YEAR 5 OSCE Flashcards
Breaking Bad News Mnemonic - _______
S: Setting
P: Perception
I: Invitation
K: Knowledge
E: Emotions and empathy
S: Strategy and summary
S stands for setting the scene. This first part may be difficult to show in an OSCE situation. On the wards, doctors need to make sure that the setting is appropriately private. This means that bad news should preferably not be made behind a paper curtain, as this does not constitute real privacy. The doctor should also make sure that there are no disturbances: they should turn off their phone and hand their bleep to the nurse-in-charge if at all possible.
P stands for perception. This means that the candidate should make an obvious attempt early in the consultation to try and check the patient’s understanding about what has happened so far. In this case, the patient has a very poor insight into the situation, which is not his fault. This makes the task much more difficult. It also highlights the importance of always making it clear, why certain investigations are being performed. If one doctor decides not to fully explain the situation, like the GP in this case, they will make the task much more difficult for the next clinician. If doctors are doing investigations to look for the possibility of cancer, the patient should be informed.
I stands for invitation. This is an invitation that the candidate gives to the patient - they will ask whether the patient wishes to know the results of the tests. It may be appropriate at this point to fire a “warning shot” so that they are aware that the news is not going to be good. Excellent candidates may also ask whether they would like to continue the conversation now or whether they would like someone with them. This signposts to the patient (and the examiner) that you are about to break bad news and you are being sympathetic to the patient’s needs.
K stands for knowledge. This represents the need to actually convey the bad news to the patient. This needs to be done in an unambiguous, clear way. On the wards, patients often take in very little of what is said to them in these circumstances, therefore, it is a real test of the candidate’s communication skills. Excellent candidates will check understanding, allow the patient to ask questions and relay information in non-medical, universal terms.
E stands for empathy. This is self-explanatory. Despite what may be assumed, empathy can be learned and practiced. The more candidates practice these types of conversations, the better they will become at them. Stressed candidates are less likely to display empathy. Communication skills such as these are seen on the wards to different degrees. Excellent candidates will learn from what the good examples that they see on placement.
S stands for strategy and summary. This is the final stage of the conversation. Candidates should try and come up with a joint plan with the patient. They will also summarise the case and check understanding.
This station has the added complication that the patient is already upset with the health service in general. It is not uncommon for patients to have hidden agendas when coming into a consultation. Excellent candidates will be able to discuss the patient’s concerns in a non-confrontational manner.
Excellent candidates will behave in a calm and considered manner, even if patients have insulted them or their profession. Candidates are likely to become frustrated with patients who behave in this way, however, they must remember that often there are very valid reasons. Doctors should always consult in a non-judgemental manner.
Although there is still some doubt in this case, as a histological diagnosis has not been made, candidates should not be overly optimistic or try and appease a distressed patient. This will only cause more pain in the long run as there is enough evidence to support the diagnosis of metastatic bowel cancer which has a poor prognosis.
Candidates should not guess about the prognosis if they do not know. It is impossible to answer the question “how long do I have left” with a precise length of time. Candidates should not attempt this. Excellent candidates will be honest and try to explain in an empathetic manner that they cannot answer such a question. They will reassure the patient that the whole multidisciplinary team will work hard to help the patient in every way possible.
Emergency Contraception Discussion.
4 things to explore in presenting complaint _____
DCMMP - DOLLY CAN MANIPULATE MY PENIS
- Details of sexual intercourse (When/Who/Consensual/Regular partner/ Age of partner)
- Current contraception (type/reason for failure)
- Menstrual history (LMP/Regularity/ Cycle length/ Estimated day pf ovulation - 14 days before next menstrual period is due) - luteal phase always 14 days.
- Medications? CYP inducing medications can lower effectiveness of EllaOne and Levonelle (ex. TCA’s/Antiepileptics/macrolides/anti-psychotics etc.)
- Pregnancy? Have they already taken emergency contraception this cycle?
Always advise screening for STI’s in unprotected sex.
Emergency contraception options?
IUD
EllaOne
Levonelle
Counselling points for EllaOne And Levonelle
Can restart normal hormonal contraception 5 days after EllaOne and 2 days after Levonelle
Barrier protection in the meantime.
When restarting COCP - Use barrier protection for 7 days.
When restarting Progesterone only pill - Use barrier protection for 2 days.
NB - Levonelle can be taken again in same cycle but not EllaOne.
