F1 "On Call"

F1 On-Call

An Interactive Case Scenario

Congratulations, you have graduated from medical school!

You have had a month’s holiday to relax, change your title to “Dr” on all your bank cards and prepare for your first job.

Tonight, its your first night on call and you are the surgical F1! With your SHO, you are going to be looking after 8 surgical wards throughout the night. It is down to you to deal appropriately with any medical issues including emergencies.

Don’t forget, you can always bleep the on call registrar if you get stuck, but try not to call them unnecessarily otherwise you may become very unpopular!

Good Luck

Continue …

Time: 21:34Place: Doctor’s Mess

Your first night on call is going very smoothly. You are just about to reward yourself with a well deserved sandwich, but as you sit down in the doctors mess and unwrap your lunch box, your bleep goes off loudly. You check the number and see that it belongs to one of the surgical wards. As look at your sandwich, it looks at you… mocking you.

A) Answer the bleep quickly, it could be urgent!B) Eat the sandwich and take a 15 minute break, It almost definitely isn’t urgent.

Back to Beginning

Call the registrar! I don’t know what I’m doing!

Place: Doctor’s Mess Back

You ring the ward, the nurse on the phone tells you that she is concerned about Mrs M, a 70 year old lady who underwent an open cholecystectomy this afternoon. Mrs M was doing well initially after her operation, but she has now got worse, with an early warning score of 5. She has dropped her blood pressure and seems a little confused. She is catheterized but has not passed any urine in 4 hours.

You head down to the ward. As you do, you consider what could cause a drop in blood pressure in the post operative patient.

To the ward……

Place: Doctor’s Mess Back

You ignore the bleep for the time being, and enjoy your sandwich. As you sit back on the comfortable sofa your head begins to nod….

You violently awake to the sound of your bleep! You run to answer the phone, the registrar is very annoyed with you. You are on call and it is your duty to answer your bleep quickly, once you know what you’ve been called for, you can then decide how urgent it is!

You call the registrar for help…

The registrar is angry that you have called him for something so simple as answering your bleep. He asks you if you are really cut out for this job.

Well? Are you?

Back

Image taken from http://www.ncbusinesslitigationreport.com/tags/statute-of-limitations/

Time: 21:40Place: The Ward Back

You arrive on the ward and the nurse hands you Mrs M’s notes and her observation chart. She explains that Mrs M was due for surgery at 9.00 am, but due to a couple of emergencies, her surgery was pushed back to 3:00 pm and she came out of surgery at 4:40pm. Over the last couple of hours her observations have been declining and she has not passed any urine in 4 hours.

See initial clerkingSee observations chartSee drugs chartSee recent pathology tests

Go and see Mrs M….

See fluid balance chart

Clerking on Admission for Mrs M, 70 years old

PCRecurrent biliary colic

HxPC3/12 Hx abdo painPain in the epigastric regionSudden Onset.Pain is colicky.Pain sometimes radiates to the right shoulder tipThe pain is usually brought on after eating fatty foodPain usually lasts for about 3-5 hours at a time and occurs increasingly frequentlyPain is exacerbated by movement.She rates the pain at about 8/10 at its worstNausea and vomiting associated with episodes of pain. No Hx feverShe has noticed no change in bowel habit, stool colour, urinary habit or urine colour.

PMHxCholecystitis 2/12 agoAsthma, mild intermittentHypercholesterolaemiaAppendicitis 10 years agoMenorrhagia 20 years ago

PSHxAppendicectomy 10 years ago Hysterectomy 20 years ago

Current Medication NKDASimvastatin 40mg OD POSalbutamol 150 micrograms PRN Inhaled

Family HistoryMother had Gall Stones

Social HistoryRetired sweet shop owner, lives with her husband in Tiverton. Fully mobile and enjoys walking. Ex Smoker since 15 years. Used to smoke 20/day since 16 years old. Drinks small amounts of alcohol at weekends.

BackNext

Examination on admission

CVSBP 124/80HS I----II----0No signs of cyanosis/ anaemia

RSRR: 14Inspection: Breathing easily, no chest scars seen.

Palpation: No lymph nodes felt, Chest expansion normal.

Percussion: Normal and equal both sides.

