Other OSCE stations Flashcards
DNACPR discussion OSCE
Confirm patient name and DOB
Explain that you want to discuss resuscitation in the event of health deterioration - is this ok?
Would you like anyone else present for our discussion?
Explain that as part of your illness there is a risk that you may become so unwell your heart stops beating
Explain CPR (chest compressions, ventilation, defibrillation, and intravenous drugs), explain is an invasive process, likely futile with poor outcomes
A DNACPR means that in the event of a cardiac arrest CPR would not be administered, not apply to other treatments - will still carry on treating you
This is a medical decision made by the healthcare team and is part of normal advance care planning
Do you understand everything we have talked about, do you have any questions?
Summarise - if disagree address concerns and refer to a senior for a second opinion
Can sign f1 and above, lasts for 24 hours if want to last longer need counter signature from senior dr
Either put in the front of patient notes or give to patient or carer if in the community. Communicate to members of the team.
Dietary changes in CKD OSCE
Ask about renal disease, how progressive?
Ask if had any advice on their diet before
Ask about current diet and fluid intake - say why important
Advise a low protein low potassium diet, avoid large amounts of meat, fruit, smoothies
Maintain low glucose and low salt if DM, HTN respectively
Avoid large volumes of fluid, match to volume of urine output
Refer to dietician, offer leaflet
Airway management
In an acute situation can open a patients airway using head tilt chin lift or jaw thrust. Jaw thrust used if significant trauma and suspect C-spine damage or instability.
Guedel - used to prevent tongue/ soft palate blocking the airway - measure length from incisor to angle of mandible. Insert upside down and rotate. Poorly tolerated if conscious due to gag reflex, can damage teeth and mucus membranes - in kids not need to insert upside down
Nasopharygeal airway - bypass obstructions in nose, mouth, nasopharynx or base of tongue. Used in conscious patients, lubricate and insert into the right nostril, measure length from tip of nose to the tragus. Can cause nasal dmg, should not be used if base of skull #
Supraglottic airway devices
- sit on the larynx above the vocal cords
- alternative to ET tube in minor ops, cardiac arrest
- not a definitive airway, don’t protect against aspiration
- air can enter oesophagus, can cause laryngospasm, can also obstruct airway if not placed correctly
- Has a tube for NG tube passage
Are 2 types: laryngeal mask airway (inflate) and igel
Bag valve mask - used to oxygenate and ventilate prior to definitive airway - can achieve 100% O2 - inflate bag by occluding the end where attaches to mask/ igel
Suction can be used to clear airway of secretions, saliva, blood, gastric contents
Intubation - laryngoscopy + insertion of ET tube
Laryngoscope held in left hand, inserted along right side of tongue and positioned between tongue and epiglottis. Can dmg teeth and oropharyngeal tissues
ET tube - 7.0 for women, 8.0 for men, should sit at 20-24cm once inserted. Definitive airway, risk of laryngospasm on removal
Bougie can be used if difficult to intubate
Tracheostomy - last resort
Emergency - cricothyroidectomy
Planned - surgical tracheostomy - through trachea below cricoid
O2 OSCE
Nasal canulae - 24-30%, 4L/min - non invasive, good for mild hypoxia, can cause nasal drying and irritation
Hudson mask - 30-40%, 5-10L/min - sits over face, risk of aspiration if vomit whilst mask is in place
Non rebreathe - up to 70%, 15L/min - need to obscure valve to fill up reservoir.
Venturi, dependant on the flow rate can provide different oxygen concentrations - good for COPD
Humidified O2 can be added to prevent the drying effect of oxygen as well as the subsequent heat and fluid loss . Also helps break down respiratory secretions. Water can pool obstructing O2 flow so need to drain regularly
Urinalysis
glucose, ketones, bilirubin, urobilinogen, nitrates, leukocytes, protein, pH, RBC, specific gravit
WIPE
Collect specimen, have a look at colour, appearance and smell.
Put on pair of gloves check expiry date on bottle
Insert stick for specified period then remove and place on a paper towel. Wait until period of time for complete result and then compare to pot. Note down result and discard strip and urine.
Result:
- +ve glucose - diabetes, renal tubular disease, SGLT2 inhibition’s
- +ve ketones - DKA or starvation
- +ve bilirubin - bile duct obstruction
- high urobilinogen = haemolysis, low = obstruction
- +ve nitrates - UTI
- +ve Leukocytes - UTI
- +ve protein - Nephrotic syndrome
- +ve RBC - UTI, stone, cancer, nephritic syndrome, pyelonephritis, trauma, vaginal contamination
- low pH - DKA, metabolic acidosis due to sepsis, starvation
- high pH - UTI, metabolic alkalosis due to vomiting, diuretics
- low specific gravity - DM, acute tubular necrosis
- High specific gravity - dehydration, glycosuria, proteinuria
Emergency contraception - counselling
Ask about why need, when last time had sex
Ask about if it was consensual, whether feel safe and supported in their relationship
3 types
IUCD - can be inserted up to 5 days post sex, or up to 5 days after the earliest estimated date of ovulation. Works by inhibiting fertilisation and implantation.
