OSCE clin skills Flashcards
Which diabetes drugs cause weight gain
Sulphonylureas
Insulin
Which diabetes drugs cause weight loss
SGLT2i
Incretins
Which diabetes drugs cause hypos
Sulphonylureas
Insulin
First line management for all diabetes patients
Metformin
What does second line management for diabetes depend on
CKD or HF
History of atherosclerotic CVD
Weight gain should be avoided
Risk of hypo should be avoided
Second line management for diabetes if history of atherosclerotic heart disease
SGLT2i
GLP 1
Second line management for diabetes if history of CKD or HF
SGLT2i
Second line management for diabetes if hypos should be avoided
Anything from
- GLP 1
- SGLT2i
- DPP4i
- TZD
What is another name for for thiazolidinediones
Glitazones
Second line for management of diabetes if weight gain should be avoided
GLP1
SGLT2i
Main side effect of GLP 1 agonists
Diarrhoea and feel sick
Main side effects of gliptins
Pancreatitis risk
Retinopathy
Main side effects of metformin
Diarrhoea
Lactic acidosis
When is metformin contraindicated
Liver failure
Severe renal disease
Chronic HF
Side effects of SGLT2i
Genital infections
When does someone move between different diabetes therapies
If after 3 months Hba1c doesnt reach target
What metformin is given initially
Standard release
What is given if standard release metformin not tolerated
Modified release metformin
If a patient is on a drug that can cause hypos on monotherapy what is target Hba1c
53
What is target Hba1c for metformin
48
When on dualtherapy for T2DM what is target Hba1c
53
When Hba1c rises to what do you move up a therapy
58
Causes of slow AF
Hypothermia
Digoxin toxicity
Some anti-arrythmics
What does an OT do
Looks for things that can help a person go home- help and improve peoples daily life by allowing them to function as best they can- very individualised
What does a physio do
Make sure muscles are strong allowing you to carry on normal daily life- for example getting from bed to chair. We dont want you to be falling again so theyre going to make sure your legs have good balance and can support you
Questions to ask in scenario where someone is going home and need to advise them about physio and OT
Whos at home with you
Do you have any neighbours, children and friends who can help you
Do you live in a flat
Are there any stairs/ is there a lift
What does a normal day look like
What are some things you like to do in a day
How to explain sulphonylurea, gliptin and incretin to a patient
They increase insulin production
How to explain SGLT2i to a patient
Wee out more glucose
How to explain metformin to a patient
It helps activate insulin and makes sure more of it acts as that door
How to structure an explaining station
BUCES Brief history Understanding of patient Concerns Explanation Summarise
How to structure the explaining part of a station
Normally we can probably manage Normal physiology What disease is Causes Problems of it Management
Brief history qs for diabetes
Whats brought you in today? Have you had any symptoms? Feeling thirsty? Weeing out more water than usual? Tired? Infections of your genitals? Past medical history? What is your diet like? What is your daily activity like? What job do you do?
Understanding question to ask?
From what youve been told so far/What do you know about X?
Explaining diabetes
So normally when we eat our body breaks it down into sugar and this enters the blood to go around the body for cells to use it as energy. However sugar cant just enter cells it needs a gateway into them so when we eat we also produce a hormone called insulin that goes into blood that acts as a door allowing the sugar into cells
In type 2 diabetes that you have some of the insulin doesnt work so not all glucose can get into cells meaning that it builds up and damages some of our blood vessels
Just to check that you understand would you be able to just run me through what you understand so far?
In terms of what causes it, its often a mix of both sometimes people are born with faulty insulin so and as they get older waht they eat that contain lots of sugar it causes this insulin to be faulty and the cells dont respond
Do you have any questions at this point
So with diabetes it can lead to everyday symptoms such as feeling tired, going to toilet more or can often get infections on your penis which can be uncomfortable but the main problem with diabetes is that silently when youre totally unaware of it your all this sugar is damaging certain parts of your body and what that leads to
In your eyes can lead to vision loss
In your nerves can lead to not be able to feeling your hands and feet
In your kidney causing kidney failure
In your brain increasing risk of stroke
In your heart leading to heart attacks
So im sure at this point thats all sounding very scary but this can be managed and even in the early stages can be reversed through a variety of lifestyle modifications and medicines
How to do MSU sample explaining
Good afternoon my names owen vineall etc
Can i just confirm your name and DOB please
Ive been asked by the doctor today to come and explain to you how to take whats called a mid stream urine sample is that ok with you?
Have you ever had this before?
From what youve been told so far what do you uderstand about this procedure?
