Showing posts with label osce. Show all posts

Sunday, January 7, 2024

EM Medications

Heparin

1ampule: 25,000 unit

Preparation: 45ml NS +25000 (5ml) heparin

Rate of infusion: Desired dose x Quantity / Drug concentration

Example:(100units x50)/25,000 units = 0.2ml/hr

- an anticoagulant(blood thinner) that prevents the formation of blood clots

- used to treat and prevent blood clots in the veins, arteries or lung, reduce risk of blood clot in surgery

- check the body weight before injection

Dopamine

1ampule : 200mg/5ml

amount of drug needed per 50ml ifusion solution:

amount of drug to dilute = body weight x3

Example: 70kg x3= 210mg

amount of drug = (210x5ml)/200mg =5.25ml

Preparation: 44.75ml NS +5.25ml drug = 50ml

1ml= (210mgx1000)/50ml = 4200mcg

Rate of INFUSION: (mcg x body weight x 60min) / drug concentration

Example : (5mcg x 70 x 60)/4200mcg = 5ml/hr

Midazolam

preparations ready in vial, so can infuse without dilute

1ml = 1mg available (5ml vial)

Lasix

Direct IV, no dilution

1 ampule = 20mg(2ml)

Rate of infusion: Desired dose x Quantity / Drug concentration

Adrenaline

- to reverse severe low blood pressure, wheezing, severe skin itching, hives and severe allergic reaction (anaphylaxis).

Vasopressin

- 1ampule - 20units/1ml

usual dose: 0.01 to 0.03 unites/minute

preparation: 20 unites in 50 ml NS

Drug concentration: 20 units/50ml = 0.4 units/ml

- raise B/P by constricting the blood vessels

- to treat diabetes insipidus

Phenytoin

- 1 ampule: 250mg/5ml

loading dose: 15mg.kg at a rate not greater than 50mg/min for 20-30 minutes

maintanence dose: followed by 100mg every 6-8 hours

Prophylaxis: 200-600mg/day PO IV

Antiarrythmic : 10mg IV every 15 minutes until arrythmia stops

- antiepileptic drug / anticonvulsant

- does not treat all kinds of seizures

Insulin

- 40units=1ml

preparation: 40 units(1ml) + 39ml NS = 40ml

40ml needs 40unit of insulin. if 4units/hr means 4ml/hr

Dobutamine

Fentanyl

-treat ongoing chronic pain, sedation

Amiodarone

Sandostatin(octreotide)

- reduce flushing episode and watery diarrhea caused by tumors

Nitroglycerine

- prevent angina with CAD.

used when heart doesnt get enough blood

Propofol

- general anesthesia for surgery

Labetalol

- treat high b/p

- beta blocker

Wednesday, October 21, 2020

Clinical Skills for Respiratory system

HI everyone!

This is a page where I accumulate all the study resources in one place especially for respiratory system, enjoy!

It includes:

Respiratory clinical skills checklist
Things to master for respiratory OSCE
Sample OSCE demonstration
Chest X-ray Quizzes
Sample Cases for practice
Peak flow meter and Inhaler techniques
Common used Malay terms for doctors in Malaysia
Further readings on management for common Respiratory diseases

Clinical skills checklist

Things to master for OSCE EXAM

Communication Skills

1. Elicit a comprehensive occupational and social history from a patient.

2. Elicit a comprehensive past medical history from a patient.

3. Give simple instructions to a patient.

Clinical examination skills

1. Carry out a fluent and structured examination of the respiratory system in a simulated patient.

2. Recognise normal breath sounds, wheeze and crepitations using the stethoscope

3. Recognise abnormal findings on percussion and auscultation and explain the pathological processes that would produce these.

4. “Putting All Together” to reinforce clinical reasoning and introduction to early differential diagnosis.

