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OsceExpress Session8 BethanyTurner(FY1) VanessaDatta(FY1) InToday’sSession… 01 02 03 Managing Multimorbidity+ Q&A+ Uncertainty Polypharmacy 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 Osce Express Co-Founder5Osce Express and FY1 Doctor FY1 Doctor FY1 Doctor OsceAce Co-founder LNRTrust LON Trust LNRTrust Holly Garcia BethanyTurner Nevash Maraj VanessaDatta FatimaAhmedi FY1 Doctor FY1 Doctor FY1 Doctor FY1 Doctor FY1 Doctor LNRTrust SY Trust NWTrust LNRTrust LNRTrust 01 Managing Uncertainty Layout - Simulated patient – 5 minutes 01 history taking and 5 minutes to explain differential Dx and management plan Managing 02 - Diagnostically relevant findings Uncertainty will be told at the end of the first 5 minutes by the examiner 03 - No questions from examiner – purely observingStationLayoutTopTips 1. Managing uncertainty – the diagnosis will be uncertain! 2. Have a logical system based approach when taking the history (eg cardiovascular, respiratory, GI, psych..) 3. Remember ICE! – and address these in your management plan 4. Management plans – start simple and then suggest more specialist investigations if known. You will mainly be assessed on having a logical approach to the case and suggesting valid investigations, management and safety netting advise. TopTips 5. Pick up on patient cues – don’t forget to have a biopsychosocial approach when questioning 6. Keep it succinct – you will need to ask some closed questions 7. Don’t forget to safety net depending on the case – important in GP land! 8. Screen for red flags - fever, drenching night sweats, weight loss (>10% in 6 months), fatigue..Murtagh’sWhatyouwillbeassessedon.. 1. Communication skills, data gathering, patient centred care, patient safety, duty of candour 2. Focused history taking 3. Communication skills 4. Diagnostic reasoning 5. Appropriately communicating uncertainty to the patient … this station is about NOT getting the correct diagnosis, rather appearing comfortable dealing with and managing uncertainty. You will most likely lose marks if you state one correct diagnosis you think it is! 6. Clinical reasoning skills including investigations and management 7. Time management skillsApproach ExampleLayoutPractiseWithUs You are working as a Foundation Doctor in a GP practice and you are about to see Mr Smith, who has come in with breathlessness. You will need to: Take a focused history from the patient (0-5 minutes). You will then be told the examination findings. Explain the differential diagnosis and management plan to the patient (5-10 minutes)PractiseWithUs..Approachtohistorytaking HPC, PMHx, PSHx, Drug Hx, allergies, FHx, social Hx …. But keep it relevant and succinct Onset – acute, subacute, chronic.. (to narrow down the differential). Always screen for red flags (fever, nt sweats, wt loss).. System based approach: Cardiac: arrhythmias (?palpitations) acute pulmonary oedema, chronic heart failure, silent MI.. Pulmonary: asthma, COPD, pneumonia, PE, lung ca (?B symptoms), pleural effusion.. Other: anaemia, psychogenic breathlessness (social Hx), metabolic (DKA acutely, thyroid disorders), diaphragmatic splinting (ascites, obesity, pregnancy)Examinationfindings.. HR 81 bpm BP 139/80 Sats 99% O/A Chest clear, HS I + II +0, abdo SNT BM normal Apyrexia Investigationsandmanagementplan Bedside,bloods,imaging,specialtests Cardiac: ECG, ?24 hour tape referral, if chest pain or exertional SOB consider referral to rapid access chest pain clinic where CTCA could be organised Pulmonary: CXR, sputum cultures if applicable, peak flow, spirometry referral Bloods: FBC (?anaemia), LFTs, U+E’s, CRP, HbA1C, lipid profile.. Safety netting – worsening SOB, chest pain, dizziness etc – then seek medical attention Patient information leafletsQuestionsaboutthiscase?2 nd case.. You are working as a Foundation Doctor in a GP practice and you are about to see Ms Rogers, who has come in with fatigue. You will need to: Take a focused history from the patient (0-5 minutes). You will then be told the examination findings. Explain the differential diagnosis and management plan to the patient (5- 10 minutes)Approachtohistorytaking.. Systembased approach HPC, PMHx (?chronic conditions), PSHx, drug Hx, allergies, FHx, social hx (occupation, smoking and alcohol, exercise, ?psychosocial life events or stressors) Cardiovascular, pulmonary, GP (red flags), neuro, psych.. Metabolic – DM (?polyuria, polydipsia, weight changes, family history..), hypothyroidism (?weight gain, hair loss, dry skin, cold intolerance, constipation, menorrhagia..) Explore diet and lifestyle in social HxHistorytaking..Examinationfindings… BP 124/70 HR 78 bpm, regular Chest clear, HS I + II +O, abdo SNT Apyrexial No goitre palpable Some conjunctival pallor present, hands cold to touchInvestigationsandmanagementplan.. Investigations: Bloods – FBC, haematinics, LFTs, U+E’s, CRP, bone profile (?hypercalcaemia, hypomagnesaemia..), HbA1C, lipids, thyroid function (?hypothyroidism) Urine dip/ACR - ?haematuria, proteinuria Pelvic USS – if symptoms of menorrhagia reported Management plan suggestions: Secondary care referral, manage underlying causes, patient information leaflets, sleep hygiene advice if applicable, lifestyle advice eg rest periods, relaxation techniques, healthy eating.. Managing stress, anxiety, depressionQuestionsaboutthiscase? 