AV - most effective, can stay in place for 10 years, no hormones, no effect on other meds
Dv - Irregular bleeding for few days after, heavier periods, requires a procedure to insert, contraindicated if STI
Complications - can form hole in womb, can fall out (check monthly), infection, ectopic
Ellaone - one pill - effective up to 5 days post sex. Stops implantation and ovulation. contraindicated if severe asthma.
AV - very few SE, no procedure
DV - N+V, changes to next period
Levonelle - effective up to 3 days post sex. Works same as ellaone.
AV - same as ellaone
DV - Same as ellaone + shorter window, needs double dose if over 70kg or BMI >26
Confirm not pregnant with pregnancy test or period
Can take multiple pills during one cycle but must be the same type
Preop counselling
Introduce self, ask what know already and ask if had a GA or operation before
Before I talk you through what will happen on the day do you have any ICE?
On the morning of your operation its important that you don’t eat for 6 hours before and don’t drink for 2 hours before.
Arrive at hospital at the time written on your letter and the hospital staff will get you changed and bring you to the ward. Before going to theatre a member of the anaesthetics department will come and do some final checks and answer any questions you have.
When we are ready we will take you into theatre where we will attach some measuring equipment including BP, ECG, )2 saturation and put a small tube in your hand.
GA Risks: Airway and breathing related problems Aspiration risk Post op nausea and vomiting Sore throat Accidental dental damage Awareness - rare Risk of allergic reaction and anaphylaxis
LA/ regional anaesthesia risks
If you are having a LA e.g. spinal we will do this before we send you to sleep (risk of post dural puncture headache, nerve injury, infection risk, urinary retention)
RA - may have to convert to GA,
Next we will get you to breath some oxygen. We will then give you some medication to drift you off to sleep.
From that point on during your surgery we will always be with you and make sure everything is ok. During the procedure there may be a risk of bleeding are you happy for us to perform a blood transfusion if needed?
If all goes well you shouldn’t wake up during the procedure however there is a remote chance this could happen . We will be doing everything we can to prevent this
When you wake up you will have a sore throat from where we put a tube in your mouth to protect your breathing. You may also feel nauseous and we will give you some medication to minimise this. It is likely given the surgery that you will feel some discomfort when you wake up however we will pre-empt this with some painkillers. As well as this once you are finished in theatre we will transfer you to recovery where there is one to one care and we can give any medications needed to make you feel as comfortable as possible
Catheter
WIPE
Explain inserting tube into penis to drain urine, will use a local anaesthetic to make as pain free as possible
Offer a chaperone
Open out pack, wash hands and don sterile gloves
Clean penis with saline
Remove gloves and put on fresh pair
Place sterile drape and insert instillagel into penis - pressure for 1.5 mins, then wait 3.5 mins
Insert catheter, fill balloon, pull out to feel stop then connect collector
Tell patient to ask for help if painful or start feeling unwell
Note the details of the procedure urine appearance, residual volume
PSA
Do PSA if >50, request, haematuria, erectile dysfunction, obstructive LUTS
- Urgent referral if 50-69 and level is >3
- An increase in PSA of 0.75micrograms/L/year may be a sign of cancer
PSA counselling
- ask about LUTS, haematuria, family history, weight loss
Produced by both normal and cancer cells
Is used to detect cancer at an early stage before development of symptoms allowing early treatment of cancer
However it isn’t the best test
75% of those who are positive will not have cancer
- more tests and risks than needed
- anxiety
About 15% of cancers will be missed
- not help
At 80 about 80% of men will have cancer cells but only 2 out of 50 will die from this
- undergo lots of treatments affecting their QOL when wouldn’t have affected them
- treatment effects continence and sexual dysfunction
Point to websites to find out more
Before have – no UTI, no ejaculation for 48 hrs, no heavy exercise for 48 hours, no prostate biopsy within 6w
- <10 = low risk
- 10-20 = intermediate risk
- > 20 = high risk
Interpreting spirometry - obstructive vs restrictive and the values and meanings
Obstructive = FEV1 <80%, FEV1:FVC <0.7 - causes are COPD, asthma, bronchiectasis, CF
Restrictive = FEV1 <80%, FEV1:FVC >0.7 - causes are ILD, Pulmonary oedema, neuromuscular, skeletal abnormalities
FEV1 > 80% = normal
FEV1 < 80% - either have airway obstruction or decreased compliance and elasticity
Asthma = reversibility of >12% with bronchodilator
FVC - total volume expelled from max inspiration to forced max expiration
Reduced in restrictive conditions due to reduced lung expansion and holding volume
Normal FEV1:FVC = 0.7-0.8
TLC - RV+FVC - It is high in emphysema due to high RV due to reduced elasticity preventing expiration, it is low in restrictive due to reduced FVC
TLCO = total diffusing capacity of lung KCO = diffusing capacity per unit
TLCO is low but KCO normal in Pneumonectomies and restrictive disorders of incomplete expansion (gas exchange normal just less of it)
TLCO is low and KCO is low in ILD, emphysema (impaired diffusion) and vascular problems such as PE and hypertension
HIV testing - Testing counselling
WIPE
Confidentiality
Ask why think need a test
Enquire about risk of transmission (partner and contraception)
Broadly speaking are 3 types
- 4th generation HIV antibody detection and HIV p24 antigen detection - this is performed in clinic and is the most reliable test. It can identify HIV 4-6 weeks after exposure, detects 99% of cases at 45 days. The results are generated either on the same day or within a few days.
