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ISCE Structure 8 Stations • 2 Examination Stations • 2 Acute Stations (4 min history) + Clinical Skills • Communication Station (7 min history) • Pharmacology Station (7 min history) • SBAR Station (4min history) • CBD Station Learning Outcomes Imaging • CXR Bedside Tests • NEWS chart • AXR/ CT abdomen • Spine XR/ MRI (cervical/ lumbar) • ECG • CT/ MRI head • MSK X Ray • Lung function tests/ spirometry • Peak flow diary Bloods • FBC • Urinalysis • Urea & Electrolytes • Microbiology report • Liver Function Tests • ABG NEWS Chart/Observations NEWS Chart Don’t say: “Patient has high resp rate, low O2 sats, low blood pressure, increased heart rate, normal temperature” ü Confirm patient details (name/ DOB/ time taken) ü Patient is tachypnoeic, hypoxic on air, hypotensive, tachycardic, normothermic. ü Work out the NEWS score ü This patient is haemodynamically unstable… I am concerned about shock. If hyperthermic ü I am concerned about sepsis ü I would initiate Sepsis 6 Microbiology Report Microbiology Report • Antibiotic sensitivities R = resistant S = sensitive • Should ask about allergies in the history • Look for allergy bracelets • State that you would confirm allergy status + check local guidelines using Microguide • Call microbiology if complex/uncertain Urinalysis Urinalysis • Glucose (glycosuria) à Diabetes/ DKA • Ketones à ↑FA metabolism due to DKA • Leucocytes + Nitritesà Infection (UTI) • Protein + blood à Acute nephritis (also infection) • In elderly population – urine dip of less valueECG: Data Interpretationrpratation • Confirm patient details + time taken, state that you would like to compare to any previous ECG readings • Quickly confirm paper speed and voltage • Use a structured, methodical approach ØState most obvious abnormality ØRate ØRhythm ØAxis ØMorphology • Overall impression; know what normal looks likeTerritory Leads Artery Inferior II, III, AVF RCA Lateral I, aVL, V5, V6 Circumflex branch of LCA Anterior V1 - V4 LAD Septal V1, V2 LAD1) Rate: Use Rhythm strip 300/R-R (number of boxes between R peaks) OR count QRS complexes on the rhythm strip and multiply by 6 2) Rhythm Sinus = P waves before EVERY QRS Spot diagnosis: Atrial Fibrillation – irregularly irregular QRS complexes with absence of P wavesAxis Left Axis Deviation L for LeavingRight Axis Deviation R for ReachingMorphology • Shape of P waves, QRS complexes, T waves • Intervals PR: 3-5 small boxes (start of the p wave to q) QRS duration: 2-3 small boxes Scan for ischaemic changes • ST elevation/ depression, T wave inversion ECG: Case 1 A 67 year old man presents after an episode of syncope. He was attending an exercise class. After the class he began to feel sweaty and nauseous. He began to make his way to the bathroom but lost consciousness. He was unresponsive for 2 minutes. During the episode he was incontinent. When he came around he was feeling nauseous but recovered after 30 minutes. His past medical history includes Type 2 diabetes and osteoarthritis. ECG: Case 2 Mr Johnson is a 65-year-old male who presented to the emergency department with severe chest pain that started about an hour ago. The pain is located in the centre of his chest and radiates to his left arm. He also reports feeling short of breath, nauseous, and dizzy. He has a history of hypertension and hyperlipidaemia, and he takes medications for both conditions. On examination, he appears uncomfortable and diaphoretic. His blood pressure is 150/90 mmHg, heart rate is 110 beats per minute, respiratory rate is 22 breaths per minute, and oxygen saturation is 92% on room air. His cardiac exam reveals a regular rhythm with an S4 gallop, and his lungs are clear to auscultation. An electrocardiogram (ECG) is obtained. ECG: Case 3 Mrs. Jones is a 68-year-old female who presented to the emergency department with palpitations and shortness of breath that started suddenly while she was resting at home. She denies chest pain or any other symptoms. She has a history of hypertension, hyperlipidaemia, and type 2 diabetes, which are well-controlled with medications. She does not smoke or drink alcohol. On examination, she appears uncomfortable but is alert and oriented, with a heart rate of 130 beats per minute and a blood pressure of 160/90 mmHg. Her cardiovascular exam reveals an irregularly irregular rhythm with no murmurs or gallops. Her respiratory and neurologic exams are within normal limits. Common ECGs • Atrial fibrillation • STEMI • NSTEMI • Complete Heart Block • Ventricular Tachycardia – Broad Complex Tachy • Normal ECG • Sinus tachycardia Full Blood Count: Case 1 Sarah, a 40-year-old female, presents to her GP with complaints of fatigue, weakness, and shortness of breath. She reports