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TACKLING MEDICAL TAKE SHIFTS Bassant Abdelfadeel & Matt MoxonObjectives ◦ To understand the structure of take shifts ◦ To review the basic principles of effective clerking and documentation ◦ To learn a systematic approach to diagnosing and managing various common acute medical presentations ◦ To practise applying this learning to tackling common clinical scenarios.STRUCTURE OF TAKE SHIFTSOVERVIEW OF SHIFT F1 shifts include: 1) Day, 2) On-call, 3) Night, 4) Take/Post-take 0800 Day Team 1700 On-call Team 0000 Night Team 0800 Take shifts are for completing the initial assessment and management of new patients Clerk new patients and Collect bleep complete tasks Return bleep Receive Handover to handover from On-call Team Day TeamPRINCIPLES OF CLERKING AND DOCUMENTA TION CLERKING 1. History ◦ PC ◦ HPC ◦ PMH ◦ DHx ◦ SHx ◦ ROS 2. Examination 3. Investigations 4. Impression 5. Plan CLERKING 1. History ◦ PC ◦ HPC Bedside Laboratory Imaging ◦ PMH • BM • Bloods • USS ◦ DHx • Ketones • Blood cultures • XR ◦ SHx • Urine dip • Urine cultures • CT ◦ ROS • Beta-hCG • Swab cultures 2. Examination • ECG • Stool samples • VBG orABG 3. Investigations 4. Impression 5. PlanDOCUMENT ATIONCOMMON MEDICAL PRESENTATI ONSSCENARIO 1 Mr Harvey is a 59 year old man who was admitted to ED with central chest pain. History: ◦ HPC – Central chest pain. Sudden onset at 10.30AM and lasted ~30mins. Crushing in nature. Radiates to jaw and left arm. Associated clamminess and SOB. 9/10. No fever/cough/urinary or bowel symptoms. ◦ PMH – HTN, T2DM. ◦ DHx – Ramipril 2.5mg OD, Metformin 500mg BD ◦ SHx – Lives with wife. Ex-smoker. Minimal alcohol. Examination: ◦ NEWS 1: RR 22, SpO2 96% on air, BP 124/87, HR 111, Alert, Temp 36.7 ◦ Appears clinically stable but visibly in a lot of pain. ◦ WWP. Pulse reg, good volume. HR >100. HS normal. ◦ Chest clear. Good AE throughout. ◦ Abdo soft, non-tender. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – eGFR >90, CRP 12, Na 136, K 4.2, LFTs NAD, INR 1.0, WCC 9.2, Hb 135. ◦ CXR – No focal consolidation.Images: https://litfl.com/anterior-myocardial-infarction-ecg-library/OVERVIEW OF ACS Investigations MONiCAS ◦ Bedside: ECG, VBG ◦ Bloods: CRP, U+Es, FBC, Clotting, Troponin M Morphine ◦ Imaging: ECHO O Oxygen Ni Nitrates (UNLESS low BP) Management: C Clot prevention A-E→ hypotensive / has HF/ syncope = 2222 +/- shoAk Antiplatelets S StatinsOVERVIEW OF ACS Investigations ◦ Bedside: ECG, VBG MONiCAS ◦ Bloods: CRP, U+Es, FBC, Clotting, Troponin M Morphine ◦ Imaging: ECHO Management: O Oxygen A-E→ hypotensive / has HF/ syncope = 2222 and shock Ni Nitrates (UNLESS low BP) ◦ Oxygen ◦ Analgesia C Clot prevention ◦ Aspirin 300mg STAT + Clopidogrel 300mg STAT A Antiplatelets ◦ GTN spray ◦ Fondaparinux 2.5mg S Statins ◦ Atorvastatin 80mg ◦ URGENT PCI – refer to CardiologySCENARIO 2 Mrs Chen is a 79 year old woman who was admitted to ED following an unwitnessed fall. History: ◦ HPC – After getting out of bed to go to the toilet, felt “funny” and collapsed. Hit head on side cabinet. No LOC. Unable to get herself up. Increased urinary frequency. No fever/cough/SOB/chest pain/abdominal pain/bowel changes. ◦ PMH – HTN, Osteoarthritis, AF. ◦ DHx – Bisoprolol 2.5mg OD, Ramipril 2.5mg OD, Apixaban 2.5mg BD. ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: ◦ NEWS 0: RR 18, SpO2 98% on air, BP 122/77, HR 72, Alert, Temp 37.4 ◦ Appears clinically well. ◦ WWP. Pulse irreg, good volume. HR 70. HS normal. Chest clear. Good AE throughout. ◦ Abdo soft, non-tender. BS present. ◦ Calves SNT. No oedema/erythema. ◦ Normal power in all four limbs. Not yet mobilised. ◦ Superficial laceration to R temple. No other signs of injury. No bony head/chest wall/spinal/limb/pelvic tenderness. Investigations: ◦ ECG – AF ◦ Bloods – eGFR 82, CRP 56, Na 135, K 3.3, LFTs NAD, INR 2.2, WCC 13.6, Hb 112, CK 542OVERVIEW OF FALLS Investigations ◦ Bedside: L/S BP, Urine dip, ECG, 24hr tape, VBG ICaPS ◦ Bloods: CRP, U+Es, FBC, Clotting I Injuries ◦ Imaging: CXR, Other XR, CT Head, CT Trauma Ca Causes P Prevention Management ◦ Analgesia S Setting ◦ Review and adjust medications ◦ PT/OT ◦ Discharge planningSCENARIO 3 Mr Singh is an 81 year old man who