Contraindications to Emergency Contraception
IUD ____
EllaOne ____
Levonelle ____
IUD
- Pregnancy
- Gynae cancers
- PID <3months
- Copper allergy or Wilsons disease
- Small uterine cavity
EllaOne
- Pregnancy
- Asthma / Liver disease
- < 18 yo
Levonelle
- Pregnancy
- **Acute Porphyria ** - Abdominal pain (particularly in luteal phase)/Dark urine/N+V/Motor neuopathy and seizures (late signs)
Remember EllaOne and Levonelle may be less effective if patient is taking other enzyme inducing medication (anti-epileptics/ anti-psychotics/ macrolides - clarithromycin / TCAs etc)
Side effects of Emergency contraception
IUD ____
EllaOne and Levonelle ____
IUD
- Pain on insertion (use ibuprofen)
- Infection
- Menorrhagia/Dysmenorrhoea
- Vasovagal (1/10)
- Expulsion (1/20)
- Perforation (1/1000)
EllaOne and Levonelle
- PV bleeding (at any time - immediately/at menses/after menses)
- Nausea and Vomiting
- Pelvic and Breast Pain
- Headache
X-RAY Interpretation Steps
- Patient and scan details (Time / AP / PA / Erect or supine)
- RIPE
- ABCDE
RIPE
Rotation - medial side of spinous process should be equidistant from borders of vertebral columns
Inspiration - At least 5/6 anterior ribs should be visible (or 11/12 posterior ribs)
Picture area - Lung apices and costodiaphragmatic recesses/costophrenic angles should be visible. Lung apices shouldnt be above clavicle and scapulae should be out of the way.
Exposure - Verterbral bodies should be visible behind cardiac shadow (over exposure = too black / Underexposure = Too white)
ABCDE
Airway - Tracheal deviation (away from a pneumothorax/large effusion or towards a collapsed lung)
Breathing - Lung fields and pleura
Air
Fluid
Consolidation
Lobar collapse
Lesions
Pleura: thickening and lung borders for pneumothorax
**Circulation **-
Heart size - <50% ribcage (cardiomegaly suggests HF)
Heart position - can be displaced in lobar collapse or pleural effusion
Heart shape and borders - NB right border = right atrium Left border = Left ventricle
Great Vessels - Aortic knuckle (i.e arch should be visible)
Mediastinal width (< 8cm - if not - aortic dissection)
Diaphragm -
Position and shape - right slightly higher due to liver usually. FLAT in COPD due to emphysema and hyper inflated lungs pushing down on diaphragm.
Costophrenic angle - blunting indicates an effusion
Air below diaphragm - Abdo viscus Perforation
Extra things -
Bones (trace if clinically suspiscious i.e trauma etc)
Soft tissues - swelling/ surgical emphysema or subcutaneous air/ masses/ calcification of aorta
To summarize I would look at previous films and ascertain the clinical hx.
Summarize and suggest differentials.
COPD SIGNS ON XRAY
Hyperinflation (>8 anterior ribs above diaphragm)
Flat Hemidiaphragms (emphysema and hyperinflation pushes D down)
Bullae (black lesions more air)
Decreased lung markings
Prominent Hila
Heart failure signs on XRAY
ABCDE
Alveolar shadowing/oedema (bats wings)
B-Lines (kerley) - interstitial oedema
Cardiomegaly
Diversion of blood to upper lobe
Effusion
What does CURB 65 stand for? What are its uses and scores?
CURB65 is a tool used to estimate severity of community acquired pneumonia at time of presentation by evaluating mortality data
It allows clinicians to decide on inpatient vs outpatient treatment
Also allows clinicians to decide on intensity of inpatient treatment including PO vs IV antibiotics, and escalation of monitoring / care to HDU/ITU setting
Points are scored for
Confusion AMTS ( abbreviated mental test score) < 7/10
Urea value >7mmol/l
RR>30/min
SBP <90 or DBP <60
Age >65
0-1 - outpatient care with oral antibiotics and repeat chest x-ray in 6 weeks is appropriate
2 - Inpatient admission is warranted
3 or above - inpatient admission, IV antibiotics, and consideration of HDU/ITU care may be appropriate
DEATH CERTIFICATE
Criteria to be met before filling in certificate?
- Pupils fixed and dilated with no response to light.
- No central pulse (1min)
- No Respiratory effort/Breath sounds on auscultation (1min)
- No heart sounds (1min)
- No pain response to trapezius squeeze
Criteria for death certficate as the doctor filling out the form.
- Must have seen the patient in last 14 days before or after death
- Must have provided care to patient in last illness before death
- Registered GMC
- Knowdledge and belief of cause of death
- Must not meet criteria for referral to coroner
Criteria for referral to coroner
- In hospital <24hrs
- Unknown cause of death
- In custody
- Any suspicious circumstances
- Any drugs involved
- Acute alcohol
- Industrial deaths
- Any blame
- Following accident/fall/violence
- Operation <1 yr
- Unknown identity
End of life/Anticipatory medications for which symptoms?
