OSCE Flashcards
What is a normal INR?
1
What is the INR target range for people taking warfarin?
2-3 (aim for 2.5)
How does warfarin work?
Anticoagulant that decreases the bodies ability to form clots. It blocks the enzyme vitamin K epoxide reductase, so clotting factors 2, 7, 9 and 10 have a decreased ability to clot.
What does a high INR show?
Blood takes longer to clot
Give symptoms associated with a high INR
Headache, severe stomach ache, increased bruising, prolonged bleeding after minor cuts, prolonged menstrual bleeding, bleeding from gums, haematemesis, haematuria, bloody or dark stool
What is the most common cause of elevated INR
Too much anticoagulant medication
Which medications increase INR
Aspirin, NSAIDs, herbal medication like St. Johns, some abx, rifampicin, prednisolone
Give two organic causes of elevated INR
Liver failure, bleeding disorders e.g. haemophilia and factor VII deficiency
Give three lifestyle factors you would advise a warfarin pt to practice
Stable vitK levels, avoid binge drinking (can increase INR), quit smoking
How do we treat elevated INR?
VitK, blood components to help stop bleeding, if no clear explanation reduce dose and repeat INR in 4-7 days
How can I prevent an elevated INR?
Have your INR measured regularly (once a month)
Take your medication as directed (refer to warfarin usage section)
Eat the same amount of Vitamin k daily
Limit alcohol
Do not smoke
How can I decrease bleeding risk?
Avoid activities that may cause bleeding or bruising
Brush and shave gently
Tell your dentist and other healthcare professionals if you take anticoagulant medicine (e.g. medical alert jewellery)
Why may INR be out of the target range?
any recent illness, fever, N/V/D, significant pain or stress?
Side effects of warfarin? (all of the bleeding ones)
Any diarrhea or vomiting?
Dose (DHx)- confirm current Warfarin dose, any missed doses? Taking it at the same time everyday? Double dosing?
Drugs (DHx)- any new medicines, discontinued medicines since last INR check? NSAIDS, aspirin, antibiotics, amiodarone, steroids
Diet (SHx)- any major changes (fasting, weight watchers), liver or 7 consumption? Diet rich in vitamin K or lacking vitamin K I .e. sudden change in intake of vitamin k rich foods? cranberry juice?
What is HbA1c?
Glycated haemoglobin, gives the average blood glucose level over the previous 2-3 months
Normal HbA1c in %?
Normal <6%, pre 6.4%, high 6.5%
What are the benefits of lowering HbA1c?
Reduces the risk of Retinopathy Neuropathy Diabetic nephropathy Less likely to suffer from: Cataracts Heart failure Amputation
How do we manage T2DM?
Dietary modifications, physical activity, insulin/metformin/sulfonylureas
In which conditions may HbA1c be falsely raised?
Kidney failure, chronic excessive alcohol intake, VB12 deficiency
In which conditions may HbA1c be falsely decreased?
Blood loss, sickle cell, thalassemia
Which medications may increase HbA1c levels?
Corticosteroids
What advice do you give to a T2DM pt?
Be carefulwhat you eat– be particularly aware of how snacking and eatingsugary foodsor carbohydrates can affect your blood sugar level.
Stick to yourtreatment plan– remember to take your insulinor otherdiabetes medications as recommended by your care team.
Be as active as possible–getting regular exercise can help stop your blood sugar level rising, but you should check with your doctor first if you’re taking diabetes medication, as some medicines can lead to hypoglycaemia if you exercise too much
Take extra care when you’re ill–your care team can provide you with some “sick day rules” thatoutline what you can do to keep your blood sugar level under control during an illness.
Monitor your blood sugar level– your care team may suggest using a device to check your level at home, so you can spot an increase early and take steps tostop it.
What is a good BM overall?
4-7, less than 8.5 2 hours after meals
Give an alternative to salbutamol.
Terbutaline, another SABA used for relief of bronchospasm
Give two good peak flow habits.
Take your peak flow before using the preventer inhaler, and always use the same peak flow meter
Give red flags for asthma/COPD
Wheeze is getting worse, affecting daily activity, waking up at night with symptoms, using reliever inhaler more than usual
What do you see in obstructive lung disease?
Takes a long time to exhale (wheeze), so not much breathed out at 1 second but volumes not too bad
FEV1 lower than FVC
FEV1/FVC < 0.7
FEV1 < 80% predicted
Give causes of obstructive lung disease
Reversible (asthma), irreversible (COPD), bronchiectasis, inhaled foreign body, tumour
Give causes of restrictive lung disease
Scoliosis, kyphosis, ankylosing spondylitis, neuromuscular diseases like polio, GBS, myasthenia gravis, pulmonary fibrosis, sarcoidosis, asbestosis
What do you see in restrictive lung disease on spirometry?
Due to restriction, lung volumes are small and most of breath is out in the first second
FVC proportionally lower
FEV1/FVC > 80%
Key Qs for peak flow history?
