Clinical Mock 12
Instructions for the Clinical Station
You have 5 minutes to go through this scenario.
These scenarios work best when used as a pair. One person can act as the examiner and the other as the candidate.
Candidate Instructions
A 73 year old lady is mobilising around the ward 2 days after a right total hip replacement. You are asked to see her as she has been found collapsed in the toilet. She currently fully alert and orientated. Her past medical history is significant for hypertension and atrial fibrillation.
Examiner Instructions
Ensure the candidate goes through a systematic A-E answer within 3 mintues. Encourage the candidate to move through the scenario and stick to time.
If the candidate has not tailored their answer to this specific scenario, prompt them using the examples below.
Questions
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How would you manage this situation?
How would you manage this situation?
Prompts
- Use an ABCDE approach.
- If the candidate mentions pupils in ‘disability’, question what in particular they would be looking for.
- Prompt the candidate mentions some additional steps and/or additional investigations.
Main concern:
- Unknown mechanism of injury- ?head injury. AF – On blood thinners
- I would urgently attend to this patient, assess them according to the ALS principles.
- Ask the nurses to do observations including oxygen saturations, respiratory rate, heart rate, temperature and blood pressure.
Airway:
- Communicate with patient, she is alert and orientated, her airway is likely patent.
Breathing
- Recheck respiratory rate and oxygen saturations
- High flow oxygen 15L through non-rebreathe mask
- Inspect, palpate, percuss and auscultate chest
- Look for signs of obvious injury, flail chest, bruising, reduced air entry, additional noises.
- CXR
- ABG
Circulation
- Recheck temperature, HR and BP.
- Assess capillary refill time and fluid status.
- Listen to heart sounds- ?murmur.
- IV access with 2 wide bore cannula in antecubital fossa.
- Bloods- FBC, CRP, U&Es, coagulation screen. To look for infective causes of fall, deranged clotting secondary to being on blood thinners.
- Sign of bleeding – chest, abdomen, pelvis, long bones
- IV fluid resuscitation with fluid challenge if hypotensive
- Consider major haemorrhage protocol.
- ECG to look for arrythmia-related cause of fall.
Disability
- Check pupillary light reflex and size for obvious signs of head injury Blood glucose- hypoglycaemia leading to fall.
Exposure
- Exposure from head to toe for any obvious signs of bleeding, bruising, obvious fractures
- Examine hip wound.
Summarise: 73 year old lady, with unknown mechanism of fall, 2 days post right total hip replacement. I am most concerned about a possible head injury (with associated neurological symptoms). Given she is on blood thinners, she fits the criteria for a CT head. Additional:
- Alert seniors
- Full neurological exam.
- Discuss and approve scans with radiologist.
- Neurological observations
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With this scenario in mind, what are the indications for a CT head?
With this scenario in mind, what are the indications for a CT head?
Prompts
Prompt the candidate to talk about different time frames for a CT head (based on NICE guideliens). e.g. 8 hours, immediate.
** Link to knowledge tutor
Immediate:
- GCS < 13 on initial assessment
- GCS < 15 at 2 hours after injury on assessment
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture
- Post-traumatic seizure
- Focal neurological deficit
- More than one episode of vomiting since the head injury
Within 8 hours:
- On anticoagulation – she fits criteria based on this.
- Loss of consciousness or amnesia + 1 of:
- Age > 65 years
- History of bleeding or clotting disorder
- Dangerous mechanism of injury
- 30 minutes’ retrograde amnesia of events
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Can you name some of the possible causes for her fall?
Can you name some of the possible causes for her fall?
Prompt
Encourage candidate to categories their answer e.g. operative, patient related factors, external factors
Operative factors: dislocation of prothesis restricting mobility, wound infection.
Patient-related factors: AF, infective, cardiac e.g. arrythmia, neurological (epilepsy, stroke).
External factors: fall hazards.
Any other sensible classification is acceptable
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How would you perform a falls assessment?
How would you perform a falls assesment?
Prompts
Ensure history, investigation and examinations are covered
This can be a short answer
Detailed history – before, during and after.
Collateral history- who witnessed fall, baseline mobility at home.
Systems enquiry- cardiovascular, respiratory, neurological, urinary, GI, musculoskeletal
Medication review
Clinical exam
Investigations including orthostatic hypotension, urine dipstick, ECG, imaging (CT head)