House Officer Preparation

Case study

• 65 yr old female• Referred by GP ? Appendicitis• Pt had pain+++ but not many signs so not

sure• Central and RIF pain• Now severe – pt moaning• Sudden onset• Nausea, no vomiting

• PMH COPD, hypertension, intermittent claudication

• o/e Confused, moaning, writhing in pain• Clammy, pale• Pulse irreg. irreg. 140• BP 80/40• Approx 50kg

• How do you proceed first?

a. Give cautious IV morphine

b. Carry on examination and examine chest

c. Give O2 15L/min

d. Insert IV line, take blood and give IV fluids

• On examination her chest is clear• O2 sats are 84% but erratic• Her radial pulses are not palpable but her brachials are • You should:

a. Take blood gases from the brachial arteryb. Take blood gases from the femoral arteryc. Take venous blood and analyse it insteadd. Insert an IV line, give fluids, take ABGs later when BP

improved and pulses palpable

• Describe how to take ABGs

• Blood gases show

• pH 7.30• pO2 23.5• pCO2 2.9• HCO3 17• BE -6

• This picture shows:

a. Metabolic acidosisb. Respiratory acidosisc. Metabolic alkalosisd. Respiratory alkalosis

• Metabolic acidosis is commonly caused by

• (true or false for each)

a. Diarrhoeab. Vomitingc. Shockd. Aspirin overdose

• You insert 2 Large bore IV lines• You take bloods and want to start IV fluids• Which of the following would be most

appropriate?

a. 1L Hartmann’s statb. 500 mls dextrose saline statc. 1L Hartmann’s over 6hrsd. 250 mls Hartmann’s stat

• On examination• Abdo not distended• Abdo slightly tender in RIF but no guarding• Absent bowel sounds

• She is still in pain, hypotensive and her urine output is low• Which of the following would be the most appropriate analgesia:

a. Paracetamolb. Ketorolacc. Morphined. Codeine

• Hb 17• WCC 25• Plt 400• PCV 50%• Na 135• K 2.9• Ur 13• Cr 110• LFTs normal• Amylase 220

• The most likely diagnosis is:

a. Acute pancreatitis

b. Appendicitis

c. Strangulated femoral hernia

d. Mesenteric ischaemia

• IV fluids have corrected the hypotension.• The medical registrar suggests you give a loading dose

of digoxin and correct the hypokalaemia.

• What would be her normal daily requirement for potassium

a. 70mmolb. 30mmolc. 50mmold. 100mmol

• Suggest some fluids to correct her hypokalaemia

• If she wasn’t NBM what else could you give her?

• The ideal value above which her serum K+ needs to be to control her AF is:

a. 3.0

b. 3.5

c. 4.0

d. 4.5

• Your boss arrives and commends you on an excellent job keeping her alive. However when she palpates her abdomen it is now rigid.

• The most likely cause is:

a. Perforation

b. Muscle spasm secondary to hypokalaemia

c. Bacterial translocation and peritonitis

d. Voluntary guarding

• Your boss tells you to sort the patient for theatre while she goes to get some coffee to wake her up.

• What do you need to do?

• You take the patient to theatre and find 2 feet of ischaemic small bowel which your boss resects.

• She has an uneventful recovery from the anaesthetic but due to lack of HDU beds has to go back to a normal ward.

• 20 minutes after you finally get to bed and fall asleep you are called by the ward saying that her urine output was 15mls then 0mls in the last 2 hours

• Her minimum acceptable hourly urine output should be:

a. 35

b. 30

c. 25

d. 20mls / hr

• What should you do?

a. Tell the nurses not to worry – it’s a natural response to trauma / surgery where you secrete more ADH, and go back to sleep

b. Ask the nurses to take an order over the phone for 250mls of Hartmann’s stat then phone you back if the urine output doesn’t improve; go back to sleep

c. Ask the nurses to speed up her fluids to 4 hourly, and go back to sleep

d. None of the above

• Run through the steps of what to do if a post op. patient has a low urine output

• The only nurse who can do an ECG is on her 2hr break. You have to do it yourself. How?

