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ISCE BOOST Menti: 5634 1858 Common and Important Presentations 1 Devon WardHow are we feeling about the ISCE? Menti: 5634 1858Overview Menti: 5634 1858 Today, we will look at: • Specific example cases focussing on common and important presentations • Potential answer structures and summary sheets Any questions put them in the chat and we’ll get to them as we can!STATION 1 Menti: 5634 1858Station 1 Menti: 5634 1858 Station: Acute Surgery Student briefing: You are a 4 year medical student on a Hospital Front Door placement. Setting: Emergency department Patient’s details: Miss Sharna is a 19-year-old who has come into hospital with worsening abdominal pain. Student’s task: Take a focussed history from this patient.After 4 minutes, you will be asked some questions and asked to perform a clinical skill.Station 1 Menti: 5634 1858 Presenting complaint Family history Open question Systems review Social history SOCRATES Bowel, bladder Travel history Pregnancy Past medical history Smoking history Occupation Alcohol history Diet Past surgical history ICE Drug history Allergies Compliance SummariseStation 1 Menti: 5634 1858 Miss Sharna, 19yo F presenting with PMHx – asthma abdominal pain PSHx – nil PC: feeling generally unwell since yesterday. Central abdominal pain started after lunch DHx – salbutamol inh 2 puffs PRN, and has worsened. Microgynon, NKDA S – started in the middle, now more over right FHx – nil GI issues SHx – no travel history.Smokes 5 cigarettes hip a day.Social drinking on weekends ~8 units. O – started after eating lunch, suddenly No recreational drug use.Psychology C – crampy, sharp student.Unsure if could be pregnant, on pill. R – none A – vomited once this morning Eats well, exercises regularly. T – worsened steadily I – had suspicious meat 2 days ago, may be food poisoning E – none noticed C – pain is really bad and not getting better S – 8/10 E – needs something for the pain Otherwise generally wellStation 1 Menti: 5634 1858 Summarise your findings. What are your top 3 differentials? What investigations would you order for this patient? pregnancy Ovarian cyst Gastroenteritis Ovarian torsion Gastric ulcer Bedside Bloods Imaging Special tests Urine dipstick FBC, UE, LFT,Clotting Pregnancy test CRP Group and Pelvic US BP BHCG save PR CulturesStation 1 Menti: 5634 1858 Interpret these results. Patient name: Nina Sharna DOB: 22/03/2003 Hb: 130 (115-160) The haemoglobin, platelets, mean cell WBC: 13.2* (4-11) volume, lymphocytes and HCG are Plt: 380 (150-400) normal whereas the white cells and neutrophils are raised.This represents MCV: 93 (78-100) a neutrophil- predominant Neut: 9.8* (2.0-7.5) leucocytosis.Combined with the Lymph: 4.3 (1.0-4.5) negative pregnancy test, this supports my most likely differential of acute HCG: 2 (<5) appendicitis. Menti: 5634 1858 Station 1 Given the likely diagnosis of appendicitis, this patient requires a cannula before she can go to surgery.Please put a cannula into the model provided. LC Xerte by Clinical Skills department: Wash your hands your hands before a step, do it! Better https://xerte.cardiff.ac.uk/play_10655#page1 safe than sorry!) YouTube video by Geeky Medics: Speak to the patient if they’re ready, if they have a preferred https://www.youtube.com/watch?v=vE99rZ7JT3Q arm, etc.Get those points!) If you don’t get blood (it is 100% fine if you don’t get flashback.If you have enough time, they may ask you to repeat, but this is not a fail! Explain that you would dress the wound, get more equipment, re-clean and start again!)Acute appendicitis Menti: 5634 1858 Pathology: Buzzwords: inflammation Young Pt of appendix, Central → RIF often due to Anorexia Management: obstruction 1ish vomit Investigations: Clinical diagnosis Appendicectomy – Presentation: FBC, UE, LFT, CRP open or laparoscopic Abdo pain – central to RIF Prophylactic Vomit once or twice (neut leuc) antibiotics Coag, group and save Abdominal lavage if Mild fever Pelvic US Anorexia perforated Peritonitis Rovsing (LIF→RIF pain) Psoas (pain on extending hip)Acute Pathology Menti: 5634 1858 MI Meningitis Stroke Asthma Sepsis AAASTATION 2 Menti: 5634 1858Station 2 Menti: 5634 1858 Station: Pharmacology and therapeutics