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OsceExpress Session6 NidhiAgarwal(FY1) ShailiKadambande(FY1) InToday’sSession… 01 02 03 Specialties Deteriorating Q&A+ withintheED Patients CasesDisclaimer This course has been designed to help final year students with practical OSCE exams and is an unofficial resource that covers themes present in the University of Leicester Final OSCEs. We have nonetheless made this course as applicable to other final year OSCEs as possible, but there may be discrepancies in your University’s expectations. OSCE Express sessions are peer-reviewed by junior doctors, but we take no responsibility in the accuracy of the content, and additionally our sessions do not represent medical advice. Please use our sessions as a learning aid, and if you note any errors, do not hesitate to message us at osce.express@gmail.com Kind regards, Dr Nidhi AgarwalFY1 Sumedh SridharYr5 MedicalStudent OSCEExpressco-creatorsCourseOverview Osce Express 1. 11 session guide to common OSCE finals stations 2. Delivered by Foundation Year 1 Doctors 3. Peer-Reviewed Cases + Video Guides provided to all participants (published on MedAll, osceace.com) 4. Preparation for OSCEs… 5. …And also preparation to be a safe FY1 Meet the Team Nidhi Agarwal Sumedh Sridhar SaraSabur NikitaChoudhary Shaili Kadambande FY1 Doctor (NW) Yr5 MedStudent FY1 Doctor FY1 Doctor FY1 Doctor Osce Express Co-Founder Osce Express and LNRTrust LON Trust LNRTrust OsceAce Co-founder Holly Garcia BethanyTurner Nevash Maraj VanessaDatta FatimaAhmedi FY1 Doctor FY1 Doctor FY1 Doctor FY1 Doctor FYCore Committee LNRTrust SY Trust NWTrust LNRTrust 01 Specialities withintheED Layout 01 • Any speciality with emergency presentations - History + physical examination or 10Min 02 higher-level communication Specialities skills - Real patients or models station 03 - Expected to diagnose, with appropriate investigations + reason a management planExaminerexpectations *Mark scheme variable as per SpecialtyTopTips 1. Chance for examiners to evaluate your diagnostic and reasoning skills 2. Focus on differentials early: most likely, not-to-be missed. Remember red flags! 3. Revise your emergency presentations from: O&G, paeds, psych, ophthal, neuro, ENT, derm, oncology 4. Keep an ear out for safety concerns - ?safeguarding, ?driving Potentialcases 1. Obstetrics: placental abruption, praevia, (pre) eclampsia, PROM 2. Gynaecology: torsion, ectopic, HMB, miscarriage 3. Paeds: respiratory infections, foreign body, appendicitis, jaundice, epilepsy, meningitis, Non-accidental injury, DKA, asthma attack 4. Psych: psychosis, overdose, suicidal ideation, NMS, dystonic reaction 5. Ophthal: sudden visual loss, GCA, red eye, acute glaucoma 6. Neuro: stroke, seizures, syncope, MS, cauda equina 7. ENT: epistaxis, hearing loss, OM/OE, epiglottitis, anaphylaxis, 8. Derm 9. Oncology: MSCC, neutropenic sepsis, SVCO, TLS, SIADH Tips: Screen for conditions through the surgical sieve: VITAMIN C Differentiating features: onset or patterns, triggers, pain, fever, dizziness, vomiting, appetite Case1 You are the FY1 in the Emergency Department Audrey Edwards is a 78-year-old presenting to the ED with vision loss. You have 10 minutes to: - Take a history from the patient - Explain the likely diagnosis, any investigations that may be required, and your management plan - Answer any questions the patient hasIdeasforapproach History Differentials Investigations Management Onset GCA Ophthalmic exam Medical Pain CRAO Slit lamp Surgical Discharge CRVO ECG Lifestyle Visual acuity Retinal detachment Bloods - Driving Associated sx Vitreous TAB/USG - Charities haemorrhage - ?register as PMH + risk factors Stroke blind Case2 You are the FY1 in the Emergency Department Mary Howard is a 32-year-old primigravida presenting with PV bleeding at 34 weeks You have 10 minutes to: - Take a history from the patient - Explain the likely diagnosis, any investigations that may be required, and your management plan - Answer any questions the patient hasIdeasforapproach History Differentials Investigations Management Onset + pattern Placenta praevia CTG Medical Volume Placental abruption Bloods inc. Hb, Surgical Pain ?PROM clotting, G&S, Lifestyle Discharge Kleihauer - Smoking Associated sx USG - Trauma - Swabs ?safeguarding Examine for fFN – pre-term tenderness PAMG-1/GFBP-1 - Hard woody uterus Case3 You are the FY1 in the Emergency Department Jasmine Brown is a 13-year-old presenting to the ED with Susan their mother. Please take a history from her mother for abdominal pain You have 10 minutes to: - Take a history from the mother - Explain the likely diagnosis, any investigations that may be required, and your management plan - Answer any questions