Structured Assessment using Multiple Patient. Scenarios (StAMPS) Preparation and Practice Scenarios

Transcription

1 Structured Assessment using Multiple Patient Scenaris (StAMPS) Preparatin and Practice Scenaris M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 1

2 1. Preparing fr yur StAMPS Exam Befre prceeding t cnsider the practice scenaris, the fllwing general cmments may be useful t assist candidates t answer the examinatin questins in a cmprehensive and prfessinal manner. 1. Remember all scenaris are generated frm an actual patient cnsultatin/encunter, therefre during the reading time reflect back t when yu last saw a patient presenting in a similar manner and think thrugh hw yu managed that cnsultatin/encunter. 2. Yur examiner cannt read yur mind, s it is imprtant that yu clearly utline yur thught prcesses. Fr example, dn t just say I ll prceed t a primary survey yu must utline exactly what yur apprach is. Dn t frget the basics such as having the patient in a mnitred/resus area fr majr trauma/medical emergency and briefly discuss hw yu want them mnitred, what IV lines yu wuld insert, whether yu wuld have them n xygen, what staffing persnnel yu wuld want available. a. It may be helpful t think abut frmulating yur answer as thugh talking a junir dctr thrugh the prcess t ensure yu dn t mit the basic steps. 3. Remember that this is a Fellwship exam and as such yu are expected t answer in a highly cntextualised manner, nt just demnstrating that yu remember lists frm medical schl. The cntext is nt nly abut the medicine, but als the circumstances f the patient and the envirnment in which yu are wrking. a. Make ntes during the 5 minute reading time, identify hw the infrmatin dictates the cntext and be sure t demnstrate that yu have cmprehended the cntext. Fr example: a scenari that cvers a ptentially septic Abriginal baby that yu are assessing in a remte area clinic identify t yur examiner that yu recgnise the baby is seriusly unwell, yu may have issues with language and yu knw hw t access the assistance f an Abriginal Health Wrker and yu are very unlikely t be able t prvide the definite management in yur current lcatin s that after initial management yu will need t arrange fr transprt t an apprpriate paediatric centre. 4. Pay attentin t the time allcatin fr each part f the scenari, if fr example it is ne minute, then yu are nly expected t be prviding a very brief utline answer, if hwever it 5 r 6 minutes, then a mre detailed and well structured answer is expected (dn t wrry here, yur examiner will intervene with prmpting questins if required). 5. At the end f each day r week, think abut ne patient cnsult/encunter yu ve had and cnstruct a scenari and wrk thrugh all the issues raised by that encunter. 6. Enlist help frm yur supervisr and/r medical educatr t run yu thrugh practice scenaris. Ideally d this under exam cnditins have a 5 minute time t think abut yur respnse and ensure yu allcate a ten minute timeframe t answer. If yu are sitting fr the AST examinatins enlist the help f a specialist clleague in yur AST discipline. If sitting fr the AST-Emergency Medicine examinatin, ensure yu have recent experience in an Emergency Department supprted by FACEMs and where there is supprtive supervisin. 7. Ensure yu are abslutely aware f the guidelines fr life supprt, bth BLS and ALS, make sure yu are very familiar with legal and ethical issues, eg yu must be able t clearly discuss hw yu prceed with reprting ptential child abuse and issues related t an impaired clleague. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 2