• You diagnose an MI. How should you proceed. True or false for each.

a. Thrombolysis

b. IV Heparin

c. LMW Heparin

d. Aspirin

• You discuss with your boss on the phone and she says she will talk to the ITU consultant on call about the possibility of a bed on ITU / HDU.

• What additional support will they be able to offer?

• Four days later the patient returns from HDU. Her clinical picture is good. She has passed flatus this morning, but your boss is reluctant to feed her yet. She asks you to prescribe maintenance fluids for the next 24hrs

• What is her daily requirement for sodium?

• What is the sodium content of N Saline?

• What is the sodium content of Hartmann’s?

• What is the sodium content of 5% Dextrose?

• What are the other constituents of Hartmann’s?

Table 1 Composition of crystalloid and colloid solutions usually available in hospital

Na+ (mmol/l)

K+ (mmol/l)

Cl - (mmol/l)

Ca2+

(mmol/l)

HCO3-

(mmol/l)

Energy (kJ/l)

Crystalloid

Normal saline (NaCl 0.9%) 154 - 154 - - -

NaCl 0.9%, KCl 0.15% 150 20 150 - - -

Dextrose - saline (NaCl 0.18%, dextrose 4%)

30 - 30 - - 669

Dextrose 5% - - - - - 837

Dextrose 5%, KCl 0.15% - 20 20 - - 837

Hartmann's solution 131 5 111 2 29 -

Colloid

Gelatine:

Gelofusine 154 0.4 125 0.4 - -

Natural:

Human plasma protein 157 2 118 - - -

Intravascularvolume (I)

Interstitialfluid (I)

Intracellularfluid (I)

Normal

Plus plasma 1.5 l

Plus 0.9% saline 1.5 l

Fig 1 Early effect of isotonic glucose, saline, and colloid infusion on intravascular volume, interstitial fluid, and intracelluar fluid

Plus 5% glucose 1.5 l

Estimated blood loss 1000 ml

               

 

Estimated blood loss 2000 ml

Estimated blood loss >3000 ml

Fig 2 Examples of fluid therapy in hypovolaemic shock

• What are the dangers of giving too much N saline?

• Her temperature is 38ºC, how does this affect how much fluid you should give

• Your team are away at a conference the next morning.

• You have to do the ward round on your own.

• What do you want to check?

• On the ward round, one of the nurses points out that the pt hasn’t had any Clexane since being transferred from HDU.

What do you do?a. Nothing – it’s too early post-op, the pt may

haemorrhageb. Give 20mg Clexane s/c odc. Give 40mg Clexane s/c odd. 1mg per kg bde. 1.5 mg per kg od

• The patient is still pyrexial.

• What are the possible sources of sepsis?

• What investigations should you do?

• The phlebotomists have been already this morning so you have to take your own bloods. What bottles do you need for the tests you have ordered?

• What order should you fill them and why?

• In general which bottle should not be underfilled?

• In general which bottle needs to be handwritten?

• Describe how to take blood cultures.

• How do you ensure you get your results back the quickest?

• Your boss phones you to ask how the patient is doing. You tell your boss that she has an Hb of 8.9. Your boss tells you not to transfuse. However after putting down the phone, being an ultra-sharp PRHO, you remember a reason to transfuse. What is it?

• How many units should you request? • How?• Why should you not transfuse too much?• What are the risks with transfusion?

• On day 7 post-op you are on nights again and whilst you, your reg and boss are all scrubbed in with an emergency aneurysm repair, you are bleeped to say that your pt has developed chest pain. Your boss says that she needs you to retract for another 5 minutes and then you can go.

• What do you ask the nurse to do in the meantime?

Sinus tachycardia

What blood tests do you order?

• Following her previous episode of anuria and MI she has developed renal failure.

Which test do you try and line her up for the next day?

a. VQ scanb. CT pulmonary angiographyc. Pulmonary angiographyd. Doppler US scan of her legs

• Radiology confirms PE.

What treatment do you start her on?

a. Clexane 60mg sc odb. Clexane 1mg/kg bdc. Clexane 1.5mg/kg odd. Warfarin

• How long does she need to be on Warfarin for?

• How do you decide her daily dose of warfarin?

• How do you arrange follow up for her INR check and warfarin dosing