure 
Ask if patient has any pain anywhere before you begin!

Gait

Observe the patients normal gait

Stance – a broad based gait is noted in cerebellar disease
Speed – often slow & unsteady – looks very similar to a drunk person walking
In unilateral cerebellar disease there is deviation to the side of the lesion due to hypotonia 

Heel to toe

Ask the patient to walk with their heels to their toes
This is a very sensitive test and will exaggerate any unsteadiness
It is particularly sensitive at assessing function of the cerebellar vermis
This is the first function to be lost in alcoholic cerebellar cortical degeneration

Romberg’s Test

How to do it?

Romberg’s test involves asking a patient to:

• Stand up with their feet close together & hands by their sides
• Close their eyes
• Keep still as possible

You need to closely observe for signs the patient is losing balance
Make sure to be stood close to the patient when performing this test to prevent them falling

What’s a positive test?

A POSITIVE test is when the patient fails to maintain their balance with their eyes closed

What is it testing for?

It relies on the premise that a person requires at least 2 of the following 3 senses to balance:

• Proprioception- the PNS & spinal cords dorsal columns monitor the bodies position in space
• Vestibular function – the inner ear, vestibular nuclei & pathways into the cerebellum
• Vision – visual feedback from the eyes to orientate the brain in space

The Romberg test therefore assesses the bodies sense of position (proprioception)
The Romberg test is therefore used to distinguish the cause of ataxia in patients presenting to clinic

So what does a positive/negative result tell me about the pathology?
A positive test indicates the pathology is proprioceptive in origin – spinal cord / dorsal columns
A negative test in a patient with ataxia suggests the pathology is likely cerebellar in origin

Head

Speech

Speech can often be affected in cerebellar disease
Staccato speech is characteristic of cerebellar dysfunction
It results in the individual pronouncing each syllable separately

Ask the patient to repeat the following phrases:

• British Constitution
• Baby Hippopotamus
• 42 West Register Street

Nystagmus

Ask the patient to keep their head still & follow your finger with their eyes
Move your finger throughout the various axis of vision
Look for multiple beats of nystagmus – a few can be a normal variant
Other disturbances of gaze seen in cerebellar disease include:

• Dysmetric saccades
• Impaired smooth pursuit

Arms

Tone

Support the patients arm by holding their hand & elbow
Tell the patient to relax and allow you to fully control their arm
Move the arm’s muscle groups through their full range of movements 
Is the motion smooth or is there some resistance?
In cerebellar disease there is often mild hypotonia - difficult to detect clinically

Reflexes

In cerebellar disease mild hyporeflexia is often noted

• Biceps (c5, c6) 
• Triceps (c7) 
• Supinator (c6) 

Co-ordination

Pronator Drift 
Ask patient to hold out arms outstretched in front of them with palms facing upwards
Tell them to close their eyes
Watch the arms / hands for drift – the hand characteristically drifts into pronation in a positive test

Finger to Nose 
Ask patient to touch their nose, then the tip of your finger in a repetitive fashion
Move your finger around and to the extremes of their reach
Look for poor co-ordination – e.g. missing their nose or missing your finger
Look for intention tremor – most noticeable at the extremes of their reach

Dysdiadokinesia 
Ask patient to tap their palm with the other hand
Then tell them to start alternating between the palm and back of their hand as they tap
Then ask them to do it as fast as they can
In cerebellar diseases dysdiadokinesia is noted (inability to perform rapidly alternating movements)

Legs

Tone

Leg roll - roll the patients leg & watch the foot, it should flop independently of the leg
Leg lift – briskly lift leg off the bed at the knee joint, heel should remain in contact with the bed

Reflexes

Knee Jerk (L3,L4)
Ankle (L5,S1)

Co-ordination

Heel to shin test -“run your heel down the other leg  from the knee & repeat in a smooth motion”

• In cerebellar disease a coarse side to side tremor of the leg/foot will be noted

To Complete the Examination…

Thank patient
Wash Hands
Summarise Findings

Say you would…
Perform a full neurological examination if indicated
Perform appropriate imaging if indicated - e.g. CT / MRI

Introduction

Wash hands

Introduce yourself

Confirm patient details

Explain examination

Gain consent

Appropriately position the patient

Visual Acuity

Snellen chart

• Stand the patient at 6 metres from the Snellen chart
• If patient is long-sighted (hyperopia) ensure they wear glasses
• Ask the patient to cover one eye & read to the lowest line they can manage
• Visual acuity is recorded as the distance from the chart (numerator) over the number of the lowest line read (denominator)
• Record the lowest line the patient was able to read (e.g. 6/6 which is equivalent to 20/20 – patient can read at 6 metres what a healthy person could read at 6 metres)
• If patient reads the 6/6 line, but gets 2 letters incorrect, you would record as 6/6 (-2)
• If patient gets more than 2 letters wrong, then the previous line should be recorded as their acuity
• You can have the patient read through a pinhole to see if this improves vision
• If vision is improved with a pinhole, it suggests there is a refractive element to their poor vision
• Repeat above with the other eye

Fine print reading

Ask patient to cover one eye

Ask patient to read a paragraph of small print in a book/newspaper

Repeat with the other eye

If they normally wear glasses for reading, ensure these are worn for the assessment

 Visual Fields

1. Sit directly opposite the patient, at a distance of around 1 metre
2. Ask patient to cover one eye with their hand
3. If the patient covers their right eye, you should cover your left eye (just mirror the patient)
4. Ask patient to focus on your face & not move their head or eyes during the assessment, you should do the same and focus your gaze on the patients face
5. Ask the patient to tell you when they can see your fingertip wiggling
6. Position your fingertip at the border of one of the quadrants of your visual field
7. Slowly bring your fingertip inwards, towards the centre of your visual field until the patient sees it
8. If you are able to see your fingertip, but the patient cannot, this would suggest a reduced visual field
9. Repeat this process for each quadrant, then repeat the entire process for the other eye
10. Document your findings

Visual neglect / inattention

1. Sit directly opposite the patient, at a distance of around 1 metre
2. Ask patient to focus on your face & not move their head or eyes during the assessment
3. Hold both arms out, with your fingers in the periphery of both yours & the patients field of vision
4. Remind the patient to keep their head still & their eyes fixed on your face
5. Ask patient to point at which fingers are moving
6. Move the fingers of left & right hand in whichever order you choose
7. Then move the fingers of both hands simultaneously
8. If the patient only points to one of the hands, when fingers are moving on both hands, this would be suggestive of visual neglect

Visual neglect can suggest damage to the frontal or parietal lobes of the brain - stroke, trauma, etc

 Pupils

Inspection

Size
Shape
Symmetry

Reflexes

Too best see pupillary reflexes, the room should be dimly lit

Direct pupillary reflex

Shine light into the pupil & observe constriction of that pupil
Sluggish or lack of constriction may suggest pathology – optic nerve / brain stem pathology, drugs

Consensual pupillary reflex

Again shine a light into the pupil
This time observe the contralateral pupil
A normal consensual response involves the contralateral pupil constricting
Lack of a normal  consensual response may suggest:

• Damage to one or both optic nerves.
• Damage to the Edinger Westphal Nucleus

Swinging light test

• Move the pen torch rapidly between the 2 pupils
• This test may detect a  relative afferent pupillary defect (RAPD) - caused by damage of the tract between the optic nerve & optic chiasm, such as optic neuritis in multiple sclerosis. It is also known as a “Marcus-Gunn” pupil.)
• A RAPD can be detected by paradoxical dilatation of the affected pupil when light is shining into it (it should normally constrict)

Accommodation reflex

• Ask the patient to focus on a distant object
• Then ask them to focus on a much closer object (often a finger or pen torch)
• A normal accommodation reflex involving constriction & convergence of the pupils should be observed

Cover / Uncover Test

Firstly inspect for a squint (strabismus) whilst the patient is at rest looking straight ahead

Then perform the cover / uncover test to detect if a manifest strabismus (heterotropias) or a latent strabismus (heterophorias) are present:

• Alternating Cover Test
• Unilateral Cover Test

Eye Movements

Ask the patient to keep their head still & follow your finger with their eyes

Move your finger through the various axis of eye movement (“H“ shape)

Observe for restriction of eye movements – e.g. inability to abduct eye in affected eye in abducens (VI) nerve palsy

Observe for any obvious nystagmus and saccades:

Physiological Nystagmus is often observed at the extremes of gaze (end point nystagmus)

The rapid, jerky movement that corrects the gaze after the slower deviation is called a saccade

Fundoscopy

Preparation

Darken the room

Ideally the patient should have their pupils dilated with short-acting  mydriatic eye drops (e.g. 0.5% tropicamide)

Ask the patient to fixate on a distant object

Assess for red reflex

Ideally this should be assessed at a distance of around 30cm
Looking through the ophthalmoscope observe for a reddish / orange reflection in the pupil
The red reflex is caused by light reflecting back from the vascularised retina
Absence of the red reflex in adults often is due to cataracts in the patients lens, blocking the light, but it can also be associated with retinoblastoma

Move in closer & examine the eye with the fundoscope

Begin medially & assess the optic disc - colour / contour / cupping
Assess the retinal vessels – cotton wool spots / AV nipping / neovascularisation
Finally assess the macula – ask to look directly into the light – Drusen seen in macular degeneration

To complete the examination

Thank patient

Wash hands

Summarise findings

Mention further investigations you would like to perform:

• Ishihara colour testing plates
• Retinal photography
• Full cranial nerve examination

Introduction

Wash hands

Introduce yourself

Confirm patient details

Explain examination

Gain consent

Appropriately position & expose the neck for optimal examination

General inspection

Identify any scars on the neck – may suggest previous surgery (e.g. thyroidectomy)

Observe for any obvious masses in the neck

If a mid-line lump is present:

• Ask the patient to swallow some water – the thyroid or a thyroglossal cyst will rise
• Ask to protrude the tongue - thyroglossal cyst will rise with tongue movement, whereas thyroid will not

Look for obvious systemic signs that may relate to neck pathology:

• Cachexia - malignancy
• Exopthalmos / Proptosis - Graves disease

If there is a mid-line lump / scar or systemic signs suggestive of thyroid disease ,ask examiner if a full thyroid status exam should be performed.

Palpation

Lymph nodes

Can be enlarged for a number of different reasons such as infection or malignancy

Normally lymph nodes are smooth & rubbery, with some mobility.

An enlarged, hard, irregular lymph node would be suggestive of malignancy.

• Supra-clavicular - left sided enlarged lymph node – Virchows node 
• Anterior cervical chain
• Posterior cervical chain
• Sub-mental
• Sub-mandibular
• Occipital
• Pre-auricular
• Post-auricular

Palpate the neck

Mid-line

• Lymph nodes – often multiple, may suggest infection or malignancy
• Thyroid gland - located below thyroid cartilage
• Thyroid nodule – can be single or multiple – adenomas, cysts, malignancy
• Thyroglossal cysts – painless, smooth, cystic – rises on tongue protrusion

Anterior Triangle – area of the neck anterior to sternocleidomastoid 

• Lymph nodes
• Salivary gland swelling (doesn’t move on swallowing)
• Branchial cyst – often located at anterior border of sternocleidomastoid – present since birth
• Carotid aneurysm -pulsatile mass  – bruit present on auscultation
• Carotid body tumour – transmits pulsation – can be moved side to side but not up & down (due to carotid sheath)
• Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing

Posterior triangle – area of the neck posterior to sternocleidomastoid 

• Lymph nodes – often multiple - can be rubbery or hard depending on etiology
• Subclavian artery aneurysm – pulsatile mass
• Pharyngeal pouch – may present as a reducible mass
• Cystic Hygroma – most commonly on left side – fluctuant mass – trans-illuminates
• Branchial cyst

Assessing the lump

Size – width, height, depth

Location - can help narrow the differential – anterior / posterior triangle or mid-line

Shape – well defined?

Consistency – smooth, rubbery, hard, nodular, irregular

Fluctuance - if fluctuant, this suggests it is a fluid filled lesion – cyst

Trans-illumination – suggests mass is fluid filled – e.g. Cystic hygroma

Pulsatility - suggests vascular origin – e.g. carotid body tumour / aneurysm

Temperature - increased warmth may suggest inflammatory / infective cause

Overlying skin changes – erythema, ulceration, punctum

Relation to underlying / overlying tissue - tethered? mobile? (ask to turn head)

Auscultation – to assess for bruits – e.g. carotid aneurysm

To complete the examination

Thank patient

Wash hands

Summarise findings

Mention further investigations you’d like to perform:

• Ultrasound scan
• Fine needle aspiration
• Full examination of the lymphoreticular system

Introduction

Introduce yourself

Check patient details:

• Ensure the patient is not on any anticoagulants
• Check platelets are not low & confirm coagulation blood results are normal
• Take note of whether the patient is requiring oxygen & record how much (e.g. 15L)

Explain procedure:

“I need to take a sample of blood from an artery in the wrist to assess the oxygen levels in your circulation. It will be a little painful, but will only take a short time”

Gain consent

Allen’s Test:

1. This test involves the assessment of the arterial supply to the hand
2. Ask the patient to raise their hand & make a fist for 30 seconds
3. Apply pressure over both the radial & ulnar artery at the wrist, occluding them
4. Then ask the patient to open their hand, which should appear blanched
5. Remove the pressure from the ulnar artery, whilst maintaining pressure over the radial
6. If there is adequate blood supply from the ulnar artery, colour should return within 7 seconds

If colour does return within 7 seconds, this is considered a “negative” result.
Alternatively, if the colour does not return within the timeframe, this is considered a “positive” result.
A positive result suggests that the ulnar arteries supply to the hand is inadequate.
This suggests that sampling from the radial artery on the hand is unsafe, due to the reliance on the radial artery to supply the majority of the hands tissues.
It should be noted that there is no evidence performing this test reduces the rate of ischaemic complications of arterial sampling.

