Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

YEAR 3 OSCES Mairead McGlinchey PLAN • Important info • Investigations • General advice • Management • Types of stations • Resources • Histories • Counselling • Examinations • Procedures IMPORTANT INFO • Week beginning 10 June • 6 minutes per station • 1 minute warning • 1 minute reading time • 12 active stations across 2 days • 1 or 2 rest stations • Will include specialties encountered in LIC ONLY –NO year 4 content e.g.gynae Hx,paeds Hx,psych Hx,etc. GENERAL ADVICE • It is a jump from 2 year • Don’t neglect year 1 & 2 skills • Informed consent • Remember who you are and where you are • Try to stay calm and put the last station out of your mind • Ask for seniors • Read feedback from 3 and 5 th • Empathy e.g.offering analgesia, year OSCEs acknowledge their feelings • Remember the basics: • Wash your hands & clean equipment • Obtain consent • No technical language • Patient score YR 3 FEEDBAC K Year 3 –Assessment information – scroll down toAdditional information – click‘OSCEs’ YR 5 FEEDBAC K Year 5 –Assessment information – scroll down to OSCEs PRACTICE • Timed conditions • With medics and non-medics (counselling) • Real patients • Good resources: • Geeky medics –OSCE station bank • OSCEStop • Practice on your own:cxr,axr,ecgs,data interpretation, fluids • Be open to criticism • Muscle memory YELLOW CARDS • Patient safety or professionalism issue e.g.incorrect disposal of sharps • Does NOT mean you have failed the station • Will be contacted by QUB to discuss it • Red cards don’t exist TYPES OF STATIONS • Histories e.g.chest pain,difficulty swallowing,tiredness,abdo pain • Counselling: • Conditions e.g.type 1 diabetes,psoriasis,eczema,nephrotic syndrome,CKD • Medications e.g.ACE-i,Methotrexate,Insulin,warfarin • Examinations e.g.resp exam,knee exam,cranial nerve exam,diabetic foot • Procedures:BP measurement,urinalysis • Interpretation:CXR,ECG,AXR,PFTs,NEWS chart,fluids charts • Management:hyperkalaemia,DKA HISTORIES • Consent • Still wash hands • Structure:Hx:PC,HPC (SOCRATES & systemic),PMHx,DHx,FMHx,SHx,ICE,head to toe • Driving e.g.dizziness,MI • Think of differentials for vague symptoms e.g.tiredness,weight loss • OSCEStop has a good differential list • Show empathy –patient score is worth 5 marks • Questions on investigation and management: • Answer the question asked e.g.if asked for further exams don’t say investigations • Start from bedside and work way up e.g.start with exams,obs,urinalysis,sputum culture,bloods (say which bloods),CXR,CTPA • Start with basic management:get senior,analgesia for pain,oxygen for hypoxia,paracetamol for pyrexia COUNSELLING • New to third year • Geeky medics –explanations and stations • OSCEStop –under communication –table of common drugs to counsel on • Practice,practice,practice • Non-medics –friends /family who don’t know much about that condition /medication and don’t know medical jargon • No medical jargon • Chunk and check • Driving e.g.diabetes,OSA • Get a structure: • Brief history:“what has happened up to this point?” • Acknowledge that this new diagnosis may be a lot for them to take in • ICE • Answer their questions /explain the condition or medication • LEAFLET COUNSELLING • Condition: • Medication: ATHLETICS • Normally -normal • Action • We –what the disease is • Timing • Can -cause • How to use • Probably –problems /complications • Length of time • Manage –management (include things they • Effects can do e.g.weight loss) • Tests • Important SEs • Contraindications EXAMPLES OF COUNSELLING • Conditions: • Medications: • Acne • Statins • Eczema • ACE-i • Psoriasis • ARBs • CKD • Methotrexate • Nephrotic syndrome • Steroids • Asthma • Metformin • COPD • Roaccutane • Diabetes • Blood transfusion EXAMPLE OF COUNSELLING STATION Counsel on acne: • Informed consent • Brief Hx: “what has happened up until this point?” • Acknowledge the diagnosis and affect on their life • ICE: • I: “what do you already know about acne?” Chunk and check • C: “is there anything in particular you are concerned about with this?” • E: “is there anything you would like to discuss today?” • Normal:openings in skin called pores which are normally clear • What it is:in acne these pores become blocked by oils and bacteria grows leading to spots • Cause:very common,hormones,runs in families (NOT caused by lack of hygiene or poor