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Data interpretation for 3 rd year OSCE’s

Data interpretation for 3 rd year OSCE’s. By Roheel Sajid. OSCE Types. Pure data interpretation stations Data and explanation History/Exam + Data. Tips. Look around and check you have all the information Work through information systematically Make notes as you go along

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Data interpretation for 3 rd year OSCE’s

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  1. Data interpretation for 3rd year OSCE’s By RoheelSajid

  2. OSCE Types • Pure data interpretation stations • Data and explanation • History/Exam + Data

  3. Tips • Look around and check you have all the information • Work through information systematically • Make notes as you go along • Talk through your thoughts out loud if it helps

  4. Anaemia • Defined as a low level of haemoglobin. If someone has it, they are anaemic • 3 types depending on the Mean Cell Volume (MCV) • Microcytic - Small • Normocytic - normal • Macrocytic - large

  5. Causes of anaemia

  6. Common causes of anaemia Iron deficiency anaemia • low serum Fe, high serum TIBC, Low ferritin, low Transferrin saturation • Causes: Chronic blood loss (menorrhagia, GI ulcer + varices), Increased demand (pregnancy), Poor absorption (coeliac, gastrectomy), Poor intake • Rx: Treat cause, iron supplements B12 deficiency: • Stomach produces intrinsic factor, which binds to B12 and is absorbed in the terminal ileum • Causes: Pernicious anaemia, post-gastrectomy, terminal ileum disease • Rx: hydroxocobalamin (B12) injections 3-monthly

  7. Common causes of anaemia Anaemia of chronic disease • Causes: any chronic disease • Low serum Fe, low TIBC, ferritin normal • Treatment: treat cause, transfuse if Hb<70 Haemalytic anaemia • When red blood cells are destroyed, haemoglobin is degraded and bilirubin + LDH is liberated. • Haptoglobinsbind to haemoglobin and become saturated • Bone marrow tries making new red cells, reticulocytes are primitive red cells • So: Anaemia: elevated bilirubin, elevated LDH, low haptoglobin, elevated reticulocyte count • Causes: Inherited (Spherocytosis, Thalassaemia), Autoimmune (cold + warm)

  8. Polycythaemia • Increased Conc. of red blood cells • Can be true or apparent • Apparent due to reduction in plasma volume • True - increased in red cell mass - and can be caused by hypoxia or excess EPO • Ix: ABG, EPO, Ultrasound of abdomen

  9. White blood cells

  10. Platelets Thrombocytopenia • Causes: • Decreased production: bone marrow failure, aplastic anaemia, megaloblastic anaemia • Increased destruction: DIC, TTP, ITP, HUS Thrombocythaemia • Causes: • Primary: Essential thrombocythaemia, • Secondary: Bleeding, inflammaiton, infection

  11. Blood films Hypersegmented neutrophils - Megaloblastic anaemia Schistocytes - Microangioplastichaemolyticanaemia Target cells - Thalassaemia, liver  Tear-drop cells: Myelofibrosis

  12. Liver function test • Liver function may be classified into 3 types • Hepatitic (parenchymal) - incre. in ALT / AST • Cholestatic- incre. in ALP + GGT • Mixed • Bilirubin conjugated in liver • Cholestaticjaundice - conjugated bilirubin detected in urine

  13. Causes of HepatiticLFTs • Viral hepatitis • Autoimmune hepatitis • Drugs and toxins • Alcohol • Metabolic disorders • Fatty liver • Malignancy • Congestive cardiac failure

  14. Causes of CholestaticLFTs • Obstruction in bile duct lumen • Bile duct gall stones • Abnormal bile duct wall • Bile duct stricture • Cholangiocarinoma • External compression • Pancreatic carcinoma (painless jaundice) • Nodes at the porta hepatis • Ampullary carcinoma

  15. Common causes of jaundice • Pre-hepatic: Haemolysis • Hepatic • Gilbert’s syndrome • Hepatitis (which itself has any causes) • Cirrhosis • Drugs • Liver cancer • Post-hepatic • Gallstones • Pancreatic cancer • Cholangiocarcinoma • Bile duct stricture

  16. Urea and Electrolytes Acute Kidney Injury • Increase in creatinine more than 1.5 X baseline in last seven days • Or urine output < 0.5 ml/kg/hr for 6 hours • All patients need • Urine dipstick • Bloods: FBC, U&E, CRP, Ca2+, PO43-, PTH • VBG • Accurate fluid balance chart • Stop nephrotoxic drugs – DAMN Drugs • DAMN drugs • Diuretics • ACE- I/ARBs • Metformin • NSAIDs

  17. Pre-renal failure • Most common cause of AKI • Causes: Hypovolaemia, Sepsis, renovascular disease • Low BP, Incre. Urea, Incre. creatinine • Ix: Fluid volume assessment, renal artery doppler • Rx: IV fluid resuscitations

  18. Intrinsic failure • Causes: Acute tubular necrosis, acute interstitial nephritis, acute glomerulonephritis • Ix: • Urine dip (Blood + protein -> glomerulonephritis) • Urine protein-creatinine ratio (PCR) - proteinurea • Nephritic screen - ANA, ANCA, anti-GBM, Complement • Renal biopsy • Rx: Treat cause

  19. Post-renal failure • Causes: urinary tract obstruction (prostate, stones, stricture, tumour, blood clot) • Ix: Renal tract ultrasound, CT KUB • Rx: Relieve obstruction

  20. Chronic Kidney Disease • Presence of marker of kidney damage (proteinuria) or decreased eGFR for > 3 months • Common causes • Diabetes • Chronic hypertension • Chronic glomerulonephritis disease • Rx: • Treat cause • General: Fluid restrict, reduce protein intake, ACE-inhibitors • Dialysis: when GFR < 15

  21. Scenario 1 • A 4-year-old girl presents with lethargy, dyspnoea, bone pain, fever, and bruising. On examination she has hepatosplenomegaly. Chest x-ray shows a mediastinal mass and pleural effusion. BLOODS Hb: 90 (135-180) WCC: 2 (4-11) Platelets: 100 (150-400) Q)What is the most likely diagnosis? Q) How would you manage this patient?