Repeat test at 3 months if negative
- NAT test, detect viral RNA, often can detect HIV earlier than antibody tests however are rarely done as very expensive and increased risk of false positives
- Rapid serum/saliva point of care test - this involves taking a spot of blood or a sample of saliva, once again 4w window period. The results are ready within 30 minutes. A positive result needs to be confirmed with a serum test.
Confirm with positive tests on 3 separate assays
Why have the test:
Insurance companies are not allowed by law to ask whether someone has had a test or a negative result
Know your status
If negative - can clear your mind, know you are safe with regards to your health and future sexual partners
If positive - with correct treatment can live a long and high quality of life similar to that of normal. If considering getting pregnant knowing your status can help reduce transmission to the baby. Helps support behaviour change to prevent future sexual transmission. Prevents opportunistic infections
Discuss fact risk of transmission is lower than you think
How to interpret a chest xray
Name and DOB
Time and date
Position, what of (e.g. AP radiograph of the chest)
Rotation distance of clavicles from spinous processes
Inspiration - 5-6 ant ribs
Exposure - see vertebra behind the heart
A- airway - trachea, carina, bronchi and hilar structures
B - Breathing - lungs and pleura
C- Cardiac - heart size and borders, aortic knuckle
D - Diaphragm - costophrenic angle
E - everything else - mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas.
How to read an ECG
Name and DOB
Date and time
Look at rate - number x6
Look at rhythm - irregularly irregular/regularly irregular
Look at axis - highest in II norm, III right, I left
Look at p wave - present, absent, followed by QRS
Look at PR interval (3-5 small squares)
Look at QRS (<3 squares), look for wide (BBB, abnormal depolarisation), Q wave, hypertrophy, RSR in V1 = RBBB, RSR in V6 = LBBB
Look for ST elevation
Look for T wave tenting, inversion
Look for U wave
Levothyroxine counselling
Synthetic version of normal thyroid hormone
Take tablet (number depends on dose) once daily before breakfast
Are on lifelong
Takes a few weeks to work
Initially need a review at 2-3 weeks then every 2-3 months and once TSH normal every year
SE are rare, if dose too high can get hyperthyroid symptoms (palpitation, hot, diarrhoea, tremor)
No contraindications
Metformin counselling
Increases sensitivity of cells to insulin
Tablet, take once a day at first but can be up to 3 times
Take in morning after breakfast at same time each day
Will work instantly and will be on lifelong
If miss a dose take as soon as you remember, not double dose
Do U+E before and 12 monthly
Weight loss, abdo pain, N+V, diarrhoea
Risk of lactic acidosis so stop if renal function or anaesthetic or contrast imaging
Check information leaflet in packet for over the counter meds. store in dark cool location out of reach and sight of children.
Structure for drug counselling
How work How take them What monitoring needed What SE Ask about drug history and allergies What contraindications What interactions Store in cool, dry place away from heat and light. Out of reach and sight of children.
Steroid counselling
Come in topical, inhaler, injection, tablet
In tablet form are taken once a day
Often no side effects if taken at a low dose for a short period.
If taking for longer will need yearly reviews to investigate risk of osteoporosis, glaucoma, DM, HTN, peptic ulcers
To stop GI/ osteoporosis may give PPI, avoid NSAIDS and vit D/ ca supplements
Seek medical help if increased urinary frequency, signs of systemic illness, start developing stomach pains or vomiting blood
Once started don’t suddenly stop as can precipitate Addisons crisis due to adrenal hypoplasia
SE can include increased appetite, development of cushingoid features, mood changes, difficulty sleeping
Warfarin counselling
Warfarin is a blood thinner that helps stop clots from blocking blood vessels within the body. It does this by blocking the function of vitamin K
It is taken once a day in the tablet form
If you miss a dose for any reason then just take the same single tablet the next day. Do not double dose
Takes 2-3 days to begin working, on these days re given a higher loading dose
Monitor INR - aim for 2-3, write in yellow book
take 3m for DVT
take 6m for PE
Lifelong AF
Wear warfarin alert bracelet
Seek medical help if GI bleed, Epistaxis, trauma, cuts that won’t stop. Can cause diarrhoea, rash, hair loss, nausea.