3 8. The examiners have been very clearly instructed t assist yu t demnstrate yur cmpetency in managing the scenari presented. a. If yur examiner interrupts yu, it is with the intentin f prviding guidance t assist yu t prvide the desired discussin. b. If yu dn t understand what yur examiner has asked, seek clarificatin. 9. N ne wrks in prfessinal islatin, s remember t discuss with yur examiner the circumstances under which yu wuld call a specialist clleague fr advice and when yu will arrange fr yur patient t be referred t anther centre fr nging management. In the situatin where transprt is required, be sure t discuss the ptential issues with this and hw yu prepare fr transfer f care. 10. Make sure yu are familiar with the relevant curriculum fr the examinatin and ensure yu revise thse areas that yu may nt be s familiar r cmfrtable with. Lk at the Assessment blueprint it will guide yu t thse dmain areas mst likely t ccur in the examinatin. 11. Cnsider undertaking the emergency curses prir t the examinatin if this is an area yu have limited experience in. The ALSO curse is highly beneficial fr thse candidates with limited bstetric experience. 12. Read thrugh yur lcal hspital guidelines fr managing trauma and medical emergencies. 13. Finally, remember that this is a Fellwship exam and if yu are enrlled, then yu shuld have undertaken the necessary training and have the necessary experience, s think f it as an pprtunity t demnstrate t yur examiners that yu are ready t be practicing independently. 14. Pay particular attentin t yur cmmunicatin t ensure that yur examiner has a clear understanding f yur management f each scenari. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 3

4 2. Practice scenaris These practice scenaris presented are examples frm past examinatins. The Infrmatin prvided t Candidates n the fllwing page is the infrmatin that is given t the Candidates at the cmmencement f the examinatin; the fllwing table n the next page is the actual dcument frm which the examiner wrks. On the examiner dcument yu will see that there are 4 clumns: the first is an indicatin f the time t spend n each part; the secnd is the questin that the examiner will ask (this is delivered wrd-fr-wrd exactly the same t every candidate); the third clumn lists bth the key cncept which is the ver-riding r headline issue t be discussed with a breakdwn f key issues ; the final clumn is a list f pssible questins the examiner may ask if the candidate hasn t spntaneusly ffered the requisite infrmatin. It needs t be nted that the key issue sectin is heavily referenced against current guidelines/best practice, but is nt necessarily ttally extensive, furthermre a candidate may well pass withut mentining everything n that list. Suggested apprach: 1. Read thrugh the Infrmatin t Candidate, make ntes. 2. Think abut the time allcatin fr each part and then prceed t answer the primary questins; ideally t d this withut lking at the third clumn which lists the pints expected. 3. Read thrugh the ntes at the end f the scenari t familiarise yurself n the standard expected this sectin will discuss issues that will lead t a fail grade and thse that may result in a brderline grade. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 4

5 Primary Curriculum StAMPS NB fr this examinatin, scenaris will be based in the envirnment prvided by the Cmmunity Prfile psted n the website. The Primary Curriculum defines the minimum scpe and standards fr independent practice anywhere in Australia, with a particular fcus n rural and remte settings. It sets ut the utcmes expected at ACRRM Fellwship (FACRRM) level. Dctrs achieving a FACRRM are expected t be able t: Initially stabilise Australian Triage Categry 1 and 2 patients with the supprt f an experienced clleague (which may be thrugh distance technlgy) pending definitive emergency medical care, and Cmpetently prvide definitive emergency medical care fr mst Australian Triage Categry 3, 4 and 5 patients and determine when additinal supprt is required. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 5

6 ACRRM Primary Curriculum -StAMPS Examinatin Example Practice Scenari: 1 Scenari Infrmatin prvided t Candidate: Maria is a 59-year-ld widwed cleaner wh lives n her wn in twn. Her fur children and five yung grandchildren all live in the reginal city 500km away. She was diagnsed with type 2 diabetes 10 years ag and hypertensin five years ag. Her diabetes has been well cntrlled with her HbA1c usually in the range % (53-58mml/ml) until the death f her husband thirteen mnths ag. Her bld pressure recrdings ver the past 2 years have all been <130/75 mmhg. She usually presents fr regular review every three mnths after her rutine pathlgy tests. Unusually, she failed t present fr her mst recent review and was recalled last week t have her verdue rutine blds dne. Her usual medicatins include: Insulin glargine 30 units SC mane Metfrmin extended release 2g PO mane Gliclazide mdified release 90mg PO mane Perindpril 5mg PO mane Aspirin 100mg PO mane Tday, fingerprick randm bld glucse is 22.0mml/L, seated bld pressure is 165/90mmHg, Frm the pathlgy test taken last week her HbA1c was 10.8% (95mml/ml) and her albumin: creatinine rati was 28mg/mml (nrmal range <3.5mg/mml). Her weight has increased and her bdy mass index is nw 37, up frm 34 at her last visit five mnths ag. She tells yu she stpped taking her insulin glargine a few weeks ag because it was making her feel puffy and sluggish. She avids eye cntact and appears untidy and exhausted. This scenari has 3 Parts: estimated time fr each Part: Part 1 1 minute, Part 2 6 minutes, Part 3 3 minutes M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 6