Gather equipment

Arterial blood gas needle - heparinised 

Alcohol swabs

Gauze

Tape

Taking the sample

Wash hands

Position patients arm -  ideally the wrist should be extended to make the artery more superficial

Palpate radial artery - most pulsatile on the lateral anterior aspect of the wrist

Put on gloves 

Clean the site with an alcohol wipe

Attach needle to the syringe & expel the heparin 

Inserting the needle:

• Use one hand to palpate the radial artery
• Ensure you fully understand the course of the artery
• Insert the needle using your other hand at an angle of 30 degrees
• Aim towards the pulsation you are palpating with your non-dominant hand
• As you puncture the artery, you should observe bright red blood flashback into the needle
• The needle should begin to self-fill, in a pulsatile manner
• Once the required amount of blood has been collected, quickly remove the needle
• You should immediately press down firmly with some gauze over the site
• You need to press down firmly for at least 5 minutes, to prevent haematoma formation
• Some ABG needle sets come with a rubber block, to insert the used needle tip into
• Remove the needle from the syringe & discard into a sharps bin
• Place a cap on the syringe, and fill the cap with blood

To complete the procedure

Dress puncture site

Thank patient

Remove gloves and wash hands

Take blood gas sample to an analyser as soon as possible to ensure accurate results

Introduction

Introduce yourself

Wash hands

Check patient details

Explain the examination

“I need to perform a rectal examination, which will involve me inserting a finger into the back passage. It will be a little uncomfortable, but shouldn’t be painful and will only last a very short time”

Gain Consent

Request a chaperone 

Gain adequate exposure:

• Ask patient to remove trousers / underwear & to cover themselves with the blanket provided
• Leave the room & allow them time to do this
• Maintaining patient dignity is of the highest priority

Position the patient in the left lateral position with their knees to their chest

Put on gloves 

Inspection

Separate the buttocks & inspect for:

• Skin excoriation / skin tags
• Rashes
• Haemorrhoids
• Anal fissures
• External bleeding
• Fistulae

Palpation

Lubricate the examining finger

Warn the patient you are about to insert the finger

Insert finger gently into the anal canal

Rotate the finger 360 degrees to assess the entirety of the internal rectum:

• Note location & texture of any masses / irregularities – e.g. 2cm irregular mass at 11oclock
• Is there stool in the rectum? – soft vs impacted
  

In males the prostate can be located anteriorly:

• Comment on the size / symmetry & texture of the prostate
• It should be smooth, symmetrical & approximately the size of a walnut

Assess anal tone by asking the patient to squeeze your finger

Withdraw finger 

• Inspect for blood – fresh red vs malaena
• Inspect for stool / mucous

Clean patient using paper towels 

Cover patient with the sheet provided & explain the examination is over

Allow them privacy to get dressed

Wash hands

To complete the examination

Once dressed, thank patient & explain your findings

Further tests such as:

Bloods – FBC & Haematinics (?anaemia)

Tumour markers - e.g. CEA is raised in colorectal cancer

Faecal occult blood

Flexible sigmoidoscopy / colonoscopy - direct visualisation of lesions +/- biopsy

CT Abdo / Pelvis - to identify potential malignant masses / lymphadenopathy / collections

Introduction

Introduce yourself

Check patient details

Wash hands

Explain procedure

“At the moment you’re having trouble swallowing food in the normal way and therefore we need to place a fine tube through the nose going into the stomach, to enable you to receive nutrition in the meantime“

‘The procedure will be uncomfortable, but shouldn’t be painful, and it won’t take very long. If at any point it becomes too uncomfortable and  you want me to stop, let me know. You can tap my arm, if you are unable to talk”

Gain consent

Gather equipment

NG Tube – fine bore

Disposable gloves

Lubricant - to lubricate NG tube tip

Disposable bowl - in the event of vomiting etc

Paper towels - to allow patient to wipe around their mouth if needed

Large syringe - to obtain an aspirate

pH testing strips - to assess pH of aspirate

Tape / dressing to secure NG tube

Glass of water for the patient (if swallow is deemed safe)

Insertion of NG tube

1. Position the patient sitting upright with their neck straight

2. Measure the desired length to be inserted:

• Measured from tip of the nose
• Looping around the ear
• To 5cm below the xiphisternum

3. Lubricate the tip of the NG tube

4. If available, a local anaesthetic spray can be used on the back of the throat

5. Insert the NG tube in through a nostril - warn the patient prior

6. Gently advance the NG tube through the nasopharynx:

• This is often the most uncomfortable part for the patient, so don’t go too slowly
• If resistance is met, rotating the NG tube can help, however DO NOT force the NG tube
• If the patient is becoming distressed or gagging, pause to allow the patient to relax
• It’s useful to look inside the patients mouth intermittently to ensure the NG isn’t coiling in there

7. Continue to advance the NG tube down the oesophagus

• Ask the patient to take some sips of their water & swallow
• This can help facilitate the advancement of the NG tube
• However avoid giving patients a drink if their swallow is deemed unsafe

8. Once you reach the desired insertion length, fix the NG tube to the nose with a dressing

9. Attempt to aspirate gastric contents:

• If aspiration is successful, test the pH – if <4 this suggests correct placement
• If aspiration is unsuccessful or the pH is >4 the patient will require  a CXR
• Some hospitals require a CXR regardless of pH, so check your local guidelines
• Acceptable pH ranges also vary between hospitals, so consult local guidelines

10. One NG tube is deemed safe for feeding, the guidewire can be removed

 To complete the procedure

Explain to patient that the procedure is over

Reassure that the NG tube will become more comfortable over the next few hours

Offer patient paper towels to clean face / nose

Wash hands

Document clearly the procedure of NG tube placement:

• Your full name & medical grade
• Procedural details & any complications
• Aspirate pH (if you were able to aspirate anything)
• CXR details if used - e.g. NG tube visible dissecting the carina & sits below the left hemidiaphragm 
• Outcome - e.g. “SAFE to commence feeding”
• Your signature, bleep/DECT number and GMC number

Inform nursing staff that the NG tube is inserted & safely positioned

Before death confirmation

Indicate you would check the resuscitation status of the patient before doing anything else:

• If the patient is not for resuscitation, continue to confirm the death
• If there is uncertainty as to the resuscitation status, CPR should be commenced whilst this is clarified

Ask the ward staff about the circumstances surrounding the death, as you should ideally document this.