Auscultation: Normal breath sounds.

Abdominal ExamInspection: Abdomen looks normal, with no obvious masses or liver signs. 2 Scars present. Hernial orifices clear.

Palpation: Tenderness in RUQ, no masses felt. Liver edge not felt, gall bladder not palpable. Kidneys not felt.

Percussion: normal, no hepatomegaly or splenomegaly.

Auscultation: Bowel Sounds Normal.

NeuroCN I-XII OKPERL

RUL LUL RLL LLLPower 5 5 5 5Tone Ok Ok Ok OkReflexes N N N NSensation Ok Ok Ok Ok

OBSPulse: 76BP: 124/80RR: 14SaO2: 98% OATemp: 36.8

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Observations ChartBack Next

Back

Medication chartBack

Turn over to see analgesia…

Back

22/2/1108:00 18:00 20:00

Hb 12.4

MCV 86

WBC 11.6

Platelets 245

Neutrophils 3.5

Total Bili 20

ALT 46

AST 34

ALP 40

GGT 30

Albumin 44

Na 142

K 3.9

Cl 105

Urea 4.4

Creat 100

C-reactive protein

10

Back

Back

Place: WardBack

You make your way to see Mrs M, she is lying in bed with her eyes closed. She seems drowsy and confused. She says she is not in any pain and is feeling better thanks to the patient controlled analgesia.

When you examine her, you find that she has a regular pulse of 90/min and a blood pressure of 94/52. Her respiratory rate is about 16/min and her oxygen saturation is 97% without oxygen. Capillary refill time is 3 seconds and there is an apparent loss of skin turgor. Her pupils are small and sluggish to react to light. Her mouth looks dry and her tongue is a healthy pink. Her lungs are clear and her cardiovascular exam is normal. You inspect her abdomen. She has a dressing on the RUQ and 2 drains which have produced a small amount of blood as well as 2 old scars from previous surgery. She is catheterised with approximately 130ml of urine in the bag. On palpation of her abdomen, there is tenderness over the sight of the wound and you can palpate a mass in the suprapubic region. There is some dullness to percussion over this area. Otherwise her examination is normal. You check her fluid charts and find that she has not produced any urine in the last 4 hours.

Next

Place: Ward Back

What are you going to do first?

A) Give 1 litre of normal saline IV and review in 1 hourB) Flush the catheterC) Give Naloxone 10mg IV Stat. D) Ask for 15 minute obs and review in 1 hour.


Check clerkingCheck obs chartCheck medication chartCheck bloodsCheck fluid balance

Oh Dear! After half an hour you are bleeped, the nurse tells you that Mrs M’s blood pressure and heart rate have picked up slightly, but she is still anuric.

When you see her, She is still confused and is beginning to become agitated. You wonder what you have done wrong. The question is what do you do now?

A) Give another litre of fluidB) Give 20mg IM furosemideC) Flush the catheterD) Give Naloxone 10mg Stat


BackPlace: Ward

Image taken from http://www.choicehow.com/2009/02/how-to-calculate-dextrose-when.html

Place: Ward Back

Good thinking! You flush the catheter which produces a few hundred millilitres of relatively dark urine. You find that the lump in her abdomen is no longer palpable and percussion is no longer dull in that area. You decide to take some blood to investigate her renal function. What else can you do?

A) Record the volume drained and take a sample for testing

B) Request plain film KUBC) Request urgent renal ultrasound

Image taken from http://www.lifelinesupply.co.uk/UrineCollectionBag.html

INFOStudent BMJ article on Post operative Oliguria:http://archive.student.bmj.com/issues/08/01/education/028.php

http://archive.student.bmj.com/issues/08/01/education/028.php

Place: Ward Back

You give 10mg Naloxone IV. After a short period Mrs M sits bolt upright in bed and screams. She then falls back into bed clutching her abdomen in pain. Her respiratory rate increases to 20 breaths per minute but her other observations do not change. She tells you that she feels like her bladder is about to burst. You realise that her catheter must be blocked.

You flush her catheter and give her a bolus of morphine to calm her down.

Continue… Image taken from http://www.atforum.com/newsletters/2007summer.php

Place: Ward

Back

You are bleeped by the nurse after 45 minutes. Mrs M’s Obs are declining and she now has an early warning score of 7.

