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ACUTE HISTORY TAKING + SBAR HANDOVERS Presentation by Dr. Risma Remsudeen (Co- founder ISCE101 and Surgical FY2, Rhyl)LEARNING OUTCOMES • History Taking in an OSCE - the basics • Acute History - how is that different • Tips and Tricks to succeeding Acute histories • SBAR Handovers • Common differentials, and how to answer investigations and management55 year old male Sharp sudden chest pain What are we thinking?THE BASICS OF HISTORY TAKING - Introduce yourself with your full name Top Tip: NEVER FORGET ALLERGIES!! - Introduce and check patient name and details Presenting Complaint History of Presenting Complaint Systems Review Past Medical History/ Surgical History Drug History Family History Social History Ideas, Concerns, ExpectationsTop tips Top Tip: Respond to patient cues!! • First 30 seconds - do not interrupt - allow patient to speak • Never forget ICE! • Avoid leading questions: you haven’t missed any doses of medications, have you? • Avoid asking multiple questions in one go: do you have chest pain or shortness of breath • Confidence! NOW HOW DO WE FIT IT INTO 4 MINS???ACUTE HISTORY • Acute Conditions! • Consider the set of Red Flags associated with each symptom Major Symptoms and their Red Flags: • Pain • Vomiting • LOC • SOB • Cough • Bleeding (Hemoptysis, haematuria) • DiarrhoeaTHE BASICS OF HISTORY TAKING - Introduce yourself with your full name Top Tip: NEVER FORGET ALLERGIES!! - Introduce and check patient name and details Presenting Complaint History of Presenting Complaint Systems Review Past Medical History/ Surgical History Drug History Family History Social History Ideas, Concerns, Expectations55 year old male Sharp sudden chest pain What are we thinking? SOCRATES: 55 year old male - Site Sharp sudden chest pain - Onset - Character - Radiation - Associated Symptoms - Timings CARDIO RESP - SeverGIy MSK OTHER Myocardial Pulmonary Reflux/ GORD Costochondrit Panic Infarction Embolism is attack Angina Pneumothorax Gastritis Muscle strain anaemia Aortic Dissection Pleurisy Pericarditis Myocarditis SOCRATES: - Site Sharp headache - Onset - Character - Radiation - Associated Symptoms - Timings physiological Intracranial Extracranial - Severity Tension headache GCA Trigeminal neuralgia Cluster headache Meningitis Sinusitis Migraine Intracranial bleed AACG Medication SAH induced CO poisoning Venous sinus thrombosis Raised ICP physiological Intracranial Extracranial Tension headache GCA Trigeminal neuralgia headache Cluster headache Meningitis Sinusitis Migraine Intracranial bleed AACG Medication SAH induced CO poisoning Venous sinus thrombosis Raised ICP Tension Cluster Migraine Trigeminal headache headache neuralgia Band like pain Around the eye Unilateral Stabbing pains Stress 30mins-3hours Pulsating Trigeminal nerve distribution Later in the day Lacrimation Aura Triggers (E.g. shaving) Flushing photophobia Sx's of cause (e.g. MS, aneurysm)Cardiovascular Neurological Other Arrhythmias (cardiac Seizure Drug OD syncope) Postural hypotension TIA/Stroke Alcohol intox Vertebrobasilar Vasovagal Mechanical fall insufficiency Aortic stenosis Raised ICP Shock caused by external diagnosis Carotid sinus Intracranial bleeds hypersensitivityAcute History Summary • Start with open question • Then follow it up by specific closed questions • Do not forget main relevant questions • Have acute differentials in mind but also don’t be too narrow Presenting a Patient -Follow same format as how you take histories - State positive findings/symptoms. - Only mention red flag symptoms you ruled out + any big relevant ones - Offer several differentials:my most likely differential is X 2 systems – i.e., SOB could have resp + cardio) Y & Z (at least - Investigations: BBOXES - Management: Conservative/medical/surgical -Don’t go through investigationsor management unless specifically asked by the examiner to do so.Investigations: BBOXES ◦ Bedside investigations ◦ Bloods ◦ Orifice tests ◦ X rays and other imaging modalities ◦ ECG ◦ Special tests ◦ Important point: If examiner asks “how would you like to manage the patient and they haven’t given you any investigations then you should state the investigation work up you would like to do and also after state the management (based off your most likely differential- specify this in your answer e.g. “assuming this is X….” TESTS Basics FBC + U&E + CRP Bloods Basics ultra pro LFTs + TFTs Basics ultra pro max Blood culture Surgical/bleeding risk Coag screen (+ INR) + group and save + cross match Intoxication, acute comatose Tox screen, paracetamol levels Cardiovascular Troponins (+D-dimer) Ortho/elderly/electrolyte Bone profile + PTH + magnesium + CK abnormalities Anaemic/neuro Iron studies + B12 + folate + HbA1c/glucose GI IgA-TTG + IgA + amylase/lipase Tumour markers Ca-125, PSA etc Narrow therapeutic range Lithium, theophylline, digoxin, gentamicin Orifice tests In and out: - Swabs: nasal, oral, wound, vaginal (bonus marks for specifying type of swab - charcoal or NAAT), - cultures: sputum, stool, urine, line (central), amniotic fluid – specials: faecal calprotectin X-rays and other imaging Least hassle/expensive and work your way up - Ultrasound: FAST, bladder scan, echo, dopplers (DVT, pregnancy) - CXR/AXR/Orth X-ray etc. (erect CXR if abdo obstruction) - CT: specify of what region + if vascular (i.e., CTPA) - MRI: specify of what region - Endoscopy/colonoscopy (cystoscopy, laryngoscopy/bronchoscopy) - Radio fluorescence imaging - specials: DEXA, PET Cautions: Radiation exposure – pregnancy (especially for PE – V/Q vs CTPA), young children MRI – implants, metal prostheses Special tests Based on history: - Spirometry - biopsy - EEG - HIV testing, occupational hazards (Hep B, TB) - Special blood test (i.e., anti-AchR/anti MuSK in myasthenia gravis) - biologics