Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Medical Series: Acute Medicine Dr. Kitty Monks Foundation Year 2 DoctorSocial Medias Case 1 Question On a night shift, you are called to see a 23-year-old with known asthma who the nurses report is struggling to breathe, has been desaturating and ‘sounds very wheezy’. The nurses have already put the patient on oxygen and given her some 5 mg salbutamol nebulizers. Despite this, the patient appears to be worsening. What would you do next? A/ Patent E/ A. 15L NRB B/ B. Further 5mg salbutamol nebs Sats 94% 5L O2 RR 35 C. Hydrocortisone 100mg D. Ipatropium 0.5mg/6h C/ D/ HR 121 Regular GCS 15 E. Don’t know BP 95/30 BM 8.0 CRT 4 seconds PEARL HS I + II + 0 Temp 37.0 Case 1 Answer What is the most likely cause? The patient has already been given step 1 A. 15L NRB and 2 of the asthma treatment algorithm. B. Further 5mg salbutamol nebs The next sensible step would be to give the C. Hydrocortisone 100mg patient a steroid – either IV hydrocortisone D. Ipratropium 0.5mg/6h or PO prednisolone. As the patient is quite E. Don’t know sick – the IV option seems the better option. Case 1 Explanation • O – Oxygen: drive the nebs with the oxygen Classifying asthma severity: • S – Nebulized Salbutamol: 5mg ‘back-back’ nebs • H – Hydrocortisone – or PO prednisolone - Life threatening: PEFR <33%, Sats <92%, • I – Ipratropium Cyanosis, • T – Theophylline Hypotension, Exhaustion, Silent • M – MgSO4 • E – Escalate Chest, Tachycardia - Severe: PEFR <50%, can’t finish sentences, RR>25, HR>110 - Moderate: PEFR <75% - Mild: PEFR >75% Case 2 Question You are asked to see a 32-year-old man in the Emergency Department, who has come in with blurred vision following ‘a big night out’ yesterday. He also reports having some palpitations, but his ECG shows sinus tachycardia. Since his arrival in the ED the nurses report he has passed urine 4-5 times and his initial bloods show U+Es: Na+ 137mmol, K+ 4.7mmol, Urea 14.5, Creatinine 176. How would you treat his high blood pressure? A/ Patent E/ A. Bisoprolol 5mg B/ B. Labetalol 20mg Sats 95% OA RR 17 C. Glyceryl trinitrate 30mcg D. Nicardipine 5mg C/ D/ HRBP 250/145ar Patient agitated E. Don’t know L+R arm BM 8.0 CRT 4 seconds Pupils dilated HS I + II + 0 Temp 37.0 Case 1 Answer A. Bisoprolol 5mg Patient has SBP >220 and DBP >120 with B. Labetalol 20mg evidence of end organ failure – we can C. Glyceryl trinitrate 30mcg therefore call this malignant hypertension. D. Nicardipine 5mg Therefore, labetalol is our choice of E. Don’t know treatment. Explanation for wrong answers Images Case 1 Explanation • Malignant hypertension – is a medical emergency • dysfunctioned blood pressure– with new/progressive organ • Treatment aim – reduce BP to protect organs • Reduce mean arterial BP by 25% within an hour, then aim normal BP 24-48 hours Case 3 Question A 67-year-old man is admitted to the emergency department with sudden onset dysphasia, and full paralysis of the right-hand side. His wife reports that the symptoms came on about 2 hours ago and she brought him in straight away. A CT head shows complete occlusion of the left carotid artery. What would be the next appropriate step ? A/ Patent E/ A. Intubation and ventilation B/ B. Insulin infusion Sats 95% OA RR 17 C. Aspirin 300mg D. Alteplase C/ D/ HR 101 Regular GCS 7/15 E. Don’t know BP 110/70 BM 12.0 CRT 4 seconds PEARL HS I + II + 0 Temp 37.0 Case 3 Answer A. Intubation and ventilation This man has presented with an acute TAC B. Insulin infusion stroke. Prior to commencing treatment, the C. Aspirin 300mg patient needs to be stabilised. D. Alteplase GCS - 7/15 ‘8 = intubate’ E. Don’t know Therefore, first point of treatment would be intubation and ventilation Case 3 Explanation • CT scan has confirmed ischaemic stroke • Therefore - 1 line treatment is supportive care • Alteplase • Mechanical thrombectomy • Antiplatelet – aspirin (24 hours) Case 4 Question You are called to see an 86-year-old woman on the wards who has been complaining to the nurses about ‘feeling her HR’. The nurses have done a set of observations which shows the patient is tachycardic at 135 and because of this they have done an ECG for you to review. It shows a narrow complex, regular tachycardia. You ring the medical registrar having done an A-E. What can you do in the meantime? A/ Patent E/ A. 15L NRB O2 B/ B. 6mg Adenosine Sats 98% OA RR 19 C. 12mg Adenosine D. Vagal manouevres C/ D/ HR 135 Regular GCS 15 E. Don’t know BP 135/67 BM 8.0 CRT 4 seconds PEARL HS I + II + 0 Temp 37.0 Case 4 Answer A. 15L NRB O2 Following the algorithm for tachycardia– B. 6mg Adenosine first line of treatment would be vagal C. 12mg Adenosine manouevres. D. Vagal manouevres E. Don’t knowCase 4 Explanation Case 5 Question A 32-year-old woman with a history of poorly controlled Crohn’s disease presents to the Emergency Department with a 24-hour history of headache, fever, drowsiness, and on examination you elicit pain in her lower back when you flex her hip and ask her to extend her knee. You believe