The registrar is reviewing the patient and would like a word with you... Outside…

Image taken from http://brawl247thebook.com/2010/12/can-you-fight-cancer-or-any-illness/



You bleep the registrar who calls back shortly. To your embarrassment he diagnoses the problem over the phone and suggests that you take a little more time to reflect on the findings of your examination.

Go back to the ward…


Image taken from http://nps.cardinal.com/nps/content/nucpharm/complex/index.asp


You give another litre of saline and leave. 1 hour later you are bleeped again and return to the ward. The registrar is waiting for you. He asks you why you thought it appropriate to give this lady 2 litres of fluid when she was obviously in urinary retention. In a completely anuric patient, you should always consider urinary outflow obstruction. In this case a blockage in the patient’s Foley catheter is the most likely cause. In men, prostatic hyperplasia can also cause acute urinary retention. If this is not treated promptly, patients can become hydronephrotic, which can lead to acute renal failure!

Clues to look for-

No urine output Palpable bladderDiscomfort

Remember!When the urine output is low, always check for lower urinary tract obstruction. Palpating the bladder will give you an idea.

Place: Ward Back


http://emedicine.medscape.com/article/436259-overview


You give her 20 mg of IM furosemide. One hour later, you are bleeped again and return to the ward. The registrar is already there. He asks why you gave furosemide to an anuric, hypovolaemic patient. You explain that you were concerned about the patients poor urine output. He tells you that the patient’s urine output was poor because of a blocked catheter and because you had failed to recognise this the patient is now in danger of developing renal failure.

He tells you to go home and read up on post operative care. You are clearly not competent enough to be allowed to deal with patients on your own.

Place: Ward Back

INFOStudent BMJ article on Post operative Oliguria:http://archive.student.bmj.com/issues/08/01/education/028.php Image taken from

http://well.blogs.nytimes.com/2010/10/07/when-doctors-get-depressed/


You call the registrar and tell him about Mrs M’s anuric state. He asks you if you have checked to see if Mrs M has a urinary outflow obstruction.

“It’s quite simple, can you palpate her bladder? If so she’s probably got a blocked catheter. You need to flush it quickly!”

Feeling a little foolish, you return to the ward.

Back to the ward….

Correct!You need to record the volume drained and to collect a sample for microscopy and culture.

Measuring the volume will help you to decide if this is just a simple “one off” case of acute urinary retention caused by a blocked catheter or if this is an acute on chronic episode.

Culture and microscopy will help you to exclude any serious causes of acute urinary retention as well as urinary tract infections (common in a catheterised patient), haematuria and markers of renal failure.

Continue...

Back

INFOMap of Medicine, NHS. Guidance for acute urinary retention. http://eng.mapofmedicine.com/evidence/map/acute_urinary_retention_aur_in_adult_males1.html

http://eng.mapofmedicine.com/evidence/map/acute_urinary_retention_aur_in_adult_males1.html


Incorrect!A KUB X-ray is helpful in diagnosing the presence of ureteric calculi (or kidney stones) and can be useful if a bowel obstruction is suspected. However, we have no reason to suspect either of these events based on our patient’s history and examination.

You should measure the volume of urine drained to help you to decide if this is just a simple “one off” case of acute urinary retention caused by a blocked catheter or if this is an acute on chronic episode.

You should also take a sample for culture and microscopy. This will help you to exclude any serious causes of acute urinary retention as well as urinary tract infections (common in a catheterised patient), haematuria and markers of renal failure.

Continue...

Back




Incorrect!A renal ultrasound would be necessary if prolonged high volume urinary retention had occurred. You may yet need to order one if the renal function tests come back as deranged.

You should measure the volume of urine drained to help you to decide if this is just a simple “one off” case of acute urinary retention caused by a blocked catheter or if this is an acute on chronic episode.

You should also take a sample for culture and microscopy. This will help you to exclude any serious causes of acute urinary retention as well as urinary tract infections (common in a catheterised patient), haematuria and markers of renal failure.

Continue....

Back




Place: The Ward

Congratulations! You have solved the problem of Mrs M’s anuric state. But you’re not finished yet....

