by Josh Tipple
When asked a clinical question in an interview (or when asking yourself at work) it is important to make sure that you are covering all the information and show your understanding of the information that you have been given. It is thus very beneficial to approach any clinical question with a structure that will enable you to clearly show what you think is relevant, why it is relevant and how are you going to manage the problems that you have found.
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After working with students and newly-grads over the past few years, I have used a certain method with them for handing over patients and helping them in their clinical reasoning. I've called this The Vowel Method: it’s a 5-step process that will allow you to show your clinical reasoning systematically ("show your workings" for those who have done Maths).
Firstly lets go through the letters:
A – Assessment
In this part of your answer, you will want to pick out all of the relevant points that you can find in the scenario you are working with. For this part, just get used to pulling out the information that does not seem to be within its normal ranges or that are not following the pattern that you would expect. This is your problem list that will dictate your treatment plan.
E – Explanation
Extremely important! And very easily missed. Never expect that the interview panel know what you are talking about, spell it out to them, they want to know what you are thinking. Relate the information that you have highlighted in the assessment to the patient, explain to the panel why these things are important and how they may affect the patient in the given scenario.
I – Intervention/Implementation
What is your treatment plan with this patient, remember to relate this back to the 2 previous steps, what is relevant/important, why is it relevant/important (and how does it affect the scenario), and now say how you are going to manage those issues. This is a good time to bring in any evidence you know, and make sure if you talk about a treatment technique that you are ready to explain or demonstrate.
O – Outcome/Observation
In this section, you should talk about what you expect to see, what would be the desired effect on the patient. To show good understanding, explain the mechanisms involved in your treatments.
U – Update
What is your further management of this patient. In this section, think about what strategies you can use to keep the benefits of your intervention, you should also think about any onward referrals or handovers that you need to do.
Let’s try an example:
You are called into the ward to see a patient with pneumonia who has recently desaturated (normally 98% now 88%), they have had a recent ABG (pH 7.35, PaO2 7.4kPa, PaCO2 4.6kPa, BE 1, HCO3 22.5), the nurses report that they are awake but are very weak and that throughout the day they have been productive of thick green phlegm, but they have not seen them cough for a while.
When you get to the patient, you notice:
- The patient is slumped in bed
- Their RR is 26
- The patient is warm peripherally and has a CRT of under 2 seconds
- The patient is responsive and reports she feels that her chest is tight and that she has some phlegm but is finding it difficult to get it out, she also states she has a history of bronchiectasis
- On auscultation there are bi-basal crackles which are quite coarse
To approach this, you can use a table - this will help you systematically deal with the issues.
|
A |
E |
I |
O |
U |
| Hypoxaemia (PaO2 7.4kPa) |
Hypoxaemia is defined as a partial pressure of O2 below 8, this patient has a V/Q mismatch, most likely caused by the phlegm in her chest impeding gaseous exchange. |
The first thing to do is to get the patient on O2 as long as it is not contraindicated. This will require a doctor to prescribe. |
You would expect the PaO2 level to increased and her saturations improve. If they do not, you could try a salbutamol nebuliser or titrate the O2 up. |
Any addition of O2 should be closely monitored, close working with yourself and the medical team to ensure correct dosage. Also you would want to start the weaning process as soon as possible. |
| Poor Position (Slumped in bed) |
If the patient is slumped this has the effect of closing down the bases of the lung and impedes the normal functioning of the diaphragm. Also if parts of the lung are not taking part in gaseous exchange due to secretions we would want to ventilate the parts of the lung that are not affected. |
Position the patient appropriately, this would probably be your first treatment, you would base the position on your assessment and the patient’s tolerance. |
With some movement and patient involvement, you may get some expectoration, you would expect an improvement in her work of breathing and improvement of her saturations. If the patient does not improve or deteriorates, try another position, you may also want to try manual techniques. |
Ensure that the positions that the patient was improving with are clearly documented, you would also document any positions that caused desaturation. Make sure that the nursing staff and the physio team are aware, and any family members. |
| Secretions (Poor cough, crackles on auscultation) |
If a patient has unmanageable secretions, then this fluid will fill the parts of the lung that are involved in gaseous exchange. Low oxygen levels affect our energy levels and this has an effect on the cough mechanism, this patient seems to be losing their cough |
ACBT is the most effective form of chest clearance, it has the best evidence behind it and as long as the patient can follow the instructions then it is appropriate. |
You would want to see some sputum produced. If the patient does not, add in manual techniques and maybe a saline nebuliser. You could also try postural drainage. |
Teach the patient to do this themselves and ensure that they do it regularly to keep bringing up the phlegm. |
As you can see, your train of thought is clearly shown and you are able to systematically work through the problems that you have identified in the assessment. If you manage to approach clinical cases in such a way then you should cover everything you need to, especially in an interview situation. This can be used across all clinical areas (MSK/Resp/Neuro/Community) and can be modified to the timeline that you need. Obviously in an interview setting you do not need to go into a lot of detail but just get the main points in - remember, what the interviewers will want to see is that you are able to safely and systematically go through an assessment and treatment plan with a patient.
It can also be a good tool for discussing clinical cases with your seniors and peers once in the job. Wherever you use it, if you do, it’s not a prescription: it’s just a tool that you can change to your needs!
Nailed it!
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