02 Multi-morbidity andPolypharmacyStationguidance “Skilled and fluent history and explanation. No or only minor omissions. Excellent interaction with patient – appears natural. Assured answers given to questions with full explanation, showing a deep level of understanding. Highly-appropriate rationale for any changes to medication, communicated to the patient with a high degree of skill. Works in partnership with patient to develop and agree the plan.” StationLayout - Discharge letter 01 Review the available notes during the 2 min reading time and start forming a plan Medication 02 - Brief history review Including the patient’s agenda and ICE 03 - Medication review Personalised to patient’s situation, condition and wishes 1. DischargeLetter ● Reason for admission ○ Indicates most current problem ○ Control of condition? ● Information on stay ○ Complications? ○ New diagnoses? ● Recommendations for GP ● Medication changes ○ Necessary? ○ Interactions ○ Side effects MAKE NOTES 2.BriefHistory ● HCP ● PMHx ● DH ● Social Hx ● ICE → Useful later when thinking of and negotiating medication changes 3.MedicationReview “Discuss each of the patient’s medications with them, including indications and any relevant side effects” ● Start with what the patient is most concerned about (ICE) / highest yield ● ?Compliance “Suggest any appropriate changes to medications, explaining why these are indicated” ● Dose changes, medication changes, stopping/ starting “Negotiate and agree an acceptable plan with the patient” ● Patient-centred ExampleIssues… Interactions Contraindicated ● NSAID and ACEi ● NSAID without PPI ● Blood thinners/ NSAID / SSRIs ● COCP rules ● Methotrexate and trimethoprim ● Hepatic/ renal impairment? ● ACEi and potassium-sparing diuretics ● Medication rules e.g. bisphosphonate holiday Side effects ● Disease-specific guidelines e.g. ● Constipation, nausea with opiates clopidogrel for 12mth after MI ● Swelling, hypotension, headaches ● Propranolol in asthma with CCBs ● Dry cough ACEi Correct use/ compliance: ● Corticosteroids in diabetes/ mood ● Inhalers disorders ● Bisphosphonates ● Sick-day rulesExaminerexpectations UseBeyondOSCEs? ● Even the basic interactions still cause issues in practice ● Over 70% of ADRs are avoidable ● Most common culprits are: ○ NSAIDs ○ Antiplatelets ○ Diuretics ○ Warfarin ○ ACEi and ARBsCases CASE 1:AngelaBard,73y/oF Mrs Bard was admitted on 10/01/24 PMH • COPD • HTN following an infective exacerbation • Hypercholesterolaemia of COPD. She received antibiotics • Previous MI (2019) and steroids, and remained in • AF hospital for 3 days before being • Salbutamol 2 puffs PRN discharged home. Her BP was Drugs on • Fostair inhaler (beclometasone/ consistently low during admission. discharge formoterol) BD • Amlodipine 10mg OD eGFR 70. U+E NAD. • Ramipril 5mg OD • Aspirin 75mg OD • Clopidogrel 75mg OD GP to please review medication. • Bisoprolol 10mg OD • Simvastatin 20mg Nocte • GTN spray 1 puff PRN • Apixaban 5mg BD • Alendronate 10mg OD PotentialChanges ● COPD control - how many exacerbations? Smoking? Limits on daily life? Spacer? Flu jab? ● Low BP - on three BP lowering drugs ○ ?SE - swelling, headaches / dry cough, electrolytes ● Blood thinners ○ Clopi > 12mth ○ Aspirin and apixaban - no added benefit in stable disease ● Bisphosphonate holiday? ○ 3-5 years consider break Learningpoints ● Guided by patient ● Knowledge of guidelines where possible ● Consider referral to specialist clinics ● Consider lifestyle changes CASE 2:DavidYong,68yr/oM PMH T2DM Mr Yong was admitted on 08/01/23 Heart failure for a fall with 3 rib fractures. He remained in hospital for 2 days for New Ibuprofen 400mg TDS pain management. He was also medications Paracetamol 1g QDS struggling with shortness of breath Codeine 30/500 2 tabs QDS and a chest X-Ray showed Oromorph 15mg QDS pulmonary oedema so his furosemide was increased and Medication Furosemide 80mg BD INCREASED changes Dapagliflozin 10mg OD NEW dapagliflozin was added. GP to please review medication. Existing Ramipril 5mg OD medications Bisoprolol 10mg OD Gliclazide 80mg Tolterodine 4mg OD Amitriptyline 25mg NOCTE PotentialChanges ● Risk of going to toilet at night ○ Amitriptyline - drowsy, anticholinergic burden ○ Tolterodine - anticholinergic burden ○ Underlying prostate issue? ● New furosemide ?dose ● Gliclazide and dapagliflozin together - hypo ● Ibuprofen without stomach protection ● Opiate burden ○ Negotiate with patient, additional risk of pneumonia if inadequate ventilation ○ Codeine and oromorph ○ Reduce frequency? ○ Laxatives Learningpoints ● Negotiate with patient taking their wishes into account ● Anticholinergic burden ● Reasons for medicationQuestions? KeyTakeaways… Establish the patient’s concerns and wishes early in the 01 consultation 02 Use the reading time to its full potential Review treatment pathways of common chronic conditions, 03 and the STOPP START ToolNextSession…Feedback Thanks ! Follow us for updates @osce.express Cases: osceace.com/osceexpress