You review Mrs M’s observations:

Pulse: 96 Regular BP: 92/50RR: 16Temp: 36.8SaO2: 97% without oxygen

What is the most likely cause of her deranged observations?

A) HypovolaemiaB) SepsisC) Pulmonary embolismD) Opiate toxicity

Back

Correct!

A tachycardia and hypotension after surgery strongly suggest a low blood volume. This can be due to bleeding and dehydration. In this case dehydration is the most likely cause because:

•Mrs M’s operation was scheduled for 9am and then pushed back to 4pm which means she will have been nil by mouth since midnight the night before. Although patients are allowed to drink water at this time, they often don’t drink enough to stop them becoming dehydrated. •Mrs M is showing classic signs of dehydration:- loss of skin turgor, dry mucous membranes and slow capillary refill (>2 seconds). •You have already checked Mrs M’s wound and drains which have shown no signs of significant blood loss and there is no sign of bruising or blood leaking from the wound.

However, you MUST always consider bleeding in the postoperative patient with hypovolaemia. If you suspect bleeding or are unsure in any way, call for senior assistance!!!

Continue

Back

Incorrect!

Mrs M has only come out of surgery a few hours ago and is apyrexial. It is very unlikely she will be in septic shock. Infection is a rare complication of most general surgical procedures and doesn’t tend to present until at least a day later.

Early signs of infection can be seen at the sight of surgery. Look for any signs of inflammation including redness, swelling, heat and pain.

Try again....

INFOMore information on the symptoms, signs and management of septic shock:http://emedicine.medscape.com/article/786058-overview


Incorrect!

Massive pulmonary embolism can cause hypovolaemia due to a cor pulmonale however it is very unlikely. You would expect to see signs of breathlessness, reduced SaO2 and chest pain.

Try again...

INFOMore information about the symptoms, signs and management of a massive PE hereBritish Thoracic Society Guidelines on management of a suspected massive PE here





http://www.patient.co.uk/doctor/Pulmonary-Embolism.htm

http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pulmonary%20Embolism/Guidelines/PulmonaryEmbolismJUN03.pdf

Incorrect!

This lady has a tachycardia and hypotension. Opiate toxicity would present with pupillary miosis, respiratory depression and drowsiness.

Try Again...

INFOInformation on opioid overdose: http://eng.mapofmedicine.com/evidence/map/opioid_overdose2.html

http://eng.mapofmedicine.com/evidence/map/opioid_overdose2.html

Place: The Ward

How should you address her apparent hypovolaemia??

A) Give 2 litres of saline over 8 hoursB) Give a fluid challengeC) Refer to ICU for central venous pressure moni

toring. D) Encourage oral fluids over night and review in

the morning.

Call the registrar! I don’t know what I’m doing!!

Back

Place: Ward Back

You prescribe 2 litres of saline with instruction for this to be given slowly over 8 hours. You are called back half an hour later as her observations are getting worse. Her obs are

Pulse: 122BP: 90/50RR:16Urine output (last hour)- 10mlTemp: 36.3SaO2: 96%

You call your registrar, who suggests you give a bolus of fluid to replace the deficit. You are currently giving too little too slowly. He tells you to give a fluid challenge.

Continue…

What is a fluid challenge?

A) 1 litre of Saline given over 30 minutes followed by re-assessment.

B) 250 ml of Colloid over 10 minutes followed by re-assessment.

C) 500 ml of Hartmann’s given over 45 minutes followed by re-assessment.

D) A pint of water to be downed in the fewest number of gulps possible.

Back

Picture taken from http://www.hamovhotov.com/fun/?m=20070730&paged=2

You phone ICU and explain your situation to the SHO on the receiving end. To your embarrassment, he tells you to that F1 doctors on their first night on call should not be making ICU referrals without having consulted their seniors. He suggests you administer a fluid challenge.

Back…

Image taken from http://www.alcoholics-information.com/Alcoholic_Rehab_Center.html

Despite a lot of encouragement, Mrs M does not manage to consume much water. She is now delirious, agitated extremely dehydrated. You need to give her more fluid more quickly!!