Medications for pain
Conversion of patient’s usual daily dose of opiate analgesia to a 24 hour dose for use via a syringe pump, with 1/6-1/10 of the daily dose prescribed as ‘breakthrough’ analgesia. Should be reviewed every 24 hours.
- Morphine
First line for pain management
Good for all types of pain
Monitor for constipation
Monitor for unwanted sedation
Please note that when coverting from oral morphine to subcutaneous morphine, you must divide the total dose by two - Diamorphine
- Oxycodone
- Alfentanyl
Useful for patients with renal failure who cannot take morphine
**Breathlessness **
May be a result of disease process (e.g. lung cancer, anaemia)
Therapeutic oxygen
Morphine
Midazolam
Nausea and vomiting
Levomepromazine
Cyclizine
Haloperidol
Metoclopramide
For people in the last days of life with obstructive bowel disorders who have nausea or vomiting, consider:
hyoscine butylbromide as the first‑line pharmacological treatment
octreotide (somatostatin analogue) if the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide.
Medications for restlessness and confusion
Haloperidol
Levomepromazine (sedative)
Midazolam
Respiratory tract secretions
Hyoscine hydrobromide
Hyoscine butylbromide (BUSCOPAN)
Glycopyrronium
Atropine
(antimuscurinics/anticholinergics)
- NICE Guidance: Care of dying adults in the last days of life - NICE Clinical Knowledge Summary (CKS): Palliative care - general issues
https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/
Causes of Hyperkalaemia?
- Reduced excretion from kidneys
- Release from cells
- Acidosis
- Drugs
- Reduced excretion from kidneys
AKI
and
Addison’s
- Cellular Release:
Rhabdomyolysis
Digoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECG
Tumour Lysis Syndrome
Massive Haemolysis
- Acidosis:
DKA or any other metabolic acidosis
- DRUGs that reduce K+ excretion from the kidneys : **KBANK **:
K+ containing laxatives (movicol/fybogel)
Beta Blockers
ACE inhibitors
NSAIDs
Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general
Heparin (which inhibits aldosterone release)
and
Ciclosporin
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;
Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotective
Intravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Causes of Hyponatraemia?
Remember to classify into:
Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)
Euvolaemic (SIADH / Hypothyroidism)
Hypervolaemic
and drugs:
Thiazide diuretics > Loop Diuretics > K+ sparing diuretics
Hyponatraemia Management
What is the role of the medical examiner?
Medical examiners are senior medical doctors who are contracted for a number of sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.
The purpose of the medical examiner system is to:
provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
ensure the appropriate direction of deaths to the coroner
provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
improve the quality of death certification
improve the quality of mortality data.
Causes of Falls in the elderly?
Sensory Disturbance: (visual impairment/vestibular dysfunction/peripheral neuropathy)
Cognitive impairment: Dementia/Delirium
Polypharmacy: Anticholinergics/Opiates/Benzo’s/Antihypertensives
Co-morbidities
Enviromental Hazards: (loose rug)
Physical Ageing Process/Frailty
Orthostatic Hypotension
Motor problems: Gait and Balance problems/ Muscle weakness
When a health professional feels that the person with power of attorney may not be acting in the patients best interests, who could they contact?
Alert the office of the public guardian who will investigate and can apply to the court of protection. Colleagues, safeguarding lead, defence union also useful
What measures should be taken to reduce the risk of delirium during an admission?
- Ensure team of healthcare professionals who are familiar to the person at risk.
- Avoid moving people within and between wards; worth reflecting on the realityof hospital care and the difficulty in achieving this.
- Specialist MDT assessment and personalised care plan. Liaison geriatrics / joint care.
- Appropriate lighting and clear signage / a clock and a calendar should also be easily visible.
- Re-orientate frequently.
- Facilitate regular visits from family and friends.
- Address dehydration and / or constipation.
- Avoid unnecessary catheterisation / lines / restrictions.
- Encourage mobility and keep mobile / active when able.
- Assess for pain, including non-verbal clues of pain and address pain adequately.
- Carry out a medication review.
- Encourage good nutritional intake
- Ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order.
- Promote good sleep patterns and sleep hygiene.
- Consider alcohol withdrawal regime.
Be vigilant for withdrawal symptoms and
treat if required.
Common causes of delirium can be remembered using the mnemonic ______ :
DELIRIUMS
D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
E - Eyes, ears and emotional (reduced input)
L - Low Output state (MI, ARDS, PE, CHF, COPD) - low oxygen
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
or can use
PINCH ME
- Pain
- Infection
- Nutritional compromise
- Constipation
- Hydration (dehydration / electrolyte disturbance)
- Medication
- Environmental
Treatment of Hyperkalaemia if K+ is > 6.5 mmol/L or ECG changes / Symptomatic
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Which patient profile requires breaking confidentiality and informing social services?