Warn surgeons
Can interact with medications including over the counter like St johns wart - read information leaflet
Avoid foods high in Vit K including liver, spinach, cranberry. Avoid alcohol binges. Avoid contact sports.
Contraindicated in pregnancy, if at high risk of falls
Lithium counselling
ICE
A - Mood stabiliser
T - Take once or twice a day - take in evening so easier monitoring
H - Tablet or syrup
L - take lifelong with follow up
E - takes 1-2w to work
If miss a dose: if <6 hours then take if >6 hours then skip
T - Do some blood tests, heart trace and BMI before start then will test level once a week for first few weeks. Then will do blood tests every 6 months. Will also keep and eye on your BMI, Ca, TFT, Renal function every 6m
I - SE are feeling or being sick, diarrhoea, a dry mouth, polyuria, tremor and a metallic taste in mouth.
C - Is a risk of toxicity, causes vomiting, dizziness, tremor, confusion. Can also cause renal, hypothyroid.
C - contraindicated in 1st trimester, breast feeding, renal/cardiac/hypothyroid
SSRI counselling
Treat depression and anxiety
Correct chemical imbalance in brain
Start off low dose of one tablet, increase once every 2 weeks
Keep on until 3-6m after feel better
Can take 4-6 weeks for effects of the drug to be felt, in this time can make your symptoms worse
Can increase risk of suicide so if you get these feeling please seek help
SE include, GI disturbance, nausea, diarrhoea, headaches, weight change, anxiety, sexual dysfunction
- Don’t stop taking these often wear off quickly
If want to stop is important you let us know and we take you off the drugs gradually
Can interact with some over the counter medication including St Johns wart so important to read medication leaflet
Is contraindicated in pregnancy and breast feeding
Review in 2 weeks if <35
Pain ladder OSCE - what to cover?
Take a pain history Ask what patient has already been taking and evaluate how well they are taking them Ask for any allergies Would follow the who pain ladder Give an example of each analgesic Discuss side effects, contraindications Routes of administration
Pre op assessment
Nature of surgery Previous history of anaesthetics Family Hx of problems with anaesthetics Systemic conditions - Resp, CV, anaemia, coagulopathies, OSA Current medication ASA grade Potential issues with intubation Investigations
Bowel cancer screening - counselling
Faecal immunochemical testing - identifies blood in the stool. Done every 2 years from age of 60-74
The bowel cancer screening test for people aged 60 or over is a kit you use at home. It involves collecting a single sample of poo into a small plastic sample bottle and then posting this back to a laboratory for testing. This sample is used to check for tiny amounts of blood in your poo. It does not diagnose bowel cancer, but it’s a simple way to find out if you need further tests.”
When collecting sample:
- Write the date on the sample bottle
- Use a container or toilet paper to catch the sample without it touching the toilet water
- Twist the cap to open the sample bottle.
- Scrape the stick along the poo until all grooves are covered.
- Push the stick into the sample bottle and click the cap to close it. Do not reopen the bottle after use.
- Wash your hands
- Put the sample bottle in the supplied return envelope.
- Seal the envelope and post back to the laboratory.
Will get your results within 2 weeks
Normal - no blood, no further testing, repeat again in 2 years
Abnormal result - blood present, should have colonoscopy, not necessarily mean they have cancer
Summaries, ask if any Qs, offer leaflets, thank
Explaining OSCE
Brief Hx Understanding Concerns Explanation - normal, what is disease, cause, complications and management Summarise
Smoking cessation
Ask about current smoking status, take history
Advise patient on risks of smoking
Assess patient understanding of consequences, explore views on cessation and if/why they want to stop. Quantify their motivation
Assist patient by setting a date, telling them to inform family and friends, anticipate challenges, remove all tobacco products and recommend counselling
Group, individual counselling
Nicotine replacement therapy with patches, gums, sprays
Bupropion - 1-2 weeks before quit date and then for 12 w after
Varenicline - start 1 week before and cont for 12 w
Arrange follow up in 1-2w
Condom demonstration
Ask if allergic to latex,
Condom is worn on the penis to prevent sperm entering the woman’s vagina
It is important the condom is put on when the penis is erect and before it comes into contact with your partners body. It can also be used during oral sex to reduce the risk of STI
Before using a condom its important to check the expiry date and make sure there are no holes in the packet. Make sure have CE and kitemark
To open the condom packet push the condom to one side and then rip down the other side - do not use your teeth or scissors. Make sure your eyes are clean
Hold the tip of the condom between your forefinger and thumb to make sure it’s put on the right way round and no air is trapped inside (the condom may split if air is trapped inside).
Place the condom over the tip of the penis.
While squeezing the tip of the condom, roll it down over the length of the erect penis.
If the condom will not unroll, it’s probably on inside out – start again with a new condom as there may be sperm on it.
Make sure that the condom stays in place while you’re having sex. If it comes off, stop and put on a new one.
After ejaculation and while the penis is still hard, hold the condom in place and carefully withdraw the penis from your partner’s body.
