Clinical Reasoning - Collapse (Arrhythmia).pdf

7/29/2019 Clinical Reasoning - Collapse (Arrhythmia).pdf

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Year2OSCEPractice2011

Set1,ClinicalReasoningStation

CandidateInstructions

The patient in the next room is Sharon,who is 55yearsold. She has been brought in to the

EmergencyDepartmentbyambulanceaftershecollapsedattheStateofOrigin.Youhavebeen

giventhispatientsfullhistory.

Youhaveeight(8)minutestodiscusswiththeexaminerthreedifferentialdiagnoses-theseshould

bethemostlikelydiagnoses.

You should includeatleast two (2)positiveandtwo (2) negativefeaturesofthishistory,other

thanthoselistedabove,whichsupportorrefuteyourdiagnoses.

Youshouldexpecttheexaminertoaskquestionsaroundyourreasoning.

Tasks

Differentialdiagnoseswithreasoning8minutes


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HistoryofPresentingComplaint

Name-Sharon

Age-55

OccupationPart-timebankteller

Socialhistory-Livesinsinglelevelsuburbanhomewithhusbandand2daughters(17and22)

Drug/alcohol20packyearsmokinghistory.2-3unitsalcoholmostnights(rumandcoke).Nil

recreationaldrugs

Presentingcomplaint

SharonwasbroughtintotheEDbyambulancefollowingasuddencollapseattheStateofOrigin

gameatSuncorpStadium.

Sharonstatesthatshewasenjoyingthegamewithherhusbandandyoungestdaughterwhenshe

jumpedup fromherseattowatchDarrenLockyerscorea try.Shereportsfeeling thatherheart

was racing, feeling light-headed and seeing spots in front of her eyes briefly before losing

consciousness and collapsing onto the seats in front. Her husbandwitnessed the collapse and

reports2-3jerkingmovementsofSharonsleftlegimmediatelyafterhercollapse.Shereceived

minor lacerations to the forehead and a large ecchymosis across her abdomen, and was

embarrassed to discover that she had voided urine during her collapse. She regained

consciousnessafterapproximately30secondsandreportsfeelingwobblyforseveralminutes

afterwards, but denies any confusion. She did not notice any limb weakness or hemiparesis

following her collapse and denies any paraesthesia, visual disturbance or aphasia. Head and

abdominalCTonarrivaltotheEDhasclearedherofanyoccultinjury.

Sharonreportsonepastlossofconsciousness,whichoccurredfollowingaheadinjuryduringa

motorvehicleaccidentwhenshewas27yearsold.

Sharonusuallyworkspart-timeasabanktellerinBrisbaneCity,howeverhasbeenoffworkforthe

past3months following ananterior STEMI. She spent2weeksatRBWHunderthecareofthe

cardiologyteam,andhasbeenattendingcardiacrehabilitationtwiceweeklysinceherdischarge

10weeksago.

HerMIcameasquiteashocktoherdespiteherextensivesmokinghistory.Hercardiologisthas

advisedhertoloseweight,withthegoalofreducingherwaistcircumferencefrom110cmtoless

than80cm.ShehasbeenattemptingtodothisthroughtheSlimfastmilkshakediet.Hehasalso

counseledSharontoreduceheralcoholconsumption,howeversheadmitsthatshehasnotbeen

successfulindoingthisandattributesherdrinkingtofinancialstress.


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Sharonliveswithherhusbandof25years,Gavinandhertwodaughters.

GeneralHealth

Centrallyobese,leadsasedentarylifestyleandenjoysfrequenttreatfoods.Describeschroniclow

energyandlowexercisetolerance.

PastMedicalHistory:

CoronaryarterydiseasewithLADterritorySTEMI-Dx3monthsago

Hypertension-Dxonroutinemedicalexam45yo

Type2DM-Dxonroutinemedicalexam43yo

MVAwithsternal,Lfemoralandskullfracture-27yo

ClassicalMigraine-14yo-current

Meds

Enalapril10mgbd

Carvedilol25mgoncedaily

Clopidogrel75mgoncedaily

Atorvastatin40mgoncedaily

Metformin500mgbd

Sumatriptan50mgPRN

Allergies/ADRs

None

PastSurgicalHistory:

ORIFFemoralfracture-27yp

OB/GYN

G2,P2

2xvaginaldeliveries,nocomplications

LMP5yearsago


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Immunizations:

Uptodate

FamilyHistory:

Father(deceased85yo)-Type2Diabetes

Mother(deceased65yo)HTN,CAD,CVA,MI

Brother-MIage50

LifestyleSmokingAlcoholDietExercise

Smoker:20packyears

2-3unitsalcohol/day,noalcoholfreedays

Swimmingatcardiacrehabilitation2xperweekpast8weeks

Hobbieswatchingfootball

Pets none


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InstructionstoExaminers

The patient is Sharon a 55 year old woman, who is 3 months post anterior STEMI and has

collapsedsuddenlyattheStateofOrigin.Thecandidatehasbeengiventhispatientshistory.

Thecandidatehaseight(8)minutestodiscussthreedifferentialdiagnoses,includingpositiveand

negativefeaturesofthishistorywhichsupportorrefutetheirdiagnoses.

Conductofthisstation

Ensurethecandidateunderstandsthetaskthathe/shehastodo.

