OSCE 1- ECG
candidate instructions
A 28 year old patient presents to the emergency department with an episode of syncope. He has had previous episodes of syncope in the past. He now feels well and wishes to go home.
You are expected to:
DOMAINS being examined are:
You are expected to:
- Take a focussed history
- Diagnosing the ECG changes if any
- Giving a probable diagnosis and
- Proposing a management and investigation plan.
DOMAINS being examined are:
- Medical Expertise
- Communication
- Scholarship and Teaching
role player instructions
You are a 28 year old Male who presents with 2 episodes of “dropping” over the last week.
Today you were at the 24 hour gym in the late evening. You were on the treadmill when you suddenly started to feel dizzy and breathless. 30 seconds later you got palpitations for a few seconds then collapsed and fell off treadmill. You do not believe that you were out for long.
Had only been running a few minutes,
Full recovery, no injuries
No tongue biting/muscle soreness/incontinence/post ictal phase
Exactly the same thing happened at last week whilst resting at home following playing soccer – assumed it was due to dehydration so just ignored it – didn’t seek medical advice/no one was present
No infective sx/postural sx/chest pain/SOB
(Answer “no” to all other symptoms enquired about)
No recent travel
Today is the first time you have ever had an ECG
Never had nocturnal symptoms but has always slept alone
Normally fit and healthy
No medications, OTC drugs, recreational drugs
SH – computer programmer, single, drink alcohol 1x per week (4 units usually – you don’t have the enzymes to handle alcohol well!)
FH – Father had heart failure and his uncle dies at an young age.
Today you were at the 24 hour gym in the late evening. You were on the treadmill when you suddenly started to feel dizzy and breathless. 30 seconds later you got palpitations for a few seconds then collapsed and fell off treadmill. You do not believe that you were out for long.
Had only been running a few minutes,
Full recovery, no injuries
No tongue biting/muscle soreness/incontinence/post ictal phase
Exactly the same thing happened at last week whilst resting at home following playing soccer – assumed it was due to dehydration so just ignored it – didn’t seek medical advice/no one was present
No infective sx/postural sx/chest pain/SOB
(Answer “no” to all other symptoms enquired about)
No recent travel
Today is the first time you have ever had an ECG
Never had nocturnal symptoms but has always slept alone
Normally fit and healthy
No medications, OTC drugs, recreational drugs
SH – computer programmer, single, drink alcohol 1x per week (4 units usually – you don’t have the enzymes to handle alcohol well!)
FH – Father had heart failure and his uncle dies at an young age.
examiner instructions
OSCE 2- COMMUNICATION
CANDIDATES INSTRUCTIONS
You are a consultant working at your tertiary referral centre, it is 11 am on a Wednesday.
The patient, John, is a 40 year old man who is currently in an acute cubicle. He has presented with a sudden onset of severe headache that occurred 3 hours earlier.
He is not a headache sufferer and has never had a headache like this before.
A CT brain at approximately 4 hours is normal.
You registrar has mentioned the use of a lumbar puncture in patients however the patient does not wish to have a lumbar puncture and the registrar has asked if you would discuss the situation with the patient.
This OSCE will assess the following domains:
The patient, John, is a 40 year old man who is currently in an acute cubicle. He has presented with a sudden onset of severe headache that occurred 3 hours earlier.
He is not a headache sufferer and has never had a headache like this before.
A CT brain at approximately 4 hours is normal.
You registrar has mentioned the use of a lumbar puncture in patients however the patient does not wish to have a lumbar puncture and the registrar has asked if you would discuss the situation with the patient.
- Discuss the history and presentation
- Discuss the potential causes for the patient’s presentation
- Explain the use of the CT at less than 6 hours
- Explain other investigations that may be appropriate including LP and discuss with the patient the usefulness of this test.
This OSCE will assess the following domains:
- Medical Expertise
- Scholarship & Teaching
ROLE PLAYER INSTRUCTIONS
You are a 40 year old man who has had a sudden onset of severe headache some 4 hours ago. You were sitting having breakfast when you had asevere headache like someone hitting you on the back of the head with a shovel. You thought you were going to lose consciousness, but didn’t.