Student briefing: You are a 4 year medical student on a GP placement. Setting: General practice Patient’s details: Mr McAllister is a 65-year-old man who was diagnosed with a deep vein thrombosis and started on warfarin. Student’s task: Explain what their warfarin therapy will entail.After 7 minutes, you will be asked questions on patient care.Station 2 Menti: 5634 1858 Establish the story Side effects Open question Brief HPC Monitoring ICE Lifestyle Current understanding Questions Medication Summarise Mechanism UseStation 2 Menti: 5634 1858 Mr McAllister is a 65-year-old man presenting with questions about warfarin. HPC – pain in L calf for a day after returning from a long-haul flight from USA.Went to A&E Why being prescribed warfarin? and was given warfarin and discharged.Now What are the risks of taking it? attending to answer questions. How often will I need tests? I – have friends who take it, know it’s a blood What if I miss a dose? thinner C – worried about how often will need testing E – hoping to answer 4 main questions No other medications.No allergies.Station 2 Menti: 5634 1858 Summarise your consultation. Menti: 5634 1858 Station 2 BOB McAllister 07/06/1959 Another patient is admitted to A&E with a head injury whilst taking warfarin. Interpret this CT head. This axial image shows a fracture of the R temporal bone.There is an underlying extradural haemorrhage and overlying soft tissue injury.There is midline shift.No evidence of infarcts or other bleeds. This represents a significant intracranial bleed in a patient taking warfarin, which is https://doi.org/10.53347/rID-40731.org(Accessed on 22 Apr 2024) emergency. Menti: 5634 1858 Station 2 His INR is found to be 9.2.What is your short-term management of this patient? I would ensure his blood pressure is stable and give IV 0.9% normal saline if not, with consideration of blood I would follow an ABCDE approach to ensure the products depending on the mechanism of the injury. patient is stable.I would get early involvement of a senior, including my own senior as well as using an SBAR approach to hand over to the neurosurgeons. He may require IV mannitol to decrease the intracranial pressure, as well as IV broad spectrum antibiotics due to the skull fracture. Regarding the warfarin, I would follow the guidelines for high INR and major bleeding.This would involve stopping the warfarin and giving IV vitamin K and I will also ensure he has adequate analgesia.Moving prothrombin complex concentrate to reverse the forwards, he is likely to receive a craniotomy for anticoagulation. evacuation of the haematoma.Intracranial haemorrhage Menti: 5634 1858 Pathology: Buzzwords: Bleeding EDH –lucid within the interval SAH – Investigations: cranial vault thunderclap FBC, UE, LFT, CRP INR Management: Presentation: Coagulation Conservative if small Usually trauma GCS Craniotomy EDH – was fine before BP suddenly declining CT head SDH – confusion, decreased consciousness, coma SAH – sudden headacheWarfarin Menti: 5634 1858 How to take: Indication: Monitoring: Take it the same time every Mechanism: Treat blood clots INR – how long blood takes day anticoagulant Prevent future to clot If missed, take as soon as blood clots • Your target would be 2- 3, so it takes 3x longer remembered but if next day, skip to clot Side effects: • Happens every 3 days Bleeding – normal to have longer until within range, then periods, nosebleeds longer, gum twice weekly for 2 bleeding, bruising weeks, then every 12 Lifestyle: Serious bleeding – stop warfarin and go to A&E if melena, large bruises, weeks Must stop if pregnant nosebleed >10min, severe headaches Avoid changes in diet Rash and hair loss are common • Given yellow booklet for Avoid cranberry juice, INR monitoring grapefruit, alcohol Urgent review if jaundice or skin necrosisMedications Menti: 5634 1858 Warfarin Statins COCP InhalerSTATION 3 Menti: 5634 1858Station 3 Menti: 5634 1858 Station: Child health Student briefing: You are a 4 year medical student on a paediatrics rotation. Setting: Paediatric ward Patient’s details: Mr Davies is a 12-year-old boy who was admitted with a worsening cough.His parents are parking the car and have said it is okay for him to talk to you whilst they’re on