Data Interpretation Dec 2016 With Answers

OSCE Data interpretation
stations
Dr Cathy Armstrong
Consultant Anaesthetist
Dec 2016
www.cmft.nhs.uk/undergrad
Objectives
• The stations
– Format
– Tips
• Blood tests
– Patterns to look for
• examples
Format
• Instructions
– Brief background
– Study data – ‘after 5 minutes the examiner will ask
you some questions on diagnosis & initial
management’
Format
• Data
– Blood tests incl blood gases
– ECG
– Imaging e.g xray or CT scan
– Observations
Format
• Questions from examiner

– Structured / standardised
• ‘what do the blood tests show?’

• ‘what does the CXR show?’
• What is your most likely diagnosis? What is your top
differential?
• What will your initial management be?
Tips
• Use your thinking time wisely
• Use succinct language & be confident

– Likely to be some normal investigations also
• Show reasoning behind your thoughts
• Flag up potential dangers

Tips
• Differential diagnosis
– Start with your top & why
• Initial management
– Might include oxygen / fluids / nebulisers
– Remember management packages – e.g sepsis 6
– Further detailed history
– Other definitive investigations – e.g.echo, CT
– Don’t forget SENIOR HELP / INPUT
Investigations
Full Blood Count
• Hb
– Males 135 – 180g/l
– Females 115 – 160 g/l
• WCC
– 4.0 – 11 x 109/l
• Platelets
– 150 – 400 x 109/l
Anaemia classification by MCV
MCV – mean cell volume (76 – 96 fl)
• Normal MCV (Normocytic)

– Acute blood loss
– Anaemia of chronic disease
• Low MCV (microcytic)

– Iron deficiency
– Thalassaemia
• High MCV (Macrocytic)

– B12 or folate deficiency
MCV – 76-96 fl
Anaemia quiz
• 1) Hb 86, MCV 80 • A) menorrhagia
• 2) Hb 82, MCV 70 • B) acute haemhorrage
• C) Vitamin B12
• 3) Hb 89, MCV 102 deficiency
MCV – 76-96 fl
Anaemia quiz
• 1) Hb 86, MCV 80 • A) menorrhagia
• 2) Hb 82, MCV 70 • B) acute haemhorrage
• C) Vitamin B12
• 3) Hb 89, MCV 102 deficiency
Hyperkalaemia
• Mild 5.5 - 6.0 mmol/l
• Mod 6.1 – 7.0 mmol/l
• Severe > 7.0 mmol/l
• Causes
– ↑ intake
• Food ingestion / supplements
• Rapid blood transfusion
– Intercompartmental shifts
• Trauma / crush injuries
• Burns
• Acidosis
– Decreased excretion
• Acute / chronic renal failure
• Adrenocortical insufficiency (e.g. Addisons disease)
– Medications
• Potassium sparing diuretics, digoxin
Hyperkalaemia
 ECG changes
 Peaked T waves
 Prolonged PR interval
 Widened QRS
 Loss of P wave
 Loss of R wave amplitude
 Sine wave pattern
 Asystole
 Management of mod / severe
 Treat underlying cause
 Calcium gluconate
 Insulin dextrose infusion
 Nebulised salbutamol
 dialysis
Hypokalaemia
• Mild 3.0 – 3.5 mmol/l
• Mod 2.5 – 3.0 mmol/l
• Severe < 2.5 mmol/l
• Causes
– ↓ intake
• Iatrogenic (no K in IV fluids)
• Malnutrition
– Renal losses
• Renal tubular acidosis
• Hyperaldosteronism (Conn’s syndrome)
– GI losses
• Diarrhoea, vomiting
– Intercompartmental shifts
• insulin
• Alkalosis
– Medications
• Diuretics, β2 agonists
Diseases with electrolyte patterns
• Addisons disease (Primary adrenocortical
insufficiency)
– Na K Ca
• Cushings syndrome (excess plasma cortisol)

– Na K Ca
• Conn’s Syndrome (hyperaldosteronism)

– Na K
Diseases with electrolyte patterns
• Addisons disease (Primary adrenocortical
insufficiency)
– Na ↓ K↑ Ca ↑
• Cushings syndrome (excess plasma cortisol)

– Na ↑ K↓ Ca ↓
• Conn’s Syndrome (hyperaldosteronism)

– Na ↑ ↔ K↓
Raised Urea & creatinine
• Both raised in renal failure
• Alternative causes of a raised urea with

relatively normal Cr
– Dehydration
– GI haemhorrhage
– High protein diet
Deciphering between acute & chronic renal
failure using blood results
 Chronic renal failure