Ok so what were doing is taking a sample of your urine and then its gonna go off to the lab who are going to look for an signs of infection and then youll get the results back in a few days the doctor will call you
So whats important about this sample is that we dont get it contaminated with any of the germs on your skin so waht you do is so you take this cup to the toilet with you and before you start weeing take the cap off having it ready at the side taking special care to make sure you dont touch the inside of the lid and cup. So you start weeing with the cup in your hand or on the side then after a bit of weeing put the cup in front of your stream to catch some of it and before you finish weeing put the bottle on the side and finsh your wee then when youre done flush wash your hands and put the cap back on the cup making special care again not to touch inside of lid and cap.
then its gonna go off to the lab who are going to look for an signs of infection and then youll get the results back in a few days the doctor will call you
AF management advice station
Brief history for AF
Have you ever had it before?
SOB, chest pain, palpitations, fainting- when started
Heart problems in the past
Any illness in the past
Any medications
What lifestyle like active?
Do you understand
ICE
Explain about irregular rythm, blood pools can form clumps of cells that cause stroke, fast want to reduce work on heart, rythm return will increqse CO helping activity
Management start anticoagulation, depends on factors if start rate or rythm management
4 factors that influence if move up asthma scale
Symptoms at night
Using reliever inhaler more than 3 times a week
Symptoms interfering with daily activities
Number of hospitilisations
How to explain MDI use
Introduce self- explain why here
How are you feeling- any chest pain or SOB
What inhalers?
Ask about understanding of inhalers
Explain what inhalers are for
Go through parts of inhaler with patient and check expiration date
Explain procedure by demonstrating
Mention washing out mouth if steroids
Explain some potential side effects
- salbutamol heart racing and tremor
- steroids can get sore mouth so wash mouth
Safety net about when to use in an excacerbation and if doesn’t work after 10 call 999
Check if have any concerns
Any questions?
What is difference between clean, aseptic and sterile
Clean- clear from any marks and stains
Aseptic- clear from any pathogens
Sterile- free of all microorganisms
Contraindications for venepuncture
Burns area
Limb damaged by stroke, hemiplegic
Sited for surgical procedure
Suspected fracture
What do cannula gauges run from
14-24
Indications for taking blood
Diagnostic levels
Monitor drugs
Sample for group and save
Monitor treatment
What goes in purple bottle
FBC
ESR
Blood film
Hba1c
What goes in blue bottle
INR
Clotting
D-dimer
What goes in yellow bottle
U&Es LFTs Calcium Lipids Troponin TFTs Phosphate Magnesium
What goes in grey bottle
Glucose
Lactate
Complications of cannula and venepuncture
Systemic infection Syncope Allergic reaction Haematoma Air embolism
Venepuncture- whole thing
Introduce self
Been asked by the doctor take your blood today is that ok?
Ok great so this is to look at the levels of x which will help doctor have more of an idea of whats going on, this will involve just putting a small needle into your arm does that sound ok?
Have you had your blood taken before?
How are you with needles?
Are you in any pain at the moment?
Any recent surgeries?
Any allergies?
Any medications?
Ok so im going to go and get my equipment ready I will see you in a minute
Needle
Cap
Gauze
Alcohol wiples gloves
Blood bottles
Tape
Tourniquet
REMEMBER TO HAVE GAUZE READY
Ok so thats all done how was that?
So try and keep that on for 30 mins and avoid any heavy lifting
Some things to look out for around this site and redness and if it becomes hot so if that does happen seek medical assistance as soon as possible
So now im going to write this all up it will go off to lab and the doctor will contact you with the results
Thank you for your time today
Questions before for venepuncture and cannulation?
Have you had your blood taken before? How are you with needles? Are you in any pain at the moment? Any allergies? Any medications?
What is contained within grey blood tube
Sodium fluoride
What is contained within pink and purple bottles
EDTA
What bottle is EDTA in
Purple- FBC etc
What is contained within blue blood bottle
Sodium citrate
When do you put gloves on in bloods
After collecting all equipment and returning to patient
What would make you avoid a particular vein
If its hard as suggest phlebitis
How do you check for second flashback in cannula
Withdraw needle a little bit when have advanced tube a little bit
Cannulation full station
Introduce self Im just going to be putting a small plastic tube into your arm to deliver some fluids is that ok with you Have you had your blood taken before? How are you with needles? Are you in any pain at the moment? Any recent surgeries? Any allergies? Any medications? PREPARE AND DO PROCEDURE Ok so thats all done someone will come and change it in 2 days but if you think the site gets very hot, red and painful let a member of staff know and theyll come and change it Do you have any questions for me?