Children (<18)
and
Adult w/o capacity
Which patient profile requires NOT breaking confidentiality and not referring to social services or any other body?
Adults with capacity who have not given their consent
Options for safeguarding referral in children/adults w/o capacity and adults w/ capacity?
Children and adults w/o capacity - social services
Adults with capacity - police / Local domestic abuse service/ counselling service/ social services
If you feel an urgent social services assessment is required or the child is at immediate risk , then an ____ can be sought if required.
**Emergency protection order **
In a domestic abuse station, make sure to establish the details of the abuse / take a good social history/ and establish RISK.
For example ____
- Type (physical/sexual/emotional)
- Perpetrator (Who is it/ whats the relationship)
- Pattern (when/are drugs and alcohol involved)
- Timeframe (how long/has the abuse been escalating?)
- Coping (how have they coped/have they tried anything to stop it or get away?)
- Who else is involved (any children or vulnerable adults?)
Social History
* Who do they live with
* Are there weapons in the house
* Does the patient have an emergency safety plan? - if not construct one with patient and signpost police
* Do they work
RISK Assessment
* To patient: Do they currently feel in danger? What would happen if they go home?
* Has it affected their mood? have they considered harming themselves or taking their own life?
* Any children or vulnerable adults involved?
Which drugs should be avoided in the elderly where possible?
NSAIDS
Benzodiazepines
Anti-cholinergics
Tricyclic Antidepressants
Glibenclamide (causes hypoglycaemia)
Doxasozin (adrenergic antagonist - BPH)
Which phenotyoical frailty assessment score can be used to assess a patients frailty on acute admission to the hospital?
Remember frailty can be assessed by 4 major main themes:
Cumulative
Phenotypical
Surrogates
“Eyeball”
Bournemouth Criteria:
> 90 - automatically frail
Age: 75-89 - 2 of the following to be considered frail:
Immobility
Incontinence
Cognitive impairment (i.e dementia/delirum - does not include learning disabilities)
Instability (i.e falls)
Iatrogenesis (i.e polypharmacy - > 5 drugs)
*65-75 - need to be instituionalised (nursing/residential home)
A comprehensive geriatric assessment includes which team members and which domains of assessment?
Patient/ Their care giver and
- Doctors • Nurses
- Therapy (OT/PT/Nutrition/swallow etc)
- Social services
- Community services
- Pharmacist
*CGA is not a form but a process of accumulating data on patient by all team members*
Includes:
- Physical Assessment (illness/pain/incontinence/nutrition?ADL’s etc)
- Psychological (Sleeping/Mental Health/Alcohol)
- Social
- Medication review
These domains all inform care plan for patient.
Frailty Management
• Gold Standard: Comprehensive Geriatric Assessment: MDT
approach holistic assessment considering physical issues, function,
environment/ support, _mobility and balanc_e, psychological issues
and medication. Care plans can be put in place
- Exercise interventions: core strength, flexibility, balance, endurance training
- Good nutrition, considering total protein intake, calcium and vitamin D
- Role for BMI reduction? Raised BMI associated with poor outcomes
• Medication reviews
• Advance care planning
Other than falls, what other risk factors increase the risk of a fragility fracture? (2 mark)
•Previous osteoporotic fragility fracture.
- Current or frequent recent use of oral corticosteroids.
- Low body mass index (less than 18.5 kg/m2)
- Smoker.
- Alcohol intake > 14 units per week.
- A secondary cause of osteoporosis
How would you assess risk of a fragility fracture ?
- Calculate 10 year fragility fracture score (eg FRAX or Qfracture)
- https://www.sheffield.ac.uk/FRAX/ - Fracture Risk Assessment Tool
- DEXA if score >10% or Straight to DEXA if PMH fragility fracture
Maureen returns to her GP having had a DEXA scan showing a T-score of -1.5.
What does the T-Score on a DEXA scan relate to?
- Osteopenia: T score _____
- Osteoporosis T-score ____
Normal range T score _____.
T score: A measurement of bone mineral density as compared to that of a 30 year old adult (Z score: compares your BMD to what is normal in someone your age and body size)
- Osteopenia: T score -1 to -2.4
- Osteoporosis T-score -2.5 and below
Normal range T-score -1 and above
Drugs particularly associated with adverse outcomes in
frailty
• Anticholinergics: unsteadiness, blurred vision, dry mouth,
urinary retention, confusion
• Benzodiazepines: falls, regular use increases all-cause
mortality, confusion
• Opioids: constipation, falls, delirium
• NSAID: AKI and gastric ulceration
• Antihypertensives: AKI, falls
What is the acute management of Ischaemic Stroke?
Patients should be approached in the DR ABCDE manner.