Ask how they are feeling Recent infections/illnesses How well do you think it is being controlled? Any exacerbating factors? Impact of condition on life
What is CRP?
Non-specific inflammatory marker, produced by liver
Where do we measure CRP?
Auto-immune/auti-inflammatory conditions
Active infection/response to abx therapy
SLE vs RA, Crohn’s vs UC
What can cause an acutely elevated CRP?
Burns, trauma, infections, MI, inflammatory diseases, IBD, certain cancers
What is ESR?
is defined as the distance that erythrocytes settle in anticoagulated whole blood, under gravity, in one hour. Longer phase over weeks
What can cause an elevated ESR?
Malignancy
Multiple myeloma
Anaemia of acute or chronic disease (not iron def alone),
Connective tissue disorders like SLE, RA, polymyalgia rheumatica, temporal arteritis,
Infections like TB, hepatitis or bacterial
What personal information do we need to calculate a FRAX score?
Age, sex, weight, height, femoral neck bone mineral density
What is the FRAX score used for?
Risk assessment tool for estimating 10-yr risk of osteoporotic fracture in untreated patients
What in the PMH can increase fracture risk?
RA, secondary osteoporosis (kidney failure, Cushings, coeliac, MS, hyperparathyroid, hyperthyroid, diabetes), previous fracture
Which drugs increase fracture risk?
Glucocorticoids, lithium, barbiturates
What in the FH can increase fracture risk?
Parental fractured hip and also ask about normal fracture
What in the SH can increase fracture risk?
Smoker, alcohol intake
What is a Z score?
Compares the condition of your bones with someone of your age, sex, weight, and ethnic or racial origin
What must you ask in the DH for a WELLS score?
Are they on HRT or OCP?
What must you ask to calculate a WELLS score?
Active cancer? Recently bed ridden >3 days or major surgeries Previous DVT Long hall flights Redness/swelling of leg? Tender?
How do we score a Wells score?
> or equal to 2 – DVT likely (D dimer and USS)
> or equal to 1 – DVT unlikely (D dimer)
What increases your risk of diabetes?
Male, age, ethnicity, waist measurement, BMI, htn, FH
Give symptoms of hyperglycaemia
Polyuria, polydipsia, unexplained weightloss, visual blurring, genital thrush, lethargy
What is the scoring system used in diabetes risk.
Low (0-6)
Increased (7-15)
Moderate (16-24)
High (25-47)
How can you reduce your diabetes risk?
Regular meals, portion size, decrease fat/sugar/salt, moderate alcohol, exercise (150mins/week)
What are the 5 Ts?
Toilet (weeing more than normal)
Thirsty (more than normal)
more tired than usual
thinner (weight loss without trying to)
thrush (genital itching 20 to genital infection)
Others: slow wound healing, blurred vision
What is ISHRUG?
Inguinal lymph nodes
Stools–examine the stools if clinically indicated
Hernial orifices (femoral and inguinal)
Rectal examination (always with a chaperone)
Urine–obtain urinalysis
Genitalia (examine the male external genitalia). A vaginal examination may be indicated in parous or sexually active females (only when clinically indicated and always with a chaperone)
What is Courvoisier’s Law?
Courvoisier’s Law states that in the presence of a palpable gallbladder, jaundice is not likely to be due to gallstones)
What is the Q-risk score?
Risk of having a MI or stroke over the next 10 years
What in the PMH increases risk of thrombotic event?
CKD, AF, RA, diabetes, HTN
What is a moderate and high risk in Q-risk?
10-20% MODERATE
> 20% HIGH
What is the CHA2DS2- VAS score?
Risk of stroke in AF pts
What does CHA2DS2- VAS score stand for?
CHF, HTN, Age >75, Diabetes, Stroke/TIA (2pts), Vascular disease, Age 65-74, Sex (female)
How do we manage moderate risk of 1 in male?
Consider oral anticoagulant, like vitamin K antagonist or non-VKA oral anticoagulant (apixaban, rivaroxaban)
When do we offer anticoagulation in CHA2DS2- VAS score?
If 2 or greater
What is the disadvantage of NOAC?
Non-reversible, increased bleeding risk, expensive, contraindicated with renal impairment and history of GI bleed
What is the disadvantage of warfarin?
Daily INR, teratogenic, can interfere with other medications, increased bleeding risk, diet control, reversible with vitamin K
How would you finish a respiratory examination?
Check sputum pot for volume, consistency, colour, odour and blood
Assess peak flow
How would you complete a cardiac examination?
Perform opthalmoscopy for hypertensive retinopathy
Obtain a 12-lead ECG
How do we complete a hip examination?
Examine the patient’s lumbar spine and the ipsilateral knee joint
perform a neurovascular examination of the lower limb
How would you complete a spinal examination?
Full neurological examination of the uppre and lower limbs
Peripheral vascular examination (rule out vascular claudication)
If lower back pain, abdo exam
If neck pain, shoulder exam
How complete shoulder exam?
Cervical spine, elbow and neurvocasv of shoulder
How do we assess sensation?
Soft touch, pin prick, temperature, vibration