7 Questins Key Cncepts/Issue t be Demnstrated Pssible Prmpting Questins 1 1/60 2 6/60 3 3/60 Very briefly, what are the areas f cncern that need t be addressed during this cnsult? Yu ve identified that depressin may be a significant factr affecting Maria s capacity fr self care. Hw wuld yu explre this further with her tday? What are the key issues regarding her diabetic cntrl yu wuld want t address? Key Cncept: Identifies that this presentatin has tw key cmpnents Deterirating diabetic cntrl Pssible underlying depressin r develpment f hypthyridism Key Cncept: Demnstrates clear understanding f depressin diagnsis and management Prepared t explre the pssible diagnsis f depressin with Maria Takes a clear mental health histry must include symptms that may indicate endgenus depressin Explres patient s safety and excludes suicidal intent Demnstrates familiarity with varius diagnstic tls (eg K10, DASS, SPHERE) and can discuss the relative merits f them Cnsiders apprpriate testing t investigate differential diagnses fr depressin eg FBE, EUC, LFTs, calcium, TSH, irn studies, B12, flate, CRP, ESR, sleep studies Elabrates a plan t further explre this pssible diagnsis: engages with mental health team as apprpriate Preliminary discussin f pssible medicatin able t discuss the merits f the different classes f antidepressants Identifies a clear time frame fr review n this issue Demnstrates understanding f and explres issue f ptential scial islatin frm family Discusses supprt services available within the cmmunity and access t them Discusses wrk issues, cncerns re pssible retirement and cnsequences f that fr her bth financially and with respect t friendships, supprt Key Cncept: Demnstrates sund understanding f the principles f management f patients with type 2 diabetes Demnstrates appreciatin f the implicatins f: 1. Deteriratin in HbA1c 2. High randm BSL 3. BP measurement 4. Increase in BMI 5. Pssible renal impairment raised ACR 6. Nn-cmpliance with medicatin explres if cmpliant with ral Rx recently Explratin f the patient s expectatins arund management Arranges further investigatins re: high HbA1c and ACR: requests EUC, lipid prfile Discusses lifestyle factrs f smking/diet/exercise Demnstratin f clear management plan that will priritize issues fr this patient Refers back t f the key psych-scial issues fr this patients ability t manage her chrnic disease: prbable depressin/abnrmal grief reactin, islated frm family Invlvement f assciated practitiners: phthalmlgist / ptmetrist / dentist / pdiatrist / dietician / diabetes educatr / endcrinlgist Why d yu think her results have changed s much? Hw will yu establish the severity f Maria s depressin? What further assessments might yu use? What pathlgy tests will yu rder? Wh might yu refer Maria t? Generally speaking, hw d yu decide which antidepressant t use? Wuld yu start antidepressant medicatin tday? If s what? What fllw-up arrangements might yu make? What are the key areas that must be regularly addressed with diabetic patients and why? Are there any ther investigatins yu might like t d and why? Hw wuld yu explre Maria s expectatins f her management? Why might Maria be reluctant t cmply with her medicatin regime? M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 7

8 References: 1. General practice management f type 2 diabetes, page dcument c-written by RACGP and Diabetes Australia. Available nline at 2. Assessing patients with depressin [revised February 2013]. In: etg cmplete [Internet]. Melburne: Therapeutic Guidelines Limited; March (Hme > Psychtrpic > Depressin > Assessing patients with depressin) 3. Principles f treatment [revised February 2013]. In: etg cmplete [Internet]. Melburne: Therapeutic Guidelines Limited; March (Hme > Psychtrpic > Depressin > Treatment f depressin > Principles f treatment) M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 8

