Showing posts with label stations. Show all posts
Showing posts with label stations. Show all posts

Tuesday, August 11, 2020

ATLS overview (OSCE)

Definition: 

  1. ATLS : life threatening with pulse
  2. 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)
  1. Danger
    • access the situation, ensure you are safe first
  2. 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... 
  1. Alert
  2. Verbal
  3. Pain
  4. 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 
                  

 (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!   
      • Trauma - Trauma Assessment - Glasgow Coma 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)

other links:

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!

 

Wednesday, May 13, 2020

CTG report basics

Cardiotopography (CTG) reporting - basics


CTG: to record fetal heart rate during contractions
When reviewing the CTG trace, assess and document contractions and all 4 features of fetal heart rate: baseline rate; baseline variability; presence or absence of decelerations (and concerning characteristics of variable decelerations* if present); presence of accelerations.

1. check baseline rate

  • normal rate: 110bpm to 160bpm
    • continue usual care as the risk of fetal acidosis is low

2. Baseline Variability

  • normal: 5bpm - 10bpm
  • increased: >25bpm

3. Acceleration

  • to be cautious and take necessary actions when
    • >15bpm
    • >15s
  • The presence of fetal heart rate accelerations (if it is constant with contraction and within range), even with reduced baseline variability, is generally a sign that the baby is healthy.

4. Deceleration

  • to be cautious and take actions when 
    • >15bpm
    • >15s-40s
    • uniform and repetitive
  • If it occurs with contraction < 20s, it is called early deceleration
    • need constant monitor and stand by for Mx

5. To monitor frequency of contraction

  • is it present or absent?

Notes:

1. If CTG is normal, can reexamine again in 7 days time. it varies and depends on situation 
2. If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician



Tips:


1. Document the condition of the woman and unborn baby (including cardiotocography [CTG] findings)systematically every hour, or more frequently if needed. 

2. CTG findings alone could not determine what is the next action that is needed for the mother.

3. Take into account the mother's condition, any antenatal and intrapartum risk factors, the current wellbeing of her and unborn baby and the progress of labour. 

4. Ensure that the focus of care remains on the woman rather than the CTG trace.

5. Remain with the woman in order to continue providing one-to-one support.

6. Talk to the woman and her birth companion(s) about what is happening and take her preferences into account.

More explanation on the different types of situation click here.

References:
1. https://www.nice.org.uk/guidance/cg190/resources/interpretation-of-cardiotocograph-traces-pdf-248732173
2. Video: https://www.youtube.com/watch?v=N9hNCjaL_dE 

Wednesday, May 6, 2020

EPR OSCE sample - I


In this post I would like to share some examples of how the OSCE will be asked during Examination for Provisional Registration (EPR) part II.
Start practicing with your friends and think how will you manage your time to answer the question within 10 minutes.




Station 1


Station 2




Station 3

Answers to S2 & S3

Station 4


Answers-S4


Their respective answer can be found after you finish reading the questions.

It can be quite difficult to try practicing this by yourself as you have no real patient, so it would be good if you can find friends who could play the role as the patient and the examiner.

This is for your reference only, to help you get prepared for the exam. 

References: IMU OSCE 2008 





Saturday, March 28, 2020

USM OSCE - EPR 2019 Dec

Past Year Topics for USM OSCE - 2019 - Part I

Hi all, in this post I am going to share the topics they have on year 2019 for Examination for Provisional Registration-/EPR. (the year I took my exams😁Thank God I passed)

** EPR is a special exam where International Medical Graduates must take to get full licence to work in Malaysia. 

So I will provide more details on how the questions were asked and what I experienced specifically for the USM December 2019 session. However I won't be able to recall the questions fully word by word, but will try my best to explain what was being asked.
The other session for 2019 are USM-Feb  and IMU-July will be posted in another post.

Reminder:

You have 1 minute to read the questions outside the room and once the bell rang, you have 9 minutes to finish the station. the second bell will ring, and you will have to move to the next station quickly to read the next question.

USM (December 2019)

Emergency medicine
1. Patient involve in motor vehicle accident, access the patient and do immediate management
   - Emergency management of Pneumothorax
   - Name all the equipment needed in ED (we have to name the equipments shown on the table)
   - explain the safe triangle position in detail
   - perform the procedure from the safe triangle


Orthopedics
2. Patient involve in motor vehicle accident and have problem walking, you are require to do a lower limb PE
  -  identify short limb gait (at least that is what I think it is) ** real patient walking
  - so I proceed with full lower limb physical examination and LLD(Limb Length Discrepancy) diagnosis
  - Physical examination necessary to identify LLD

3. Hip X-ray with a problem, patient short history provided
   -  Describe the X-ray, give a diagnosis and explain your further management
   - identify all structures shown in the picture and explain their functions.