Back…

Image taken from http://www.sciencemadesimple.co.uk/page72g.html

The registrar thanks you for phoning him. He also congratulates you on spotting the blocked catheter! He explains that the patient is most likely hypovolaemic as she has been nil by mouth all day as her surgery was delayed until the afternoon. He suggests you give her a fluid challenge.

Back…

Incorrect!

A fluid challenge is a useful thing to know about! It is the first port of call for when dealing with a patient with evidence of volume depletion. A 250ml bolus of colloid should be given over 10-30 minutes depending on which guidelines you follow. The patient should then be reassessed. If the blood pressure does not increase, or increases and then returns shortly, the patient is hypovolaemic and further 250ml boluses of fluid should be given until normovolaemia is reached. If the blood pressure increases and remains increased, this suggests the patient is already normovolaemic and an alternate cause of their apparent hypovolaemia should be investigated. If the patient fails to respond to 2 fluid challenges, call senior help as they may require Central Venous Pressure monitoring.

INFOhttp://archive.student.bmj.com/issues/04/04/education/144.php (Student BMJ : Acute care, Volume resuscitation)http://www.sign.ac.uk/pdf/sign77.pdf (Sign Guidlines for post operative management in adults. Page 31 covers fluid challenges)

Continue….


http://www.sign.ac.uk/pdf/sign77.pdf

Correct!

This is indeed the guidance set out for administering a fluid challenge. Fluid challenge is the first port of call for when dealing with a patient with evidence of volume depletion. A 250ml bolus of colloid should be given over 10-30 minutes depending on which guidelines you follow. The patient should then be reassessed. If the blood pressure does not increase, or increases and then returns shortly, the patient is hypovolaemic and further 250ml boluses of fluid should be given until normovolaemia is reached. If the blood pressure increases and remains increased, this suggests the patient is already normovolaemic and an alternate cause of their apparent hypovolaemia should be investigated. If the patient fails to respond to 2 fluid challenges, call senior help as they may require Central Venous Pressure monitoring.


Continue….



Incorrect!

Not quite, but you’ve got the right idea. A 250ml bolus of colloid should be given over 10-30 minutes depending on which guidelines you follow. The patient should then be reassessed. If the blood pressure does not increase, or increases and then returns shortly, the patient is hypovolaemic and further 250ml boluses of fluid should be given until normovolaemia is reached. If the blood pressure increases and remains increased, this suggests the patient is already normovolaemic and an alternate cause of their apparent hypovolaemia should be investigated. If the patient fails to respond to 2 fluid challenges, call senior help as they may require Central Venous Pressure monitoring.


Continue…



Well obviously not!

Med School is over, this is not the time or place to play pub golf.

Try again…

You give Mrs M 250ml Colloid solution and re-assess her. There is no change in her blood pressure and heart rate yet. You repeat the fluid challenge and her heart rate begins to decrease and blood pressure picks up to 100/60. You give 2 more fluid boluses over next hour and then start her on some maintenance fluids.

You notice that she is still drowsy and her respiratory rate has dropped to approx 8 breaths/minute. Her SaO2 is now 93%. You give high flow oxygen which increases her saturation to 97% but her respiratory rate is still very low. What should you do?

A) Give IV Naloxone 2mgB) Remove PCA and replace with a 75 mcg fentanyl patchC) Give IV Naloxone 100 mcg and re-assessD) Call the crash team


Back

You give Mrs M a 10mg bolus of Naloxone. She jump sits up suddenly, screams in pain and punches you in the face. As you hold onto your bleeding nose, she collapses back into bed clutching her abdomen in pain. You do notice that her respiratory rate has now increased to 22 breaths per minute. As you approach her to give some more pain relief, she swears at you and tells you to leave her alone as you’ve done enough damage already! The next morning on the ward round, she points you out to your consultant and asks him not to let you treat her any more.

What a shame! You were doing so well…….

Back...

INFOManagement guidelines on opioid toxicity:http://eng.mapofmedicine.com/evidence/map/opioid_overdose2.html


You remove the PCA and give Mrs M a 75mcg fentanyl patch.

When you return to the ward 3 hours later you find the crash team trying to resuscitate Mrs M, but with little success! The Anaesthetist in charge asks you why you thought it suitable to give Mrs M such a high dose of fentanyl when she had developed no opioid tolerance at all!