her mother hasIdeasforapproach History Differentials Investigations Management SQITARS Appendicitis Abdo exam Medical Pattern DKA Urine dip Surgical Constipation Stool culture Lifestyle Associated sx : UTI Bloods - ?diabetic Vomiting Repro: cysts/torsion Imaging - US/CT counselling Eating/drinking Splenic rupture - ?MH Bladder + Bowels IBD Consider pregnancy Fever Gastroenteritis test PMH Recent illnesses Case5 You are the FY1 in the Emergency Department Victor Webb is a 78-year-old presenting to the ED with weakness in his legs. You have 10 minutes to: - Take a history from the patient - Explain the likely diagnosis, any investigations that may be required, and your management plan - Answer any questions he hasIdeasforapproach History Differentials Investigations Management Onset Cauda equina Neuro exam Medical Pain MSCC - UMN vs LMN Surgical Paraesthesia Sciatica lesion Lifestyle MS Bloods - Driving Falls/syncope Spinal abscess MRI - Work PMH Questionsabout SpecialitiesintheED? 02 Howtoassessthe deteriorating Patient Layout 0-8 Mins - Perform an A-E assessment, 01 asking for observations and clinical signs through your examination Deteriorating - Perform a clinical skill relevant to 02 patient the A-E assessment 8-10 mins: - Interpret the investigation 03 findings and appropriate SBAR to a senior Assess a mannequin case summary NOT required) CSF/CTF roleplaying as nurse Clinicalskills ● Airway insertion; nasopharyngeal, oropharyngeal ● Administering oxygen/ nebulisers inc. venturi ● ABG ● Venepuncture ● Cannulation ● Subcut/Intramuscular injection ● Intravenous fluid administration ● Blood glucose ● BLS/ Choking Investigationstointerpret ● CXR, AXR ● ABG/VBG interpretation ● Blood results ● ECG PotentialA-Escenarios ● Anaphylaxis ● Hyperglycaemia; DKA and HHS ● Asthma ● Head injury (criteria for CT head) ● Opioid/ drug overdose ● Seizure ● Vomiting ● Stroke ● Stridor ● Hypothermia ● Choking/ foreign body ● Hypo/Hyperkalaemia ● Asthma/ COPD acute ● Hypoxia ● Pneumonia ● Cardiac tamponade ● Pulmonary embolism ● Haemorrhage/ Bleed ● Pneumothorax ● Urinary retention ● Hypovolaemia ● Pericarditis ● Sepsis ● Acute heart failure ● Atrial fibrillation/ Tachyarrhythmia ● Sepsis ● Bradyarrthymia ● Hypovolaemia ● MI/ ACSTopTips 1. Keep calm: Go through the steps 2. Ask someone to gather the arrest trolley, the notes (documentation), an ipad (for prescribing), and start a set of observations 3. Pull the curtains (privacy) 4. Delegate tasks to team members. Ask someone to call for help 5. Introduce yourself to the patient (and the rest of the team) 6. Treat abnormal findings as you come across them 7. UHL guidelines are always available. Nervecentre prescribing 8. A good SBAR is really important when calling a senior for further management 9. Documentation 3 Cases Layout - The Unconscious Patient 01 Cases 02 - The Hypoxic Patient 03 - The Unresponsive patient Case1:TheUnconsciousPatient Youare theFY1 on-calland thenurseinformsyouthather patient is unconscious inhis chair. Whatare yournext steps? BeforetheA-E 1. AVPU: Unconscious and unresponsive to sternal rub. Patient breathing 2. Get patient in bed and start set of observations 3. Peri-arrest call, crash trolley, and call for help 4. Ask someone to get an IPad/prescription chart, patient’s notes and start documenting. No respect form in place 5. Pull the curtains 6. Check 3 points of ID PatientbackgroundsBar Patient is a 63 year old man Had a laparoscopic right hemicolectomy for bowel cancer 3 days ago Checked operation notes, no complications during surgery No Respect form in place PMH: COPD, HTN, Bowel cancer, Diverticular disease, Hypercholesterolaemia Dx: Atorvastatin, Salmeterol, Tiotropium, Amlodipine, Dalteparin 5000Units, Ondansetron PRN, Oramorph PRN No allergies Airwayassessment Patient still unresponsive. No response to sternal rub Head-tilt chin-lift and look inside mouth Patient starts vomiting coffee-ground vomitus Airwaymanagement 1. Naso-gastric tube 2. Nasopharyngeal airway 3. Lie on left lateral position 4. Suction vomit contents Breathingassessment ● RR 20 ● Oxygen saturations 85% on air ● Trachea central and chest expansion equal bilaterally ● Percussion resonant equally. Air entry equal bilaterally with expiratory wheeze bilaterally Breathingmanagement 1. ABG 2. Portable CXR 3. Oxygen 15L non-rebreathe mask 4. Back-to-back nebulisers salbutamol Circulationassessment ● HR 104 and BP 70/40 ● CRT 4s, Patient peripheries cool, pale and clammy ● Heart sounds normal, no raised JVP or peripheral oedema ● Dry mucous membranes ● One cannula in-situ pink 20G cannula ● Bloods: VBG, G&S, FBC, U&E, Coagulation profile ● ECG Circulationmanagement 1. Insert 2 wide-bore cannulas orange or grey 2. Fluid