The headache is gone now and you feel well, although tired.
You are apprehensive about an LP and want to understand the consequesnces of the disease, the risks of a lumbar and other possible investigations.
You can prompt to other imaging ie., a MRI scan and try to understand other options.
You want to know what would happen if you didn’t have the LP
You want to know the risks of the LP and if it would rule the condition out.
You want to know how the LP is done
You want to understand other procedures that may be done instead of an LP.
The headache is gone now and you feel well, although tired.
You are apprehensive about an LP and want to understand the consequesnces of the disease, the risks of a lumbar and other possible investigations.
You can prompt to other imaging ie., a MRI scan and try to understand other options.
You want to know what would happen if you didn’t have the LP
You want to know the risks of the LP and if it would rule the condition out.
You want to know how the LP is done
You want to understand other procedures that may be done instead of an LP.
EXAMINER INSTRUCTIONS
OSCE 3- EQUIPMENT
CANDIDATES INSTRUCTIONS
You are working in a rural emergency department. The ambulance calls in a patient expect, who is a 62 yo male with the complaint of one episode of haematemesis. He is a known alcoholic, with known varices. They are driving in from the surrounding town and are expected in 45 minutes.
His vitals are BP 94/52, HR 104, Sats 98% on RA
Your hospital has no gastroenterology services. You do have a General Surgeon available, but he does not perform endoscopies.
You have enough time to explain to the registrar an approach to this patient.
You will be assessed on your explanation of your approach to this patient:
This OSCE will assess the DOMAINS OF:
His vitals are BP 94/52, HR 104, Sats 98% on RA
Your hospital has no gastroenterology services. You do have a General Surgeon available, but he does not perform endoscopies.
You have enough time to explain to the registrar an approach to this patient.
You will be assessed on your explanation of your approach to this patient:
- Stabilisation and resuscitation if needed.
- Pharmacological treatment
- Tamponade options
This OSCE will assess the DOMAINS OF:
- Medical Expertise
- Communication
ROLE PLAYER INSTRUCTION
You are a registrar working in this department. You are aware of the theory however have never treated an unstable haematemesis patient.
You want to find out about
Stabilise with Blood, may need clotting factors
Use of Octretide- may assist in haemostasis, better with endoscopy
If patient bleeding need to discuss the Sengstaken Blakemore tube
If mentioned produce tube from box and ask how it works.
If not mentioned by 5 minutes prompt with
”Isn’t there some kind of Minnesota tube we can insert?”
Need to describe the whole procedure.
You want to find out about
Stabilise with Blood, may need clotting factors
Use of Octretide- may assist in haemostasis, better with endoscopy
If patient bleeding need to discuss the Sengstaken Blakemore tube
If mentioned produce tube from box and ask how it works.
If not mentioned by 5 minutes prompt with
”Isn’t there some kind of Minnesota tube we can insert?”
Need to describe the whole procedure.
EXAMINER INSTRUCTION
OSCE 4-PROCEDURE
CANDIDATE INSTRUCTIONS
Doctor Jones is a PGY3 junior doctor who wishes to discuss a patient with you. The history is as follows:
You are at your tertiary referral centre, it is 11 am on a Wednesday.
The patient, John, is a 40 year old man who is currently in an acute cubicle. He has presented with a right sided knee effusion and very red and tender knee.
The patient is currently stable under the care of a senior registrar who has performed a knee joint aspiration prior to you arriving and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
This OSCE will assess the following domains:
You are at your tertiary referral centre, it is 11 am on a Wednesday.
The patient, John, is a 40 year old man who is currently in an acute cubicle. He has presented with a right sided knee effusion and very red and tender knee.
The patient is currently stable under the care of a senior registrar who has performed a knee joint aspiration prior to you arriving and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
- Discuss the history and presentation
- Discuss the potential causes for the patient’s presentation
- Explain what investigations would be required
- Outline the procedure of a knee joint aspiration
This OSCE will assess the following domains:
- Medical Expertise
- Scholarship & Teaching
ROLE PLAYER INSTRUCTION
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen John, a 40 year-old man who is currently in an acute cubicle. John has presented with a red, hot swollen right knee, with no history of trauma. There is excruciating pain on any movement of that knee joint.