  22. Answer Diagnosis: Acute Lymphoblastic leukaemia Management: • Ix • Peripheral blood smear - “immature” blasts • Bone marrow biopsy - >20% blasts • Refer to haematology /Speak to senior

  23. Acute Lymphoblastic leukaemia Rapid onset if myeloprofileration in a clonal line Characteristic Sx are related to pancytopenia • Anaemia: Fatigue, pallor, shortness of breathe • Throbocytopenia: Easy brusing, bleeding • Decreased WCC: Increased suspceptibility to infections

  24. Scenario 2 • A 35-year-old man with no past medical history presents to the emergency department after he noted cola-coloured urine. He denies pain or fever associated with the bleed, but has had a sore throat for the past 3 days, which is getting better. He has not had a similar episode previously. Examination reveals a non-blanching purpuric rash over both his legs. There are no other abnormalities. Urine dipstick: Protein ++ Blood + Urine dipstick: Protein ++ Blood ++ Q)What is the most likely diagnosis? Q) How would you manage this patient?

  25. Answer Diagnosis: Glomerulonephritis Management: • Bloods: FBC, U&E, LFT, CRP • Nephritic screen: ANA, ANCA, anti-GBM, Complement • Renal biopsy • Refer to nephrology /speak to senior

  26. Scenario 3 • A 67-year-old man presents feeling 'generally unwell' and complaining of pain in his back and legs. His wife also reports that he has been slightly confused for the past two weeks. Basic blood tests are ordered:. BLOODS Hb: 121 (135-180) WCC: 7.6 (4-11) Platelets: 390 (150-400) Na+: 143 (135-145) K+: 5.3 (3.0 - 5.0) Urea: 15.7 (2 - 7) Creatinine: 208 (55-120) Bilirubin: 17 (3-17) ALP 101 (30 - 100) ALT 44 (3- 40) GGT 67 (8-60) Albumin 31 (35 - 50) Calcium: 3.10 (2.1 - 2.6) Phosphate 0.79 (0.8 - 1.4) Q)What is the most likely diagnosis? Q) How would you manage this patient?

  27. Answer Diagnosis: Multiple myeloma Management: • Urinalysis • ESR • Skeletal survey • Bone marrow biopsy • Refer to oncology/ Haematology

  28. Multiple myeloma Clonal proliferation of plasma cells Mneumonia: CRAB • HyperCalcaemia • Renal failure • Anaemia • Bone pain Urinalysis: Bence-Jones protein ESR: Elevated Skeletal survey: Lytic bone lesions Serum protein electrophoresis: High M protein Bone marrow biopsy: > 10% Plasma cells

  29. ECG Basics • Calibration (25mm/sec and 10mm/mV) • Rate & Rhythm • Axis • P waves • PR interval • QRS • ST segment • T waves

  30. Atrial fibrillation abridged Rx • Rate control (if > 65 and IHD /No sx) • 1st line: Bisoprolol or Verapamil or Diltiazem • 2nd line: Digoxin or Amiodorone • Rhythm control (<65 y/o, CCF, 1st presentation) • 1st line: Flecainide (if no structural heart disease) • OR IV amiodorone (if structural heart disease) • Rate control is main therapy • Rhythm control if young, CCF, presenting for 1st time with lone AF • If HF/Unstable (shock)  - Synchronised DC cardioversion

  31. STEMI This ECG shows an STEMI Next steps • A to E approach • Referral for immediate PCI • Give analgesia, nitrates and antiplatelets • Immediate senior review

  32. Tension Pneumonthorax • Tension pneumothorax is treated with emergency needle decompression  • This is done in 2nd intercostal space, mid-clavicular line (same space as aspiration in pneumothroax)

  33. Chest X-ray basics • D - Details • R - RIPE (Rotation, Inspiration, Projection,Exposure) • A – Airway & mediastinum • B – Breathing & Bones • C – Circulation • D – Diaphragm • E – Extras (NG tubes etc.) • S – Soft tissue

  34. Pulmonary oedema • Chest x-ray: • Bat's wing appearance • Upper lobe diversion (increased blood flow to the superior parts of the lung) • Kerley B lines • Pleural effusion • Cardiomegaly may be seen if there is cardiogenic cause Management - Sit up + High flow Oxygen  - Venous vasodilator: Diamorphine 2.5 mg IV + Cyclizine 50 mg IV  (+anti-emetic) - Furosemide 80-250 mg IV  If no response - urgent haemodialysis or haemofiltration needed  Consider continuous PEEP  IV nitrates also have a role

  35. Fitting the pieces together • Pin down that top diagnosis • Ask yourself: • Is this patient acutely unwell • Do more investigations need to be done • What is the initial management • Who else needs to be involved?

  36. Thanks

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