Hand Washing OSCE

This could be presented in the MCEM OSCE as a station asking you to teach a medical student proper handrub/handwashing technique.

Diabetic Ketoacidosis (DKA)

Precipitants

Infections (Recent URTI, Gastroenteritis, UTI)
Noncompliance with Insulin Regime

(Download Link: DKA Download Here )

DIC (Disseminated Intravascular Coagulopathy)

Causes: 

Gram Negative Sepsis (E. Coli and Neisseria)
Rocky Mountain Spotted Fever
Malaria
AML
Pancreatic Ca
Crush Injuries
Rattlesnake Bite
Amniotic Fluid Embolism
Abrutio Placenta

Pathology

Activation of coagulation cascade by Tissue Thromboplastin: Consumption of Clotting Factors
Platelet clot formation: Reduced Platelets
Microclots in circulation: Fibrinogen
Hemolysis of RBCs: Anemia
Clot lysis: FDPs and D Dimer

Petechiae and bruises
Bleeding from all orifices

Laboratory:

Increased PT and APTT (Consumtion of Coagulants)
Reduced RBC and Platelets counts
Schistocytes
Increased FDPs and D Dimer
Reduced Fibrinogen

Treatment:

Treat the Cause
Transfuse FFP, Platelets, RBCs, Cryo

Succinyl Choline (Suxamethonium)

A great drug of choice for paralysis in RSI, but carries it's own list of side-effects and C/I.

Dose: 1.5 mg/kg IV

Side Efects (BAHAMAS)

Bronchospasm
Anaphylaxis
Hyperkalemia
Arrythmias (Brady and Tachy)
Malignant Hyperthermia
Apnea (especially in inadequate pseudo-cholinesterase)
Secretions (Salivation)

Contraindications (CNBC Eye)

Crush Injuries
Neurological: Spinal Cord Injury, Myotonic dystrophy
Burns
Chronic Renal Failure
Eye (Penetrating injury of the eye)

(To know more about Anesthesiology Visit www.gasexchange.com)

Sickle Cell Anemia Case OSCE

The Case Mostly will involve history taking and may ask about further management plans for a Sickle Cell patient.

Sickle Cell Anemia is an autosomal recessive disorder due to missense mutation at the 6th position of beta globin chain where Glutamate replaces valine (MCEM Part A).

Remember these patients will present in the ED with varied complaints like chest pain, bone pain, seizures, septicemia, etctetra. Hence, it becomes essential for us to know what are these emergencies possible in these patients, so that we could target our history to look for clues.

Vaso-occlusive crisis:
Brain: Seizure, Stroke (Children), Bleeds in adults, Coma
Bone: Pains in humerus, tibia, femur (Avascular Necrosis), Vertebra
Acute Chest syndrome +/- fever,
Pain abdomen: Splenic Sequestration
Priapism
Skin Ulcers

Hemotological crisis:
Especially recent viral infection (Parvovirus B19)

Infectious Crisis: Capsulated organisms like Streptococci, meningococci, Hemophilus, Klebsiella, and Salmonella Typhi murium (MCEM Part A)

(Before we move ahead, I wanted to give some pearls not directly related to this topic, but, just for our learning.

1. Stroke in Kids, think of sickle cell
2. Stroke in Young female, think of SLE Lupus anticoagulant.
3. Parvovirus B19: Remember Slapped Cheek appearance in pediatrics with erythema infectiosum
4. Osteomyelitis in Sickle Cell patients, provide cover for Salmonella)

The precipitating factors for any of the above are:
Stress: Emotional, Physical.... So think of infections, trauma, dehydration, hypoxia
Alcohol

So a Standard approach would be,

Introduction
Asking for pain and offering analgesia outright
Asking Vitals and correcting them if inappropriate (May need IV hydration)

Asking history of presenting complaints

SOCRATES Associated Symptoms
Similar event in past, and what they did (most patients will tell you what works best for them)
Histroy of Precipitant: Dehydration, infection, alcohol
Complications: Crisis
Family history
Past medical and surgical history
VACCINATIONS against Influenza and Pneumonia
Medications

When asked about management:
Investigations should include FBC, Reticulocyte Count (increased upto 12 - 15%), CXR, Septic Screen
Treatment:
IV Analgesia
IV Hydration
Hemotologist review
Admit

When do we do Blood transfusion: If Hb Less than 8, or the symptoms do not subside in spite of adequate analgesia and hydration. May consider autotransfusion)

Lower Back Pain

A frequently tested topic in the OSCE part of the MCEM Examinations

History taking
Examination

Remember if the station involves history, go about in these steps:

Hi, My name is Dr.                                , one of the emergency department registrars. May I know your name please? How old are you? And What do you do for your living?

I understand that you have back pain.... I would like to give you some medications for your pain. Well,... I have been asked to take a history about your pain, Is that Okay with you?

Ask SOCRATES of pain, Past similar complaints, Allergies, Past Medical & Surgical History, Medications, Urinary and GI habits, Social history.

Remember to look for REDFLAGS: TUNA FISH

T     Trauma, Tuberculosis
U     Unexplained loss of weight, Night sweats
N     Neurological Deficits, Bowel & Bladder incontinence
A     <20 and="">55
F     Fever
I      IVDU
S     Steroid use or immunosuppressed
H    History of Cancer, early morning stiffness

Ask for Physical examination to be performed, and certain tests like FBC, U & E, CRP, X ray and/or MRI

Thank the patient and Examiner

1. For OSCEs asking for physical examination, remember the following things:

Hi, My name is Dr.                                , one of the emergency department registrars. I understand that you have back pain.... I would like to give you some medications for your pain. Also, I would like to do a physical examination on you. Is that Okay with you?

Before I begin, I would like to know/obtain the vital signs of my patient.

The examination of spine consists of:

1. Range of movements of spine
2. Neurological examination of the lower limb
3. Nerve Stretch tests: SLR, Femoral Stretch tests
4. Gait

Read the question carefully, as they may just ask you to perform specific components. Look for the following videos for further idea about the examination.

(Video Credits: Dr Claire B. & Dr Simon C.)