Ask for the patients notes:

• Double check for a resuscitation status form
• Read the last few entries for some background

If family or friends are present:

• Introduce yourself
• Offer your condolences
• Explain the need to confirm the death
• Offer the family the opportunity to wait outside - respect their preference 

Death confirmation

1. Wash hands

2. Confirm the identity of the patient - check the wrist band

3. General inspection - skin colour / any obvious signs of life 

4. Look for signs of respiratory effort

5. Does the patient respond to verbal stimuli? – “Hello Mr Smith, can you hear me?”

6. Does the patient respond to pain? - press on fingernail / trapezius squeeze 

7. Assess pupils using pen torch - After death they become fixed & dilated

8. Feel for a central pulse - carotid artery

9. Auscultation:

• Listen for heart sounds for at least 1 minute
• Listen for respiratory sounds for at least 3 minutes

10. Assess for a pacemaker - not essential, but good practice, as will need to be checked prior to cremation

11. Wash hands and exit the room – ensuring the door is closed / curtains are drawn

Documentation

Once you have completed the above, document your assessment clearly

Ensure you adhere to hospital documentation guidelines - date / time / your name & grade

Document each of the examination steps you performed & the result of each step

Finally document that you are confirming the death & the time at which you did so

Sign & print your full name, grade, GMC number and Bleep/DECT number

To complete death confirmation

Inform nursing staff that you have confirmed the death:

• They will then inform next of kin, if not already present
• They will also contact the porters to arrange transfer of the body to the morgue

Offer to speak with the family - to discuss any questions or concerns

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Knowing which blood bottles to use for different tests may not be that important for passing your finals, but will be absolutely essential when you start work on the wards afterwards. It is one of those practical things which tends to be poorly taught at medical school, if at all. Instead you are seemingly expected to just pick it up on your first day as an F1, when taking bloods correctly will suddenly become a massive cornerstone of your workload. Even though most hospitals now have printable stickers for bottles which tell you which ones to use, it is still vital to have a basic understanding of which bottles are used and why, to prevent embarassing mistakes and/or awkward phone calls from the lab.

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The colours of the Vacutainer bottles are standardised, but depending which hospital you end up working in there may be some variation in preferences between individual laboratories, especially when it comes to tests which are performed less commonly. I have used as many sources as possible to compile the information below, so hopefully it is as accurate as possible, but obviously I cannot guarantee it will be applicable to all hospitals. Always check local guidelines if you’re not sure.

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For more information on how to perform venesection, see here for the Geeky Medics OSCE guide.

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THE PURPLE ONE (aka “Lavender”)

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These bottles are generally used for haematology tests where whole blood is required for analysis.

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ADDITIVE: contains EDTA (ethylenediaminetetraacetic acid), which acts as a potent anticoagulant by binding to calcium in the blood. EDTA also binds metal ions in the blood and is used in chelation therapy to treat iron, lead or mercury poisoning. Its blood-binding capacity also means it can be labelled with radioisotopes and used as an EDTA scan to test renal glomerular filtration rate.

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COMMON TESTS: 

• full blood count (FBC)
• erythrocyte sedimentation rate (ESR)
• blood film for abnormal cells or malaria parasites
• reticulocytes
• red cell folate
• Monospot test for EBV
• HbA1C for diabetic control
• parathyroid hormone (PTH)*
• less commonly used for: ciclosporin/tacrolimus levels, some viral PCR tests, G6PD, ACTH level*, porphyria screen*, plasma metanephrines*, fasting gut hormone screen*

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TIPS FOR USE: the purple tube needs inverting about 8 times to mix the sample with the EDTA. About 1ml of blood is sufficient to do a full blood count, but to get an ESR you need a full purple bottle.

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THE PINK ONE

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The pink bottles work in the same way as the purple ones, but are specifically used only for whole blood samples being sent to the transfusion lab.

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ADDITIVE: this tube also contains the anticoagulant  EDTA.

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COMMON TESTS:

• group and save (G&S) - this simply means the patient’s blood is typed and tested for antibodies, then saved in the lab in case it is required; it DOES NOT get you blood products for transfusion. If you need blood products you have to request a crossmatch.
• crossmatch (XM) – this means that the patient’s blood is typed and tested as above, then matched to specific units of blood, platelets or other products for transfusion. You need to specify on the form how many units you need, why you need them and when they are required. A full crossmatch takes about 45-60 minutes in the lab – if you have an unstable bleeding patient and think you’ll need blood products sooner than this, you still need to send a crossmatch sample, but you can ask the lab for units of type-specific blood (which take 10-20 minutes), or in a genuine emergency you can use their stocks of O negative blood from the fridge.
• direct Coomb’s test (aka direct antiglobulin test) for autoimmune haemolytic anaemia
• less commonly used for: testing for specific red cell antibodies (3 bottles required), can be used for other haematology tests such as FBC if the ward runs out of purple bottles.

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TIPS FOR USE: the pink tube needs inverting about 8 times to mix the sample with the EDTA. It should contain at least 1ml of blood, but more is preferred by the labs if at all possible. It has a special label which needs to be carefully filled in by hand at the bedside to ensure the correct patient details are used and prevent potentially catastrophic mismatched blood transfusions. If you need blood for a patient urgently, or have any unusual or complicated requests, you must ring the transfusion lab and let them know, or you risk invoking their terrifying wrath.

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For more detail on safe blood transfusion, see here for the Geeky Medics OSCE guide.

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THE BLUE ONE

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The blue bottle is used for haematology tests involving the clotting system, which require inactivated whole blood for analysis.

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ADDITIVE: contains buffered sodium citrate, which acts as a reversible anticoagulant by binding to calcium ions in the blood and subsequently disrupting the clotting cascade. Sodium citrate is also added to blood products for transfusion, and acts as a preservative by stopping them from clotting in the bag.

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COMMON TESTS:

• coagulation screen including bleeding time for platelet function, prothrombin time (PT) for extrinsic pathway, activated partial thromboplastin time (APTT) for intrinsic pathway, and thrombin time (TT) or fibrinogen assay for the final common pathway
• D-dimer for thrombosis e.g. due to DVT or PE
• INR for monitoring patients on warfarin (this is calculated from the prothrombin time)
• activated partial thromboplastin ratio (APTR) for monitoring patients on IV heparin infusions (this is calculated from the APTT)
• anti-Xa assay for monitoring patients on high-dose low molecular weight heparins like tinzaparin
• less commonly used for: specific clotting factors e.g. factor VIII, factor IX, von Willebrand factor, thrombophilia screen, lupus anticoagulant

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TIPS FOR USE: the blue bottle needs to be inverted 3-4 times to mix the sample with the anticoagulant. The sodium citrate liquid in the bottle dilutes the blood sample, and the machines in the lab are specifically calibrated to interpret results based on a set ratio of blood to anticoagulant. It is therefore essential that the bottle is filled to the line marked around its edge to ensure the tests are interpreted accurately – otherwise the samples may be over-anticoagulated. Some clotting tests need to be taken at specific times; INRs should ideally be done in the morning, and anti-Xa assays must be taken 3-4 hours after tinzaparin is given. APTR timings are often indicated on the prescription algorithm.

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THE YELLOW ONE (aka “Gold”)

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These bottles are used for a huge variety of tests requiring separated serum for analysis, including biochemistry, endocrinology, oncology, toxicology, microbiology and immunology.

