OSCE revision - the recognition and management of an unwell patient using the A-E approach

Welcome fellow medics!

I hope we are all well and revision is going to plan..

Here I have put a summary together of the basic approach to an “unwell patient” which will be a station in the OSCE exam/clinical skills exam.

KEY POINTS:

This station is to check you can RECOGNISE AN UNWELL PATIENT and also MANAGE AN UNWELL patient

The approach used is the “A-E” approach- which stands for Airway, Breathing, Circulation, Disability and Exposure.

This is a quick guide- for more in depth info please refer to: https://www.resus.org.uk/resuscitation-guidelines/abcde-approach/ (which is amazing trustworthy information).

This is in no shape or form comprehensive. It is a quick summary to get you thinking.

The process is simple but can catch candidates out due to a few simple errors, which can be amended by:

1) if something is wrong in the “A-airway: - you fix it and THEN move on to “B-breathing” etc. A-E is in order of saving the patients life. DO NOT move on until you have fixed the section.

2) Vocalise what you are looking for, ask for the answer “I would like the blood oxygen levels” and then place the sats probe on the mannikin.

3) USE THE EQUIPMENT! If you want a blood pressure, pick up the BP machine, if the examiner is not looking to mark this, they will give you the answer, STOP and MOVE on.

4) Although you feel you have to be quick on this station because it is an “emergency” the best candidates are those who are calm, relaxed and clear. So ironically, slow down!

5) Vocalise what is on your mind. The examiner cannot and will not read your mind. Aim your discussion at the examiner. Speak to the mannikin, make it real and natural.

You will be given an information card ie “you are a FY1 and have been asked by the nurse to come see Mr Smith, whom they are worried about”

AIRWAY

The one and simple question to check airway - talk to the patient. literally.

“Hello Mr Smith, how are you feeling?”

This can then go a few ways:

He responds - AIRWAY PATENT MOVE ON…(most likely as this is checking your A-E approach)

He is gargling- you need to sort the airway - ie suction

He IS NOT RESPONDING - that is another station..this will then become BLS/CPR etc

BREATHING

So Mr Smith is chatting to you, so you can now move onto his breathing. This is everything to do with the lungs essentially.

You want the following information : LOOK LISTEN FEEL

• SAY you are checking the colour of the patient

• CHECK blood saturations - find that probe

• CHECK (auscultate) lungs - physically examine the patient/mannakin. The examiner will stop you to give findings

• ASK for respiratory rate

React to what is being said to you - listen to the examiner (some examples)

• Blood saturations low- place oxygen mask on mannikin

• Chest findings ie “crackles on left side” ACKNOWLEDGE + INTERPRET “I am considering this may be a chest infection”. Now you might think, why would i say it now…well you might forget/run out of time at the end, so say it when you realise it.

• Raised respiratory rate - may indicate infection, etc. Again ACKNOWLEDGE.

• He looks blue around the lips, well hopefully some O2 will help him out.

CIRCULATION

So you have sorted out his breathing, you have put some oxygen on him, he is looking OK, he is talking to you, and his colour has improved. Now you want to check his circulation, this being the next important factor.

• LOOK/FEEL fingers - are they warm and well perfused? good.

• CHECK CAPILLARY REFILL

• CHECK blood pressure - LOOK for BP cuff

• CHECK pulse

• CHECK JVP - for cardiac failure

• CHECK for bleeding

• LISTEN to heart sounds

• GET IV ACCESS- whilst there - take full set of bloods

• GET an ECG/attach patient to a cardiac monitor (remember you are vocalising all of this)

React to what is being said to you:

• Low BP - GIVE fluids- ie a fluid bolus of 500ml

• Cap refill time increased - again this may indicate low BP due to ? sepsis. ACKNOWLEDGE and vocalise and react with ie fluids.

• Raised pulse - ? septic, infection.

• Has chest pain/ an odd ECG- ? MI. State you would consider treatment for this/alerting your cardiac colleagues.

• raised JVP- state you feel this may be cardiac failure, and therefore would consider “furosemide”

DISABILITY

So Mr Smith’s blood saturations are improving, he has had his ECG (no acute findings), his BP and pulse are much better with some fluids and you are happy to move on.

• CHECK drug chart - ? drug reaction, any drugs on there of concern/culprits

• CHECK pupils - PEARL?

• CHECK AVPU- conscious level

• CHECK BM- ? hypogylcaemic

React to what is being said to you:

• if a drug is the issue - take drug off drug chart

• Pupils - pinpoint ? opiate overdose. You would reverse this.

• BM- low - is this a insulin OD, fix it with glugogel etc

EXPOSURE

• ASK the patient if they are happy to be exposed. Remember to cover the patient after. You don’t want to lose an easy mark for “patient dignity”

• uncover the patient/manakin and check for any rashes/bleeding etc

• I would do an abdominal examination if the complaint was GI related etc

I hope the above summary gave some clarification on this type of station.

Remember to speak out loud, speak to the mannikin as if a real patient, speak to the examiner with what your thoughts are…“I am checking the blood pressure” “I am looking for bleeding”.

You are summarising/explaining your findings to the examiner “I am worried about his low BM and therefore would consider safely administering glucose”.

Practice makes perfect. It may feel odd initially as it feels unnatural BUT with practice you will feel more confident in just doing it without worrying.

Best of luck with revision, be safe, be confident and say what is on your mind - otherwise you wont get the mark..

Happy revision and happy vibes!