feeling tired all the time, even after getting plenty of rest, and finds it difficult to keep up with her daily activities. She has also noticed that she has been more short of breath than usual, even with mild exertion.Parameter Result Reference Range Hemoglobin 8 g/dL 12-15 g/dL (women) Hematocrit 25% 35-45% (women) 4.2-5.4 x 10^6/µL Red blood cells 3.5 x 10^6/µL (women) Mean corpuscular 75 fL 80-96 fL volume (MCV) Mean corpuscular 25 pg 27-31 pg hemoglobin (MCH) Mean corpuscular hemoglobin 33% 32-36% concentration (MCHC) Platelets 300 x 10^3/µL 150-450 x 10^3/µL White blood cells 7.5 x 10^3/µL 4.5-11.0 x 10^3/µL Full Blood Count Red Cells White Cells • Haemoglobin (Hb) • Neutrophils – bacterial • Mean cell volume (MCV) • Lymphocytes – viral • Red cell count • Monocytes • Haematocrit • Eosinophils • Mean Corpuscular Haemoglobin • Basophils • Red blood cell distribution width Causes of Anaemia Type of Anemia Causes Microcytic Anemia Iron deficiency anemia, Thalassemia, Anemia of chronic disease, Lead poisoning Acute blood loss, Chronic kidney disease, Hemolysis, Bone marrow disorders, Normocytic Anemia Inflammatory disorders, Endocrine disorders Macrocytic Anemia Vitamin B12 deficiency, Folate deficiency, Alcoholism, Liver disease Causes of Anaemia by MCV Thalassaemia Anaemia of chronic disease Iron deficiency Lead poisoning Sideroblastic anaemia Urea and Electrolytes: Case 2 John, a 60-year-old male with a history of hypertension and diabetes, presents to the emergency department with complaints of fatigue, decreased urine output, and swelling in his legs and ankles. show a blood pressure of 160/90 mmHg, a heart rate of 100 beats pers minute, and a respiratory rate of 20 breaths per minute. His abdomen is distended and tender on palpation, and his legs and ankles are swollen.Urea and Electrolytes Patient Results Reference Range Sodium (mmol/L) 130 135-145 Potassium (mmol/L) 6.5 3.5-5.0 Chloride (mmol/L) 98 98-107 Bicarbonate (mmol/L) 16 22-28 Urea (mmol/L) 45 2.5-7.1 Creatinine (µmol/L) 400 60-110 Urea and Electrolytes Acute Kidney Injury “an abrupt decrease in kidney function that occurs over a period of hours to days, and is typically characterized by an increase in serum creatinine levels and/or a decrease in urine output.” Causes of AKI • Pre-renal: shock, dehydration, HF à hypoperfusion of kidneys • Renal: nephrotoxic medications • Post-renal: obstructive uropathy Acute Kidney Injury NICE Guidelines: Classification of AKI 1.AKI stage 1: A rise in serum creatinine level of ≥26 µmol/L within 48 hours or a percentage increase of ≥50% to <200% from baseline, or a urine output of <0.5 mL/kg/hour for 6-12 hours. 2.AKI stage 2: A rise in serum creatinine level of >200% to <300% from baseline or a urine output of <0.5 mL/kg/hour for ≥12 hours. 3.AKI stage 3: A rise in serum creatinine level of >300% from baseline (or serum creatinine level ≥354 µmol/L with an acute rise of at least 44 µmol/L in <48 hours), or initiation of renal replacement therapy (RRT), or a urine output of <0.3 mL/kg/hour for ≥24 hours, or anuria for ≥12 hours.Nephrotoxic Medications Hyperkalaemia Stop all K+ supplementations (inc IV fluids), K+ promoting medications Investigations: NEWS observations, 12 lead ECG, IV access ECG changes (tended T waves, loss of P wave, wide QRS, sine wave) ECG changes à calcium gluconate to stabilise cardiac membrane 10 units Actrapid in 250ml 10% Glucose IV +/- salbutamol neb Re-check U+E + ECG after 2-4 hours (handover) Liver Function T est: Case 3 Mr. Smith, a 65-year-old male with a past medical history of gallstones, abdominal pain, jaundice, and dark urine. His physical examination reveals icteric sclera and mild epigastric tenderness.Test Name Result Reference Range Total Bilirubin 4.5 mg/dL 0.1 - 1.2 mg/dL Direct Bilirubin 2.8 mg/dL 0.0 - 0.3 mg/dL AST (Aspartate 80 U/L 5 - 40 U/L Aminotransferase) ALT (Alanine Aminotransferase) 60 U/L 5 - 40 U/L ALP (Alkaline 400 U/L 30 - 120 U/L Phosphatase) GGT (Gamma- Glutamyl 200 U/L 9 - 48 U/L Transferase) Liver Function T ests • ALT is a marker of acute hepatocellular ALT damage AST ALP • ALP + GGT raised à cholestasis GGT Bilirubin • Albumin↓ Prothrombin time↑ Albumin ØReduced synthetic function of the liver PT ØAdvanced disease e.g. cirrhosis Arterial Blood Gas: Case 1 department with shortness of breath, chest tightness, and wheezing that started suddenly while she was at home. She has a history of asthma and reports that she has been experiencing worsening symptoms over the past several days, despite her usual use of inhaled corticosteroids and salbutamol as needed. She denies any recent illness or changes in her medication regimen. On examination, she appears uncomfortable and is using accessory muscles to breathe. Her respiratory