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ADDITIVE: this tube is known in the lab as the SST (serum separating tube). It contains two agents; silica particles and a serum separating gel. The silica particles work to activate clotting and cause the blood cells to clump together. The serum separator consists of an inert polymer gel which floats as a layer between the blood cells and plasma to form a physical barrier between them. This means that the sample can be centrifuged (spun) in the lab and the separated serum easily removed.

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COMMON TESTS:

• biochemistry tests are the ones you will encounter most commonly:
• urea and electrolytes (U+E) – this includes urea, creatinine, sodium and potassium
• C-reactive protein (CRP)
• liver function tests (LFTs) – this includes bilirubin, ALP, AST/ALT, GGT, total protein and albumin
• amylase assay
• bone profile - this includes calcium, phosphate, ALP and albumin
• magnesium assay
• iron studies - this includes serum iron, ferritin, transferrin saturation and total iron binding capacity
• lipid profile – this includes cholesterol, LDL, HDL and triglycerides
• thyroid function tests (TFTs) – this includes TSH, free T4 +/- free T3
• vitamins e.g. vitamin B12
  
• troponins – this requires 2 samples to be taken at different times to assess the acute trend
• creatine kinase (CK)
• urate
• serum osmolality – this requires a urine sample to be taken at the same time
• endocrinology: beta-hCG, calcitonin*, cortisol, EPO, sex hormones, growth hormone, IGF-1
• tumour markers: PSA, CEA, CA-125, CA19-9, AFP, lactate dehydrogenase (LDH)
• toxicology: ethanol, cannabis, opiates, benzodiazepines, other drugs e.g. cocaine, amphetamines
• drug levels: paracetamol, salicylates (aspirin), digoxin, lithium, gentamicin, carbamazepine
• microbiology/virology: serology for a wide variety of bacterial, viral, fungal and parasitic infections including HIV and viral hepatitis
• immunology: immunoglobulins, complement, autoantibody screen, rheumatoid factor, thyroid antibodies, α1AT, ACE

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TIPS FOR USE: the yellow bottle needs to be inverted about 5 times to mix the sample with the silica and separator. Don’t panic if the blood starts to clot or separate in the bottle, it’s supposed to! The amount of blood required will depend on how many tests you’re doing, but at least 1ml is ideal. You can usually get about 12 tests from one full yellow bottle. Remember that different labs may be located in different areas and technicians don’t like sharing – this means you’ll need to put your biochemistry and microbiology samples in separate yellow bottles to go to their respective laboratories.

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THE GREY ONE

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The grey bottle is only used for two tests, so compared to the yellow one it’s fairly easy to remember! It is used for biochemistry tests requiring whole blood for analysis.

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ADDITIVE: contains two main agents. Sodium fluoride acts as an antiglycolytic agent to ensure that no further glucose breakdown occurs within the sample after it is taken. Potassium oxalate acts as an anticoagulant. Some variants of the grey bottle use EDTA as the anticoagulant instead.

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COMMON TESTS:

• glucose - this can be fasting or non-fasting, or part of a glucose tolerance test (GTT)
• lactate
• less commonly used for: blood ethanol if not for legal purposes

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TIPS FOR USE: the grey bottle needs to be inverted about 8 times to mix the sample with the fluoride and oxalate. Only a tiny amount of blood is required for a glucose, but for a lactate the bottle should ideally contain at least 1ml of blood. Venous glucose results are generally more accurate than fingerprick BM tests, especially in hyperglycaemic patients, but can take a while to come back from the lab. If you need a blood glucose urgently then ask one of the nurses to do a BM for you on the ward. Samples for venous lactate need to be sent to the lab immediately. Again, the results tend to take a while to come back, so if you’re desparate for a lactate see if you can get access to an ABG machine that does arterial lactates – these are often available in A+E or ITU, and take about 2 minutes to process.

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THE RED ONE

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The red bottle is less common – it is used for biochemistry tests requiring serum which might be adversely affected by the separator gel used in the yellow bottle.

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ADDITIVE: contains silica particles which act as clot activators.

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COMMON TESTS: 

• the use of this bottle varies greatly -  some hospitals use it for many sensitive tests, including hormones, toxicology, drug levels, bacterial and viral serology and antibodies, whereas others seem to only use it for a few very specific purposes and use the yellow bottle for most things.
• my hospital definitely uses it for ionised calcium, but not much else
• less commonly used for: fluoride, cryoglobulins, cold agglutinins

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TIPS FOR USE: the red bottle needs inverting 5 times to mix the sample with the clot activator. There is also another version of the red bottle made out of glass, which contains no additives whatsoever.

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THE DARK GREEN ONE

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This less commonly used bottle is for biochemistry tests which require heparinised plasma or whole blood for analysis.

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ADDITIVE: contains sodium heparin, which acts as an anticoagulant.

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COMMON TESTS:

• ammonia*
• insulin*
• renin and aldosterone
• less commonly used for: aluminium, gut hormones, amino acids, homocysteine, chromosomal tests

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TIPS FOR USE: the green bottle needs to be inverted about 8 times to mix the sample with the heparin. This bottle cannot be reliably used to assess sodium levels.

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THE LIGHT GREEN ONE

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This rare species of bottle is used for biochemistry tests requiring separated heparinised plasma. I have never actually used one but have seen them on the dermatology ward.

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ADDITIVE: this bottle is known as the plasma separator tube (PST). It contains lithium heparin, which acts as an anticoagulant, and a plasma separator gel similar to that used in the yellow bottle, which acts to separate out the plasma layer.

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COMMON TESTS: it can be used for routine biochemistry, but most hospitals seem to use the yellow bottle for this. It can also be used for blood ethanol provided the sample is not for legal purposes.

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TIPS FOR USE: the light green bottle needs inverting about 8 times to mix the sample with the heparin and separator. This bottle cannot be reliably used to assess lithium levels.

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OTHER ONES I HAVE LITERALLY NEVER SEEN

Despite 18 months of adventures on the wards, there are still some blood bottles I have not yet encountered. I can only assume this means they are hardly ever used and therefore not ones you’ll need to know in detail. They include:

• dark blue – used for toxicology and trace elements such as zinc, selenium and copper (however, the ever-versatile yellow bottle can also be used for these)
• tan – used to test for lead
• orange – contains a thrombin-based clot activator which allows stat serum testing
• light yellow – used for HLA phenotyping, tissue typing, DNA analysis and paternity testing
• white - used for molecular diagnostics such as PCR and DNA amplification studies
• black - for paediatric ESR
• clear lid - used as a discard tube, for example when taking bloods from a central line

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BLOOD CULTURES

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Blood culture bottles contain a culture medium to encourage the growth of any bacteria in the blood sample. There are different bottles available with culture media for aerobic (blue lid) and anaerobic (purple lid) organisms, alongside a variety of others, including one with a black lid for mycobacterial cultures. Until recently, many hospitals required both aerobic and anaerobic culture samples from a patient, whilst others were happy with just aerobic samples. However, there is now a move towards using the purple top (aka “burgundy”) anaerobic bottles as the standard receptacle for all blood cultures, as studies have shown that they are more effective. Check local guidelines if you’re not sure.