she is septic, so commence sepsis 6. What would be your next management step? A/ Patent E/ A. Lumbar puncture B/ B. CT head Sats 95% OA RR 21 C. Antibiotics D. Dexamethasone and C/ D/ Antibiotics HR 101 Regular GCS 14 BP 85/43 BM 8.0 E. Don’t know CRT 4 seconds PEARL HS I + II + 0 Temp 40.1 Case 5 Answer A. Lumbar puncture This patient has a clinical diagnosis of B. CT head bacterial meningitis. They have a fever, C. Antibiotics headache, drowsiness and on examination D. Dexamethasone and have elicited Kernig’s sign. By commencing Antibiotics sepsis 6 – you have started supportive care. E. Don’t know Case 5 Explanation • Bacterial meningitis is a medical emergency, in which there is life- threatening inflammation of the meninges. • In the UK usually caused by strep pneumoniae, Neisseria meningitidis and haemophilus influenzae type b • It is more common in older patients, or those who are immunocompromised • If suspected – need to start treatment immediately • Investigations: blood cultures, LP (unless signs of high ICP), supportive care • Once confirmed – follow local guidelines for specific pathogen specific antibiotics Case 6 Question You are called by the nurses to see a 56-year-old male patient on the ward who is having profuse ‘coffee ground’ vomit. On arrival the patient is still profusely vomiting dark red vomit. You perform an A-E and find observations as below. You decide this is an emergency, and call your senior who asks you to resuscitate the patient. You start the patient on oxygen. What would you like to give next? E/ A/ Patent A. IV Omeprazole B/ B. IV crystalloid Sats 89% OA RR 32 C. Un-crossmatched blood D. Tranexamic acid C/ D/ HR 125 Regular GCS 15 E. Don’t know BP 77/54 BM 8.0 Tender in epigastric CRT 6 seconds PEARL region HS I + II + 0 Temp 36.6.0 Abdomen soft Case 6 Answer A. IV Omeprazole Difficult question! All of these answers B. IV crystalloid could be right – if we look at the C. Un-crossmatched blood observations and back to our A-E. This D. Tranexamic acid patient is very unstable – and they will need E. Don’t know un-crossmatched blood next, we don’t want them to arrest before the blood arrives! Case 6 Explanation • Upper GI bleeds – common on night shifts! • Differentials: peptic ulcer disease, oesophageal varices, Mallory- Weiss tear • Need to act quickly + keep them stable before arrival of senior help • 2 large bore cannulae, bloods, VBG • IV fluids • Uncrossmatched RBC • IV omeprazole • TXA always has a role Case 7 Question A 50-year-old male has been brought into the emergency department in a remote DGH with acute crushing central chest pain that radiates into his L arm that started an hour and a half ago. His ECG shows ST elevation in II, III and aVF. The patient was given GTN spray and analgesics in the ambulance. What would be the most appropriate next action? A/ Patent E/ A. Fondaparinux and Aspirin B/ 300mg and Clopidogrel 300mg B. Measure Troponin I Sats 95% OA RR 23 C. Give Aspirin 300mg and D/ Clopidogrel 300mg C/ GCS 15 BP 148/70 BM 8.0 D. Give O2 15L via NRB HS I + II + 0 PEARL E. Don’t know Temp 36.6 Case 7 Answer A. Fondaparinux Clinical diagnosis of a STEMI– ECG changes B. Measure Troponin I and symptoms of ischaemia. C. Give Aspirin 300mg and In a remote hospital, primary PCI not always Clopidogrel 300mg available within 2 hours, so fibrinolysis first, D. Give O2 15L via NRB then they can be transferred to acentre to E. Don’t know have PCI within 24 hours.Case 7 Explanation Case 8 Question Following the ward round, you are checking some bloods when you see an anomaly. Gerald, a 74-year-old has deranged U+Es: Na 142mmol (137-144), K 7.0mmol (3.5- 4.9), Creatinine 245 (60-110), Urea 15.2 (2.5-6.5). You are immediately worried so go to assess the patient; you perform an A-E and ask for and ECG. It shows sinus rhythm with an elongated QRS complex and tall tented T waves. What is the most important first-line treatment? A/ Patent E/ A. IV calcium gluconate B/ B. IV insulin and dextrose Sats 95% OA RR 17 C. Nebulised salbutamol D. Oral calcium resonium C/ D/ HR 95 Regular GCS 15 E. Don’t know BP 115/72 BM 8.0 CRT 4 seconds PEARL HS I + II + 0 Temp 37.2 Case 8 Answer A. IV calcium gluconate This patient has very severe hyperkalaemia B. IV insulin and dextrose with ECG changes – therefore our first line C. Nebulised salbutamol of treatment should be protecting the D. Oral calcium resonium myocardium and preventing any life- E. Don’t know threatening arrythmias, therefore IV treatment is necessary. Case 8 Explanation • Hyperkalaemia ECG changes: prolonged PR interval, flattened/absent P waves, tall tended T waves, wide QRS • In hyperkalaemia this severe, will need to give IV calcium gluconate and patient will need transfer to HDU for cardiac monitoring until resolved • Differentials: CKD, AKI, metabolic acidosis, DKA, drug-related O O F Feedback & Instagram + 3C N O Please complete feedback to receive slides and cheat sheet!Follow our In3tagram pa e for MCQs! NH O Cl CH 3 CH3 OH CH 3 CH OH 3 3HC CH3 3HC O