You have been in the cubicle with the senior registrar. You have heard the history but were called away for teaching and returned just as the senior registrar had completed performing a tap of the joint. The patient is stable and in good hands with the senior registrar, who is waiting for results. You are seeking guidance about the procedure of knee joint aspiration in this setting. You are also wondering what could cause this, as well as how the knee aspirate will help..
As a junior doctor you recognise that this may be a septic arthritis, but have never performed an arthrocentesis procedure, nor are you aware how the cell count is interpreted.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down begin a discussion.
‘I’ve just seen John, a 40 year-old man who is currently in acute 5. He has come in following several hours of a swollen hot right knee, that is now causing severe pain if there is any movement of the joint. The only relevant past history is that he has a small cut on the right thigh, where it got caught against a nail in a fence 2 days ago. I have been in cubicle with Jack, the senior registrar. Jack is sorting it. He has already tapped the knee joint, however I was away at teaching whilst this occurred. The patient is stable and in good hands. I was wondering if you could help me by explaining the procedure and its interpretation and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
The candidate should explain the procedure to you.
The interpretation and teaching with the procedure should take around 4 minutes. Then the discussion needs to move to possible causes, investigations and acute management in case of deterioration, might be required.
‘What are we looking for in the knee aspirate?
The candidate must discuss
Septic arthritis
Gout and Pseudogout
You can prompt with “How do I differentiate between gout
And how to differentiate them. and pseudogout?”
The results return whilst you are there and you show them to the candidate.
KNEE ASPIRATE
Appearance: Yellow/Cloudy
WCC 62000/mcL
PMN% 66%
Crystals: Present, Birefringent
You have been in the cubicle with the senior registrar. You have heard the history but were called away for teaching and returned just as the senior registrar had completed performing a tap of the joint. The patient is stable and in good hands with the senior registrar, who is waiting for results. You are seeking guidance about the procedure of knee joint aspiration in this setting. You are also wondering what could cause this, as well as how the knee aspirate will help..
As a junior doctor you recognise that this may be a septic arthritis, but have never performed an arthrocentesis procedure, nor are you aware how the cell count is interpreted.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down begin a discussion.
‘I’ve just seen John, a 40 year-old man who is currently in acute 5. He has come in following several hours of a swollen hot right knee, that is now causing severe pain if there is any movement of the joint. The only relevant past history is that he has a small cut on the right thigh, where it got caught against a nail in a fence 2 days ago. I have been in cubicle with Jack, the senior registrar. Jack is sorting it. He has already tapped the knee joint, however I was away at teaching whilst this occurred. The patient is stable and in good hands. I was wondering if you could help me by explaining the procedure and its interpretation and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
The candidate should explain the procedure to you.
The interpretation and teaching with the procedure should take around 4 minutes. Then the discussion needs to move to possible causes, investigations and acute management in case of deterioration, might be required.
‘What are we looking for in the knee aspirate?
The candidate must discuss
Septic arthritis
Gout and Pseudogout
You can prompt with “How do I differentiate between gout
And how to differentiate them. and pseudogout?”
The results return whilst you are there and you show them to the candidate.
KNEE ASPIRATE
Appearance: Yellow/Cloudy
WCC 62000/mcL
PMN% 66%
Crystals: Present, Birefringent
EXAMINER INSTRUCTION
OSCE 5- PROCEDURE
CANDIDATE INSTRUCTIONS
You are the Consultant in charge, in a tertiary ED. Your registrar has reviewed a 4 year old boy with a 5cm laceration to his right upper arm after falling from play equipment. The X-ray is normal and the wound is clean and there are no other injuries.
The child is non-compliant with attempted nitrous administration. His mother is also very upset. You have made the decision to repair the wound under ketamine sedation and you area about to transfer the child and his mother to the resus bay. The child has EMLA on but no cannula.