Airway protection (in patients presenting with depressed consciousness) and aspiration precautions (in patients presenting with swallowing impairment) are very important.
Subsequent stroke management depends on whether the stroke is ischaemic or haemorrhagic. CT head should be performed on arrival to the emergency department to distinguish ischaemic from haemorrhagic stroke. (The most sensitive test for confirming ischaemic infarct is a diffusion weighted MRI. This is generally used if the diagnosis is unclear but is not normally possible in the emergency setting due to logistical challenges)
Alteplase (tissue plasminogen activator) is indicated in patients presenting within 4.5 hours of symptom onset and with no contraindications to thrombolysis (e.g. recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, and INR).
Mechanical Thrombectomy can be performed in patients with anterior circulation strokes within 6 hours of symptom onset, provided that they have a good baseline functional status and lack of significant early infarction on initial CT scan. Mechanical Thrombectomy can also be performed in posterior circulation strokes up to 12 hours after onset.
If hyper-acute treatments are not offered, patients should receive aspirin 300 mg orally once daily for two weeks. If hyper-acute treatments are offered (i.e thrombolysis or Thrombectomy), aspirin is usually started 24 hours after the treatment and following a repeat CT Head that excludes any new haemorrhagic stroke.
What Stroke investigations would you do to identify cause of stroke? (post-acute)
In ischaemic stroke: carotid ultrasound (to identify critical carotid artery stenosis), CT/MR angiography (to identify intracranial and extracranial stenosis), and echocardiogram (if a cardio-embolic source is suspected). In young patients further investigation e.g. a vasculitis screen or thrombophilia screen may be necessary.
In haemorrhagic stroke: serum toxicology screen (sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke).
Further investigations to quantify vascular risk factors include:
- serum glucose (all patients with stroke should be screened for diabetes with a fasting plasma glucose or oral glucose tolerance test)
- serum lipids (to check for raised total cholesterol/LDL cholesterol).
Stroke management (chronic i.e secondary stroke prevention)
Mnemonic HALTSS: + MDT!!!
Hypertension:
No benefit in lowering the blood pressure acutely (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure >180 mmHg). Anti-hypertensive therapy should, however, be initiated 2 weeks post-stroke.
Antiplatelet therapy:
Patients should be administered Clopidogrel 75 mg once daily for long-term antiplatelet therapy.
In patients with ischaemic stroke secondary to atrial fibrillation, however, warfarin (target INR 2-3. or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke.
Lipid-lowering therapy:
Patients should be prescribed high dose atorvastatin 20-80 mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke).
Tobacco:
Offer smoking cessation support.
Sugar:
Patients should be screened for diabetes and managed appropriately.
Surgery:
Patients with ipsilateral carotid artery stenosis more than 70% should be referred for carotid endarterectomy.
Rehabilitation and supportive management will include an MDT approach with involvement of physiotherapy, occupational therapy, speech and language therapy, and neurorehabiliation.
Risk Factors for Falls
A history of falls is one of the strongest risk factors for a fall - after a first fall, people have a 66% chance of having another fall within a year
Conditions that affects balance, mobility or strength, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson’s disease.
Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.
Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).
Environmental hazards, such as loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially in the bathroom), loose fittings (such as handrails), and poor footwear.
The more risk factors a person has, the greater their risk of falling.
Falls can also be a sign of underlying health issues, such as frailty
MDT Management of Falls in the Elderly
- Analgesia titration to allow mobility.
- Orthopaedic support, but likely non-surgical (“conservative”) management.
- Delirium risk reduction (Lighting/clock/continuation of staff).
- Medication review - hold ACEi / beta-blocker / alpha blocker with low B.P.
-
Multi-factorial falls assessment, including gait and balance / lying and standing B.P / medication review / Alert technology whilst inpatient, certainly patient activated “call bell” for assistance but with dementia consider automated system such as a falls alert mat / consider “bay tag” observation
with cognitive impairment. - Treat other co-morbidities (for example, constipation,pneumonia)
- Patient education with falls risk.
- Further cardiac monitor (ECG)
- Further falls risk assessment as MDT as part of discharge planning including:
o Medication review when lying and standing B.P are known.
o Gait and balance specialist assessment and balance and strengthening exercise programme and review walking aids.
o Environmental review with interventions.
o Vitamin D supplementation - check levels, fragility fracture / osteoporosis secondary prevention.
o Assistive technology (falls sensor for possible future falls to alert and avoid “long lie”).
Key points to ascertain in a history of falls?
When did you fall?
Did anyone see you fall?
Where did you fall?
What happened before/during/and after?
How many times have you fallen over the last few months?
Bone health - previous fractures / family history of fracture / smoking, alcohol /
calcium intake
Previous Mobility
Which tools can be used to identify non-specific cognitive dysfunction?