diet) • Problems /complications:scarring,effect on self-confidence /mood • Management:pick treatment based on severity and discuss this medication • Give leaflet EXAMPLE OF COUNSELLING STATION 2 Steroid counselling: • Consent • Brief Hx –allergies,other meds • ICE • Action: Work in the liver to reduce the amount of cholesterol made and to remove cholesterol from the blood • Timing:once a day at the same time every day usually at night • How to take it:a tablet you take through the mouth • Length of time:lifelong • Effects:reduces cholesterol which helps to reduce fatty buildup in blood vessels therefore reducing the risk of heart attacks and strokes,explain that they won’t feel any different but should keep taking it • Tests:blood tests to check cholesterol levels and liver function before and during treatment • Important SEs:sore muscles,muscle breakdown (seek medical attention if unwell),diarrhoea,constipation,nausea,headache • Contraindications:liver problems • Other things to discuss:lifestyle changes to reduce cholesterol,may interact with other meds so let your dr /pharmacist know you’re on this,no grapefruit • Leaflet EXAMINATIONS • Informed consent • Ask about pain • Chaperone:breast,chest exam,femoral pulse • Always remember to inspect –use a system e.g.around bed,patient in general,focus on relevant system • Comment on findings e.g.if you auscultate say what you hear • If it involves the legs get them to walk • If your unsure of what to do: • MSK:look,feel,move • Cardio /resp /abdo:inspect,palpate,percuss,auscultate • Neuro:inspect,tone,power,co-ordination,reflexes • Look at skills listed in logbook –any of these could come up as an OSCE • Learn relevant exams in OSCEStop book EXAMINATION EXAMPLES 1 • Cardio /vasc: • Ophthalmology: • Cardiac exam • Inspect (work from outside inwards) • Pulses exam • A- acuity • PVD exam • F- fields Unlikely to be asked to do all of these in 1 station • Resp exam • R- reflexes • O- ophthalmoscope • Neuro: • Cranial nerves • ENT: • Cerebellar • Nasal exam • Oropharyngeal exam • UMN • LMN • Neck exam • Ear exam* EXAMINATION EXAMPLES 2 • Endocrine: • Derm: • Thyroid • SSSCAMM:site,size,shape,colour, associated secondary changes, • Diabetic foot morphology,margins • GI: • ABCDE for pigmented lesions • Abdo exam • Other: • PR • Breast • MSK:hand,shoulder,spine,hip,knee, • Male external genitalia foot/ankle • Hydration status • Nutritional status CHALLENGING EXAMINATIONS • Peripheral vascular disease exam • Will usually just be lower limbs • Inspect, • Inspection is very important –start distally and go proximally • Palpation: • Temp • CRT • Pulses:femoral (chaperone),popliteal,post.tibial,dorsalis pedis • Gross sensation • Further exams:Buerger’s,ABPI MM1 CHALLENGING EXAMINATIONS • Diabetic foot exam • Gait and inspect shoes • Inspection –look in between toes and bottom of foot • Ulcers,arterial signs,venous signs,charcot joints • Palpate:temp,CRT,pulses • Sensation:monofilament, vibration,proprioception • Ankle-jerk reflexSlide 20 Mairead McGlinchey, 09/05/2024 MM1 PROCEDURES • BP measurement • Urinalysis: • Check expiry date • Check patient details • Wait the correct amount of time • Say what you see • Blood glucose measurement • Most procedures e.g.taking blood,cannulas,catheterisation are very unlikely to come up INTERPRETATION • ALWAYS check name,DOB and H&C on EVERY piece of info you are given • Say what you see and if it is normal /high /low • Examples: • CXR • AXR • ABG • ECG • PFTs • NEWS chart • Fluid balance chart CXR • Details • Patient:name,dob and h&c • Airway –trachea central,obstruction,carina, • X-ray:when it was taken, AP/PA bronchi • Breathing –lungs top to bottom (compare R to L), • Previous x-rays for comparison • Radiograph quality: hila,trace around lungs for pleura • Circulation –heart size (only PA),heart borders, • Rotation –spinous processes equidistant from medial heads of clavicles aortic knuckle,aortopulmonary window • Diaphragm and costophrenic angles • Inspiration -number of ribs • Penetration -see spinous processes through vertebraeEverything else –bones,tubes,valves,pacemakers • Enough included –above supraclavicular space and • Review areas –lung apices,retrocardiac area, below diaphragm behind diaphragm,peripheral regions of lungs,hilaCXR EXAMPLE AXR • Details: • Large bowel:haustra • Patient:name,DOB,H&C • Diameter:SB:3cm,colon:6cm, caecum:9cm • Radiograph:date taken,projection • Organs:name every organ • Previous imaging • Radiograph quality:RIPE • Bones • Bowel: • Everything else –artefact,calcification e.g.renal stones,surgical clips • Small bowel –valvulae connniventes (full width)AXR EXAMPLE ABG • pH • Base excess • Up –alkalotic • Very positive –metabolic alkalosis • Down -acidotic • Very negative –metabolic acidosis • PaO2 –are they hypoxic? • Glucose ROME: • PaCO2 • Lactate –can tell you if it is lactic acidosis Respiratory opposite Metabolic equal • Up –holding on to CO2 • Potassium • Down –getting rid of CO2 • HCO3- • Up –holding on to bicarb • Down –getting rid of bicarbRome: Respiratory opposite ABG TABLE Metabolic equal pH PaCO2 HCO3- Metabolic ↓ ↓ (compensatory) ↓ acidosis Metabolic ↑ ↑ (compensatory) ↑ alkalosis Respiratory ↓ ↑ ↑ if chronic causing acidosis compensation Respiratory ↑ ↓ - alkalosis ABG EXAMPLE 64 year old gentleman with a history of COPD presents with worsening shortness of breath and increased sputum production. • pH:7.21 (7.35-7.45) • pO2:7.2 (10–14) • pCO2:8.5 (4.5–6.0) • HCO3:29 (22-26) • BE:+4 (-2 to +2) What does theABG show? Differential diagnosis ABG EXAMPLE 64 year old gentleman with a history of COPD presents with worsening shortness of breath and increased sputum production. • pH:7.21 (7.35-7.45) -acidotic • pO2:7.2 (10–14) -hypoxic • pCO2:8.5 (4.5–6.0) -hypercapnic • HCO3:29 (22-26) -high • BE:+4 (-2 to +2) -high What does theABG show?Type 2 respiratory failure with partial metabolic compensation Differential diagnosis:IECOPD ECG • Details • Follow along: • Patient- name,DOB, H&C • P waves: • ECG:date and time • present (AF) • Calibration:25mm/s • Is each followed by a QRS (AV block) • Rate • PR interval (3-5 small squares) (> =AV block) • Regular:300 / no.large squares from R-R • QRS complex: • Irregular:6 x no.complexes on rhythm strip • Width:<3 small squares (> =BBB) • Rhythm (count no. squares between Rs) • Height • Morphology:Q wave (previous MI) wave progression, • Regularly irregular delta wave • Irregularly irregular e.g. AF • ST segment (elevation,depression) • Cardiac axis • T waves (height e.g. hyperkaelaemianversion) • Normal:lead 1 +ve,lead II most +ve,lead III -ve • Summary • DiagnosisECG EXAMPLEECG EXAMPLE • Rate:84bpm • Rhythm:regular • Cardiac axis:normal • P waves:present & each followed by QRS • PR interval:3 small squares therefore normal • QRS complex:2 small squares therefore normal width,normal height,normal morphology • ST elevation in leadsV1 –V5 and ST depression in leads II,III and aVF • T waves normal • Diagnosis:anteroseptal STEMINEWS CHART FLUID BALANCE CHART front backB 9/5 9:00500ml 0.9% NaCl - STAT MMcG MANAGEMENT • Likely to be asked at the end of stations • Always ask for protocols • Start with the basics • Call seniors Remember: • Examples: • If sugars are low give sugar and reduce insulin o Low glucose –lower insulin • DKA • If sugars are high flush it out and give insulin • Hypoglycaemia o High glucose –higher insulin • Sepsis –say the words‘sepsis 6’ • HyperkalaemiaDKA DKA • IV Fluids • 1L in first hour • 2L over next 4 hours • 2L over next 8 hours • 1L every 6 hours subsequently • Insulin:fixed rate IV infusion of 0.1 units per kg per hour • STOP normal short-acting insulin,continue long-acting insulin as normal • Potassium: monitor very closely, unless high will need replaced • Treat DKA until ketones are fixed (not glucose) HYPOGLYCAEMIA Consider reducing future insulin doses Contact diabetes team SEPSIS • High NEWS score • Sepsis 6 • Take blood cultures • Take lactate (VBG) • Take urine output • Give IV fluids • Give IVAntibiotics according to local guidelines • Give Oxygen • Call a senior • Find the sourceHYPERKALAEMIA • 30mls 10% Calcium gluconate over 10 mins • Will NOT bring down K+ level,only to protect heart • Check CBG • 1glucose IV over 5 minsn and 50mls of 50% • 10mg nebulised Salbutamol • Check CBG again and correct if needed • Lokemla • Prevent rebound hyperK+ • Monitoring • Other: • Review Kardex and stop K+ drugs • Treat constipation • ManageAKI • Exclude digoxin toxicity HYPERKALAEMIA RQIA GAIN guidelines hyperkalaemia RESOURCES • OSCEStop book • Geeky medics website • Geeky medics station bank • QUB medical portal • Life in the fast lane for ECGs • The wards –speak to and examine patients,look at ECGs, ABGs etcGOOD LUCK!