the way. Student’s task: Take a history from this patient.After 7 minutes, you will be asked some questions.Station 3 Menti: 5634 1858 Consent Family history Presenting complaint Social history Open question Systems review Home life Education SOCRATES Bowel, bladder Smoking history Activities Alcohol history Diet Past medical history ICE Drug history Allergies Compliance SummariseStation 3 Menti: 5634 1858 PMHx – nil Mr Davies is a 12-year-old boy presenting PSHx – nil with a worsening cough. DHx – nil, NKDA HPC – always has a cough, but worsened and FHx – nil respiratory issues became productive in past 2 weeks.Clear SHx – born in Bulgaria, moved here when 2. mucus, no blood.Feels wheezy.Has had Lives at home with parents, no concerns. several chest infections like this in the past. Doing well at school, feels supported.Loves SR – noticed some weight loss recently and rugby.Nil smoking, alcohol. some abdominal pain. I – another chest infection C – doesn’t know why he gets so many E – the usual antibioticsStation 3 Menti: 5634 1858 Summarise your findings. What are your top 3 differentials? What investigations would you order for this patient?monia Asthma exacerbation GORD Bronchiectasis Bronchitis Bedside Bloods Imaging Special tests Observations inc Sweat chloride O2 and RR FBC, UE, LFT, CRP CXR test Sputum culture Amylase Genetic testing Spirometry Blood glucoseStation 3 Menti: 5634 1858 Lee Davies 03/12/2012 Interpret this x-ray. This is a PA chest x-ray image for Lee Davies. The film is not rotated, is well-exposed, and there is good inspiratory effort.The lung fields are broadly clear with no consolidation or pneumothorax.The cardiac shadow is normal and not enlarged.The diaphragm is normal, with no evidence of effusion or free air.The gastric bubble is present in the left upper quadrant.There is no evidence of fractures, but there are unfused growth plates within the proximal humerus bilaterally.There are no tubes, pacemakers or leads.Overall, this represents a normal chest x-ray for a child and Lloyd-JonesG. 11-year-old, Radiologymasterclass.co.uk(Accessedon 22 Apr 2024)rts a diagnosis of CF. https://www.radiologymasterclass.co.uk/gallery/chest/quality/chest-x-ray-ageStation 3 Menti: 5634 1858 Given the likely diagnosis of cystic fibrosis, how would you manage this patient? Long-term management requires a multi-disciplinary approach. I will split my answer into the short and long-term management. For his chest, this patient should engage in chest physiotherapy to move mucus from his airways.We can also use medications, specifically mucolytics like dornase alfa and bronchodilators like salbutamol to help improve his breathing. In the short-term, I will use an ABCDE approach to ensure the Given his weight loss, he should be referred for patient is not acutely unwell.I will contact a senior respiratory nutritional support.He may require Creon and vitamin physician and handover potential cystic fibrosis patient and ask A, D, E and K supplementation. He should start on a if there are any interventions they would recommend.I will give high-calorie, high-fat diet. antibiotics for the underlying infection following local guidelines and manage the underlying infection. He should be given education about his condition, and advised to avoid other patients with CF. He will need regular follow-up with his GP and the local cystic fibrosis team to address new issues as they arise. Menti: 5634 1858 Cystic fibrosis Pathology: Buzzwords: Management: autosomal Young Pt Airway recessive disorder Recurrent chest Investigations: • Chest physio due to mutations problems Diagnosis • Mucolytics in CFTR causing Weight loss • Sweat chloride test • SABA sticky mucus Failure to thrive • NSAIDs (high=diagnostic) • Prophylactic Abx • Genetic testing (CFTR) • CFTR modulators – Monitoring Presentation: • Sputum culture ivacaftor Infant – meconium ileus, failure to thrive • Spirometry Nutrition Child/adult • CXR and CT • Creon • Chronic cough and wheeze • Vit ADEK supplements • Recurrent resp infections (bronchiectasis) • High calorie, high fat diet • Malabsorption – weight loss, • OGTT Regular review for • DEXA complications like diabetes, steatorrhoea • Infertility liver disease, infertility