Putting the PE in pregnancy OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You are in a tertiary hospital ED. Your patient is 37 yo woman who is 18 weeks pregnant who presents with pleuritic chest pain. She has no history of malignancy or previous Thromboembolism (TE). She is G2P1. There is no family history of TE. There is no history of recent immobilisation or leg swelling. The RMO who assessed the patient is concerned that she has a pulmonary embolus and requests that you review the patient. There is no evidence of respiratory distress or tachycardia and the examination findings are unremarkable. No other cause for her symptoms has been identified.

Instructions for the candidate

Please discuss your strategy for further investigation of possible pulmonary embolus with the patient, in particular the pros/cons of each component.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Given that you are a lay person it is reasonable to expect clear but simple explanation from the candidate. They should not make assumptions about your understanding.

For the examiner

No prompts are given.

Domains Assessment Objectives

Medical Expertise
Investigation of Pulmonary Embolus

Prioritisation And Decision Making
Ability to discuss risk/benefits with patients

Communication
Ability to effectively and respectfully communicate complex information to patients

Other Assessment Notes

Candidates must recognise the issues surrounding the investigation for PE, particularly in the pregnant patient
Probability of having PE increased by pregnancy
Recognise that this patient is has no risk factors other than pregnancy for PE
Hence pre-test probability is relatively low
Discuss the use of Clinical decision tools such as Wells/Geneva and PERC as they apply to this patient
Discuss the utility of D Dimer in pregnant patients
May discuss the utility of leg USS
Better candidates will give detail regarding the utility in second trimester patients with no clinical evidence of DVT
Recognise the risks to foetus from radiation exposure from CTPA and VQ
Better candidates will be able to give more detailed discussion of the various modalities in terms of radiation exposure
Discuss risks of Imaging modalities to the patient
CTPA: risk of contrast (anaphylaxis and renal)
Increased radiation to breast tissue resulting in increased lifetime risk of malignancy (particularly so during pregnancy/lactation)
VQ: small risk of indeterminate result, less risk of malignancy, often not readily available
Discuss the option not to investigate further, determined my patients wishes/informed consent/degree of personal ‘risk tolerance’


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Comments:

CTPA causes 10 times higher radiation to breast as compared to VQ If in doubt and clinically high risk=CTPA

krunal at 15:20 27 Apr 2018