The registrar has just completed an anaesthetic rotation and there will be an experienced emergency nurse available in the resus bay in about 10 minutes time. You would like the registrar to prepare for the procedure in the resus bay. There is also an SRMO allocated to resus who is seeing a cat 2 chest pain patient at this time, in the acute area.
Your task is to:
You will be assessed on the following domains:
The child is non-compliant with attempted nitrous administration. His mother is also very upset. You have made the decision to repair the wound under ketamine sedation and you area about to transfer the child and his mother to the resus bay. The child has EMLA on but no cannula.
The registrar has just completed an anaesthetic rotation and there will be an experienced emergency nurse available in the resus bay in about 10 minutes time. You would like the registrar to prepare for the procedure in the resus bay. There is also an SRMO allocated to resus who is seeing a cat 2 chest pain patient at this time, in the acute area.
Your task is to:
- Discuss with the mother and obtain informed consent for the procedure
- Formulate an approach to the procedure with the registrar.
- Explain the discharge plan to the mother
You will be assessed on the following domains:
- Medical Expertise
- Communication
- Leadership and management
- Teamwork and collaboration
ROLE PLAYER INSTRUCTIONS
You are upset as you child has been in ED for 3 hours and his wound is not yet closed. You want to know what is happening and how long it will take.
Prompts
During the consent process:
Are you giving a general anaesthetic?
What will happen to my child during the procedure?
What are the side effects? Are they common?
Are there any occasions when ketamine can’t be given?
Discharge planning:
Can’t I just let him sleep it off at home? His dad can help me carry him to the car.
When do the stitches need to come out?
Does he need antibiotics?
Won’t he be sore afterwards?
ROLE PLAYER REGISTRAR INSTRUCTIONS
ED Registrar (played by second examiner): You are an Advanced Trainee (PGY4) in emergency having just passed your primary exam. Your last rotation was anaesthetics, however you have never performed ketamine sedation on a child. You need some instructions to get set up for the procedure.
If asked, you have briefly reviewed the SRMOs chest pain patient, and they are pain free with a normal ECG.
Prompts
Pre-procedure:
How long should he be fasted for?
What dose should we start with? Shall we make some calculations?
Does he need a cannula?
Can we give it IM/IV? Does that change the dose? How would you like me to draw up the ketamine?
What monitoring would you like?
Do we need to get the airway trolley out? Do you want any other drugs available?
Who will give the drugs/do airway? What do you want me to do?
Prompts
During the consent process:
Are you giving a general anaesthetic?
What will happen to my child during the procedure?
What are the side effects? Are they common?
Are there any occasions when ketamine can’t be given?
Discharge planning:
Can’t I just let him sleep it off at home? His dad can help me carry him to the car.
When do the stitches need to come out?
Does he need antibiotics?
Won’t he be sore afterwards?
ROLE PLAYER REGISTRAR INSTRUCTIONS
ED Registrar (played by second examiner): You are an Advanced Trainee (PGY4) in emergency having just passed your primary exam. Your last rotation was anaesthetics, however you have never performed ketamine sedation on a child. You need some instructions to get set up for the procedure.
If asked, you have briefly reviewed the SRMOs chest pain patient, and they are pain free with a normal ECG.
Prompts
Pre-procedure:
How long should he be fasted for?
What dose should we start with? Shall we make some calculations?
Does he need a cannula?
Can we give it IM/IV? Does that change the dose? How would you like me to draw up the ketamine?
What monitoring would you like?
Do we need to get the airway trolley out? Do you want any other drugs available?
Who will give the drugs/do airway? What do you want me to do?
EXAMINER INSTRUCTION
Appropriate introduction
Shows empathy to distressed mother and is reassuring
Confirms fasting status
Explains:
Interaction with registrar:
Confirms level of training
Delegates roles
Procedure preparation checklist (evidence of a structured approach)
Post procedural discussion with mother:
Safety for discharge: Child needs to stay until they are awake/can walk unaided/not vomiting
This can be up to 2 hours
Warn that they might be a bit confused/clumsy post procedure and the need to be watchful caring for them over next 24 hr
Wound care/suture advice, including watching for signs of infection
No antibiotics indicated currently
Analgesia
Tetanus if unvaccinated
Situational awareness:
Candidate must show awareness of the SRMO’s chest pain patient and ensure attention by alternative doctor of appropriate seniority.