Practical skills

1. Accurately perform a peak flow measurement.

2. Demonstrate the correct use of an inhaler (with and without a spacer/aero chamber) to a patient.

3. Identify the key features of a plain chest radiograph and recognise common respiratory abnormalities.

Sample OSCE for respiratory

Chest X-RAY study resources

Sample cases for practice:

1. Mr. Y, is an 88-year-old gentleman who complains of progressive worsening of breathlessness since 2 weeks ago. He also complains of a pain at the right side of his chest. He used to work at the docks in the UK in his teens.

a) Does the patient require urgent intervention?

b) Is the shortness of breath acute or chronic?

c) What additional questions would you ask to learn more about his shortness of breath?

d) What is the organ system involved in the patient's shortness of breath (cardiac, pulmonary, hematologic, or psychiatric)?

2. A 55-year-old man presented with the history of cough for 4 weeks comes to the GP clinic and is very concerned after having 2 episodes of prolonged coughing that produced blood-streaked sputum. He also complaints of fever for 7 days and cough productive of yellow sputum. This is the first time he has experienced this symptom.

a) What additional questions would you ask to learn more about his hemoptysis?

b) How would you classify his hemoptysis in terms of quantity?

c) Can you make a definite diagnosis through an open-ended history followed by focused questions?

d) What are the alarm features when evaluating a patient with hemoptysis?

ENT OSCE sample

STATION 6

This patient has a 6-month history of ear discharge.

INSTRUCTIONS TO CANDIDATE:

A. Take a focused history.

B. Examine the ear and present your findings as you proceed.

C. The examiner will then ask you some questions.

Sample Marking Scheme

Readings:

Chronic suppurative otitis media (CSOM) is one of the most common childhood infectious diseases worldwide and is a common cause of hearing impairment in resource-limited settings. It is characterised by chronic drainage from the middle ear associated with tympanic membrane(TM) perforation and usually preceded from an acute otitis media (AOM.)

Clinical Presentation:

1. Ear discharge - chronic purulent middle ear discharge (typically >6 weeks)

2. Hearing loss - due to TM perforation

3. Cholesteatoma

4. Physical Examination:

- reveals TM perforation and purulent middle ear drainage, typically minimal to no edema of the external auditory canal.

- otoscope

Treatment:

1. Aural toilet along with and ototopical fluoroquinolone for initial therapy (eg, ciprofloxacin, ofloxacin).

- The goal is to eradicate the infection by making sure the ear is dry hence preventing complications. The best goal would be to have the TM heal and improve their hearing.

2. Advise strict water precautions (no swimming, prevent water to get into the ear) for prevention and management of recurrent disease

3. Tympanoplasty for patients without cholesteatoma who have recurrent disease despite water precautions, or a persistent tympanic membrane perforation for more than 6 to 12 months after resolution of CSOM.

Reference:

1. https://pubmed.ncbi.nlm.nih.gov/16198004/

2. https://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-treatment-complications-and-prevention?search=csom&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1#H9146042

Monday, September 14, 2020

OSCE sample 5

STATION 5

Madam ZZ is a 30 year old G4P3 lady at 38 weeks of gestation. She has one previous Caesarean Section delivery for cord prolapse. Otherwise her current antenatal care has been uneventful.

INSTRUCTIONS TO CANDIDATE:

A. Examine her abdomen.

B. Present your findings.

C. The patient is anxious about vaginal birth.

Address her concerns.

Marking scheme:

Tuesday, August 11, 2020

ATLS overview (OSCE)

Definition:

ATLS : life threatening with pulse
ACLS(cardiac): life threatening, no pulse

Common emergency cases: (ATOMTC)

Airway obstruction

Tension pneumothorax - silent chest, trachea deviated

Open wound

Massive hemothorax

Tracheobronchio dissociation/ fistula

empysema
crepitus, poor air entry
corrective surgery
do X-ray - is it hyperventilated?

Cardiac tamponade - JVP, increase HR, muffled heart sound

Pericardial effusion?

OSCE ATLS steps:

1. What to do when the patient came in with emergency? (DR. AVPU)

Danger

access the situation, ensure you are safe first

Response & role

check for patient response and
ask someone around you(assistants)to help

prepare airway apparatus +cervical support
chest tube, needle tube, SP02
IV line - for fluid & BT & crossmatch

Check their response to...