The crash team fail to bring Mrs M round and it is down to you to explain to her relatives what happened.

Good luck

Back



You give Mrs M 100 mcg of Naloxone and re-assess, after 300 mg her respiratory rate picks up to 14 and she seems less drowsy. He pupils are equal and reactive to light. You quickly assess her cognitive state and find she is fully orientated. You halve the bolus dose of morphine.

Continue...

Back



The crash team arrive and assess Mrs M. They quickly realise that she is showing signs of opioid toxicity. The anaesthetist in charge asks you what the signs of opioid toxicity are and how you manage it.

Back...



You call the registrar, who is very impressed with your management of the patient so far. He suggests that the patient may be taking to high a dose of morphine. He recommends that you give Naloxone to the patient, but slowly a bit at a time otherwise she will suddenly come round in pain. He then suggests you decrease the patients morphine bolus as she is obviously on too much. He asks you to call him earlier next time! He tells you that he is on his way down to check on your progress.

Back

The registrar asks you to make sure you add Naloxone PRN on Mrs M’s drug chart. He also asks “Why is this necessary?”

The Ward

A) In her already delicate state, Mrs M is more susceptible to opiate toxicity, even when the dose has been halved.

B) Mrs M’s renal function will have been compromised by her hypovolaemia, leading to a more rapid excretion of naloxone from the kidneys.

C) Naloxone has a shorter half life than morphine. D) It is purely a precaution and is to save you from being called

back to prescribe more should she need it.

Back

Incorrect!

The registrar is not impressed with your rather vague explanation and asks you to try again.

Try again....

Incorrect!

The registrar is very unimpressed with your completely incorrect explanation. “Firstly, its unlikely she is in renal failure, secondly renal failure would not increase her rate of excretion!”He asks you to have another go- and not to make stuff up!

Try Again...

Correct!

INFOFor more information about treatment of opiate toxicity:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726910/pdf/v022p00612.pdf

The registrar is impressed with your knowledge, he expands:

“The half life of Naloxone is 64 minutes compared to the half life of morphine which is around 2-3 hours. Subsequently patients who have been treated for opiate toxicity should be observed for 2-3 hours and it is wise to prescribe Naloxone PRN (as required). If this is not done, opiate toxicity could reoccur. This is most often occurs in emergency departments where heroin addicts self discharge after being treated with naloxone. They are often found dead the next morning.”

Continue...

Back

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726910/pdf/v022p00612.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726910/pdf/v022p00612.pdf

Incorrect!

The registrar shakes his head. “No there is actually a reason.... Think about it!”

Try again...

CONGRATULATIONS!!!!

You have survived your first night on call and successfully managed a patient with several common post operative complications! Of course this only covers a few of the problems you will come across as a surgical F1, but hopefully it should help you get into the appropriate mindset for tackling similar problems in the future.

Remember, when in doubt always ask for help!

Try some short cases...

Short Case 1

You are called to the ward at 4.30 am to see Steve, a 25 year old man with persistent vomiting. He has been recovering from an emergency laparotomy which was carried out 3 days ago. One of your colleagues has seen him already and prescribed anti-emetics, but no examination is documented. You see in Steve’s notes that he underwent an emergency laparotomy for trauma, the bowel was examined thoroughly, but no injury was found. NG tube was not placed after surgery and following an apparently good recovery, his catheter was removed and he has recently started oral fluids.

On examination, Steve is very distressed. His pulse is 116 and BP is 122/80mmHg, he is apyrexial and his SaO2 is 9 There is a midline incision which is covered with a dressing. His abdomen is distended and tender to palpation. Bowel sounds are not present on auscultation.

You request an urgent abdominal X-ray.

Continue....

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What is the most likely cause of Steve discomfort?

A) Ischemic bowel strictureB) Gallstone IleusC) Bowel Rupture into the Peritoneal cavityD) Paralytic IleusE) Strangulated Hernia

Back

Image taken from http://www.ganfyd.org/index.php?title=Ileus

http://www.ganfyd.org/index.php?title=Image:Axr_ileus.jpg

Bowel ischemia is unlikely in a 25 year old man. No complications were mentioned in his operation notes and if surgery had caused ischemia, he would probably have presented sooner!