9 Cmments n hw this scenari wuld be graded t result in either a brderline r fail grade: Ideally a candidate wuld set the scene t the examiner very briefly utlining that there are tw primary issues here: 1: Deterirating Diabetic cntrl and 2: Pssible depressin At the start f the secnd questin, the examiner is telling yu that yu ve identified depressin as a strng pssibility it is therefre essential that yu discuss: An assessment f suicidal risk failure t d this wuld result in an autmatic fail fr this statin, NB there are a cuple f prmpting questins t mre deeply prbe hw yu assess the severity f the depressin which shuld lead t a discussin f suicide risk. Yur examiner will nt hwever directly ask yu hw t assess fr suicide risk as this is smething that shuld be an autmatic cnsideratin fr smene at Fellwship level. A failure t cnsider the ptential rganic causes fr depressin and/r a limited apprach t general management wuld likely lead t a brderline grade. The primary questin fr the third part asks abut the key issues regarding diabetic cntrl: A failure t identify that her cntrl has significantly deterirated wuld result in a fail. A limited apprach t the crnerstnes f diabetic management may result in a brderline grade. It is expected that there wuld be a discussin regarding HbA1c significance, BP, Weight and renal functin issues. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 9

10 AST Emergency Medicine NB fr this examinatin, scenaris will be based in the envirnment prvided by the Cmmunity Prfile psted n the website. This AST Curriculum in EM builds n the emergency medicine cmpnent f the ACRRM Primary Curriculum. It fcuses n the additinal knwledge and skills required fr advanced practice in emergency medicine. In additin t the abilities required in the Primary Curriculum fr EM, dctrs achieving AST in EM are required t be able t: Cmpetently prvide definitive emergency medical care including emergency medicine prcedural interventins fr individual patients acrss all presentatins including Australian Triage Categry 1 and 2. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 10

11 ACRRM AST-EM StAMPS Examinatin: Example Practice Scenari Number: 1 Scenari Infrmatin prvided t Candidate: Yu are called t yur lcal hspital s emergency department (as per the Cmmunity prfile ) t see David wh is a 53-year-ld man brught in by ambulance after falling frm a ladder nt his L chest; nw cmplaining f severe left sided pleuritic chest pain and shrtness f breath. He arrives in a cervical cllar. Vital signs: Pulse 106/min regular, BP: 142/88 mmhg, Respiratry rate 22/min, Oxygen saturatin 96% n rm air, GCS 15. Past medical histry: Type 1 Diabetes (Dx age 18years), Hypertensin, GORD Medicatin: Insulin glargine 46units SC OD, Insulin nvrapid SC TDS (as per sliding scale), Ramipril 10mg PO mane N knwn drug allergies. NB: A majr strm frnt has passed thrugh and all rads are blcked and the airstrip clsed fr the next twelve hurs. This scenari has 2 Parts: estimated time fr each Part: Part 1 5 minute, Part 2 5 minutes Step Questins Key Cncepts/Issue t be Demnstrated Pssible Prmpting Questins 1 Please discuss yur apprach t assessing this patient, bearing in mind Key cncept: Demnstrates apprpriately structured and safe assessment f trauma patient. What mnitring is required? Hw d yu assess the risk stratificatin M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 11