You should only take the condom off the penis when there’s no further contact with your partner’s body.
Wrap the used condom in a tissue and put it in the bin. You should never flush condoms down the toilet as they may block the toilet and can cause environmental damage.
Do not use oil based lubricants as they will degrade the condom
Use a new condom each time you switch between anal, vaginal and oral sex
Inhaler OSCE
Explain what been started on and why
Show inhaler and its components
Explain why that type of inhaler is used and when
(rinse mouth out if steroid)
Happy with everything I have said so far, any questions?
Before use if not used in last 5 days take lid off shake and do one test spray
Look at dose counter and ensure not empty
Check expiry date
Hold upright, check nothing in mouthpiece, shake
sit up straight put chin up, breath out till lungs empty, form a tight seal. Breath in slow and steady while push canister, continue to breath in till lungs full. Remove inhaler from mouth and hold breath for 10s, breath out
If second puff do after 30 seconds, put back on cap after
Assess their technique
Spacer - increase drug to lungs and reduce SE
Prep, attach, breath out away from inhaler, form seal, puff once then breath in and out 2-3 times
Wash with detergent once a month, air dry. Do not wipe as causes static
If in asthma attack not improve after 10 puffs then call 999
leaflet, follow up
Eye History - what to ask
Site - one eye, both eyes Onset Character Radiation - headache Associated sx - lacrimation, itching, dryness, vision Anything make better or worse - lights Severity
Ask about headache, N+V
Vision, discharge, crusting/sticky eyes, dry eyes, halos, flashers or floaters, distortion of vision, blind patches, narrowing of vision.
Fever, cough, joint pain or rashes, GI problems, STI (pain urinating, discharge)
PMH - wear glasses, contact lenses, ocular trauma, HLA B27
DH
FH - glaucoma, AMD
SH
ICE
Urology History
Want to cover: LUTS (storage, voiding), Haematuria, Pain, Systemic signs of infection.
How often pass urine? Pass at night? Ever feel urgent? Leakage?
Slow to start? Slow to finish? Dribbling? Not feel like emptied completely? Strain?
Blood? What point? Clots? Eaten any beetroot? How much? Colour? Rifampicin? Recent strenuous exercise?
Pain? - SOCRATES
Scrotal masses, lumps or bumps
Fever, weight loss
In social history ask about smoking, rubber/dye exposure (bladder cancer), travel history
Type 1 diabetes counselling
ICE, patient perception Explain cause + symptoms effect on life treatment - self and dr summary
Diabetes is a condition where body fails to make insulin
Can lead to symptoms like going to the toilet too much, thirst, can cause emergency if not treated. Over time can have complications for eyes, kidneys, feet if not reviewed
Diabetes shouldn’t have to control your life but you might need to make some changes - diet exercise, stop smoking. Take blood sugars 4xday (before each meal and bed), count contents of meals
Treatment involves lifestyle changes and insulin
Insulin regime (Dafne, basal bolus)
Glucose targets - 5-7 on waking, 4-7 pre meal, 5-9 post meal
Important measure blood sugars before driving and every 2 hours driving
Effects of diet and illness
Sick day rules - sugars every 4 hours, drink fluids, if blood sugar over 15 check ketones (>1.5 medical help). If high (>11) increase insulin dose by 2 units
Detecting DKA, hypoglycaemia
Yearly review - eyes, kidneys, feet, CV risk, meds, neuropathy
Total daily dose is 0.2-0.4 unit/kg
CSF interpretation
Bacterial - neutrophils, low glucose, high protein, high WCC, raised opening pressure, cloudy/ turbid
- Neisseria, streptococcal
Viral - lymphocytes, normal glucose, high protein, high WCC, clear
- herpes, varicella, HIV, Adenovirus
Fungal/TB - lymphocytes, low glucose, high protein, high WCC, clear or cloudy
- cryptococcus, immunocompromised
TB - increased plasma cells
- typically have delirium, CN palsy
Do
- CSF culture, bacterial antigens, PCR
- Blood cultures
- Imaging to rule out intracranial pathology
- HIV test
- CXR if TB
GCS
Eye opening
- Spont eyes opening 4
- eyes open to sound 3
- eyes open to pain 2
- eyes not open 1
Voice - ask name, location and date
- orientated 5
- confused 4
- random words 3
- incomprehensible 2
- no noise 1
Motor response
- obeys command 6
- localises to pain 5
- withdraws from pain 4
- flex to pain 3
- extend to pain 2
- no movement 1
What questions to ask in acute diarrhoea
Recent travel Close contacts been unwell Recent food intake Recent hospitalisation Recent abx Diarrhoea in the past? Laxatives?