Try again...

Incorrect!

This is unlikely in a 25 year old man and this was not mentioned in the history. Remember gallstones typically present in: Fair, Fat, Forty year old Females!

Try again...

Incorrect!

This would present with fever, rigors and sweating. Also no complications were mentioned in the operating notes and no actual surgery took place on the bowel itself.

The X ray shows inflated loops of small bowel, which implies presence of an obstruction. What could have caused this?

Try again...

Incorrect!

Steve has a post operative paralytic ileus. An ileus is a disruption in the normal peristaltic motility of the bowel which can lead to obstruction. Ileus is common after abdominal surgery, but usually resolves within 2-3 days. If it purists, it becomes termed a paralytic ileus. Steve’s symptoms have recently erupted as he has only recently started taking oral fluids.

Correct!

Continue...

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Incorrect!

Although this can cause Steve’s symptoms, there has been no mention of any hernia in the examination or history.

However, one should always check the hernial orifices during an abdominal examination.

Try again...

How should Steve initially be managed?

A) Anti-emetics, opioid analgesia and stimulant laxatives.

B) Nasogastric tube, NSAIDs, Urinary catheter. C) Call consultant for emergency disimpaction of

bowel. D) Nasogastric tube, opioid analgesia and IV fluid

s.

Back

After an hour of treatment, there is very little change. Steve is still vomiting and his abdomen is extremely distended. However he does feel much more relaxed. You call your registrar for help and he is not impressed with your surgical knowledge. This is not how you acutely manage a bowel obstruction!

Incorrect!

Try again...

Correct!

A nasogastric tube is used to decompress the bowel and allow the contents to flow out without the patient needing to vomit.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used in preference to opioids as opioids are likely to contribute to bowel immobility.

A urinary catheter should be placed to monitor fluid output. IV fluids may be required if Steve is dehydrated.

Blood should also be taken to check for electrolyte imbalance which can cause an ileus.

Continue...

Back

Incorrect!

The consultant is not amused.

Steve can be managed by more conservative means for the moment and he is unlikely to require further surgery.

Try again...Image taken from http://www.mirror.co.uk/news/top-stories/2009/04/19/bt-are-charging-you-7-for-wake-up-call-115875-21288732/

Incorrect!

Although a nasogastric tube is needed to decompress the bowel, opioid analgesia is contraindicated as it is liable to slow bowel motility further. Although IV fluid may well be necessary, it is useful to get a measurement of Steve’s urine output first.

Try again...

Short Case 2You are called to one of the orthopaedic wards to review Doris, a 78 year old lady who underwent an elective total hip replacement 6 days ago.

The Nurse is concerned about Doris as she has become extremely short of breath in the last hour. When you arrive, you find Doris sitting up in bed with an oxygen mask on. She tells you that she gets some sharp pain in her chest when she breaths in. She struggles to speak in full sentences.

On examination she has a respiratory rate of 32/minute, pulse of 112/minute and regular and a blood pressure of 102/78. Her SaO2 is 92% and she is apyrexial. Respiratory examination is otherwise normal as is cardiovascular and abdominal examination.

Continue...

Back...

What should you do first?

A) ABG, Peak Flow and Blood Cultures

B) ECG, Chest X-Ray and ABGC) V/Q ScanD) CT Pulmonary AngiogramE) D-Dimer

Back

Incorrect!

Her Peak flow is within the normal rang but her ABGs show a decreased partial pressure of oxygen. While you wait for the results of the blood cultures, Doris dies on the ward. Your registrar is not happy with you, and neither are Doris’s relatives!Consider the clinical picture, what should you be most concerned about? Is there a quicker way to rule out an infection?

Try again...Image taken from http://www.health212.com/too-many-people-are-dying-in-hospital-against-their-wishes.html

Correct!

These are the basic initial investigations recommended by the British Thoracic Society.

Her chest X-ray is shows no obvious abnormality. Her blood gasses come back as a PaO2 of 7.0 and a PaCO2 of 3.6, but otherwise normal. Her ECG is shown below.

Continue...Image taken from http://www.learntheheart.com/PulmonaryEmbolism.html

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Incorrect!