And which tool can be used to specifically assess for delirium?
Non-specific
MOCA
MMSE
10/4 AMT
6-CIT
Delirum Specific
4AT
How do you assess capacity?
Assume capacity unless patient gives you reason to doubt
Public Health England Guidance on diagnosis of UTI in people > ___ states: “Do not perform urine dipsticks.
65
Dipsticks become more unreliable with increasing age over 65 years.
Up to half of older adults, and most with a urinary
catheter, will have bacteria present in the bladder / urine without an infection.
This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.”
Contraindications to thrombolysis (alteplase rTPA - recombinant tissue plasminogen activator) in ischaemic stroke
Recent surgery (14 days)
Recent head trauma
Intracranial or GI bleed (< 21 days)
Low Platelets (<100,000/µl )
INR < 1.7
Hypertension (S: >185 or D: >110)
Investigations in falls
Bedside
- Vital signs (BP/HR/RR/SpO2/Temperature - Sepsis/Bradycardia)
- Lying and standing blood pressure (Orthostatic hypotension)
- Urine dipstick (Infection/Rhabdomyolysis (+++ blood))
- ECG (Bradycardia/Arrhythmias)
- Cognitive screening (e.g. AMT - Cognitive impairment)
- Blood glucose (Hypoglycaemia secondary to poor oral intake)
Bloods
- Full blood count (Anaemia/Infection (raised white cells)
- Urea and electrolytes (Dehydration/Electrolyte abnormalities/ Rhabdomyolysis)
- Liver function tests (Chronic alcohol use)
- Bone profile
(Calcium abnormalities in malignancy/Over-supplementation of calcium)
Imaging
- Chest X-ray
(Pneumonia) - CT head
(Chronic or acute subdural/Stroke) - Echo (Valvular heart disease e.g aortic stenosis)
Specialist
- Tilt table test
- Dix-Hallpike test (Benign paroxysmal positional vertigo)
- Cardiac monitoring (e.g. 48hr tape) If no symptoms during monitoring episode in hospital.
HPC falls? (i.e Details to be established)
WHO
Who has seen you fall?
Ensure adequate collateral history including addressing the when, where, what and why.
WHEN
* When did you fall?
* What time of day?
* What were they doing at the time?
Looking upwards (vertebrobasilar insufficiency)
Getting up from bed (postural hypotension)
WHERE
*Where did you fall?
*In the house, or outside?
WHAT
*What happened before/during and after the fall?
Before
- Was there any warning?
- Was there any dizziness/chest pain or palpitations?
During
- Was there any incontinence or tongue biting? (indicating seizure activity)
- Was there any loss of consciousness?
- Was the patient pale/flushed? (may indicate vasovagal attack)
- Did the patient injure themselves?
- What part of the body had the first contact with the floor?
After
*What happened after the fall?
*Was the patient able to get themselves up off the floor?
*How long did it take them?
*Was the patient able to resume normal activities afterwards?
*Was there any confusion after the event? (head injury)
*Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
WHY
*Why do you think you fell?
*May have tripped over a rug or started a new medication
HOW
*How many times have you fallen over the last 6 months? Allows you to gauge the severity of the problem
DO A FULL SYSTEMS REVIEW CARDIO/NEURO/RENAL etc
If a patient is >18 yo and lacks capacity it is the doctors duty to make the decision on their behalf, acting in their best interests under the mental capacity act (note not mental health act). The relatives/friends have no right to make the decision unless they have _____.
If a life changing decision needs to be made and the patient has no family/friends to consult about their best interests, an _____ can be requested.
If you are stopping a patient without capacity from doing things (ex. leaving the hospital) you must fill out a _____.
Power of attorney
Independent mental capacity advocate (IMCA)
Deprivation Of Liberty Safeguard form (DOLS)
Supraventricular Tachycardia (SVT) is any ____ complex tachycardia characterised by a heart rate of more than 100 bpm and a QRS width of less than ____ ms on an ECG.
Atrial Fibrillation (AF), AV Re-entry Tachycardia (AVRT) and AV Nodal Re-entry Tachycardia (AVNRT) are examples of SVTs.
Patients with adverse features should be given _____ .
These features can be remembered by the mnemonic HISS, which stands for:
______
narrow
120
Investigations and Management of pulmonary oedema due to Left Ventricular Failure.