Alert
Verbal
Pain
Unconscious

2. If all above indicates emergency case signs proceed with ABCDE

Airway - jaw thrust - open the mouth and inspect for foreign substances (yonker suction could help

removing them) - check for gag reflex -

- cervical support - can be confirmed by using the NEXUS criteria

https://www.grepmed.com/images/3860/management-clearance-algorithm-cervical-canadian-mnemonic-imaging

(cervical spine evaluation in trauma)

Breathing - ventilation,

inspection: check for ATOMTC (common emergency cases, in first paragraph)
palpation: trachea location, rib intact? fracture?
percussion: hyper-resonance? dull?
auscultation: Air entry? Heart rhythm, HR?

- check Respiratory rate

- intubate if needed

Circulation - bleeding

IV 2 large bonula
IL warm NS
BT urgent panel
inspect head to toe for bleeding

EENT, abdomen (peritonitis), pelvis(spring fracture), genitalia (hematoma, scrotum, perianal bleeding, urethral)
peripheral bleeding (fracture)

Disability - pupil

GCS scale!

Exposure - environmental - do they need a blanket? (hypothermia?)

log roll for back examination (examine the spine - stepping sign)/ rectoperitoneal bleeding / prostate high riding / pelvic injury / abdominal injury / thoracolumbar injury
DRE? anal tone lac?

Simple Management mnemonic:

2(CBD, NG tube)

2(X-ray : chest and pelvic)

2(drugs and analgesia IPTT)

2 investigation(ECG, FAST u/s)

Friday, August 7, 2020

Breaking bad news: Down syndrome

How to explain to the parents about Down Syndrome?

First, you will need to know what is the problem and understand before explaining to them.

The parents will be worried, anxious and some might even cry upon receiving the news. Be ready to comfort them and help them through this journey of hardship but understanding their children together.

As a doctor, you are to tell them the truth and at the same time, comfort and reassurance.

Resources are from: https://canadiem.org/breaking-bad-news/

So.. how should you start your conversation?

1: Express your concern

- Greet the parents, introduce who you are and why are you here.

Setting

- Before telling them about their child's condition,

ask if they need someone to accompany them or if their family member is here (if they are alone).

Example: Before we go ahead, can I just ask, would you like to be with someone now?

Perception

- Ask what they realise that is abnormal about their child.

- This helps us to understand how much they know about the situation, so we know where to start.

Invitation

Tell them about the news:

Example: Unfortunately, I do not have good news, I am sorry to tell you that... ...

*wait for them to react before you continue your explanation*

👇

2. Explain and educate

Knowledge

- Explain the nature of down syndrome. definition, symptoms and signs

- Genetic Issue

- Intellectual Aspect

- Health Aspect

- To tell them their child would probably need a lot of follow up on potential health issues

- TO explain the prognosis is poor

- average lifespan is around 50-60years old,

-possible health issues of the heart, gastrointestinal, eyes and bones,

👇

3. Advice the parents

- Their character and behaviour infront of the child

- try to be encouraging to the child

- be patient and kind

-To discover the child's talent

- the child might not do well in studying but might excel in cooking, music or sports

- Diet

- to ensure good nutrition provided and not neglect the child

- they need the same/ more attention compare to normal children of the same age.

- Advice to look for special care school

- there are special school's which teaches kids who have the same problem

- opportunity to know other parents who face the same issue and share experiences

👇

4. Future follow up

- to come regularly for normal vaccination

- to check calcium development regularly

- ensure proper growth and reach their age milestone

- Series of check up for their child in the future : Eye checkup, bone density, X-ray, echocardiogram, etc.

👇

5. Encourage the parents to join a parents group

Summary

- we can give them leaflets (if available) to understand down's syndrome better

- provide reliable sources (websites) so they can read to help with the understanding

- encourage them to not give up and keep persevering till the end. the child is a gift from god, and we are to take care of them with love and care.

Example: Don't blame yourself. There is nothing that could have been done to stop this from happening. What you need to do now is to... ...

👇

-Reassurance

Example:

- I understand you are worried but...

- Do you need some time to rest?

- We will keep an eye on your child for his (results), so we can provide the treatment earlier.

- The doctor/professor who is in charge of your child is an expert on this syndrome and would try

his/her best to help your child.

- I will give you a follow up date with us in the clinic, will you be available on the ... ...?