 Anaemia of chronic disease
 Low calcium
 High phosphate
Liver Function tests
Non-specific Specific
Bilirubin ALT (Alanine aminotransferase)
AST (Aspartate transaminase)
ALP (Alkaline phophatase)
γ – GT
(Gamma –glutamyl transpeptidase)
Albumin
LFT patterns
• Hepatocellular Damage
– Large ↑ in ALT with small ↑ in ALP
• Biliary obstruction
– Small ↑ ALT with large ↑ in ALP & γ -GT
Normal ABG Values
pH 7.35 - 7.45
PaO2 10-12 kPa

IN AIR
PaCO2 4.5 - 6.0 kPa
HCO3 22 – 26 mmol/l
Base Excess -2 - +2 mmol/l

Many modern gas machines also measure
K+ Na+ Cl- SaO2 Hb COHb MetHb Lactate
Expected PO2 on oxygen
% oxygen – 10
Examples
Ryan
• Ryan is a 17 year old male. He has presented to A&E with a 2

month history of general malaise. Over the past few days he
has been vomiting with stomach cramps.
• BP 110/70, Apyrexial, RR 39
• Review the investigations provided. You will then be asked

questions on diagnosis and initial management.
Ryan
Ryan
• Hb 12.9 (9.0 – 13.0)
• ABG on air
• Wcc 7.0 (4.0 – 11.0)
• Plt 395 (150-400) • pH 7.12 (7.35-7.45)
• PCo2 3.0 (4.5-6.0)
• Na 139 (135-145)
• PO2 11.0 (10-12 in air)
• K 4.5 (3.5-5.5)
• Ur 15.0 (3.3-6.6) • HCO3 17 (22-26)
• Cr 140 (80-120) • BE -23 (-2- +2)
• Blood glucose 35mmol/l
Ryan
Ryan (answers)
• What does the CXR ?
– Normal – nil significant
• What do the blood results show?
– FBC within normal range
– U&E’s – raised urea with moderately raised creatinine – suggesting dehydration, hypovolemia and
possible acute kidney injury
– Extremely raised blood glucose
• What do the ABG’s show?
– Metabolic acidosis with respiratory compensation
• What does the ECG show?
– Sinus tachycardia
• What is the most likely diagnosis
– Diabetic ketoacidosis
• What would your initial management include
– Follow local DKA policy which will include: insulin therapy, Fluid replacement, potassium
replacement
– Involve seniors
– May need monitoring in critical care area
Jack
• Jack is a 77 year old male. He has presented to A&E with a 2

day history of abdominal pain and vomiting.
• BP 90/45, T 38.5. RR 30
• Examination of the abdomen reveals a hard abdomen with
generalised tenderness and guarding

Jack
• Hb 9.0 (9.0 – 13.0)
• ABG on air
• Wcc 22.3 (4.0 – 11.0)
• Plt 170 (150-400) • pH 7.22 (7.35-7.45)
• PCo2 6.1 (4.5-6.0)
• Na 139 (135-145)
• PO2 7.5 (10-12 in air)
• K 4.5 (3.5-5.5)
• Ur 10.0 (3.3-6.6) • HCO3 18 (22-26)
• Cr 130 (80-120) • BE -10 (-2- +2)
Jack
Jack
Sepsis 6
• Oxygen
• Blood cultures
• IV antibiotics
• Lactate & FBC
• IV fluids
• Measure UO
Jack (answers)
– Air under right hemidiaphragm
– FBC – Borderline low Hb, elevated WCC
– U&E’s – raised urea with moderately raised creatinine – suggesting dehydration, hypovolemia and possible acute
kidney injury ? Sepsis in this case
– Hypoxia
– Mixed metabolic & respiratory acidosis
– Fast AF
– Perforated viscus intrabdominally causing air under the diaphragm. Hypoxia and Type 2 respiratory failure possibly
due to diaphragmatic splinting, Sepsis from intra-abdominal perforation with hypotension and acute kidney injury.
Fast AF may have been precipitated by acute illness or may have pre-existing AF. Borderline low HB may suggest
anaemia due to chronic blood loss from bowel (? ?ulcer or Bowel malignancy)
• What would your initial management include (the list below is not exhaustive)
– Oxygen therapy
– IV fluid resuscitation (part of sepsis six)
– Sepsis six protocol – need to be able to list these – see next slide.
– Involve seniors – in particular surgical opinion
– Establish whether AF old or new onset. May require treatment.
Dorothy
• Dorothy is a 82 year old female. She has presented to A&E

with a 5 day history of productive cough with green sputum
and worsening shortness of breath.
• BP 93/50, T 38.5. RR 32