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TIPS FOR USE: blood cultures must be obtained using aseptic non-touch technique (ANTT) to prevent contamination of the samples with the patient’s skin flora or any bugs that might be lurking on your hands. They should also be taken before any antibiotics are started. The blood culture bottle should always be the first one you fill, and ideally needs 8-10ml of blood to ensure a good chance of catching any organisms. In a perfect world, you would also take another culture from a different site to maximise the diagnostic yield. The results take about 5 days to come back, so if your patient is septic you need to ring microbiology and start them on some empirical antibiotic treatment in the mean time.

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ARTERIAL BLOOD GASES (ABGs)

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An ABG is a very useful test when you find yourself confronted with a critically unwell patient, as it tells you about their oxygenation, their acid-base balance, and in some cases their potassium and lactate as well, and the results are available within minutes.

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TIPS FOR USE: ABG syringes contain heparin to prevent the sample from clotting – you need to expel this through the needle before taking your sample. Some fill automatically as the plunger is pushed back by pressure of the blood coming through the needle, whilst others require you to pull on the plunger yourself to fill the syringe. Try to get the self-filling ones – like those shown above – if you can, as they are infinitely better. Compared to taking venous bloods, ABGs are technically more challenging, more risky and much more uncomfortable for the patient. For more detail and tips on how to take an ABG, see here for the Geeky Medics OSCE guide. Once you have obtained your sample it needs to be taken straight to the lab, as it will become denatured and useless within 10 minutes.

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OTHER TIPS FOR EASY BLOOD-TAKING

“Invert” doesn’t mean “shake”. Be gentle with your samples or they’ll haemolyse.

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Tests above with a star (*) next to them need to be sent to the lab immediately “on ice” – to do this you either need to get a special ice bag directly from the lab, or if your ward has an ice freezer you can make one yourself by filling a normal sample bag with crushed ice. If you’re not sure you’re doing it right, ring the lab and check, because they can make life very difficult by refusing to accept specimens.

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The bottles can be used for other non-blood fluids too, for example pleural aspirates, ascitic taps and CSF samples obtained by lumbar puncture. The tests each bottle is used for are the same: the purple one is for cell count, the yellow one is for electrolytes, albumin and LDH, the grey one is for glucose, and blood culture bottles can be used for fluid cultures. Don’t forget to specify on your request form what kind of fluid is in the bottle and which part of the patient you got it from.

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If you are ever unfortunate enough to find yourself having to get bloods from a child, there are special paediatric blood bottles which are much smaller than the adult ones. The colours are pretty much the same. If you get really stuck and can’t find any, you can use adult bottles instead, but always take them to the lab and explain they are from a child so they don’t reject them as inadequate (they usually have special machines for processing tiny kiddie samples but like to keep this a secret).

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If you are unsure about what you need to do for a particular blood test, ask your friendly local lab technician. They are usually more than happy to give you advice as it means they can prevent you making mistakes that create lots of hassle and annoying paperwork. It’s also better for you if you check, as it saves you having to do your bloods all over again if you do it wrong, and saves your patient from the unpleasantness of unnecessary additional stabbings. Similarly, if you have a really urgent test or only got a pathetically miniscule blob of blood from your patient, take it down to the lab and explain things in person. You’ll find everything miraculously gets done ten times quicker, and smaller samples they would normally reject will often be accepted, if you talk to them face-to-face and ask nicely.

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SUMMARY

Here’s a table summarising the bottles you’ll need for common blood tests:

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I hope you found this guide helpful. Good luck!

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References

• BD Vacutainer Product FAQs, available from http://www.bd.com/vacutainer/faqs/
• BD Vacutainer Venous Blood Collection Tube Guide, available from http://www.bd.com/vacutainer/pdfs/plus_plastic_tubes_wallchart_tubeguide_VS5229.pdf
• another version of the BD Vacutainer Tube Guide including the Order of Draw, available from http://www.kch.nhs.uk/Doc/mi%20-%20059.1%20-%20guide%20to%20blood%20collection%20tubes.pdf
• UCI Pathology Services Manual – Specimen Tube Containers, available from http://www.pathology.uci.edu/PathologyServicesManual/SpecTubesContainers.html

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Author - Laura Jayne Watson

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The post Blood Bottles Guide appeared first on Geeky Medics.

Blood pressure measurement occasionally shows up as an OSCE station. It’s important you’re familiar with this relatively simple procedure if you want to look slick and score well on the station. There’s often a significant number of marks available for communication skills when explaining the procedure to the patient, so don’t overlook the importance of this aspect of the station.

Gather equipment

Before you see the patient, ensure you have the appropriate equipment to perform blood pressure measurement.

1. Stethoscope

2. Sphygmomanometer:

• Ensure you have an appropriately sized cuff
• A cuff too small may overestimate BP
• A cuff too large will underestimate BP

Introduction

Introduce yourself - state your name and role

Wash hands - with the appropriate 7 stage technique

Explain the procedure:

“I will be measuring your blood pressure”

“This will involve inflating a cuff around your arm briefly and listening to your pulse with a stethoscope”

“It shouldn’t be painful, but it may feel a little uncomfortable temporarily”

Check understanding - “Does everything I’ve said make sense? Do you have any questions?”

Gain consent - “Are you happy for me to record your blood pressure?”

Attaching the cuff

Wrap the cuff around the patients upper arm

Ensure the cuff size appears appropriate

Line up the cuff marker with the brachial artery - slightly medial to the the biceps brachii tendon

Measuring the blood pressure

Estimate an approximate systolic blood pressure

1. Palpate the radial pulse

2. Inflate the cuff until you can no longer feel this pulse

3. Note the reading on the sphygmomanometer

This is a rough estimate of the Systolic Blood Pressure

Measure the blood pressure accurately

1. Place your stethoscope’s diaphragm over the brachial artery

2. Re-inflate the cuff to 20-30 mmHg above your approximate systolic BP measured earlier

3. Begin to slowly deflate the cuff - around 2-3 mmHg per second

4. Listen carefully and at some point you will begin to hear a thumping pulsatile noise:

• This is known as the 1st Korotkoff sound 
• The pressure at which this 1st sound is heard is the Systolic Blood Pressure

5. Continue to deflate the cuff, continuing to listen until the sounds completely disappear:

• The point at which you hear the last sound is referred to as the 5th Korotkoff sound
• This is the Diastolic Blood Pressure

6. If the patient is noted to be hypertensive (>14o/90) or hypotensive you should re-check the blood pressure after 2 minutes to confirm this is an accurate result (also reconsider if the cuff size is appropriate)

To complete the procedure

Document the blood pressure recordings in the patients notes

Explain the need for follow up if hypertensive - BP monitoring / antihypertensives

Thank patient

Wash hands

The post Blood Pressure Measurement – OSCE Guide appeared first on Geeky Medics.

ECG recording occasionally shows up as an OSCE station. It’s often feared because of the lack of familiarity with the equipment. That’s why it’s important to have plenty of hands on practice with ECG equipment prior to the big day of the exam, because knowing how to do an ECG theoretically and in practice are two very different things. 