What is only time invert blood bottles 4 times
Blue
How many times do you invert blue bottle
3-4
How many times do you invert yellow bottle
5
How many times do you invert purple and most bottles
8-10
Suturing full procedure
Introduce self
Today ive been asked to come and stitch up your wound to close it and hopefully relieve some pain does that sound OK?
Identity
This will just involve me using a small needle to put some stitches in does that sound alright?
How did the cut happen?
Has someone been along to put some anaesthetic in?
Do you have any allergies?
Have you had your tetanus jab?
Are you on any medication?
DO PROCEDURE
Ok so thats all done how was that?
Ok so in terms of managing the wound now make sure you look out for any redness and discharge if this does happen go to one of our walk in clinics
Try and keep it nice and dry so avoid swimming and when youre in the shower hold it away from water
You can get your stitches removed in around x days if ask GP
Any questions?
What happens if havent had tetanus jab?
Must get booster
What must ask if have had glass in wound
X rayed
How long for all the stitches based on site to be removed
- Stitches inserted on the head can be removed in about 5 days. This is due to the good blood supply to this region of the body.
- Stitches over joints must be present for 10-14 days. This is because these areas are usually under a lot of stress due to the continuous movements which stretch the skin.
- Stitches on other body parts can be removed in in 7-10 days
What is documented on cannula sheet
Identity etc Time Reason Batch Size Site Number of attempts
How is patient position for an ECG
Sitting at 45 degrees legs supported
Where do chest leads go
V1- 4th intercostal space right sternal border
V2- 4th intercostal space left sternal border
V3- halfway between V2 and 4
V4- 5th ICS MCL
V5- halfway between V4 and 6
V6- MAL horizontal to V4
Where do limb leads go
Red- right arm
Yellow- left arm
Green- left foot
Black- right foot
What should ECG be calibrated to
25mm/second
10mm/mv sensitivity
What to do with lead sites before placing them
Clean with paper
Towel
If required use alcohol wipes
If hairy shave after gaining consent from patient
What colour needle is used for ID and sub cut injections
Orange
What colour needle is used for IM injections
green or blue
Difference in administration technique between normal sub cut and insulin
For insulin in must be at 90
Normal is at 45
Technique used for intradermal injection
Pull skin taut with thumb and forefiner of free hand
Key when documenting an injection
Get the signature of a supervisor
How is heparin normally given
Sub cut
What needles are used to draw up from glass ampules
Big purple ones as have glass filters these will have big red sheath
When drawing up a drug from container where are they normally stored beforehand
Fridge
What should be done before drawing up the drug from rubber ampule that draw from
Clean the top of it
Do you need to clean skin before su cut
Don’t have to depends on guidelines but in OSCE safe to do it
Where give IM injection
Gluteus maximus or shoulder
What type of injection is local anaesthetic
Intra dermal
How to do a local anaesthetic injection
Done intradermally
Go around the site in multiple areas pulling out whilst injecting- called continuous technique
When is only time use big syringe for injections
IM
Procedure for infusion
Introduce self
can i just check your name and DOB
ive been asked today to come and set up a drip for you is that ok this will just involve me hooking up some fluids to your cannula there which will…..
How are you doing today are you in any pain?
Do you have any allergies
examiner will act as my chaperone
Check cannula site, for example date of cannula and VIP score
Collect equipment and prescribing chart- note prescription and see if matches up to bag you have
Remove fluid bag and check expiration date, drip factor and if any punctures etc
Place fluid bag on side
Remove infusion bag port and ensure roller clamp closed
Remove cap from spike and infusion bag
Insert into bag and hang up
Open roller clamp ensuring fluid into collection chamber at least half full or up to drawing line while squeezing in
Open end and see if fluid coming out then close roller clamp
Now check cannula so clean it and flush to check primed
Insert into octopus port
Adjust drip rate to prescription- check correct with examiner
Thank patient and let them know to let medical team if start feeling unwell
What document for an infusion
•Date and time,•Patient name, hospital no.•Your name and grade•Chaperone name and grade•Prescription/name of fluid•Batch number•Fluid checked against prescription, for expiry, leakages, clarity of solution. All clear.•Attached to cannula in [location] which was deemed appropriate. •Cannula to be changed on:•Time started, time to finish•Volume•Duration of infusion•Drip rate•Sign and print name•Chaperone sign and print name•Complete fluid balance char
What ask before hand infusion
Allergies
About cannula
What are 5 rs for infusion and injection
