OSCE Flashcards
Which tubes are used for feeding v drainage? [1]
Ryles tube SBO - larger diameter
NG feeding - fine bore
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You’re prescribing bolus fluids to a patient.
How would you adapt this if they had HF? [1]
Why? [1]
250ml bolus instead of 500ml
To prevent fluid overload
QUESTION 3: UP TO HOW MANY TIMES CAN YOU REPEAT A 500ML FLUID CHALLENGE SHOULD A PATIENT REQUIRE FURTHER FLUID RESUSCITATION?
Can repeat 500ml bolus up to 4x (total 2000ml)
Prior to 4th bolus should escalate to seniors/ITU for consideration of inotropes/vasopressors
How do you calculate maintence fluids that a patient needs? [3]
A patient requires:
water 25-30ml/kg/day
Na+ K+ and Cl-
1mmol/kg/day
glucose 50-100g/day
1000ml of 0.9% sodium chloride contains : Na [] mmol, Cl [] mmol
1000ml of 0.9% sodium chloride contains : Na 31mmol, Cl 31mmol
1000ml of 5% dextrose contains how much Na & Cl? [2]
How much glucose? [1]
Na 31mmol, Cl 31mmol
50g glucose
In clinical practise, to prevent fluids being given overnight - usually given over 8hrs.
What is the rate of ml/hr? [1]
rate of 125ml/hour
It is also acceptable to write the duration each bag should be given, e.g. ‘over 8 hours’.
A-E
What are three causes of airway compromise? [3]
Inhaled foreign body
Blood in the airway: epistaxis, haematemesis and trauma
Vomit/secretions in the airway: alcohol intoxication, head trauma and dysphagia
Soft tissue swelling: anaphylaxis and infection (e.g. quinsy, sub-mandibular gland swelling)
Local mass effect: tumours and lymphadenopathy (e.g. lymphoma)
Laryngospasm: asthma, gastro-oesophageal reflux disease (GORD) and intubation
Depressed level of consciousness: opioid overdose, head injury and stroke
You’re perforing an A-E assessment. You think that the airway is obstructed.
Describe how you would initially manage this situation [2]
- Head-tilt chin-lift manoeuvre: one hand on forehead; other on the chin. Tilt forehead back and lift chin forwards; inspect airway for obstruction - if visibly obstructed use a finger sweep or suction
- Jaw thrust: identify angle of the mandible; place two fingers under the mandible and anchor thumbs on patients cheels; lift mandible forwards
A-E assessment
You consider that an airway adjunct might be useful during an A-E assessment.
What devices can you use and when would you use them? [2]
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it may induce gagging and aspiration in semi-conscious patients.
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in partly or fully conscious patients than oropharyngeal airways.
What are these devices? [1]
Describe how you would insert them [1]
nasopharyngeal airway adjunct
- lubricate outside
- push nose slightly back
- ensyure no deviated septum
- inset tip and along floor of NP
What size of NPA do you give adults? [2]
6 or 7
Nasopharynx airways are better tolerated by patients with what level of consciousness? [1]
Semi / conscious patients
e.g. alcohol intoxication
seizures
max/fax injury
When are NPAs CI? [1]
Why? [1]
Base of skull fracture - risk of entering cranial vault
What are these devices? [1]
Which patients can you only give them in? [1]
Describe how you would insert them [1]
Oropharyngeal airway
- only in unconscious patients, as it is otherwise poorly tolerated and may induce gagging and aspiration
Inserting airway:
- Remove any foreign material in mouth if there is any
- Insert the OPA upside-down position until you reach the junction of the hard and soft palate - here, rotate it 180
- Advance airway within the pharynx
- Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.
A-E assessment:
You notice someone is reduced breathing rate. Give three differentials [3]
- Sedation
- Opoid toxicity
- Raised ICP
- Exhaustion from COPD retention
A-E assessment:
You notice someone is increased breathing rate. Give three differentials [3]
- airway obstruction
- asthma
- pneumonia
- pulmonary embolism (PE)
- pneumothorax
- pulmonary oedema
- heart failure
- anxiety
You’re perfoming an A-E assessment. You have checked that there is a clear airway. Describe the next approriate steps and explain results might see in each
General inspection
Tracheal deviation
- deviating AWAY from tension pneumothorax and large pleural effusions; TOWARDS lobar collapse or pneumoectomy
Chest expansion:
- AYSMMETRICAL: pneumothorax, pneumonia, and pleural effusion can all cause ipsilateral reduced chest expansion
- SYMMETRICAL: & reduced - PF
Percussion:
- Dullness
- Stony dullness - pleural effusion
- Hyper-resonance
Ascultation:
- Bronchial breathing: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal, and there is a pause between. This type of breath sound is associated with consolidation.
ABG
CXR
You’re performing an A-E assessment. You think that positioning them differently could help with oxygenation. How would you do this? [1]
If the patient is conscious, sit them upright, which can help with oxygenation.