Methotrexate
Immunosuppressant and anti-inflammatory
Take once a week alongside folic acid (taken at another time)
SE include rash, hair thinning, headache, GI upset
Complications can include pulmonary fibrosis, bone myelosuppression leading to anaemia, infection, bleeding
If you experience any jaundice, shortness of breath, fever or other signs of infection it is important to seek medical assistance
Before you start on the medication we will need to perform some blood tests (LFT, U+E, FBC) and a chest xray. The blood tests will continue every 2 weeks until your medication stabilises and will then be 2-3 monthly
Methotrexate can interact with some over the counter medication including NSAIDs as well as alcohol and unpasteurised milk so avoid these.
If you or your partner are planning on getting pregnant it is important you let us know as we will have to take you off the medication to prevent harmful effects on the baby
Statin counselling
Statins are a drug that reduce the amount of cholesterol in your blood. Too much cholesterol can sit in your arteries and lead to heart disease, renal disease and strokes.
Tablet is taken once a day in the evening before bed
You won’t see any noticeable benefit from the statin however it is really important you take it every day as it is working away in the background to make you better
Side effects can include muscle pain, abdo pain, nausea, hair loss, itching, nose bleeds
Can cause rhabdomyolysis - coke urine, muscle pain, swelling
We will check your liver function before you start statins then at 3m and 12m. Also routinely check lipid levels
Not take if pregnant, avoid grapefruit
Psych Sections
Need:
Approved mental health professional
Section 12 approved Dr
Second independent Dr
Section 2
- 28d
- For assessment and treatment
- Cannot be renewed or extended
- Can be converted to a section 3
Section 3
- 6m
- Can be repeated and extended, at first by 6m and then by 12m
- Need to know the diagnosis and treatment required
- Need to have medication available
- After 3m achieve either patients consent or another Drs opinion that care is still needed
Section 4
- 72 hours
- Only need 1 Dr and a AMHP
- Should be converted to a section 2 once patient admitted with input from a 2nd Dr
5 principles of mental capacity act
- Deemed to have capacity till proved otherwise
- Should take any measure to allow person to make decision
- Just cos unwise decision doesn’t mean don’t have capacity
- decision should be made in best interests
- Least restrictive option
Explain DOLS
DOLS are performed when a person is subject to continuous supervision and control, is not free to leave
Checks to make sure any care that restricts a persons liberty is appropriate and in their best interests
Applies to someone who lacks capacity to their care
Must request permission from local authority body. Assessment is made by best interests advisor and a mental health assessor (psychiatrist)
Will assess 6 criteria
DOLS can last up to 12 months
Can grant an emergency DOLS that lasts for 7 days
Ascites fluid interpretation
Appearance clear/straw - cirrhosis Cloudy - SBP Blood - malignancy Chylous (milky) - TB or malignancy
High protein/low glucose, raised RCC - TB or malignancy High amylase - pancreatitis Very high RCC - trauma or haemorrhage Raised WCC - lymphocytes = TB - neutrophils = SBP
SAAG (Serum albumin - ascites albumin)
> 1.1 = transudate - cirrhosis, Budd Chiari, alcoholic
< 1.1 = exudate - malignancy, infection, pancreatitis, nephrotic
LDH
<225 - transudate
>225 - exudate
Diabetes prescription
Write patients name, DOB, address
Write the branded name of the insulin
Write method of admin - subcutaneous injection
Write the strength in units and dose (number of times a day)
What day to start, how long for (in words and figure e.g. seven (7)
Put your name, GMC number/state position, Date
Sign at bottom
COCP counselling
Why want the pill
Brief sexual history
ICE
Clarify not have any bleeding disorders, not have migraines
Contains both oestrogen and progesterone
Inhibits ovulation, thickens cervical mucus and thins the endometrium
99% effective with perfect use
AV: non invasive, effective, can make periods more regular, lighter and more pain free, can take back to back, improves acne, reduced premenstrual tension, reduce risk of ovarian, uterine, colon cancer
DV: Headache, nausea, breast tenderness, mood changes, breakthrough bleeding, not protect from UTI, user dependant
Increases risk of breast and cervical cancer, also VTE
Clarify not pregnant, smoker, migraine w. aura, family hx of breast cancer, CV risk factors, high BMI
Can start the pill at any point as long as your not pregnant, if within first 5 days of onset of bleeding you are covered if otherwise need to take another form of contraception for 7 days
Take at same time everyday, most people just before bed
Take for 21 days then break for 7 within which you will have a period. Are covered for these 7 days however any longer and you won’t be.
If miss one day then take as soon as remember
If miss 2 days then take last one as soon as remember but need to use another method of contraception for next 7 days.
If >7 pills left in a pack then break as normal, if <7 then back to back
How to break bad news
SPIKES
Setting - make sure is informal and appropriate
Perception - assess the patients perception on their current situation, understanding of recent tests
Invitation - ask if they are ready to receive their results and ask if they want anyone else to join
Knowledge - Explain what results mean, let them know the results weren’t what they hoped for, then break the news
Emotions - recognise and respond to emotions
Strategy and summarise - Organise a time to discuss next steps in treatment and referral, summarise findings for patient and answer any questions
Can give details of our clinical nurse specialist if have more questions
Offer assistance to tell others
Point towards sources of support
Offer written materials
counselling
check understanding and check safe to go home
Morphine counselling + dosing
Morphine is an opioid drug that works to prevent pain signals from reaching the brain, are very good for strong pain especially post op
Are a number of methods can be taken including tablets, IV, oral solution, patches
Dose depends on your level of pain, take regularly to get maximum effect. Usually start low and increase dose until pain controlled.