P/S: remember to check patient name and date


Internal medicine
4. Patient with chest pain and SOB, take the history and explain further management if needed
  - history taking and I suspect its AMI

5. Interpret chest X-ray and give diagnosis with treatment + physical examination of the chest
   - Tips: there is a mass in the chest x-ray

P/S: treatment plan must be specific***


Surgery
6. Patient present with mass at inguinal area, diagnose and focus physical examination
  - Inguinal Hernia - after history taking, ask for permission to do examination
  - physical examination is done on the manikin. (you can refer to this to understand the scoring)

** The examiner asked the differences of direct and indirect hernia physical examinations and their respective treatments.

7. Pneumoperitoneum - X- ray interpretation and management plan
  - management is specific

Tips: if you plan to have iv fluid, what do you want to do? (is it fluid bolus? how much you want to give? how long you plan to administer the fluid? etc.)


Pediatrics

8. Growth Chart interpretation
  - scenario given was about short stature. (explain the cause, QOL, management)

 Tips: calm the child down first so they can cooperate

9. Lumbar Puncture Consent from Parents
  - get the consent is the aim. make sure you explain all about lumbar puncture from the cause to the treatment values.
   - reassure the patient


OBGYN

10. Bimanual Examination
   - there is a huge mass in the manikin.
   - explain your examination specifically on inspection and palpation,
  - the examiner will ask for your diagnosis and your management plan for the patient

11. Patient complain is stomach pain and discomfort (a little aggitated)
  - After history taking, i suspect its a Placenta Abruption case.
  - the examiner asked for our diagnosis
  - present your case from history taking
remember to include: Gestational age calculation, GPO - all OBGYn necessary history
  - treatment plan

*P/S: I finish this station when the bell rang for us to leave the room. We only have 9 minutes to do all the above, make sure you manage your time well. 


Anesthesiology

12. Patient need to prep for surgery, as a junior doctor apply adequate oxygenation before anesthesiologist arrive.

  - full airway assessment and use the Bag valve mask (if  you observe well, you will see it lying on the table beside the manikin) -explain the indication and possible complications.

*P/S:   - the procedure was easy as i did a lot during my internship in china (finish smoothly in a few minutes), but the examiner asked a lot of questions and fully utilized the 9 minutes. Be ready to answer a lot of questions and make sure you know what and why you do what you have done.


Psychiatry

13. The patient is very sad and depressed. If you have good observation, you will see a plaster on her wrist.

 - The patient has history of suicide, so after accessing the patient and confirm it is related to suicide, I used the suicide risk assessment to confirm the diagnosis.
 - the examiner will ask how you come out with your diagnosis, luckily i still remember the specific components for the assessment. (the examiner asked how I get the score)


ENT

14. ASOM
 - acute suppurative otitis media

* I am very thankful to be able to work as a clinic assistant for an ENT doctor for almost a year. 
Really grateful I know how to use the equipment, give diagnosis, explain the cause, complication and management to the patient very quickly and specifically. I spend a lot of time sitting outside the station to wait for the next bell to ring.😄Thank you Doctor Koay! 


Radiology

15. Two CT was showed
 - I suspect it's a CT with Epidural hematoma and subdural hematoma
 - we are require to explain the CT in detail to support our diagnosis

 *P/S: this is the only station I don't know if what i did is right or wrong. because he is not satisfied with the answer i gave, and when I asked the other students, they say the same thing.. 
 Until now I still don't know what the doctor showed us, because I forgot how the CT looks like... (sad)


Community Medicine

16. Consultation on family planning
 -  asking for pregnancy advice and how to have a healthy

*P/S: the patient has diabetes after minutes of asking... So I have to quickly brief her the pros and cons on the complication of pregnancy while having an uncontrolled diabetes situation. 


If you have more questions can leave a comment below, I will try to reply as soon as possible.
Good luck!



2018 OSCE Past Year for EPR

Past year OSCE 2018

This is the past year topics asked in USM 2018 and specifically for those who took the examination for provisional registration. I didnt have the past years from those who took the exam in IMU, so if there is anyone who took the exam that year and would like to share, you are welcome to share it in the comments.^^



If you are interested in what they asked in 2017, refer to the previous post.


