My stomach is swollen OSCE by Michael

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

Scenario:

A 62yo woman has presented with new onset of ascites. As part of her work up you have decided to do a diagnostic paracentesis.

Instructions for the candidate

You are to gain informed consent from the patient, and then perform a paracentesis. The results wil be immediately available for interpretation.

Domains being examined

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

For the actor

No contraindications

For the examiner

Provide the results after the procedure is done. You can ask for an interpretation of the results as the receiving medical specialist.

Results:
Clear yellow fluid
Albumin 25 g/L
Serum albumin 40 g/L
LDH 138 mmol/L

Domains Assessment Objectives

Medical Expertise
Knowledge of paracentesis and proficient procedural skill.
Interpretation of results.

Communication
Establish rapport. Clear communication of information for informed consent.

Other Assessment Notes

1. Consent
- indications: new onset ascites, SBP, relief of pressure symptoms
- contraindications: coagulopathy, bowel obstruction/dilation, pregnancy, vessels/cellulitis at procedure site
- complications: systemic (hyponatraemia, renal dysfunction, hepatic encephalopathy, haemodynamic compromise, significant bleeding, death) intraperitoneal (peritonitis, abdo wall abscess, perforation of vessels or viscera) and local (infection, persistent leak, abdo wall haematoma)
- volume to be drained
- post-procedural care

2. Procedure
- equipment, ensure patient voided, monitoring if large volume
- position, landmarks / ultrasound guidance
- aseptic technique and PPE
- Z-tract needle insertion
- Sample taken and tests ordered (cell count, albumin, culture, total protein, glucose, amylase, LDH)
- post procedural care

3. Results
- interpretation of SAAG (>11g/L = portal hypertension - cirrhosis, cardiac, portal vein thrombosis, liver mets)
- general interpretation
- LDH high >225 = exudate
- amylase = pancreatic
- cells - >250 WCC = SBP
- malignant cells


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