Appropriate introduction
Shows empathy to distressed mother and is reassuring
Confirms fasting status
Explains:
- Indications for ketamine in this case
- Possible side effects of ketamine, including dissociative state
- Explores contraindications of ketamine
- The procedure of wound management whilst under sedation
- Signature for consent form requested
Interaction with registrar:
Confirms level of training
Delegates roles
Procedure preparation checklist (evidence of a structured approach)
- Consent (done)
- Personnel – role delegation: airway doctor, procedure doctor, drug administration (this could also be the nurse), documentation.
- Medications – ketamine doses IV 1-1.5mg/kg given slowly (0.5mg/kg doses as repeats), IM 4mg/kg (2-4mg/kg repeat dose if needed after 10 mins). Consider onset of sedation.
- Monitoring – minimum BP/HR/RR/O2 sats
- End points – level of sedation
- Positioning
- Procedure – asepsis/PPE/procedure trolley preparation
- Preoxygenation
- Prepares for unexpected airway issue: paed airway trolley requested (SOAP-ME – Suction, Oxygen, Adjuncts, re-Positioning/additional Pharmaceuticals, considers additional Monitoring and ETCo2)
Post procedural discussion with mother:
Safety for discharge: Child needs to stay until they are awake/can walk unaided/not vomiting
This can be up to 2 hours
Warn that they might be a bit confused/clumsy post procedure and the need to be watchful caring for them over next 24 hr
Wound care/suture advice, including watching for signs of infection
No antibiotics indicated currently
Analgesia
Tetanus if unvaccinated
Situational awareness:
Candidate must show awareness of the SRMO’s chest pain patient and ensure attention by alternative doctor of appropriate seniority.
OSCE 6- TOXINOLOGY (from other sources)
CANDIDATES INSTRUCTIONS
You are the consultant in charge of a regional ED. A 28 year old male has presented to the ED after a possible snake bite. He has just informed the nursing staff that he is keen to self-discharge from the ED as he feels fine.
The patient is still wearing a compression bandage to his affected limb.
The candidate is expected to:
Your tasks are to:
The patient is still wearing a compression bandage to his affected limb.
The candidate is expected to:
- take a relevant history from the patient regarding his possible snake bite
- advise the patient on his ongoing management, including initial bloods, removal of bandage, stay in hospital for up to 12 hours for subsequent bloods.
- Risks of snake bite should also be discussed including delayed neurotoxicity, myopathy and coagulopathy.
Your tasks are to:
- Take a history from the patient with respect to the possible snake bite.
- Advise the patient on the best course of management.
role player instructions
You are a 28 year old builder, with no past medical history, no regular medications and no known allergies.
You were working on a house that backs onto bush land. You felt something bite your leg above the ankle and saw a brown-coloured snake through the long grass.
If asked, you saw a wound on your leg that looks like puncture marks.
This occurred 1 hour ago.
You immediately drove yourself to hospital where the triage nurse applied a bandage to your lower leg.
You feel fine and now wish to go home as there is no one at home to feed your 3 dogs.
If asked, you have no abdominal pain, nausea, headache, weakness or blurred vision or any symptoms at all.
You live alone with your 3 dogs. You have no family close by as they live in the country.
You will be very keen to go home. You are reassured by the fact that this happened an hour ago and you still feel well. You don’t understand why you can’t just go home as it doesn’t seem very serious. Noone has explained to you the process for managing snake bite. The triage nurse applied the bandage & put you in a chair and you haven’t seen anyone since. You are not angry, just bored and keen to go home. You will be quite dismissive of the doctors concerns and will not agree to stay no matter what the doctor says. You should continue to state “but I’d still like to go home now.”
You were working on a house that backs onto bush land. You felt something bite your leg above the ankle and saw a brown-coloured snake through the long grass.