If miss a dose read information packet or contact pharmacist, don’t double dose
Can cause some SE: sleepiness, nausea, constipation
Avoid codeine containing otc meds as can worsen
Avoid alcohol to limit sleepiness
Take with meal to reduce nausea
It is possible to become addicted, however this is rare if you are taking it to relieve pain and your dose is being monitored by your Dr
Don’t stop taking suddenly as may experience withdrawal symptoms (anxious, agitated, sweating, shaking)
If think you have taken too much morphine and start struggling to breath or become unconscious get someone to seek urgent medical help
Not take if pregnant or breast feeding
For dose
New background = old total daily
New breakthrough = 1/6th to 1/10th of new daily
End of life symptom control
Pain - morphine background and PRN
N+V - broad spectrum levomepromazine
Secretions - hyoscine butyl bromide, position, stop fluids
Constipation - Senna, rehydrate, lactulose
Agitation - Midazolam, haloperidol
Dry mouth - oral hygiene, fluids, artificial saliva
Suicide attempt - risk assessment
Before, during, after
Intro self, say here to ask about what happened and how you feel
Before - prev psych hx, previous attempts, reason (situation, alcohol/drugs, health conditions), planning (get affairs in order/ how much think about it)
During - how, what do, how much and what take, when, where (anyone around), doing drugs/alcohol
After - how were you discovered, how feel now, what would you do if I sent you home, if still suicidal what intend on doing, any protective factors
Risk to self, risk to others (any dependants, violence)
Schizophrenia counselling
ICE, ask patient what already know
Info - schizophrenia is a long term condition that affects peoples ability to distinguish between abnormal thoughts and reality. This can mean experiencing hallucinations, paranoia, loss of interest in doing things.
Does this resonate with you?
Cause - the cause of schizophrenia isn’t clear, each person is different. However it commonly affects young people like yourself. Some things can trigger or worsen schizophrenia, these include significant stress or drugs. Does this apply to you?
Effect on life - Schizophrenia will always be there however with medication most people can make a recovery. There may be times when the symptoms come back and this is called a relapse. Having schizophrenia puts you at increased risk of other mental health disorders like depression and suicide. If you feel like this or your symptoms are getting worse and you think you might be having a relapse please tell someone. We hope however that with continued treatment this won’t happen.
Do you understand all this?
Treatment - long term medication that you will need to continue even if your symptoms stop. Are things you can do and things I can do however:
You - healthy lifestyle, exercise, avoid drugs and alcohol as they can make your condition worse. Is important you attend your appointments
Us: Antipsychotics, manage in combination with GP, can also use talking therapies . Put in touch with other services for employment, finances etc.
Summarise
LOC Hx
Before: How been feeling before Any headache, chest pain, SOB, warning signs (aura) Any triggers? Occur at rest or exertion On standing?
During
Collateral
Last thing remember, first thing remember
Remember hitting floor
Change in colour, breathing, movements, tone
How long
Incontinence or tongue biting
After
Anything help bring you around, how get up, how get here, how feel now, weakness or confusion?
Isotretinoin
A - helps to reduce skin inflammation and acne T - take once a day H - In a tablet form L - take until acne improved E - can take a few weeks to have effect I - Monitor LFT, cholesterol regularly C - Can cause dry skin, mucosal membranes. Skin oversensitive to UV so use spf. Not drink alcohol alongside, contraindicated in pregnancy, can increase risk of suicide in some individuals S - summarise, give leaflet
How to take insulin subcut - counselling
Store insulin in fridge
Take out 30 mins before - check leaflet to see if different. Do this to reduce pain and improve absorption time
Check expiry date prior to admin
Read leaflet on how to use specific product including:
Invert 10 times if cloudy insulin
How to prime pen - ensure plunger connected and any air expelled
Use a new needle each time
Choose appropriate injection site (lots of fat, pinch)
Not do through clothing, no need for cleaning
Inject with needle at 90 degrees, insert all the way, if long needle may need to reduce the angle
Leave in skin for 5-10 seconds to ensure all injected
Withdraw needle and apply gentle pressure over site for a few seconds
Do not rub
Chemotherapy counselling
Chemotherapy targets cells that are replicating, however it is non specific and alongside killing cancer cells it can kill other fast growing cells within the body causing side effects.
Chemotherapy drugs are often given intravenously via a PICC line or Hickmann line.
Side effects can include N+V, myelosuppression (anaemia, thrombocytopenia, neutropenia), hair loss, mucositis, diarrhoea/ constipation, neuropathy that can cause pins and needles/ difficulty holding objects, tinnitus
Can also cause renal and liver toxicity requiring monitoring
Radiotherapy counselling
Radiotherapy used to directly focus and destroy the cancer cells and can take many forms. Can include administration of a radioactive isotope, external beam or stereotactic.