👇

6. Empathy (throughout the whole session)

** Always ask if they understand what you are trying to say before going to the next point.

**ask if they have questions to ask you concerning their child and their worries.

Example: Do you understand what I am trying to explain?

Do you have any questions?

- Look them in the eye while you are talking and show that you care about them.

- If there is a break down (crying), pause the conversation and try to offer tissue or suggest them to come at a later date with their family/support.

- Have empathy and to try answer their questions at the same time.

Saturday, June 6, 2020

Consent for Bone Marrow Aspiration - Peds

Pediatrics Consultation Session

1: Ask for a chaperone

2: Talk to the parents/ guardian who bring the children

- Ask if they know about bone marrow aspiration

- what are their concern

- will they need another person to sit in and listen

3. Describe reasons for having a bone marrow aspiration

- to confirm diagnosis

- to check iff there are any blast cell

- after retrieving the samples, it will be sent for culture, biochemical test... ...

4. The way procedure was done

- Sedation for kids?

- local anesthesia?

- are parents allowed to be in the room

- any media distraction for the child while procedure is ongoing

5. Time and Cost

- how long is the procedure

- the cost, and ask if parents are able to pay for the procedure

- recovery time after procedure

6. Any complication?

- possibilities of infection if not deal with care

- child need to be put in a position that can be uncomfortable.

- try to reassure the mother/father about the success rate of bone marrow aspiration

- that it is safe

- eg. cases like this are common

7. Ask if they have any questions

- be patient and confident in what you say (make sure it is right)

- try to comfort the parents

- no big medical term.

- always ask if they understand what you say

8. Ask for consent and permission

- Do you agree?......

This template can be useful for lumbar puncture for children after a few minor changes.

TQ and good luck!

Thursday, May 21, 2020

OSCE VIDEO 1 (epr malaysia)

This is a sample video which can be helpful for you to imagine how it is like during the exam.

Just for your reference,

and

credits to the students, doctors and the volunteer from IMU.

Thank you for making this video.

Question in the video

**P/s: this is exactly what happens to my OSCE exam when I took EPR OSCE on 2019. Although the venue is different (in USM), the way they conduct the exam is the same.

There will always be a doctor in each room to evaluate your performance and ask you questions after you finish the task.

Make sure you organise your time well. For sample questions you can refer to my other posts here.

Good luck!

Wednesday, May 13, 2020

Depression and suicide risk

This post mainly focus on how medical students should do when they are asking for the patient's history, especially those suspected with depression.

It is important to know if the depression that they are facing will lead to serious issues like harming themselves.

In normal hospital setting, you can see that it is quite often that physicians tie this two together, so we can access their situation in one session.

Try not to ask their history multiple times as it could affect the way they answer the question.

History taking always starts with

Remember to always be caring and a helpful listener.

1. Introduction

Name, age, occupation, marital status

2. Ask for chief complain.

complain + duration
Depression duration: >2 weeks >1 symptoms

3. Present History

ask symptoms that could help you differentiate depression from other diagnosis

they are helpful to differentiate the other diseases related.

you can refer to the notes in this link

4. How to diagnose depression?

Remember : SIG CAPES
If they have >1 symptoms
Check if they have

Sadness
Insomnia
Guilty feeling

Observe

Concentration
Agitation
Psycho-motor system
Energy
Suicidal idea

Check if there are any manic involve. it is important to use it to differentiate between bipolar or depression

Depression :

no manic
not under medication or drug usage (cannabis)

5. Check for their suicidal risk

Any signs of them trying to harm themselves? if yes check the below

Suicide assessment (5 points)

	Details	For example:
Ideation	Idea of trying to harm themselves	e.g. to jump off the plane, etc.
Plan	Any realistic plan to harm themselves?	Booked a flight ticket
Means	Do you have the materials?	Already have a knife at home.
Intent	Do you intent to, when?	By next month
History	Past history	Prior suicide attempts, abort attempts, self-harm

SAD PERSONS scale is needed to further evaluate their risk.
Then you should check with the SAD PERSONS scale to figure out their score if they need further treatment or not.

score >7 :

Admit them immediately and get consent from them or their family members
Bio-psycho social therapy : relaxation technique, CBT, systemic desensitizing, BZD, SSRI,
Family support