ADULT CRITICAL CARE MEDICINE SAUDI BOARD PROGRAM SAUDI BOARD FINAL CLINICAL EXAMINATION OF ADULT CRITICAL CARE (2018)

Transcription

1 ADULT CRITICAL CARE MEDICINE SAUDI BOARD PROGRAM SAUDI BOARD FINAL CLINICAL EXAMINATION OF ADULT CRITICAL CARE (2018)

2 I Objectives a. Determine the ability of the candidate to practice as a specialist and provide consultation in the general domain of his/her specialty for other health care professionals or other bodies that may seek assistance and advice. b. Ensure that the candidate has the necessary clinical competencies relevant to his/her specialty including but not limited to history taking, physical examination, documentation, procedural skills, communication skills, bioethics, diagnosis, management, investigation and data interpretation. c. All competencies contained within the specialty core curriculum are subject to be included in the examination. II Eligibility a. passing Saudi fellowship Final written examination. b. Candidate is allowed a maximum of four attempts to pass the final clinical/practical examination of board certificate within a period of five years from successfully passing the final written examination provided evidence of continuing clinical practice is presented and approved by the Scientific Council. c. Upon the recommendation of the scientific specialty council, a candidate who failed to pass the clinical/practical examination with the specifications mentioned above in item (2) has to pass final written examination again, after which he/she is allowed to sit the final specialty clinical/practical examination twice provided that evidence of continuing clinical practice is presented and approved by the scientific specialty council. d. After exhausting above attempts candidate is not permitted to sit the Saudi fellowship final specialty clinical examination. III General Rules a. Saudi board final specialty clinical examination will be held once each year within 4-8 weeks after Part II written examination. b. If the percentage of failure in the clinical examination are 50% or more the examination shall be repeated after 6 months. c. Specialty clinical examinations shall be held on the same day and time in all centers, however if consecutive sessions are used, suitable quarantine arrangements must be in place. d. If examination is conducted on different days, more than one exam version must be used. IV Exam Format a. The Adult Critical Care final clinical examination shall consist of 8 graded stations each with minutes encounters. b. The 8 stations consist of 5 Objective Structured Clinical Exam (OSCE) stations with 1 examiner each and 3 Structured Oral Exam (SOE) stations with 2 examiners each. c. All stations shall be designed to assess integrated clinical encounters. d. SOE stations are designed with preset questions and ideal answers. e. Each OSCE station is assessed with a predetermined performance checklist. A scoring rubric for postencounter questions is also set in advance.

3 V Final Clinical Exam Blueprint* Domains Approach &Assessment Diagnosis Investigations&Data interpretations Prevention &Management # Stations Patient Care Dimensions of Care (Sections) Patient Safety & Procedural Skills 1 1 Communication & Interpersonal Skills Professionalism& Ethics Total Stations

4 VI Definitions Domains Approach & Assessment Diagnosis Investigations & Data interpretations Prevention & Management Focus of care for the patient, family, community, and/or population The way how to deal with critical ill patients and approach them based on critical care concept, priorities for saving lives,even this domain includes but not limited to family,community and/or populations approach. Clinical evaluation to urgent,emergent,life-threatening conditions,new conditions & exacerbation of underlying conditions and how to support, resuscitate and stabilize them based on critical care & life saving principles The clinical condition of the patient either to be acute, chronic and exacerbation of underlying disease which it will be recognized by initial presentation,taking proper medical history and clinical examination. Knowledge of all diagnostic tools either radiological exam or laboratory tests in terms of its indications,contraindications and interpretations Establishment of Supportive and critical care treatment and initiate the definitive treatment. Illness prevention covers measures not only to prevent the occurrence of illness such as risk factor reduction but also arrest its progress & reduce its consequences once established. This includes but is not limited to screening, periodic health exam, health maintenance, patient education & advocacy, & community & population health. Domains Patient Care Patient Safety & Procedural Skills Communication & Interpersonal Skills Professionalism & Ethics Reflects the scope of practice & behaviors of a practicing clinician Exploration of illness & disease through gathering, interpreting & synthesizing relevant information that includes but is not limited to history taking, physical examination & investigation. Management is a process that includes but is not limited to generating, planning, organizing care in collaboration with patients, families, communities, populations, & health care professionals (e.g. finding common ground, agreeing on problems & goals of care, time & resource management, roles to arrive at mutual decisions for treatment) Patient safety emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. Procedural skills encompass the areas of clinical care that require physical and practical skills of the clinician integrated with other clinical competencies in order to accomplish a specific and well characterized technical task or procedure. Interactions with patients, families, caregivers, other professionals, communities, & populations. Elements include but are not limited to active listening, relationship development, education, verbal, non-verbal & written communication (e.g. patient centered interview, disclosure of error, informed consent). Attitudes, knowledge, and skills based on clinical &/or medical administrative competence, ethics, societal, & legal duties resulting in the wise application of behaviors that demonstrate a commitment to excellence, respect, integrity, accountability & altruism (e.g. self-awareness, reflection, life-long learning, scholarly habits, & physician health for sustainable practice).