Common side effects include dysfunction of the adjacent region. For example skin burn, tiredness, hairloss, sex and fertility, if oesophagus problems swallowing, SOB, cough if lungs, increased risk of heart disease. Can also get long term effects due to scarring e.g. stricture and tumours
Immunotherapy side effects
AI conditions including colitis, pneumonitis, hepatitis, dermatitis.
Important to monitor TFTs, cortisol, testosterone
Immunotherapy side effects
AI conditions including colitis, pneumonitis, hepatitis, dermatitis.
Important to monitor TFTs, cortisol, testosterone
IM injections
Ask if any allergies, clotting problems or taking any blood thinning meds
Clean tray
Alcohol wipe, gauze syringe, drawing up needle, injecting needle, medication
Wash hands, check type of medication, dose and expiry
ensure matches prescription
Draw up drug, switch to injection needle
aim 2.5cm below acromium
Pull down on arm (traction)
Insert needle half way with bevel up, aspirate and inject
Remove needle, let go of traction and place gauze
Say can be sore for a while after but warn to come back if worsening pain after 48 hours
Say is some risk of haematoma formation, persistent nodules, local irritation and rarely anaphylaxis.
Snellen chart
6m, wear glasses, read lowest line possible
6/18 + 2 means that the patient can read at 6 meters what a normal person would be able to read at 18 metres, plus 2 letters from the line below
ENT-ear history
Pain Hearing loss Tinnitus Dizziness/ vertigo Discharge Facial weakness
Predisposing features to ear disease – previous ear operations, exposure to loud noises, previous ear operations, major head injury, ototoxic drugs, FHx, systemic medical problems
Audiometry
Sound proofed room
Begin with ear with best hearing
Start at 1000Hz, go down to 250, up to 8000
Decrease by 10db until pt not hear, then increase by 5db until hear again.
Get bone conduction threshold using a transducer over mastoid process
Sensorineural - both low, air better (presbycusis, noise induced, acoustic neuroma)
Conductive - air low, bone normal (wax, ruptured ear drum, effusion, otosclerosis)
Mixed - both low but air lower
If tails off at higher hz, sensorineural - presbycusis
Sudden drop at lower hz, especially 4000 think noise induced hearing loss
Low Hz conductive hearing loss - otosclerosis
If points are within 10db of each other = symmetrical hearing loss
0-20 = normal 20-40 = mild 40-70 = mod >70 = severe
Impedance - measures pressure within middle ear, the stapedius reflex and tension of tympanic membrane
ABG interpretation
- look at PO2
- Look at PCO2 - type 1 (norm), type 2 (raised).
Type 1 due to V/Q mismatch e.g. PE, pulmonary oedema, ILD
Type 2 due to ventilatory failure e.g. COPD, neuromuscular, pneumonia (reduced lung compliance), opiates - pH, see if PCO2 or HCO3 causing
- Look at Base excess
- Look for compensation - resp quick, metabolic slow (few days)
Resp acidosis - hypoventilation - COPD/asthma, GB, opiates
Resp alkalosis - hyperventilation - Anxiety, pain, hypoxia, PE, pneumothorax
Metabolic acidosis - do anion gap (Na+K - Cl - HCO3)
If high - lactic acidosis or DKA
If low - Diarrhoea, renal tubular acidosis, Addisons
Metabolic alkalosis - Diarrhoea or vomiting, nephrotic, conns, diuretics
Webers and Rinnes
Webers - towards conductive or away from sensorineural
Rinnes - A>B in normal or sensorineural, opposite in conductive
rheum history
Pain Rashes Stiffness Swelling/redness Immune - recent infection, illness Ask about signs of malignancies Ask about all systems
Anaphylaxis management
0.5mg adrenaline, 200mg hydrocortisone, 10mg chlorphenamine, fluids
Send blood samples at 0,6,24 hours
Refer to immunology clinic
Document, inform GP
Post op pain management
WHO pain ladder
Patient controlled anaesthesia - morphine
Epidural, local nerve block/spinal
SE of opioid - itching, N+V, constipation, resp depression, tolerance, dependance, misuse
PCA - advantages - patient feels they are in control of pain, pump prevents overdose, get right amount of dose
Disadvantage - Need pump,
Epidural AV and DV
AV - can provide post op pain relief for up to 72 hours, reduces stress response to surgery, reduces post pulmonary complications by reducing use of opioids, reduce thromboembolic SE
DV - PDPH, risk of nerve injury, may fail, hypotension, urinary retention, motor blockage, need specialist care
Risks of post op N+V
Female, prev PONV, hx of motion sickness, anxieties, non smokers
Inhalational anaesthetics, opiates, NO, neostigmine, antibiotics increase risk
Can avoid GA or do total intravenous anaesthesia
