A Flash in the Pan? OSCE by Laura Joyce

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

Scenario:

You are the consultant in change of the fast track area in your Emergency Department. Your Junior Registrar was reviewing the blood result of Mrs Hope who was sent by her GP to ED for an urgent review.
Mrs Hope is a 46 year old woman who has 3 days history of fever up to 38.5 and coryzal symptoms. On arrival in ED she looks unwell, is pale with non-blanching skin rash.
Your registrar has just received her blood results:

Hb 82 (125-145)
RCC 2.3 10*12/L (4.5-5.9)
MCV 98 FL (80-97)
MCH 28.2 pg (26-34)
MCHC 34.2 g/dl (32-36)
Plat 28 10*9/L (150-400)
WCC 1.6 10*9/L (4.0-11.0)
Neut 0.3 10*9/L (2.0-8.0)
Lymph 1.6 10*9/L (1.2-4.0)
Eosinop 0.0 10*9/L (0.0-0.5)


After you enter the room, you have 7 minutes to address these tasks:
- Analyse and interpret the above blood results including differential diagnosis
- Gather further information from the registrar regarding this patients history and examination findings and answer his questions
- Formulate a management plan including any further investigations required

Instructions for the candidate

After you enter the room, you have 7 minutes to address these tasks:
- Analyse and interpret the above blood results including Ddx
- Gather further information from the registrar regarding this patients history and examination findings and answer his questions
- Formulate a management plan including any further investigations required

Domains being examined

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

For the actor

Mrs Hope is usually fit and well. Has been unwell for 3 days with fever and coryzal symptoms.
Takes no medications, has not allergies.
Drinks alcohol occasionally, non-smoker.
No recent travel or infectious contacts.
Mother had IHD in 70s, no other family history of note.
Temp 38.5, BP 90/50, HR 130, RR 20, 95% RA, GCS 15

For the examiner

Domains Assessment Objectives

Medical Expertise
- blood result analysis: pancytopenia/marrow failure with all cell lines involved:
Ddx: Marrow failure (aplastic anaemia, viral illness, toxins/drugs)
Marrow infiltration (leukaemia, lymphoma, myelofibrosis)
- management plan:
Recognise possible neutropenia sepsis/unwell patient
Transfer patient to acute area, full monitoring, protective isolation
Fluid challenge
+ dose/end points eg 1000ml 0.9% saline iv, aim HR<100, MAP>65)
Appropriate broad spectrum Abx cover
eg as per hospital neutropenic sepsis pathway – tazocin 4.5g iv + gentamicin 5mg/kg iv +/- vancomycin if risk MRSA
(meropenem 1g if pen allergic)

Further investigations:
Blood film ?blast cells
Blood cultures x2
CXR ?malignancy
USS/CT abdo ?malignancy/hepatosplenomegaly
Coags – coagulopathy/DIC
Viral serology – EBV, CMV, HIV
LFTs - ?liver disease ?mets

Prioritisation And Decision Making
- recognise patient potentially very unwell with risk rapid deterioration

Communication
- clear and specific instructions

Teamwork and Collaboration
- offer to go and review patient with registrar

Scholarship and Teaching
- find out what registrar already knows
- give opportunity to ask questions
- explain methodological way of interpreting results

Other Assessment Notes

One way to do it: Introduce self Summarise stem/find out what registrar knows “I understand you were seeing Mrs Hope, and I was hoping we could discuss her case” Summarise blood results: “I am very concerned about these results. They show a pancytopenia. This is shown by a moderate anaemia, severe thrombocytopenia and a severe neutropenia.” Causes of pancytopenia: “There are two main causes of pancytopenia. These are marrow failure – such as caused by viruses, toxins or drugs; and marrow infiltration – usually by haematological malignancies such as lymphoma, leukaemia, myeloma. Is there anything in the patient’s history that would suggest one of these causes? Has she had any history of exposure to any particularly viruses, toxins or drugs such as chemotherapy agents? Does she have any symptoms on history, or exam findings to suggest malignancy, such as night sweats, weight loss, lymphadenopathy or organomegaly? Relate to stem (BIG BOXES, consultant-level summary of problems): “In the setting of a patient with fever these results are very worrying, and we should treat this patient as having neutropenic sepsis. We also need to investigate why she has a pancytopenia, and she will definitely need to be admitted to hospital”. Discuss management: “Our priorities in a patient with neutropenic sepsis are: - move to acute area with full non-invasive monitoring - protective isolation - resuscitation with 1000ml iv saline initially, aiming for HR <100 and MAP >65 - appropriate broad spectrum antibiotics o our hospital neutropenic sepsis guidelines suggests 4.5g iv tazocin + 5mg/kg iv gentamicin o if this patient is at risk of MRSA, such as previous hospitalisation, consider vancomycin - we also need to perform some further investigations including: o Blood film ?blast cells o Blood cultures o CXR ?malignancy/source of sepsis o MSU ?source of sepsis o USS/CT abdo ?malignancy/hepatosplenomegaly o U+Es ?renal impairment ?hypercalcaemia associated with malignancy o Coags – coagulopathy o Viral serology – EBV, CMV, HIV o LFTs - ?liver disease ?mets - disposition will be admission under either haematology or oncology, possibly to HDU for close observation as she has the potential for rapid deterioration Discuss with registrar: Do you have any questions about that plan? Shall I come and review the patient with you?


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