OSCE/Havin heart disease< OSCE
Readiness to change
- Delve into why someone's not ready to change
- Pants off, down to underwear, full leg exposure, access to the groin
- Inspection: ankle/foot/toe swelling, varicosities, trophic changes (especially in the skin - infarction, necrosis/black, hair loss (sometimes a line on the leg where it stops), flaky, shinyness that doesn't look good, discolouration/pigmentation, ulcer (late sign)), scars, other evidence of vascular problems (e.g. vein stripping for bypass grafts)
- Oedema (medial side of lower aspect of tibia, push for a few seconds, then release pressure to look/feel for indentation). If found, check further up the leg
- Use backs of fingers at various points up the limb to feel differences in temperature
- Pulses (bilaterally); note for presence and strength (unlike radial pulse; just measuring vitality of vascular supply)
- Femoral pulse
- Popliteal pulse (reach fingers up to midline behind the knee; fingers directly behind inferior border of patella)
- Dorsalis pedis (lateral to extensor hallucis longus; rest fngers flat)
- Posterior tibial (posterior to medial malleolus; tarsal tunnel)
- Femoral artery
- Listen for bruits (turbulent flow through the vessel) (you do this over the carotids as well); high pitched whooshing noise due to constricted blood flow through a tortuous vessel; shouldn't hear noise because normal laminar flow
Murmur = turbulent flow across a heart valve
Bruit = turbulent flow within a vessel (esp. artery)
Motivational interviewing steps
- Provide opening structure
- Ask open ended questions
- Listen reflectively
- Identify motivators for/against 'problem behaviour'
- Identify impact and implications of problematic behaviour on patient/others
- Elicit self-motivational statements
- Summarise key issues
Involve them in it: "from my point of view, losing weight by exercising/eating less is a good idea, what do you think?" "what small changes could you make?"
- This gets them to tell themselves what to do.
- Get them to talk about pros and cons
- What is the worst thing that might happen if you don't change?
- What has to happen to make you change?
- What is the next change you need to make?
- Tap into self-efficacy: "how have you been successful in the past?". Remind them that they've had successes in the past, and that it's possible for them to succeed again
- Move from contemplation to action
- Get them to come up with a goal and commit to it.
- To assess self-efficacy, get them to reflect on the things that have made it difficult for them to change.
- "Where did you see yourself being at this stage when you were young? How does this differ to how you are?"