and bone healthChild Health Menti: 5634 1858 Type I Asthma Diabetes Seizures MeningitisSTATION 4 Menti: 5634 1858Station 4 Menti: 5634 1858 Station: Acute Student briefing: You are a 4 year medical student on a geriatrics placement. Setting: Geriatric ward Patient’s details: Miss June is an 89-year-old woman who has become increasingly confused. Student’s task: Take a focussed history from Miss June’s partner.After 4 minutes, you will be asked some questions and asked to perform a clinical skill.Station 4 Menti: 5634 1858 Presenting complaint Family history Open question Systems review Social history SOCRATES Bowel, bladder Travel history Pregnancy Past medical history Smoking history Occupation Alcohol history Diet Past surgical history ICE Drug history Allergies Compliance SummariseStation 4 Menti: 5634 1858 PMHx – HTN, T2DM, MCI (2y) DHx – metformin, dapagliflozin, lisinopril Miss June, 89yo F presenting with confusion FHx – nil GI issues HPC – partner noticed increasing confusion SHx – lives with partner at home.Normally over past 3 days.Normally has MCI, but this is different.Disoriented to time and place. mobilises with stick.Normally independent of Also feels generally weak and tired.Has had 2 ADLs.Nil smoking or alcohol history.Retired episodes of urinary incontinence, which is nurse. I – worsening MCI unusual for her. C – might be progressing to dementia In hospital for #NOF which is healing well. E – can anything be done to slow the progression?Station 4 Menti: 5634 1858 Summarise your findings. What are your top 3 differentials? Sepsis New incontinence Delirium Worsening dementia UTI Stroke Menti: 5634 1858 Interpret these results. This is the NEWS chart of Glenys June.The RR is raised at 22, the O2 and BP are normal, the pulse is raised at 126, she is confused and is pyrexial at 36.5.This totals to a score of 8.Looking at the recommendations, this is a score of >7 which requires informing the registrar and a critical care outreach referral.This supports my most likely diagnosis of sepsis.Station 4 Menti: 5634 1858 How would you manage this patient? Due to my high suspicion of sepsis, I will start the This patient is acutely SEPSIS 6.I will give high-flow 15L oxygen through a non- unwell, so I would rebreathe mask.I will take blood cultures and then give assess using the IV broad spectrum antibiotics.I will give an IV fluid bolus ABCDE approach and of 500mL of 0.9% saline.I will take a blood lactate get a senior involved through a VBG.I will ask for urine output to be early. measured, which may require insertion of a urinary catheter.Station 4 Menti: 5634 1858 This patient requires an arterial blood gas sample.Please perform an ABG on the model provided. Wash your hands LC Xerte by Clinical Skills department: (if you’re not sure if you need to wash your hands before a step, do it! Better https://xerte.cardiff.ac.uk/play_10545#page1 safe than sorry!) YouTube video by Geeky Medics: Speak to the patient https://www.youtube.com/watch?v=0BSv4iN8T2 (talk them through every step, ask them E if they’re ready, if they have a preferred arm, etc.Get those points!) ABG needles (make sure that you are familiar with ABG needles, they changed our Allen test ones within 2 weeks of the exam.Know the ones in the clinical skills (don’t forget to say you’d assesscollateral blood flow to the lab, but also ask on placement to have a look.Make sure you know hands.You may be asked to do this on the examiner/patient, or how to make the needle safe! If you’re not familiar with the needle, say you may be told that the collateral flow is fine, but you must that – don’t be unsafe!) remember to say it!)Sepsis Menti: 5634 1858 Dysregulated response to Buzzwords: infection causing Confusion in Management: systemic elderly Investigations: SEPSIS6 inflammation and Looks unwell FBC, UE, LFT, CRP Give 3: organ dysfunction VBG – lactate • High flow O2 Urine output • IV BS Abx Presentation: Blood cultures • IV fluid resus Signs of specific infection (LRTI, UTI, wound) Sputum sample Take 3 Urine MC+S • Blood cultures Malaise, weakness Stool sample • Lactate (VBG) Confusion • Urine output (cath) High NEWSAcute Pathology Menti: 5634 1858 MI Meningitis Stroke Asthma Sepsis AAAQUESTIONS Menti: 5634 1858