If asked, you saw a wound on your leg that looks like puncture marks.
This occurred 1 hour ago.
You immediately drove yourself to hospital where the triage nurse applied a bandage to your lower leg.
You feel fine and now wish to go home as there is no one at home to feed your 3 dogs.
If asked, you have no abdominal pain, nausea, headache, weakness or blurred vision or any symptoms at all.
You live alone with your 3 dogs. You have no family close by as they live in the country.
You will be very keen to go home. You are reassured by the fact that this happened an hour ago and you still feel well. You don’t understand why you can’t just go home as it doesn’t seem very serious. Noone has explained to you the process for managing snake bite. The triage nurse applied the bandage & put you in a chair and you haven’t seen anyone since. You are not angry, just bored and keen to go home. You will be quite dismissive of the doctors concerns and will not agree to stay no matter what the doctor says. You should continue to state “but I’d still like to go home now.”
examiner instructions
Observe the interaction between the doctor and patient.
Medical Expertise
Knowledge of the management of suspected snake bite, including investigations required, symptoms to watch for and timing of this.
Must mention: Coagulopathy, Myopathy and Delayed Neurotoxicity as potential complications.
May mention: Renal failure, death, local complications at bite site.
Minimum 12 hours of observation & serial blood tests.
Blood tests required: Coags (INR, aPTT, D-dimer), FBC, CK, U&E
Prioritisation and Decision Making
Takes a focussed and relevant history from the patient with suspected snake bite.
Makes a sensible risk assessment for possible snake bite in this patient.
Good candidates will recognise that this is a likely snake bite with no signs of envenomation at time of review. Patient should be encouraged to stay for observation and serial investigations as per the local snake bite protocol for up to 12 hours after the bite.
Communication
Takes a focussed and relevant history from the patient with suspected snake bite.
Explains clearly the ongoing management required.
Explores patient’s reasons for wanting to self-discharge, ensures understanding of risks and tries to address any concerns of patient regarding ongoing treatment.
Communicates in a professional and respectful manner to the patient wanting to self-discharge.
Health Advocacy
Accepts the patient’s decision not to stay for further observation after a thorough discussion of the risks. Negotiates with the patient a safe alternate plan, including but not limited to: staying with a friend/relative, provide discharge advice regarding concerning symptoms and when to return to hospital, follow up with GP tomorrow for review +/- bloods.
Medical Expertise
Knowledge of the management of suspected snake bite, including investigations required, symptoms to watch for and timing of this.
Must mention: Coagulopathy, Myopathy and Delayed Neurotoxicity as potential complications.
May mention: Renal failure, death, local complications at bite site.
Minimum 12 hours of observation & serial blood tests.
Blood tests required: Coags (INR, aPTT, D-dimer), FBC, CK, U&E
Prioritisation and Decision Making
Takes a focussed and relevant history from the patient with suspected snake bite.
Makes a sensible risk assessment for possible snake bite in this patient.
Good candidates will recognise that this is a likely snake bite with no signs of envenomation at time of review. Patient should be encouraged to stay for observation and serial investigations as per the local snake bite protocol for up to 12 hours after the bite.
Communication
Takes a focussed and relevant history from the patient with suspected snake bite.
Explains clearly the ongoing management required.
Explores patient’s reasons for wanting to self-discharge, ensures understanding of risks and tries to address any concerns of patient regarding ongoing treatment.
Communicates in a professional and respectful manner to the patient wanting to self-discharge.
Health Advocacy
Accepts the patient’s decision not to stay for further observation after a thorough discussion of the risks. Negotiates with the patient a safe alternate plan, including but not limited to: staying with a friend/relative, provide discharge advice regarding concerning symptoms and when to return to hospital, follow up with GP tomorrow for review +/- bloods.
OSCE 7- MEDICAL(other source)
CANDIDATE INSTRUCTION
You are the consultant in a tertiary centre. Your junior registrar has just seen an 80 year old lady who has presented with confusion and reduced level of consciousness (GCS 13). Other vital signs are normal.