Gather Equipment

ECG machine - to record an ECG 

Self adhesive pads - for attachment of ECG leads to the patient

Razor - may be required to remove hair to provide adequate electrode contact with the skin

Introduction

Wash hands - using the appropriate 7 stage technique

Introduce yourself - greet the patient & state your name and role 

Explain the procedure:

“I need to perform an ECG which is an electrical trace of the heart”

“The procedure involves placing some sticky pads onto your chest and limbs”

“I will then connect these sticky pads to the ECG machines leads to record the tracing”

“I will have another member of staff acting as a chaperone during the procedure” - female patients

“The procedure doesn’t involve any electricity, so you can’t get an electric shock”

Gain consent - “Do you understand everything I’ve said?  Are you happy for me to perform the ECG?”

Electrode Placement

Position the patient  - ideally on a bed, sat at 45º

Expose the patient appropriately:

• A chaperone should be present for female patients
• Remove socks from a patient to expose ankles
• Expose the patients chest - ensure to only expose for the minimum time necessary

Chest electrodes (V1 – V6)

There are 6 chest electrode in total – V1 – V6 

Place the sticky pads in the positions shown below - ensure good skin contact – shave hair if needed

Once all have been applied, attach the associated electrode

Place the sticky pads in the following order….

V1 - 4th intercostal space - right sternal edge

V2 - 4th intercostal space – left sternal edge

V4 - 5th intercostal space - mid clavicular line

V3 - midway between V2 & V4  

V5 – anterior axillary line - same horizontal level as V4

V6 – mid-axillary - same horizontal level as V4

Limb electrodes

Place on a bony distal prominence on each limb

RED – Right Arm - ulnar styloid process at the wrist

YELLOW - Left Arm - ulnar styloid process at the wrist

GREEN – Left Leg -  at the ankle – medial / lateral malleolus 

BLACK – Right Leg - at the ankle – medial / lateral malleolus 

Some people find the pneumonic “Ride Your Green Bike” a useful way of remembering this!

Recording the trace

ECG machines differ significantly between hospitals and even wards

As a result you’ll need to familiarise yourself with your particular machine

Turn the ECG machine on - ensure there is paper loaded 

Double check all the electrodes are attached in the appropriate positions

Ask the patient to relax & remain still during the recording - muscle activity interferes with the trace

Press the appropriate button on the machine to record a trace

If the trace is poor, double check the connections ensuring good skin contact and ensure the patient is still

Completing the procedure

Once you have obtained an adequate trace you can switch off the ECG machine

Detach the electrodes from the sticky self adhesive pads

Remove the sticky pads - be gentle as this can be painful if hairs are pulled off!

Thank the patient and allow them to get dressed.

Wash hands

Discuss the ECG findings with the patient once dressed

Label the ECG with the patients details & document your findings

If you’re struggling to read the ECG trace check out our “Understanding an ECG” article

The post How to record an ECG – OSCE Guide appeared first on Geeky Medics.

Male catheterisation occasionally shows up as an OSCE station. It’s often feared because of the relatively large number of steps and pieces of equipment involved. That’s why it’s more important than ever to practice this station until you can do it in your sleep (although your room mates probably wouldn’t thank you for this). There’s often a significant number of marks available for communication skills when explaining the procedure to the patient, gaining consent and maintaining dignity, so don’t overlook the importance of these aspects of the station.

Gather Equipment

Male catheter – 12/14  french 

Catheter bag

Catheter pack:

• Small pot
• Cotton wool balls
• Sterile drapes
• Sterile gloves
• Sterile gauze
• Kidney dish or absorbent pad
• Tweezers

Saline (0.9%) - 10mls

Water filled syringe - 10mls – for inflation of catheter balloon

Lidocaine gel (1%) - for insertion into urethra for anaesthesia / lubrication

Trolley - to place your sterile field & other equipment onto

Apron

Introduction

Introduce yourself - state your name & role

Check patient details - name / DOB

Wash hands - using the appropriate 7 stage technique

Don apron

Ensure a chaperone is present

Explain procedure:

“I need to insert a catheter to allow us to monitor your urine output“

“This will involve inserting a thin flexible tube into penis to reach the bladder”

“The procedure will feel a little uncomfortable but shouldn’t be painful”

“I’ll insert some local anaesthetic into the penis to make the procedure as comfortable as possible”

“One of the nursing staff will be present and acting as a chaperone”

Gain consent - “Do you understand everything I’ve said?”  ”Are you happy to go ahead with the procedure?”

Setting up

1. Set up your sterile field:

• Lay out the sterile field across the trolley
• Empty the various pieces of equipment from their packaging onto the field aseptically
• Pour the 0.9% saline over the cotton balls located within the small plastic pot

2. Position the patient:

• Position the patient supine
• Ensure the bed is at an appropriate height for you to comfortably carry out the procedure
• Expose the patients genatalia 
  
• Place the kidney dish / absorbent pad between the patients thighs to reduce spillages onto the bed

3. Wash hands again & don sterile gloves

4. Make a hole in the centre of a sterile drape & place over the patients penis

5. Clean the penis:

• Hold the penis with your non-dominant hand using some gauze
• Ensure the foreskin is retracted
• Pick up the wet cotton balls with your tweezers & begin to clean the penis
• Clean in the direction away from the meatus

6. Insert the anaesthetic gel:

• Warn the patient that the anaesthetic might initially sting, but will go numb quickly
• Hold the penis vertically with your non-dominant hand
• With your dominant hand place the nozzle of the syringe of anesthetic gel into the penile meatus
• Empty the entire 10mls of anaesthetic gel into the urethra - at a slow steady pace
• Continue to hold to penis in the vertical position to ensure the gel remains within the urethra
• Give the gel a few minutes to take full effect

Inserting the catheter

The catheter should be on your sterile field in a plastic wrapper

1. Remove the tear-away portion of the wrapper near the catheter tip – don’t touch the catheter!

2. Hold the penis again using gauze with your non-dominant hand

3. Insert the exposed catheter tip into the urethral meatus - warn the patient 

4. Advance the catheter slowly but firmly - slowly removing the wrapper to expose more catheter

• The key to removing the wrapper without also pulling the catheter back out is to ensure a good grip on the penis as you pull back on the wrapper

5. As you pass the prostate you may notice some resistance & the patient may feel more discomfort:

• If the resistance is significant and the patient is in a lot of discomfort, you should remove the catheter & consider a repeat attempt or input from urology

6. As you enter the bladder you will see urine begin to drain from the catheter

7. You should continue to advance the catheter until it is fully inserted

8. Once fully inserted, inflate the catheter balloon with your 10ml syringe of water

• Ask the patient to let you know immediately if they feel any discomfort during this!