Right time Right patient Right drug Right dose Right route
What is equation for infusions
Work out ml/min then multiply by drop factor
Why do you rotate sub cut sites
Avoids abscesses and lipid hypertrophy
How long should sub cut injections be given over
10-30 seconds
Injection general procedure
Introduce self
State purpose and consent
Gather equipment
Draw up drug using filterless blunt needle for rubber bungs and filtered one for glass bottles
CLEAN BUNG
Take off drawing up needle and dispose of it
Put on correct needle and administer
When taking out the needle apply pressure
Tell them what to look out for- red and discharge seek medical attention
Where can subcut injections be given
Lateral part of arms Sides of back Anterior tummy area Thighs anteriorly Lower loins
3 sites can administer IM injection
Deltoid
Ventrogluteal
Dorsogluteal
How to present a CXR
Rotation- equidistant clavicle from spinous processes Inspiration- 6 ribs anteriorly and 10 posteriorly Penetrated- can you see spinous process behind cardiac shadow Exposure Airway - trachea central - bronchi changes (diversion mainly) Breathing - work from apices to base - opacity - lung volume Cardiac - cardiomegaly - aortic knuckle - mediastinal shift Diaphragm - flat? - air - costophrenic angles visible Everything else - bones - soft tissue such as breast - surgical emphysema - any tubes etc
How to do fundoscopy
Introduce self
Ive been asked today to come and examine your eyes today does that sound ok
Thats gonna involve me having a look in your eyes through this fundoscope which has a light and a window for me to look through. Im also going to have to dim the lights a bit to help me see better is that ok
Can i ask do you use glasses or contacts
Say to examiner id ideally use tropicamide eye drops to dilate the eyes
Start by inspecting the eyes without fundoscope
Do red reflex by asking patient to look into distance at a point
I’m gonna put my hand on your shoulder to make sure we dont bump into eachother
Examine right eye first using right hand for fundoscope and put other hand on shoulder
Zoom in to a very high plus
Start off looking at a vessel then follow up to optic disc
Examine the rest of vessels coming off the optic disc
Move on to examine macula
Clean hands and thank patient
Present to doctor
What need to think when examining the optic disc
The colour, size and margins
How does normal optic disc appear
Well defined margins yellow in appearance with paler center
In fundoscopy what is yellow part of eye
Optic disc
In fundoscopy what is the dark part of the eye
Macula
If doctor has glasses how is fundoscopy set up when doing red reflex
Start on your prescription- ie -3
How to turn light on in fundoscope
Turn part at bridge between grey and black part
What is hypermetropia
Long sightedness
What is miopia
Short sightedness
What 2 things must do before remove needle in bloods
Remove tourniquet
Get gauze ready
Looking around the bed cardio
Warfarin bracelets Medications- diabetes eg Defib pads GTN spray Oxygen masks
Signs on hands cardio
Splinter haemorrhages
Janeway lesions
Clubbing
Osler nodes
What are janeway lesions
Non-painful flat lesions
What causes janeway lesions
Septic micro emboli
Features of clubbing
Drum sticking of fingers- thing phalangeals
Curvature of nailbed
Loss of angle between nail beds- luverbonds
Cardiac causes of clubbing
Infective endocarditis Atrial myxoma Malignancy Congenital cyanotic heart disease Teratology of fallot
What are osler nodes
Painful raised nodes
What causes osler nodes
Immunological reaction
What causes splinter haemorrhages
Septic emboli
What causes tendon xanthomata
High cholesterolaemia
What is difference between CO2 retention and asterixis
In CO2 retention is symmetrical
In asterixis is asymmetrical flapping
Why is irregular pulse not pathological
Can be related to difference with breathing
What other than aortic regurg can cause collapsing pulse
VSD
Persistent ductus arteriosus
What is corrigans pulse the same as
Waterhammer pulse
Collpasing pusle
What is positive waterhammer pulse sign
Feel the pulse properly bounding- dont have to just feel the pulse put hand around it
What is pulsus paradoxus
Difference in pulse strength depending on inspiration vs expiration
What causes pulsus paradoxus
Pericardial effusion
Constrictive pericarditis
Anything affecting hearts ability to contract
In pulsus paradoxus is pulse greater in inspiration or expiration
In expiration as in inspiration when you reduce thoracic pressure more blood flows into right side of heart putting pressure on left ventricle which reduces its CO
What does pulsus alternans occur in
Anything causing LVD Aortic stenosis Hypertension Dilated cardiomyopathy IHD
Signs in face of cardio
Malar flush Corneal arcus Xanthelasma Conjunctival pallor Central cyanosis High arch palate
Difference between malar flush and malar rash
Malar flush in mitral stenosis
Malar rash in SLE
What causes high arch palate
Downs syndrome
Ehlers Danlos
Downs syndrome
Which jugular vein are you examining
Internal
What is pathological JVP
Raised above 4cm