was admitted to ED with fever, cough, and new confusion. History: ◦ HPC – Unable to give history. Collateral history from daughter reveals a 5 day history of general malaise, cough with yellow/brown sputum, SOB, and new confusion. No N+V/urinary or bowel changes. ◦ PMH – HTN, MI, T2DM, Heart failure, OA. ◦ DHx – Multiple medications ◦ SHx – Lives alone with no POC. Non-smoker. Minimal alcohol. Examination: ◦ NEWS 10: RR 30, SpO2 96% on 2L, BP 92/58, HR 125, Confused, Temp 38.7. ◦ Appears clinically unwell. ◦ Dry mucous membranes. Cool peripheries. CRT 3 secs. Pulse reg, thready. HR >100. HS normal. ◦ Quiet breath sounds. R basal crepitations. ◦ Abdo soft, non-tender. BS normal. ◦ Calves SNT. No erythema. Pitting oedema to midshins bilaterally. Investigations: ◦ ECG – Sinus tachycardia ◦ Bloods – eGFR 52, CRP 304, Na 137, K 3.2, Urea 20, Creat 96, INR 0.9, WCC 15.9, Neut 10.2, Hb 132.Images: https://commons.wikimedia.org/wiki/File:X-ray_of_lobar_pneumonia.jpgOVERVIEW OF PNEUMONIA Investigations ◦ Bedside: Urine dip, Urine antigens, ECG, ABG, Sputum SEPSIS 6 culture 1. Oxygen ◦ Bloods: CRP, U+Es, LFTs, FBC, Clotting, Blood culture2. Antibiotics ◦ Imaging: CXR 3. IV fluids Management 4. Blood cultures ◦ Oxygen 5. Lactate ◦ IV fluids ◦ Co-amoxiclav 1.2g IV TDS + Doxycycline 200mg STAT 6. Urine output and then 100mg PO ODSCENARIO 4 Miss Williams is a 21 year old woman who was admitted to ED with severe wheeze and SOB. History: ◦ HPC – 4 hour history of severe wheeze and SOB. No fever/chest pain/urinary or bowel changes. ◦ PMH – Asthma ◦ DHx – Ventolin T-TT INH PRN, Beclometasone TT INH OD, Montelukast 10mg OD ◦ SHx – Lives in student halls. Non-smoker. Minimal alcohol. Examination: ◦ NEWS 7: RR 32, SpO2 98% on 15L non-rebreathe, BP 118/62, HR 126, Alert, Temp 36.3. ◦ Appears clinically unwell. ◦ W+WP. Pulse reg, good volume. HR >100. HS normal. ◦ Unable to complete sentences. Increased WOB. Polyphonic wheeze throughout. No crepitations. ◦ Abdo soft, non-tender. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ ECG – Sinus tachycardia ◦ Bloods – eGFR >90, CRP 7, Na 134, K 3.5, LFTs NAD, INR 1.0, WCC 9.8, Hb 125. On arrival Now pH 7.48 7.37 pO2 10 26 pCO2 2.3 6.1 HCO3 24 23 BE 2 1 FiO2 21% 60% Images:;OVERVIEW OF ASTHMA Investigations ◦ Bedside: ECG, Serial ABGs, Spirometry OSHITME ◦ Bloods: CRP, U+Es, FBC, Clotting O Oxygen ◦ Imaging: CXR S Salbutamol Management H Hydrocortisone ◦ Oxygen ◦ Salbutamol 5mg NEB I Ipratropium T Theophylline ◦ Ipratropium bromide 500micrograms NEB ◦ Prednisolone 3O-40mg PO OD / Hydrocortisone 100mg IV ODagnesium ◦ ESCALATE E EscalateSCENARIO 5 Mr Johnson is a 19 year old man who was admitted to ED with confusion and SOB. History: ◦ HPC – Unable to give history. Collateral history from mother reveals 4 day history of worsening N+V and generalised abdominal pain, further to a 2 month history of lethargy and weight loss. No fever/cough/chest pain/bowel changes. ◦ PMH – NF+W. ◦ DHx – Nil. ◦ SHx – Lives with mother. Non-smoker. Moderate alcohol. Examination: ◦ NEWS 6: RR 28, SpO2 94% on air, BP 98/62, HR 126, Confused, Temp 37.5. ◦ Appears clinically unwell. ◦ Dry mucous membranes. W+WP. CRT 3secs. Pulse reg, thready. HR >100. HS normal. ◦ Increased WOB. Chest clear. Good AE throughout. ◦ Abdo soft, non-distended. Generalised tenderness. No guarding/peritonitis. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ ECG – Sinus tachycardia ◦ Bloods – eGFR>90, CRP 4, Na 137, K 3.2, LFTs NAD, INR 0.9, WCC 9.2, Hb 132.OVERVIEW OF DKA Investigations ◦ Bedside: BM, Ketones, Urine dip, ECG, VBG DKA ◦ Bloods: CRP, U+Es, LFTs, FBC, Clotting, Glucose D Diabetic ◦ Imaging: CXR K Keto A Acidosis Management ◦ IV insulin ◦ Monitor glucose, ketones, pH and K ◦ IV fluids and K replacementSummaryKey Learning Points ◦ ALWAYS stick to your system! ◦ Use all your information to formulate your diagnosis and management plan ◦ Remember there can be more than one diagnosis! ◦ Take the time to document clearly and logically ◦ Use your final year to practise clerking as many patients as possible! ◦ Download the Smart Dr or Pocket Dr apps ◦ Make sure you can arrange basic investigations and prescribe common medications ◦ If in doubt, talk to your seniors!Questions