9. Once the balloon is fully inflated withdraw the catheter until resistance is felt

• This confirms the catheter is held firmly within the bladder

10. Attach the catheter bag tubing to the end of the catheter, ensuring a tight seal

11. Hang the catheter bag on the side of the bed, below the level of the patient

12. Replace the patients retracted foreskin – failure to do so can result in paraphimosis

13. Clean up the patient & dispose of your equipment

14. Allow the patient to get dressed

To complete the procedure…

Thank patient

Wash hands

Fill out a fluid balance form and inform nursing staff of the need to monitor urine output

Document the procedure, making sure to include:

• Your details - name / grade / GMC number
• Date / time
• Consent gained
• Chaperone present
• Reason for catheterisation
• Aseptic non-touch technique used
• Volume of water inserted into balloon - e.g. 10mls
• Size of catheter
• Any complications during the procedure
• Residual volume of urine drained
• Appearance of urine – golden / haematuria / etc

The post Male catheterisation appeared first on Geeky Medics.

Female catheterisation occasionally shows up as an OSCE station. It’s often feared because of the relatively large number of steps and pieces of equipment involved. That’s why it’s more important than ever to practice this station until you can do it in your sleep (although your room mates probably wouldn’t thank you for this). There’s often a significant number of marks available for communication skills when explaining the procedure to the patient, gaining consent and maintaining dignity, so don’t overlook the importance of these aspects of the station.

Gather Equipment

Male catheter - 12/14  french – male catheters are used for both male & females to avoid confusion

Catheter bag

Catheter pack:

• Small pot
• Cotton wool balls
• Sterile drapes
• Sterile gloves
• Sterile gauze
• Kidney dish or absorbent pad
• Tweezers

Saline (0.9%) - 10mls

Water filled syringe - 10mls – for inflation of catheter balloon

Lidocaine gel (1%) 5mls - for insertion into urethra for anaesthesia / lubrication

Trolley - to place your sterile field & other equipment onto

Apron

Introduction

Introduce yourself - state your name & role

Check patient details - name / DOB

Wash hands - using the appropriate 7 stage technique

Don Apron

Ensure a chaperone is present

Explain procedure:

“I need to insert a catheter to allow us to monitor your urine output“

“This will involve inserting a thin flexible tube into the bladder”

“The procedure will feel a little uncomfortable, but shouldn’t be painful”

“I’ll insert some local anaesthetic into the urethra to make the procedure as comfortable as possible”

“One of the nursing staff will be present and acting as a chaperone throughout the procedure”

Gain consent - “Do you understand everything I’ve said?”  ”Are you happy to go ahead with the procedure?”

Setting up

1. Set up your sterile field:

• Lay out the sterile field across the trolley
• Empty the various pieces of equipment from their packaging onto the field aseptically
• Pour the 0.9% saline over the cotton balls located within the small plastic pot

2. Position the patient:

• Ensure the bed is at an appropriate height for you to comfortably carry out the procedure
• Expose the patients genatalia
• Position the patient supine with knees flexed & hips abducted with their heels together
• Place the kidney dish / absorbent pad between the patients thighs to reduce spillages onto the bed

3. Wash hands again & don sterile gloves

4. Make a hole in the centre of a sterile drape & place over the patients genatalia 

5. Clean the genatalia:

• Hold the labia apart with the non-dominant hand
• Pick up the wet cotton balls with your tweezers & begin to clean the genatalia
• Clean in the front to back direction - using each cotton ball only once

6. Insert the anaesthetic gel:

• Warn the patient that the anaesthetic might initially sting, but will go numb quickly
• With your dominant hand place the nozzle of the syringe of anesthetic gel into the urethral meatus
• Empty the entire 5 mls of anaesthetic gel into the urethra - at a slow steady pace
• Give the gel a few minutes to take full effect

Inserting the catheter

The catheter should be on your sterile field in a plastic wrapper

1. Remove the tear-away portion of the wrapper near the catheter tip - don’t touch the catheter!

2. Hold the labia apart with your non-dominant hand

3. Insert the exposed catheter tip into the urethral meatus - warn the patient 

4. Advance the catheter slowly but firmly - slowly removing the wrapper to expose more catheter

5. If there is significant resistance or the patient is in a lot of discomfort, you should remove the catheter & consider a repeat attempt or input from urology

6. As you enter the bladder you will see urine begin to drain from the catheter

7. You should continue to advance the catheter until it is fully inserted

8. Once fully inserted, inflate the catheter balloon with your 10ml syringe of water

• Ask the patient to let you know immediately if they feel any discomfort during this!

9. Once the balloon is fully inflated withdraw the catheter until resistance is felt

• This confirms the catheter is held firmly within the bladder

10. Attach the catheter bag tubing to the end of the catheter, ensuring a tight seal

11. Hang the catheter bag on the side of the bed, below the level of the patient

12. Clean up the patient & dispose of your equipment

13. Allow the patient to get dressed

To complete the procedure…

Thank patient

Wash hands

Fill out a fluid balance form and inform nursing staff of the need to monitor urine output

Document the procedure, making sure to include:

• Your details - name / grade / GMC number
• Date / time
• Consent gained
• Chaperone present
• Reason for catheterisation
• Aseptic non-touch technique used
• Volume of water inserted into balloon - e.g. 10mls
• Size of catheter
• Any complications during the procedure
• Residual volume of urine drained
• Appearance of urine - golden / haematuria / etc

The post Female catheterisation appeared first on Geeky Medics.

Blood glucose measurement occasionally shows up as an OSCE station. It’s important you’re familiar with this relatively simple procedure if you want to look slick and score well on the station. There’s often a significant number of marks available for communication skills when explaining the procedure to the patient, so don’t overlook the importance of this aspect of the station.

Gather equipment

Blood glucose reader

Spring loaded lancet (a.k.a. “the finger pricker”)

Testing strips – check expiry date is valid

Gloves

Cotton ball / Gauze

Alcohol wipe

Introduction

Wash hands

Introduce yourself - state your name & role

Confirm patient details - full name / DOB 

Explain procedure:

“I would like to check your blood glucose level”

“The procedure will involve taking a very small blood sample from your fingertip”

“You’ll experience a very brief sharp scratch”

Gain consent - “Do you understand everything I’ve said?  Are you happy for me to go ahead?”

Measure the blood glucose

1. Put on your gloves

2. Turn on the blood glucose monitor - ensure it is calibrated

3. Clean the patients finger tip - this is very important as substances on the skin can alter the reading

4. Insert the test strip into the glucose monitor - ensure the strip is within date

5. Remove the protective cap from the lancet 

6. Prick the patients finger - ideally the side of the finger as this is less painful for the patient

7. Squeeze the finger to produce a blood droplet – wipe away the first droplet

8. Place the 2nd droplet of blood onto the test strip - ensure droplet is large enough to cover the strip

9. Insert the test strip into the blood glucose monitor – record the reading

10. Apply cotton wool to the puncture site to stop the bleeding

To complete the procedure…

Dispose of spring loaded lancet into sharps bin

Dispose of gloves & cotton wool into an appropriate clinical waste bin

Wash hands

Thank patient 

Document the blood glucose reading on the appropriate chart

The post Blood glucose measurement appeared first on Geeky Medics.