5 VII Passing Score a. The pass/fail cut off for each OSCE/SOE station is determined by the exam committee prior to conducting the exam using a Minimum Performance Level (MPL) Scoring System. b. Each station shall be assigned a MPL based on the expected performance of a minimally competent candidate. The specialty exam committee shall approve station MPLs. c. At least one examiner marks each OSCE station and two examiners independently mark each part of the SOE. d. To pass the examination, a candidate must attain a score > MPL in at least 70% of the number of stations and 60% in each component (OSCE and SOE). VIII Score Report a. All score reports shall be issued by the SCFHS after approval of the Specialty Examination Committee. IX Exemptions a. SCFHS at present has no reciprocal arrangement with respect to this examination or qualification by any other college or board, in any specialty

6 X OSCE Station Sample** Internal Medicine Clinical Exam Station 1 Instructions to Resident Scene: Emergency Room A 21-year old newly diagnosed diabetic is admitted to emergency department following a night out. The patient was believed to have had an evening of excess alcohol. The patient is drowsy and agitated. YOU HAVE 10 MINUTES TO DO THE FOLLOWING:

7 1) Review and present the findings of this ABG Arterial Blood Gas result. PH Pao2. 75 mmhg Paco2. 22 mmhg HCO3. 12 mmol/l BE mmol/l Blood glucose. 27 mmol/l 2) What is the most likely diagnosis? 3) What further tests are required to confirm the diagnosis? 4) A ketonaemia is discovered at 6.2 mmol/l.what are the principles in the management of DKA? 5) According to guidelines by the Joint British Diabetes Societies (JBDS) What are the rates of change that are targeted for ketones,bicarbonate and glucose? 6) What type of fluid would you use and what regime would you follow? 7) What are the main differences in fluid and insulin regimes in a hyperglycemic hyperosmolar state compared to DKA and why? **Examples are shown to clarify station structure regardless of case details.

8 Performance Evaluation: Station 1 0 = not done, 1 = attempted but not done correctly/completely, & 2 = done correctly/completely Patient Care/Assessment,Diagnosis and investigation & Data interpretation Review and present the findings of this ABG: There is metabolic acidosis with failed respiratory compensation Raised blood sugar. 2. The most likely diagnosis: A diabetic emergency: - Likely to be diabetic ketoacidosis(dka) - Hyperglycaemic,hyperosmolar state (HHS) 3. The tests are required to confirm the diagnosis: Urine or blood ketones Management 4. The principles in the management of DKA: The primary goal and priority is ketone clearance Fluid resuscitation and correct the acidosis Insulin replacement based on DKA protocols and guidelines Controlled glucose reduction Treatment of a precipitant cause for example, antibiotics for concurrent infection. 5. The rates of change that targeted for ketones, bicarbonate and glucose: Rate of fall for ketones 0.5mmol/L/hr Rate of rise in HCO3 3mmol/L/hr Rate of fall for glucose 3mmol/L 6. The type of fluid would be used and the regime would be followed: Normal saline. If the patient is hypotensive, with a systolic pressure less than 90 mmhg, give 0.5 of fluid in 15 mins Otherwise: o 0.5 in 15 mins o 1L in1 hour o 1L in 2 hours o 1L in 4 hours o 1L in 6 hours If k+ is less than 5 mmol/l, then supplement the normal saline with potassium chloride When glucose is < 14 mmol/l, add in 10% dextrose at 125 ml/h 7. The domain differences in fluid and insulin regimes in a hyperglycemic hyperosmolar state(hhs) and DKA: In a HHS, there is severe dehydration, but due to the high risk of cerebral edema the initial fluid replacement is slower compared to DKA; approximately 6L in a 24 hours period Slower insulin regime of 0.05 units/kg/hr but only after fluid resuscitation. Slow correction of hypernatraemia due to the risk of central pontine myolinolysis. Total marks:

9 Questioning Skills (ONE choice only) Awkward, exclusive use of closed-ended or leading questions and jargon Somewhat awkward; inappropriate terms; minimal use of open-ended questions Borderline unsatisfactory; moderately at ease; appropriate language; uses different types of questions Borderline satisfactory; moderately at ease; appropriate language; uses different types of questions At ease; clear questions; appropriate use of open and closed-ended questions Confident; skillful questioning Professional Behavior with Patient (ONE choice only) Offensive or aggressive; frank exhibition of unprofessional conduct Negative attitude toward patient Borderline unsatisfactory; does not truly instill confidence Borderline satisfactory; manner inoffensive, but does not necessarily instill confidence Attempts professional manner with some success Overall demeanor of a professional; caring, listens, communicates effectively Overall Organization of Patient Encounter (ONE choice only) No logical flow; scattered, inattentive to patient's agenda Counsels patient before taking history or doing physical Minimal organization; scattered approach Appropriate approach to patient Skillful approach to patient Skillful, professional approach to patient and effective use of time Facilitation of Informed Decision Making (ONE choice only) No attempt or inappropriate attempt at information sharing (e.g., deception, slanting of facts, incorrect information) Incomplete and / or biased information; overuses jargon; does not ensure understanding of issues Attempts to share information; omits some critical facts; uses some jargon; attempts to ensure understanding Gives some information on most important facts; may use jargon; attempts to ensure understanding Gives clear information; supports patient decision making (e.g., alternatives, risks / benefits); appropriate language; ensures understanding Organized; optimizes patient decision making; significant effort to make information relevant; clear language; attentive to patient understanding

10 1) The following CT scan was obtained from a 76 year old patient how is currently incubated on ICU. What does this CT scan show? 2) What is the diagnosis? 3) What ventilatory strategies would you employ for this patient? **************************************************************** 1) What type of image is captured on this scan 2) What abnormalities does it show? 3) Do you know of a classification system for pulmonary embolus? 4) A 69- year old man with end stage renal failure has this ECG recorded. Please describe this ECG?

11 ECG 1) What is the most likely cause of peaked T-wave morphology in this case? 2) How would you manage hyperkalaemia in this patient if the potassium levels read 6.9? ********************************************************************

12 XI SOE Station Sample** Instructions to candidate: A 78-year-old man presents to the emergency department with a 3-day history of shortness of breath. Question/Ideal Answers Mark How would you approach this patient? Focused History: Details of SOB (NYHA class, orthopnea, PND) /6 Other cardiovascular symptoms (chest pain, palpitations, syncope, lower limb swelling) Past history of pericarditis, hemopericardium, TB, renal impairment and chest radiotherapy Relevant Physical Examination: Blood pressure, Heart rate,respiratory rate,temperature JVP Examine for Pericardial knock. /12 Examine abdomen for Pulsating hepatomegaly and ascites. Examine Chest for pleural effusion Examine for lower limbs edema The patient has progressive SOB, fever and productive cough Physical examination: Pulse is regular, BP 101/62mmHg, temperature is 39.4 C,normal JVP. There is a loud sound shortly after S2. Abdominal examination showed normal. Chest examination: decreased air entry on the basal of the right lung What investigations would you like to conduct? CBC with deffrintial CRP, Procalcitonin U&E ABG /12 Troponin ECG CXR Septic screening( sputum, blood and urine) A chest X-ray is performed. Please describe the abnormality Right middle lobe pneumonia /6 How would you risk stratify this patient. The CURB65 scoring system can be used: Confusion (new onset)- Abbreviated Mental Test Score (AMTS) <8 Urea >7mmol/L /6 Respiratory rate >30 breaths per minute Blood pressure- systolic <90mmHg or diastolic<60mmhg Age>65 The total number of points is then totalled with the following inference for further care: 0-1 treatment in the community 2-3 hospital admission 4-5 critical care admission Which causative organisms are most likely in this patient? Streptococcus pneumoniae Haemophilus influenzae /10 Atypical organisms (e.g. Mycoplasma pneumoniae, Legionella pneumoniae) Viral (e.g. Influenza, parainfluenza) How would you treat this patient? The following measures should be implemented: Acute assessment, resuscitation and management should ne undertaken to follow an airway, breathing,circulation, disability and exposure approach. Management to follow care bundles as listed by the Surviving Sepsis Campaign /10 Early antibiotics, including cover for atypical organisms An anti microbial regime which has coverage for both typical and atypical organisms causing communityacquired pneumonia, e.g. benzoyl penicillin and clarithromycin How would your antibiotic choice change if this patient had developed pneumonia in hospital? It would be necessary to cover for nosocomial infections Most hospital-acquired infections are Gram- negative organisms so anti microbial cover would be required to cover these Methicillin-resistant Staphylococcus aureus (MRSA) coverage will be required if the patient is MRSA screen- positive or fails to improve with initial therapy. An alternative anti microbial regime, e.g. Piperacillin- tazobactam Total /8 /80