rate is 26 breaths per minute, and her oxygen saturation is 90% on room air. Her lung exam reveals bilateral expiratory wheezing are within normal limits.ds. Her cardiovascular and neurologic examsParameter Result Reference Range pH 7.50 7.35-7.45 PaO2 80 mmHg 80-100 mmHg PaCO2 30 mmHg 35-45 mmHg HCO3- 24 mEq/L 22-28 mEq/L O2 saturation 95% 95-100%Metabolic Acidosis Metabolic Acidosis Remember to comment on oxygen • Type 1 Respiratory Failure: low O2, normal CO2 • Type 2 Respiratory Failure: low O2, high CO2 Imaging • CXR • AXR/ CT abdomen • CT/ MRI head • Spine XR/ MRI (cervical/ lumbar) • MSK X Ray • Recognise normal • Know your anatomy labels • Have a structured approach • Always present what you are given; talk through your interpretation. Imaging “I am looking compare this with any previous imaging available.”te. I would like to Is the film adequate (RIP)? • Rotation: the patient is well centered • Are the clavicles symmetrical? • Inspiration: there is adequate inspiratory effort • Can you see more than 6 anterior ribs? • Penetration: there is good penetration • Can you see vertebral bodies? If so à good penetration CXR Interpretation Airway Is the trachea central and non-deviated? Breathing Are the lung fields clear? Any focal areas of opacity, consolidation or shadowing? Cardiac/Mediastinal Contours Are the cardiac/ mediastinal contours well demarcated? Is the cardiothoracic volume normal (<0.5 on PA film)? Diaphragm + Costophrenic Angles Are they well demarcated? Any costophrenic blunting = pleural effusion. Subdiaphragmatic gas = pneumoperitoneum (due to perforation). Everything Else Any bony abnormalities e.g. fractures. Any artefacts e.g. ECG leads CXR Interpretation • Alevolar shadowing • Kerley B lines • Cardiomegaly • Dilated upper lobe vessels • Pleural EffusionAbdominal X Ray Presentationtion • Confirm patient details, time of scan. Would like to compare with any previous imaging. • This is a supine/erect AP abdominal film • Adequacy • Can you see the full abdomen from diaphragm to pelvis? • Well exposed?AXR Structure AXR Presentation • BBC approach • Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder. • Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs. • Calcification and artefact (e.g. renal stones) Most important: small bowel vs large bowel Small Bowel vs Large Bowel Small vs Large Bowel Small Large Centrally located Peripherally located Valvulae conniventes visible across full width Haustra, typically not completely transverse (unreliable) 3/6/9 Rule •Small bowel: 3cm •Colon: 6 cm •Caecum: 9 cm Viva Questions What are the causes of bowel obstruction? If suspecting perforation, what investigation would you like to do?Causes of Bowel Obstruction Small Large Adhesions (previous abdominal Malignancy surgery) Diverticular strictures Incarcerated hernia Volvulus Crohn's disease (stricture formation) Paralytic ileus CT Head CT Head • previous imagingdetails, time taken. Would like to compare this with • I am looking at an axial non-contrast enhanced CT head. • Contrast used for mets/ tumour imaging • Structured approach Blood Can Be Very Bad1 Lateral ventricle (anterior horn) 2 Caudate nucleus 3 Internal capsule 4 White matter 5 Grey matter 6 Lateral ventricle (posterior horn) 7 Falx cerebri 8 Choroid plexus (calcified)temporal bone 9 Corpus callosum (splenium) 10 Sylvian fissure 11 Corpus callosum (genu) 12 SulciBlood : extradural/subdural/subarachnoid/intracerebral (intraparenchymal) • Hyperdensity --> New bleed (white) Hypodensity --> Old bleed (black) Cisterns :assessed for effacement, presense of blood and asymmetry Brain :normal gyral-sulcal pattern (Loss of this differentiation suggests the presence of oedema which may develop secondary to a hypoxic brain injury, infarction (e.g. ischaemic stroke), tumour or cerebral abscess.) • Hypodense foci (air, fat, oedema) Hyperdense foci (blood, thrombus, calcification) Ventricles • Intravrentricular haemorrhage --> hyperdensity • Hydrocephalus --> dilation of the temporal horns Bone : Fractures MRI Head MRI Head • Be prepared to label anatomy • T1 vs T2? • Water is white in T2Spinal Imaging: C Spine XR Peak Flow Diary • Will be given patient height and age. • Read off graph normal PEFR • Diurnal variation à asthma • Bronchodilator reversibility • Give salbutamol and retest after 15 minutes • Reversibility à asthma • Non-reversible à COPD Lung Function T ests • Obstructive vs Restrictive • State what you see i.e. ↓FEV1, ↓FVC (but to a lesser extent) • FEV1/FVC ratio <0.7 à Obstructive airway disease e.g. COPD/ asthma • Also could be emphysema, bronchiectasis, CF • Restrictive disease • Pulmonary: pulmonary fibrosis, pneumoconiosis, oedema • Non pulmonary: skeletal abnormality, neuromuscular disease, obesity