Investigations
Bedside observations
Arterial blood gas
ECG
Troponin if concerned about a new cardiac event
Serum BNP
Chest X-ray
Management - POUR SOD
- Take an ABCDE approach
- Sit the patient up
- Administer oxygen
- Ensure IV access
- IV Furosemide (40mg stat)
- Consider non-invasive ventilation such as CPAP if failed medical therapy (usually in an intensive care setting)
- Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails
https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations
Management of Paracetamol overdose:
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level using** nomogram**
If ingestion 4-15 hours ago: Take immediate level and treat based on level
If staggered overdose ( which is defined as being an overdose taken over > 1 hour) or ingestion >15 hours ago: Start N-acetylcysteine immediately
Obtain following bloods:
FBC
Urea and Electrolytes
INR
Venous gas
If a patient presents after 16 hours, there is *uncertainty about timing * or has a staggered overdose then NAC should be started regardless of the nomogram.
NAC is associated with anaphylactoid reactions. These are not true anaphylactic reactions and can usually be managed by stopping the infusion temporarily and then restarting at a lower rate.
Consider need for transfer to liver unit if blood tests are worsening
Management Flow chart:
https://emj.bmj.com/content/19/3/202
Emergency Management of PE:
Massive PE and HD unstable - ______
Acute PE and stable - _____
Recurrent PE or Anticoagulation resistant - _____
Unstable: Thrombolysis - (Streptokinase/Alteplase - seek senior input)
Stable: LMWH or UFH infusion (5 days - and INR >2 on 2 consecutive days) -** bridge with NOAC or Warfarin **
NB
- Provoked PE - 3 months DOAC and check INR.
- Unprovoked PE - 6 months DOAC and check INR
(Side note: remember warfarin takes time to titrate INR but also can be reversed quickly with Vit.K)
Recurrent or treatment resistant: Inferior Vena Cava Filter
NICE visual summary:
https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893
ECG interpretation method
Details - patient/time/previous ECG’s
Rate - Rhythm strip X 6
Rhythm - count boxes between each QRS wave (use ruler and dots if neccessary)
P wave - Present before every QRS? Yes - sinus NO? - AF etc.
PR interval - <200ms or 5 boxes (each box 40ms or 0.04 secs). NO? - heart block. Primary secondary etc.
QRS wave - < 3 boxes or 120ms/0.12 seconds. NO? - Bundle Branch BLock (BBB). - William Marrow (V1 and V6)
ST segments - Compare with isoelectric line after the complex.
(ST elevation is caused by a lack of blood supply to the muscle. The potassium channels responsible for depolarization are ATP dependent and thus cannot open when there is a lack of blood)
T waves - inverted or flattened more than twice in each segment?
Axis - look at leads 1 and 3
If lead 3 is greater in amplitude than lead 1 - consider axis deviation
If leads arriving - right axis deviation
If leads leaving - left axis deviation
Everything else is normal.
Other stuff - QT/QTc Interval / P wave morphology / Ventricular hypertrophy / Strain (amplitude of QRS - can be nromal in a skinny person)
Causes of Hyperkalaemia?
3 causes:
- Reduced excretion from kidneys
- Release from cells
- Acidosis
- Reduced excretion from kidneys:
AKI
and
Addison’s
DRUGs that reduce K+ excretion from the kidneys : **KBANK **:
K+ containing laxatives (movicol/fybogel)
Beta Blockers
ACE inhibitors
NSAIDs
Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general
Heparin (which inhibits aldosterone release)
and
Ciclosporin
- Cellular Release:
Rhabdomyolysis
Digoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECG
Tumour Lysis Syndrome
Massive Haemolysis
- Acidosis:
DKA or any other metabolic acidosis
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;
Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotective
Intravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Causes of Hyponatraemia?
Remember to classify into:
Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)
Euvolaemic (SIADH / Hypothyroidism)
Hypervolaemic
and drugs:
Thiazide diuretics > Loop Diuretics > K+ sparing diuretics
Hyponatraemia Management
Tumour lysis syndrome occurs ___ days after chemotherapy whereas neutropenic sepsis is more likely to occur ___ days after chemotherapy.
A few days (around 3)
10 or more days
Tunour lysis syndrome is a condition which typically presents a few days after chemotherapy and is common for haematological malignancies, particularly non-Hodgkin lymphomas. The administration of chemotherapy can cause significant cell death in mitotically active tumours, resulting in the extravasation of intracellular contents such as nucleic acids into the circulation. These are then broken down into uric acid and phosphate. Uric acid can precipitate in renal tubules leading to an acute kidney injury, which may cause the anuria as reported by this patient. Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting.
This man has significant risk factors for tumour lysis syndrome and combined with anuria means that he may have an acute kidney injury. The most appropriate management for this should be fluid resuscitation in the first instance, particularly given his hypotension.
Febrile Neutropenia can be defined as a temp > ____ and a neutrophil count < ____
38 degrees
0.5 ×109/L
A ____ score is used to determine risk of febrile neutropenia in cance patients.
A score of > ___ is considered low risk
MASCC (Multinational Association for Supportive Care in Cancer)
> 21
*YOU WANT A HIGH SCORE*
https://www.mdcalc.com/calc/3913/mascc-risk-index-febrile-neutropenia
Management of a patient presenting with acute MSSC?