12 5/60 the limited facilities available t yu at yur lcal hspital Cnsiders the ABCs, but recgnises this patient currently has patent airway, xygenating adequately and has an acceptable circulatin. Ensures apprpriate mnitring, IV access, checks BSL (essential), ECG Prvides analgesia able t discuss issues related t this and risks f develping respiratry drive/hyptensin Able t sensibly discuss pssible regimes paracetaml IV, piates aware f titratin, supplementatin with ketamine, pssible paravertebral blck Obtains apprpriate histry t assist risk stratificatin f mechanism f injury: Establishes height f fall and nt what srt f surface -able t discuss mechanism f injury in general terms t assess risk fr significant injury Establishes if fall was attributable t syncpal episde Diabetic pssible hyp/hyper episde, pssible cerebral r cardiac event. Apprpriate examinatin, addressing ABC, Cx, Tx/Lx spine, secndary survey Cnsiders ptential injuries: Pssible Head injury -N CT scan available at small hspital, will ensure neur bs taken and repeated as indicated Able t discuss sme guideline re scanning in general, eg Canadian CT rules. Prbable Chest injury CXR, + USS if trained Pssible abdminal injury USS efast Cnsiders Cervical spine injury - aware f Canadian r ther Cx criteria may d plain XRays if indicated Cnsiders ther spinal injury: lg rll (being very cgnisant f pssible L chest trauma). Pssible ther injuries as yet nt detected (e.g. limb fractures, sft tissue injuries) apprpriate secndary survey Discusses investigatins as may be apprpriate as abve and blds including G&M depending n degree f trauma fr this patient? Given his past medical histry what are sme ther key cnsideratins? What injuries d yu think are likely in this case and hw will yu assess them in yur current setting? Any ther? What are the ptential issues related t prviding adequate analgesia in this patient? What regimes might yu cnsider? He is very irritated by the Cx cllar; can yu remve it fr him? In a different situatin where yu have ready access t all imaging, hw d yu decide n yur imaging requests? 2 5/60 During yur initial trauma assessment a CXR has been taken by yur prtable machine, This is the view that has cme up n yur machine - please reprt n this and discuss yur management. Key Cncept: Recgnises significant surgical emphysema and small pneumthrax requiring insertin f Left intercstal catheter. Recgnises marked surgical emphysema f Left chest, shuld (but nt essential) pick up n small apical pneumthrax and 8 th rib #. Recgnises need fr ICC insertin Able t discuss preparatin fr and technique f insertin f ICC: Explanatin f prcedure t patient and any family Cnsent frm patient Chice f catheter size Apprpriate mnitring Analgesia Able t discuss the technique f insertin Anatmical landmarks recgnises that insertin may be mre difficult due t the surgical emphysema What s the implicatin f thse findings yu ve mentined n the Xrays? Hw d yu prepare a patient fr the insertin f an ICC? Please discuss in detail hw yu will insert an ICC? Where des this patient need t be and why? M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 12

13 Prcess f dissectin t insert Discusses hw they secure the tube and dress the site Checks functining f underwater seal drain ensures swinging Orders check CXR Discusses dispsitin, may need fr referral t surgical unit fr nging acute care. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 13

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15 References: Initial evaluatin and management f blunt thracic trauma in adults: Authr: Eric Legme, MD Sectin Editr: Maria E Mreira, MD Deputy Editr: Jnathan Grayzel, MD, FAAEM EMST wrkbk M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 15

16 Cmments n hw this scenari wuld be graded t result in either a brderline r fail grade: The first questin requires a cnsideratin that the risk stratificatin fr the fall needs t be cnsidered fr this patient. A fail grade wuld be awarded if: There is n clearly structured apprach t a primary survey with apprpriate mnitring Failure t cnsider a medical cause fr the fall specifically mentining pssible hypglycaemia, ptential hyperglycaemia r DKA and ACS (Type 1 diabetic) Fcused nly n pssible chest trauma, lack f cnsideratin f the risk stratificatin vital t cmment t yur examiner hw yu d this in this case need t mentin height f fall. A brderline grade may be awarded where there was limited discussin f risk stratificatin, limited discussin f apprpriate imaging given the cnstraints f the health service and lack f cnsideratin f analgesia. NB there are extensive prmpting questins t assist candidates t cver all these issues. The secnd part f the questin requires recgnitin f extensive surgical emphysema and the need fr intercstal catheter and transfer t a centre suited t management f this. A Fail grade wuld be awarded if: CXR inadequately reprted Unable t discuss apprach t ICC Overall a lack f appreciatin and failure t cntextualise the ptential cmplexities in this case and lack f planning fr dispsitin f this patient wuld likely result in either a fail r brderline depending n hw limited the discussin. M:\Vcatinal Training\Assessment\STAMPS\StAMPS Preparatin Practice scenaris.dcx 16