The on-call radiologist laughs: “You might want to carry out some basic tests first and you might want to consult your seniors before coming straight to me!”

A V/Q scan may be required to confirm a pulmonary embolism, however it would be wise to rule out other causes of chest pain and breathlessness before doing this.

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Incorrect!

The on-call radiologist laughs: “You might want to carry out some basic tests first and you might want to consult your seniors before coming straight to me!”

A CTPA may be required to confirm a pulmonary embolism, however it would be wise to rule out other causes of chest pain and breathlessness before doing this.

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Incorrect!

D-Dimer is a useful test to rule out a pulmonary embolism, but is not at all specific. You may wish to carry out a few other more basic tests to rule out other causes of breathlessness first.

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You recognise the S1,Q3,T3 pattern on the ECG and suspect a pulmonary embolism. You call the registrar who asks you to do a quick “risk assessment” while he makes his way down to you.

How should you assess Doris’s risk?

A) CURB 65 ScoreB) CHADS2 ScoreC) Well’s ScoreD) Modified Glasgow ScoreE) ABCD2 Score

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Incorrect!

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CURB 65 is a scoring test to assess severity of pneumonia.

ConfusionUrea>7Respiratory Rate >30Blood Pressure <90 Systolic65 Years +

1pt1pt1pt1pt1pt

<2 Treat at home=2 Admit3-5 Severe- consider intensive care

Incorrect!

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The CHADS2 score is used to asses a patient for Warfarin treatment.

Cardiac failureHypertension Age >75DiabetesStroke Hx

1pt1pt1pt1pt2pts

>2 Warfarin is indicated

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The Wells score is used to give a rough estimate of the risk of Pulmonary Embolism. It is not a perfect test as part of it is subjective and relies on your own opinion. The test can be used to decide what further action can should be taken.

•Clinically Suspected DVT : 3pts•PE is Clinically Suspected: 3pts•Tachycardia: 1.5pts•Hx Immobilization/ Surgery in previous 4 weeks: 1.5 pts•Haemoptysis: 1pt•Malignancy: 1pt

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<2: Mild Risk2-6: Moderate Risk>6: High Risk

With no evident DVT, Doris has a score of 6 placing her in the moderate category, but only just.

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The Modified Glasgow Score is to asses the severity of acute pancreatitis.

PaO2 <8 kPaAge > 55Neutrophils (WCC) > 15Calcium <2 mmol/LRenal Function (Urea) >16Enzymes (LDH) >600 iuAlbumin <32g/LSugar (Glucose) >10mmol/L

1pt1pt1pt1pt1pt1pt1pt1pt

>3 predicts severe pancreatitis

Incorrect!

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The ABCD2 score is used to assess patients for risk of stroke following a suspected TIA.

Age >60: 1ptBlood Pressure >140/90: 1ptClinical Features, Speech: 1pt, Unilateral Weakness: 2ptsDuration <1 Hr: 1pt, >1Hr: 2ptsDiabetes :1pt

Risk of stroke in 90 days: 0-3 Low, 4-5 Moderate, 6-7 High

The registrar arrives and you present the case to him. He is impressed with your risk assessment and tells you he will take it from here.

He suggests you go to the doctors mess and put your feet up for 20 minutes. You take him up on that offer.

Image taken from http://maxcdn.fooyoh.com/files/attach/images/591/314/413/004/feet-up-cats.jpg

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Useful Resources

ResourcesStudent BMJ: Managing Post Operative Oliguria http://archive.student.bmj.com/issues/08/01/education/028.php SIGN Guidelines in post operative management can be found here, also available is a quick reference guide.

BTS Guidlines for suspected Pulmonary Embolismhttp://www.brit-thoracic.org.uk/Clinical-Information/Pulmonary-Embolism/Pulmonary-Embolism-Guidelines.aspx



http://www.sign.ac.uk/guidelines/fulltext/77/index.html

http://www.brit-thoracic.org.uk/Clinical-Information/Pulmonary-Embolism/Pulmonary-Embolism-Guidelines.aspx

http://www.brit-thoracic.org.uk/Clinical-Information/Pulmonary-Embolism/Pulmonary-Embolism-Guidelines.aspx

Documents

F1 "On Call"