1) Thorough history and examination (including neurological and PR exam) to
identify neurological deficits.
2) Referral for imaging: whole spine MRI scan is the gold standard for suspected
metastatic spinal cord compression.
3) If spinal cord compression is suspected - commence high dose
Dexamethasone 16 mg stat then 8 mg BD until imaging complete.
Follow local policy for urgent investigation and a protein pump inhibitor (e.g.
Omeprazole or Lansoprazole) if needed.
4) If pain is not controlled by step 2 of analgesics, we would escalate to step 3 (strong opioids + non opioids). This means commencing the patient on an opioid preparation (preferably on M/R (modified release) opiate, given he was taking step 2
analgesia) and stopping codeine PRN.
Consider co-prescription of a laxative and / or an antiemetic.
Additional Screen:
- FBC (rule out infection and neutropenia)
- U+E’s and LFT’s before opiate
- Bone Scan
- Myeloma Screen
(Discussion points: timescale for requesting urgent imaging, within a week vs within
24 hours - depending on clinical scenario i.e Bladder/Bowel dysfunction)
Remember
*Adhesional obstruction tends to be managed _____ (drip and suck) for a period of time (up to ____ hours).
*Obstruction **without ** previous surgery usually requires operative intervention.
A _____ study can be an aid to decision making after 48 hours of conservative management.
Contrast reaching the colon predicts resolution without surgery. The hypertonic contrast medium itself can be therapeutic.
Conservatively
72 hrs
gastrografin contrast
file:///Users/cianohalloran/Downloads/Emergency%20General%20Surgery%20%20Commissioning%20Guide.pdf
What are the diameters of bowel obstruction?
3-6-6-9 rule !
Investigations prior to surgery
Bloods:
- FBC/U+E’s/LFTs/Clotting or INR
- Group and Save / Crossmatch
- HbA1C
- ABG
Imaging:
- ECG
- ECHO
- Lung function tests (ex.spriometry etc)
MRSA screening
Investigations in Large Bowel Obstruction?
Initial Investigations
In a patient presenting with potential intestinal obstruction, peritonitis is a worrying sign and the consideration to transfer to theatre must be considered.
Some basic investigations that should be done include:
Bloods:
*FBC (Looking for leukocytosis or anaemia)
*U+Es (Organ dysfunction or signs of hypovolaemia)
*Lactate (An important examination to establish if there is bowel ischaemia or necrosis) It can be falsely low – the liver can break down lactate quickly so may not increase until late in the presentation
*Amylase (Always important in all cases of acute abdomen)
*Group and Save
* VBG (can be useful to evaluate for end-organ and for the immediate assessment of any metabolic derangement secondary to dehydration or excessive vomiting - metabolic acidosis)
Imaging:
*Abdominal and chest X-ray
*Assess in upright position to look for pneumoperitoneum
*Absence of air in the rectum can indicate complete obstruction
* Abdominal X ray – helps to establish diagnosis of large bowel obstruction
- CT Abdomen with contrast can be useful to establish cause (e.g. malignancy), as well as provide other useful information such as transition point and distinguishing between caecal and sigmoid volvulus.
Further Investigations once patients are stabilised - If no peritonitis is present and the patient is stable, the following investigations may further help:
- CT abdomen and pelvis with contrast: best diagnostic test
-Establishes underlying cause
-Establishes site of obstruction
-Establishes partial vs. complete obstruction - Small bowel contrast study using gastrograffin
- Can be used as a therapeutic measurement in partial SBO, as presence of contrast in rectum 24 hours after ingestion of substance establishes resolving partial SBO – hence reducing need for surgery
- MRI abdomen (No better than CT scan but can be useful in young patients to avoid doses of ionising radiation)
- US abdomen
Not as good as CT but can be used in children to avoid ionising radiation exposure - Diagnostic laparotomy/laparoscopy
Used to distinguish between partial and complete obstruction if no clear evidence on imaging
Clinical Presentation of bowel obstruction:
Small bowel obstruction most commonly presents with the following features:
- Abdominal pain with distension (Initially colicky pain that becomes continuous)
- Bloating and vomiting (often bilious)
- Failure to pass flatus or stool
- History of abdominal/gynaecological surgery or hernia
*Tympanic, high-pitched bowel sounds on examination
*Empty rectum on examination in complete bowel obstruction
*They may have a fever and can be significantly fluid-depleted. Peritonitis indicates severe bowel obstruction, with complications developing. This requires urgent surgical intervention.
Simple or partial SBO will generally continue to pass some flatus/stool with a mild temperature.
If untreated, SBO can lead to ischaemic or necrotic bowel as well as perforation.