screen (viruses like HIV/rubella, TB) Surgical spiel -Catheterisation -NBM and let the nurses be aware and document -+/-Drip & suck (IV cannula) -Medication review - stopping meds for surgery (anti-diabetic meds, anticoagulation etc) -VTE prophylaxis: pharmacological or mechanicalManagement Conservative - Physio, OT input - walking aids? Zimmer frame? ◦ NOF, Stroke, Confused, **Paeds: Explain the condition to both the - Diet and lifestyle modification children and parents ◦ Stroke patient: safe swallow assessment **Provide them with a leaflet and call back to ◦ Referral to the dietitian surgery/ hospital if they have any questions - one to one nursing care (depends on physical and mental state of patient) **Community and local support group (British ◦ High risk of falling/ multiple falls in hospital heart foundation, Marie Curie society, Mind ◦ DKA UK, Mental health UK - barrier nursing **Referral to alcohol liaison service for ◦ Side room: C.diff, COVID, CF addictions - Inform infectious control/ contact tracing Fall: ◦ Notifiable disease: Meningitis, Scarlet fever, STIs - Vaccinations Regular neuro observations ◦ HF, COPD: annual flu, one off pneumococcal ◦ Celiac: booster every 5 years Most important medications Analgesia: (+laxatives) VTE prophylaxis : paracetamol -> NSAID -> weak opioid -> strong opioid Usually 500mg 4-6 hourly *Morphine 5mg PRN 4 hourly Clexane = LMWH **If they are on warfarin has a massive bleed Antiemetics: *Ondansetron fixes most nausea & SE profile is low (don’t use in prolong QT) -> Stop Warfarin, IV Vitamin K *Cyclizine *Metoclopramide (contra in PD) **Parkinson’s patients -> Dopamine agonist patch if they kept NBM Oxygen: mention type of oxygen delivery system - nasal spec to start off, 15L non rebreather if a**Diabetic patients unwell -> Insulin sliding scale and consult diabetic specialist nurse Fluids: 0.9% Nacl with any electrolyte replacements if requiredManagement important tips Anaphylaxis reaction Most important thing: Remove the trigger (e.g. stop the IV drug running), keep the allergens away from patient Acute situation ABCDE, refer to senior, crash call Review ABCDE again until patient is stable or help has arrived Medications Always check allergies with patient and WCP Always check BNF for route, dosage and indication If in doubt, ask the pharmacist Explain side effects profile (e.g. steroids/ SSRI/Clozapine/ Methotrexate) Acute management [GOAL: STABILIZE the patient and make sure they are safe ] ABCDE -> Oxygen depending on Sats% 15L via non-rebreather, 2 wide bore cannula in each arm, start fluids?, pain relief?. The mentioned treatments depends on the scenario e.g. anaphylaxis-would specifically want to mention I would like to stabilise the airway using a chin lift head tilt and possible airway adjuncts if this did not work e.t.c. Senior support is important and state that you would request this Always mention who you wish to have help from: If the patient isn’t at cardiac arrest-then it will be your reg (medical or surgical). If the patient is crashing then immediately pull the alarm and ask one of the staff to put out a 222 call and state where you are. Top students - neurosurgical reg (e.g. cauda equina, spinal cord compression)/ general surgeon (bowel obstruction) Bleeding - major hemorrhage protocol PPH - major obstetric hemorrhage protocolSituation • Confirm who is on the other side • Introduce yourself • Who, where are you phoning from Ask if they have time to discuss a patient & if they are acutely unwell mention that you are concerned about them- more likely to accept the call straight away Set the scene: “This patient is called reece jones and is a 65 year old male who has presented with abdominal pain that has been going on for the last 2 weeks. I believe this is mesenteric ischaemia (always have the attention grabber). Background Give the history of the presenting complaint - SOCRATES “So the pain is in the RUQ of his abdomen and is sharp in nature, it cam on 2 weeks ago suddenly and hasn’t gone away since, It does not radiate anywhere, Nothing makes the pain better or worse. He has been experiencing nausea and vomiting alongside this. He denied any (red flag symptoms) fevers , weight changes, change in bowel habit, or blood in his stools since the onset of his symptoms and is also passing flatus” Then give background of the patient: - PMHx, PSHx, Social, Family “ The patient has not experienced any symptoms like this in the past. He has a diagnosis of AF which he takes bisoprolol for.” (doesn’t need to be long-just mention the pertinent points in the case e.g. if he’s a smoker then absolutely mention it. If he is a farmer - not as relevant) Drug allergies Assessment Examination findings and NEWS chart: they will give you this information- again don’t mention everything but always mention the important points NEWS 0 and afebrile If they give you 2 sets of obs then you must reference how they have changed: only mention the important changes e.g. temp raising from 36.7 to 39 is important, a BP going from 120/70 to 120/80 is not important. UTI - results findings - normal Blood pressure changes in pre-eclampsia patient CXR, ECG, AXR Recommendations Reinforce your hypothesised provisional diagnosis and couple of other differentials if needed State what you have done for the patient and are going to do for them: includes both investigations and management Then ask whether they agree with the plan and whether there was anything else they want you to do or any extra information that you might have missed If it’s an emergency e.g. like a mesenteric ischaemia- they will need senior review: therefore you should be opening with I think this is X and so I would like you to review the patient in the next X minutes (always give a sensible time frame)Thank you! Any questions? theisceseries101@gmail.com