The lab has just called notifying him that her sodium level is 114 mmol/L. Your registrar would like to know:
(a) How to differentiate the different causes of hyponatraemia and
(b) The indication of hypertonic saline and how to administer it
You may use pen & paper to better explain to your registrar if you wish.
Domains assessed:
Medical Expertise
Scholarship and teaching
Communication
The lab has just called notifying him that her sodium level is 114 mmol/L. Your registrar would like to know:
(a) How to differentiate the different causes of hyponatraemia and
(b) The indication of hypertonic saline and how to administer it
You may use pen & paper to better explain to your registrar if you wish.
Domains assessed:
Medical Expertise
Scholarship and teaching
Communication
ROLE PLAYER INSTRUCTION
You have just seen an 80 year old lady from a Nursing Home who presented with acute confusion and reduced level of consciousness (GCS 13). Other vital signs are normal.
The lab has just called notifying you that her sodium level is 114 mmol/L.
Hyponatraemia has always confused you, and you are after a simple and structured approach to apply on your patient to determine the cause of hyponatraemia.
You are also unsure about the indication of hypertonic saline and how much to give as you have heard about the serious side effect of such treatment.
You may require to provide the following prompts:
The lab has just called notifying you that her sodium level is 114 mmol/L.
Hyponatraemia has always confused you, and you are after a simple and structured approach to apply on your patient to determine the cause of hyponatraemia.
You are also unsure about the indication of hypertonic saline and how much to give as you have heard about the serious side effect of such treatment.
You may require to provide the following prompts:
- The patient is stable and being monitored in the acute treatment area
- What specific examination findings should I be looking for?
- What specific tests would be useful?
- When should I use hypertonic saline? How much to give? What is the end point?
- What are the potential complications in using hypertonic saline? How can these be avoided?
EXAMINER INSTRUCTION
Medical Expertise
Recognised severe hyponatremia (Na <120mmol/L)
Exclude factitious causes:
Assess by volume:
Extrarenal losses (urine Na< 20mmol/L): V &D; blood loss; third space loss
Drugs/malignancy/Post op; Hypothyroid
Hepatic Failure (urine Na< 20 mmol/L)
Renal Failure (urine Na> 20 mmol/L)
Laboratory tests:
Repeat a further 1.5mLs/kg (100mLs) if symptoms persist and check Na
100mls HS will give approximately 2mmol/L elevation of serum Na
Serum Na should not rise by > 10-12 mmol/L over 24hrs to avoid Central Pontine Demyelinolysis. For a 24 hour period, this will equate to an infusion of 0.5ml/kg/hr of 3% HS
Scholarship and teaching
Communication
Recognised severe hyponatremia (Na <120mmol/L)
Exclude factitious causes:
- Hyperlipidaemia/hyperproteinaemia-(Normotonic)
- Hyperglycaemia (Hypertonic)
Assess by volume:
- Hypovolaemic: sodium loss exceeds free water loss
Extrarenal losses (urine Na< 20mmol/L): V &D; blood loss; third space loss
- Euvolaemic: free water gain, minimal sodium loss
Drugs/malignancy/Post op; Hypothyroid
- Hyervolaemic: free water gain exceeds sodium gain
Hepatic Failure (urine Na< 20 mmol/L)
Renal Failure (urine Na> 20 mmol/L)
Laboratory tests:
- Serum urine and urine osmolarity
- Urinary sodium level.
- Seizures/ Coma / altered mental status/ focal neurological deficit
Repeat a further 1.5mLs/kg (100mLs) if symptoms persist and check Na
100mls HS will give approximately 2mmol/L elevation of serum Na
Serum Na should not rise by > 10-12 mmol/L over 24hrs to avoid Central Pontine Demyelinolysis. For a 24 hour period, this will equate to an infusion of 0.5ml/kg/hr of 3% HS
Scholarship and teaching
- Structured approach in discussing volume status and investigation
- Interacts with the registrar in positive manner
- Clearly articulates information to the registrar and checks understanding
Communication
- Appropriate level of language for professional interaction