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