The candidate is expected to discuss 3 possible differential diagnoses citing at least two (2)positiveandtwo(2)negativepointsinthepatientshistory,otherthanthoselistedabove,that

supportorrefutetheirchoices.

Theyareexpectedtohaveabalancedreasoning,andhaveprioritisedthemostlikelydiagnoses.

Theyshouldbeabletojustifytheirreasoningwithquestions,ifrequired-theyareexpectingsome

questioningfromtheexaminers.

If the candidates appear tohave chosen anunlikelydiagnosis- please ask them to justify their

choice.

Promptingthecandidateforanotherdiagnosisispermittedtoallowthemopportunitytodiscussa

morelikelydiagnosis.

TASKS

Differentialdiagnoseswithreasoning8minutes


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DifferentialDiagnoses

1.Arrythmia(VentricularTachycardia,Heartblock)

Positive

RecentSTEMIFullthicknessinfarctLight-headednessandseeingspotssuggestcerebralischaemiaPalpitationsprecedingcollapseEmotionalexcitementatfootballgame(increaseSNStone)

Negative

RapidrecoveryHxheadinjuryHxmigraineSmokerSTEMI

2.Posturalhypotension/Syncope

Positive

Light-headednessandseeingspotssuggestcerebralischaemiaPalpitationsSuddenchangetouprightpositionBetablockerACEinhibitorType2Diabetes(autonomicneuropathy)Rapidrecovery

Negative

RecentMImeansarrhythmiaandTIA/CVAmustbeexcludedUrinaryincontinenceandjerkingmaysuggestseizure

3.EmbolicTIA

Positive

RecentMI-riskofAFandmuralthrombusType2DiabetesHTNFHxCVAObese


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Post-menopausalfemaleSmokerSedentaryHxmigrainewithaura

Negative

NofocalneurologicalsymptomsRapidrecovery(minutes)ClopidogreltherapyshouldreduceriskofthromboemboliceventsNosignsonheadCT(althoughthisshouldberepeated,signstaketimetoappear)

4.GeneralisedSeizure(TonicClonic/Atonic)

Positive

JerkingmovementsfollowingcollapseUrinaryincontinenceHxheadtraumawithskullfractureRecentemotionalstress

Negative

NoHxepilepsyorseizureNopost-ictalconfusionNotonguebiting

5.HypoglycaemicEpisode

Positive

Type2Diabetes IncreasedactivitylevelatfootballgameRecentreductionofdiet

Negative

MetforminunlikelytobeassociatedwithhypoglycaemiceventsNottakinginsulinorsulphonylureaType2DMlesslikelytohavehyposthanType1DMRecoveredwithoutglucoseadministration


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MARKING

Examinersareaskedtogradestudentsperformanceonascaleof0-4intheareasonthemark

sheetincapitals.Thestandardsforawardingthesegradesare;

0=Unequivocalfail: Student was unable to demonstrate history or examination skills

without significant prompting, OR displayed unethical or

unprofessionalbehaviour.

1=Marginalfail: Student lacked a comprehensive approach, and/or needed

considerablepromptingtocompletethetask.

2=Borderlinepass: Studentperformedasystematicexaminationorhistorybutdidnot

complete some components in a number of areasof the marking

guide.

3=Clearpass: Studenthadasystematicapproach,requiredlittleornoprompting,

was confident and completed most components of the marking

guide.

4=Highpass: Studenthadahigh levelofproficiency,wellabovewhatwouldbe

expectedofastudentinYear2.

Examinersarerequiredtomakeanoveralljudgementaboutthestudentsperformancein each

areaonthemarkingsheet.Thespecificitemslistedaretheretoremindexaminersaboutissues

whichmightbeconsidered. It isnot intended that these itemsshould rigidly translate into a

score.

Itwouldbehelpful,particularlywhenfeedbackisbeinggiventopoorlyperformingstudents,if

there is some notation in the comments column. Also examiners may find it helpful, when

consideringwhatgradetoaward,tohaveindicatedinthecommentscolumnwhenitemswere

omittedorwhenpromptingwasrequired.

GlobalScore.Thismarkdoesnotformpartofthestudentsoverallmark.Thescoreshouldreflect

thestudentsempathyandoverallperformance,andisfromtheexaminersperspectiveonly.


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PassMark=15/20 Pass/Fail(Circleasappropriate)

Comments(essentialifthecandidatehasfailedthestation)

GlobalImpression-fromexaminersonly-score0-4

Feature Comment Score(pleasecircle)

General

Organisedsummariesofdiagnoses

Appropriatediagnoseschosen

Prioritisesdiagnoses

Clearcommunicationforpresentation

0 1 2 3 4

DifferentialdiagnosisONE 0 1 2 3 4

Mostlikelyandreasonablediagnosis

Appropriatesupportivepoints

Appropriatenegativepoints

DifferentialdiagnosisTWO 0 1 2 3 4

Reasonablediagnosis



DifferentialdiagnosisTHREE 0 1 2 3 4

Reasonablediagnosis



AdequateReasoning 0 1 2 3 4

Balancedreasoning

Showsunderstandingofdiagnostic

signswithquestioning

Documents

Clinical Reasoning - Collapse (Arrhythmia).pdf