USM EPR OSCE questions 2018

Gynecology
1. COCP
2. Speculum Examination and high vaginal swab

Pediatrics
3. ORS usage advice for children
4. G6PD counseling

Orthopedics
5. neurovascular examination (lower limbs)
6. Elbow Joint Dislocation (interpret the X-ray)

Psychiatry
7. PTSD

Emergency Medicine
8. CPR
9. Mallampati classification + Airway assessment

Internal Medicine
10. Hypertension
11. GI perforation
12. Pneumoperitonium

Opthamology
13. Visual Acuity Test (patient with hypertension and diabeter)

Surgery
14. DRE
15. Colonoscopy consent

Others
16. ABG interpretation and Heart attack evaluation

Sunday, January 12, 2020

OSCE stations explained!

To read this post you have probably passed your first step of EPR!

Congratulations!

So what should you do next?

Usually you will get a letter, telling you passed the exam "lulus" in a certificate.
Keep the certificate as it will be needed later on when you are applying for Houseman.


After you pass, you can start studying for your 2nd step of EPR, which is the clinical part.
Time is really precious! Its advisable to start studying right away after you know the results but if you want to take a break, go ahead! Make sure you have at least 2 months to study for the OSCE.

When will you get your results?

You will know your result roughly about a month after the exam, if you did not receive any news, EMAIL them ASAP!!! Your results are probably out but you are not being notified by the authorities.

Results collection

You will receive an email to take the results from MMC.

If you could not collect by yourself, you may ask other to collect on behalf for you. 
But, your on behalf MUST submit an Original Authorization letter (prepared and sign by you) while collect the result.
If you fail to follow the guidelines. Your result will not be given.

Application




The application for step 2 is different compare to step 1.

They will give you a call when the venue is decided, usually 3 to 8 weeks before the exam.

I wrote about the schedule for the EPR exam in this post.



  • IMU (Usually on July)

IMU provided 1 week course before the exam,
Cost: RM 900

Advantage:
1. If you stay in KL, distance to travel is less.
2. 1 week course to actually make you prepare your materials
3. To know all friends (to be colleagues) to study together!
4. A lot of food around the area

Disadvantages:
1. I heard there are less friendly? But I did not take the exam there, so it is very hard for me to judge.

  • USM (Around Dec-Jan)

USM provides 2 days course before exam,
Cost: free of charge

Advantage:
1. the professors are very friendly, they try to answer all question that you have (even the ridiculous and stupid questions..>;<)
2. far from home, no distractions
3. There are guest house in USM university, there are a few places you can choose to stay, the price range from RM 80 - 200 (depends on what kind of facility you want)


Disadvantage:
1.  The location : it is in KUBANG KERIAN, KELANTAN! You will need to take a flight there which probably cost you about RM300 (two ways from subang airport, cheaper if you use KLIA air asia)
2. Food choice are limited, more to malay style. There are a few nice looking shop around but why eat those when we should try the authentic local food?
3. The 3 days course cant prepare you to pass if you didnt study by yourself !!! It is a revision session only to help us recall important key points, and to understand how the exam is conducted.
SO do not depend on the preparatory course they provided.

I will focus on explaining how USM application works in the upcoming post since I took the exam there.


EXAM Format

1. 16 OSCE stations

    Each OSCE station will be about 10 minutes, you have 1-2 minutes to read the question outside your station and later enter into the exam room after you hear the bell. The timer starts once the bell stop. So it is very important that you plan your time properly when you are reading the question. You can start planning what you are going to do once you step into the room.

 *OSCE : Objective Structured Clinical Examination


2. Short or long questions

Short and Long Questions are a must for the local students, therefore they will have a lot of sample questions. If you do have friends in local university, do not hesitate to ask those questions from them. It is useful to help improve the knowledge you need for osce.
DO take note that there are no short or long questions for the practical exam in EPR.  
However I am not sure if they will change the format or not, please ask the person in charge before you take the exam.

3. Skills tested


4. Compulsory Subjects 


No.
SUBJECTs
Stations
1
Surgery
2
2
Medicine
2
3
Orthopedics
2
4
Obstetrics and Gynecology
2
5
Pediatrics
2
6
Emergency Medicine
1
6a
Anesthesiology
1
7
Psychiatry
1
8
Radiology
1
9
Ophthalmology or
1

Otorhinolaryngology (ENT)

10
Preventive Medicine / Family Medicine
1

Total
16




All stations have the same weight that contributes to your final pass. So make sure you are able to score as much as possible in each station. This really helps boost your final score and help with the stations that you did not do so well.

I will update more on what materials to study soon in the next post!