You are performing an A-E asssessment. You have completed the A&B part.
Describe what you would do next for investigations and procedures?
[1] INVESTIGATIONS AND PROCEDURES
HR and BP
Fluid balance chart
- Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult
Inspection:
- look for pallor and oedema
Palpation:
- assess temperature; CRT
- Pulse
JVP
Asucultation:
- pericardial rub or muffled heart sounds may indicate underlying pericarditis or cardiac tamponade
- S3 = HF
You are performing an A-E asssessment. You have completed the A&B part.
Describe what you would do next for C interventions?
[2] INTERVENTIONS:
IV cannulation
Blood cultures and tests
ECG
Cultures / swabs
Fluid resus:
- 500ml bolus of NaCl
- 250ml of if HF risk
- repeat x4 then get senior input
Blood transfusion
Bladder scan - if suspected urinary retention
What is the sepsis 6?
alert senior clinician, oxygen if required, blood cultures and lactate, IV antibiotics, IV fluids, and ongoing monitoring
You are performing an A-E asssessment. You have completed the A-C part.
Describe what you would do next for D clinical assessment?
- AVPU
- Pupils: inspect size and symmetry
- Review drug chart for causes of neurological abnormalites
- Measure BMs and ketones
- Measure temperature
You are performing an A-E asssessment. You have completed the A-C part.
Describe what you would do next for E clinical assessment?
Inspect:
- For signs of rashes
- IV lines for infection
- Abdomen
- Calves
- Surgical wounds
Palpitation for peritonism
Temperature
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take first? [1]
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a FBC? [1]
Purple
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a ESR? [1]
Purple
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a group and save or crossmatch? [1]
Pink
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a direct coombs test? [1]
Pink
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a clotting screen? [1]
Blue
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for U&Es / CRP / LFTs ? [1]
Yellow / gold
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for a glucose / lactate? [1]
Grey
You’re perfoming an A-E.
You need to take blood for investigations. Which colour do you take for ammonia levels? [1]
Dark green
What is the order of draw of blood bottles? [+]
Describe a structured approach to an abdominal XR interpretation
Film:
- Position: most are AP
- Organs: should be able to ID lung bases - neck of femur
- Penetration
- Compare to old films
BBC
Bowel:
- Small bowel: can you see v.c and normal position?
- Large bowel: can you see hastra and normal position?
- Comment on size; 3,6,9
- Riglers sign: positive or negative?
- IBD signs: toxic megacolon? leadpiping? thumbprinting?
- Other organs
Bones
Calcification:
- Renal stones?
- Pancreatic calcifications
You suspect a pneumothorax. What size needle should you use to aspirate?
16G
18G
19G
20G
21G
You suspect a pneumothorax. What size needle should you use to aspirate?
16G
18G
19G
20G
21G
Describe how you would consent a patient for a blood transfusion
Reason for transfusion
Benefits
Risks
* Viral infections (HIV: 1 in 6.5 million; hepatitis B: 1 in 1.3 million; hepatitis C: 1 in 28 million; variant Creutzfeldt-Jakob disease: 4 isolated cases)
* Bacterial infection (contamination)
* Transfusion reactions
Will never be able to donate blood again
Describe how you would request a blood product
Take a blood sample (pink tube) and fill in all details by hand at patient’s bedside (cross-referencing with the patient and their wristband)
Complete a blood transfusion crossmatch request form
Include:
* Patient (full name, DOB, sex, hospital number, address/NHS number)
* Transfusion (indication, Hb if known, blood product required, number of units, special requirements, e.g. CMV negative or irradiated)
* Doctor (name, signature)
* Date and ward
Send the form with the blood tube to the haematology laboratory
- Complete a blood transfusion prescription form (each unit prescribed separately)
- Demographic details
- Units prescribed
- Infusion rate:
- Packed red cells: normally 1 unit over 2-3 hours (maximum 4 hours)
- Fresh frozen plasma (FFP): 30 minutes
- Platelet concentrate: 30 minutes
- Cryoprecipitate: 30 minutes
- Consider prescribing 40mg furosemide IV/PO with each/every other unit if patient is at risk of fluid overload
Describe how you would set up a blood transfusion
- Introduce
- Ask for name and DOB - check with wristband. Repeat with another person
- Consent patient
- Check blood products: G number; component type; expirary date; signs of clots; leaks; irradation?
- Give through blood warmer if patient undergone surgery or requires rapid large volume transfusion
- Request observations at 0,15,30 mins
- Document; normally I unit of packed red cells over 2-3 hrs; FFP, platelet concentration, cryoprecipate over 30 mins
- Consider if need 40mg furosemide IV if risk of fluid overload
When do you use CMV serenegative components? [2]
Patients at risk of severe CMV disease:
- Pregnant
- Neonates
When do you give irradiated components? [4]
When plalelet concentrates indicated for transfusion? [4]
When are fresh frozen plasma transfusions indicated? [4]
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