Dorothy
• Hb 11.0 (9.0 – 13.0)
• ABG on 60% oxygen
• Wcc 21.0 (4.0 – 11.0)
• Plt 250 (150-400) • pH 7.35 (7.35-7.45)
• PCo2 4.2 (4.5-6.0)
• Na 139 (135-145)
• PO2 13 (10-12 in air)
• K 4.5 (3.5-5.5)
• Ur 8.0 (3.3-6.6) • HCO3 23 (22-26)
• Cr 90 (80-120) • BE -3 (-2- +2)
Dorothy
Dorothy
CURB 65
• Confusion
• Urea – 7.0 or over
• RR 30 or over
• BP
– Systolic 90 or less OR
– Diastolic 60 or less
• Age 65 or over
Dorothy (answers)
– Inadequate film (rotated with apices & R costophrenic angle not included) however patchy shadowing throughout R
lung field, particularly lower & mid zones, consistent with consolidation
– FBC – elevated WCC
– U&E’s – mildly raised urea& creatinine – suggesting dehydration.
– Relative hypoxia – oxygen significantly lower than would be expected on 60% O2
– Community acquired pneumonia – good to mention CURB-65 score at this point.(see next slide) You do not know if she is confused but she
triggers on 3 other criteria so definitely requires admission.
– Continue Oxygen therapy & adjust as appropriate
– Sepsis six protocol
– Involve seniors
.
Hyperinflation
Right sided
pneumothorax
Small bowel
obstruction
Thoracic Aortic
dissesction
Ruptured abdominal aortic aneurysm
Subarachnoid haemorrhage
Extradural
haematoma
Extra example - Tom
• Tom is a 22 year old male. He has presented to A&E with

shortness of breath and an audible wheeze
• BP 135/90, T 36.5. RR 38

Tom
• Hb 11.0 (9.0 – 13.0)
• ABG on 15L oxygen via
• Wcc 6.0 (4.0 – 11.0)
• Plt 250 (150-400) non-rebreath mask
• pH 7.35 (7.35-7.45)
• Na 139 (135-145)
• PCo2 5.9 (4.5-6.0)
• K 4.5 (3.5-5.5)
• Ur 5.9 (3.3-6.6) • PO2 9 (10-12 in air)
• Cr 80 (80-120) • HCO3 23 (22-26)
• BE -3 (-2- +2)
Tom
Tom
Tom (answers)
– Hyperinflation of the chest
– FBC – normal
– U&E’s – normal
– Relative hypoxia – oxygen significantly lower than would be expected on 15L non-rebreath mask. Tyoe 1 respiratory
failure as CO2 just at higher end of normal limits. I would be concerned that the patient is starting to tire & that they
will soon develop type 2 respiratory failure as their ventilation becomes inadequate and CO2 rises. This is a sign of
severe asthma and may lead to intubation and ventilation being required. .
– Asthma exacerbation.
– Continue Oxygen therapy & adjust as appropriate
– Asthma management protocol – bronchodilators, steroids, magnesium
– Involve seniors early, may need critical care
.
summary
 Read instructions carefully
 Take time to look at data, formulate a differential

diagnosis & initial management plan
 Be confident in your approach
 Remember senior input

Data Interpretation Dec 2016 With Answers

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Data Interpretation Dec 2016 With Answers

Uploaded by

Copyright:

Available Formats

OSCE Data interpretation

• Questions from examiner

• ‘what do the blood tests show?’

• Use succinct language & be confident

• Show reasoning behind your thoughts

• Flag up potential dangers

• Normal MCV (Normocytic)

• Low MCV (microcytic)

• High MCV (Macrocytic)

• 2) Hb 82, MCV 70 • B) acute haemhorrage

• 2) Hb 82, MCV 70 • B) acute haemhorrage

• Cushings syndrome (excess plasma cortisol)

• Conn’s Syndrome (hyperaldosteronism)

• Cushings syndrome (excess plasma cortisol)

• Conn’s Syndrome (hyperaldosteronism)

• Alternative causes of a raised urea with

 Chronic renal failure

PaO2 10-12 kPa

Base Excess -2 - +2 mmol/l

• Ryan is a 17 year old male. He has presented to A&E with a 2

• Review the investigations provided. You will then be asked

• Blood glucose 35mmol/l

• Jack is a 77 year old male. He has presented to A&E with a 2

• Review the investigations provided. You will then be asked

• Dorothy is a 82 year old female. She has presented to A&E

• Review the investigations provided. You will then be asked

• Tom is a 22 year old male. He has presented to A&E with

• Review the investigations provided. You will then be asked

 Take time to look at data, formulate a differential

 Be confident in your approach

 Remember senior input

You might also like