bolus 500ml Hartmans over 15 minutes 3. Strict fluid balance assessment Disabilityassessment ● Patient rousable, GCS 11 ● Verbally responsive, not fully alert ● Blood glucose 5 ● Pupils equal and bilateral ● Temperature 36.3 Disabilitymanagement 1. Analgesia - Oramorph 10-20MG Exposureassessment ● Head to toe assessment ● Catheter in-situ ● Abdomen hard, distended, bowel sounds absent ● Calves SNT Reassessment Airway: NG tube in-situ, Patient speaking, Airway patent, Sit patient up Breathing: RR 19. Oxygen saturations 98%- can switch to venturi mask, air entry equal bilaterally, no added breath sounds Circulation: BP 90/60, another fluid bolus, HS normal, CRT 3s, patient looks more pink Disability: Blood glucose normal, pupils equal and bilateral, temperature 36.3 Exposure: abdomen hard and distended, bowel sounds absent. Calves SNT Recommendation/Nextsteps The patient is now stable Please review the investigation results of The VBG: pH 7.30 pO2 10 pCO2 Normal HCO3 20 Lactate 9.0SBARhandover Nextsteps Call the surgical registrar, SBAR Plan fromsurgicalregistrar: CTAP immediate for ?bowel obstruction/ileus, NG tube, Analgesia, Start antibiotics, IV omeprazole 40MG Learningpoints ● Make sure you know how to contactyoursenior ● If you don’t feel confident managing a patient alone, call for senior help. ● If a patientis deteriorating, you need to call thefamily ● Surgical patients deteriorate quickly and suddenly, make sure you remind a senior the next day to put in a Respect form ● Documentclearly your A-E findings and handovertothenext team ● Check in on team members and debrief with them and your senior for further reflection and learningTheA-Eassessment Aiway ● Introduce yourself to patient; check 3 forms of ID. If they’re responding to you airway is patent and move on to breathing ● Compromised airway due to inhaled foreign body, secretions or blood in airway, laryngospasm, soft tissue swelling: look inside mouth, nasopharyngeal airway ● Anaphylaxis: adrenaline ● Vomit /secretions: suction, left lateral position ● Unconscious: head-tilt chin-lift, oropharyngeal airway ● Reassess Breathing ● Respiratory rate 12-20 ● Oxygen saturations 94-98%, COPD 88-92%. ABG and administer oxygen if low 15L non-rebreathe mask. Sit patient upright ● General inspection ● Tracheal position ● Chest expansion ● Percussion ● Auscultation; CXR ● Reassess Circulation ● HR 60-99 ● Blood pressure 90/60mmHg- 140/90mmHg. Fluid bolus if low. After 2L if not responding ITU/Senior input ● Fluid balance assessment ● General inspection ● Peripheral temperature, CRT <2s ● JVP ● Heart sounds ● Peripheral oedema ● Reassess Circulation ● 14G/16G 2 wide-bore cannulas ● Blood tests: VBG, Blood cultures, G&S samples, FBC, U&Es, Coagulation, Troponin, D-dimer, Toxicology screen, serial mast cell tryptase ● 12-lead ECG, continuous cardiac monitoring ● Bladder scan; urinary retention/obstruction ● Urine pregnancy test, urine dip, MC&S ● Catheterisation/ strict fluid balance ● Blood transfusion/ major haemorrhage procotol ● Reassess Disability ● Consciousness: Alert, confusion, verbal, pain, unresponsive ● Pupils ● Drug chart review ● Blood glucose 4-5.8 and ketones if high ● GCS<8-> Anaesthetist (part of the arrest team) ● CT head ● Analgesia ● Reassess Exposure ● Head-to-toe assessment ● Abdominal examination ● Calves ● Examine any lines/drains/catheters ● Temperature 36-37.9. Think SEPSIS ● Cultures/swabs ● ReassessQuestions?TopTips 1. Keep calm; Go through the steps 2. Ask someone to gather the arrest trolley, the notes (documentation), an ipad (for prescribing), and start a set of observations 3. Pull the curtains (privacy) 4. Delegate tasks to team members. Ask someone to call for help 5. Introduce yourself to the patient (and the rest of the team) 6. Treat abnormal findings as you come across them 7. UHL guidelines are always available. Nervecentre prescribing 8. A good SBAR is really important when calling a senior for further management 9. DocumentationHowwouldyoufeelassessingadeteriorating patient?Howwouldyoufeelassessingadeteriorating patient? Call for help! (There’s always plenty of staff around who have dealt with this before) Ask a member of staff to put out an arrest/peri-arrest call if needed. Check for respect form! For unwell patients make sure you do the A-E and get a background before calling a senior A-E assessment is also the initial measures to stabilise a patient. SBAR to senior for further management: surgical reg, med reg, LRI coordinator, DART, arrest team, ITUQuestions?NextSession… Feedback https://app.medall.org/feedback/feedback-flow?keyword=0849e69ff3b0fbe9b0b3e168&organisation=osceexpress Thanks ! Follow us for updates @osce.express Cases: osceace.com/osceexpress