Bill Flashcards
What is part of Bill’s patient profile?
He is homeless - been sleeping rough for 4 years
He is a smoker (rolls up his cigarettes)
Keeps his cuff links - wants to get better
What does the case video say about Bill when they found him?
Showed up late a night to a homeless shelter, he was groggy, they think he’s a drinker and a smoker (not sure about drugs)
He wasn’t woken up by a fire alarm at 2:30am at the homeless shelter (false alarm), v. difficult to rouse, non-verbal
Ambulance was then called - arrival at the scene he was drowsy
What does the case video say about Bill’s stats at arrival?
GCS of E3, V4, M6 (this fluctuates) Both pupils 3mm, unreactive Temperature = 37.4; BP = 89/65; HR = 97; RR = 14; O2 sats at arrival were 90% Unknown past medical history His BGL is 4.2
What had the paramedics done before his admission to hospital?
Glucogel given
One cannula in the right AVF
500ml of fluids to bring his systolic to 105
2L of O2 so sats are now at 94%
What did the paramedic find on Bill?
Smoking papers
Papers with number on
Smells of alcohol
What did his letter say?
He is susceptible to infections
He smokes
He finds it hard to get a decent meal - poor diet
Poor mental health
What do we see in Bill?
Altered mental state
Mental state consists of what two parts?
- Consciousness (attentiveness)
2. Cognition (mental proecsses / thinking)
How would you work out what is happening with Bill?
Use the symptom sieve
What is the symptom sieve used by the doctor?
Primary neurological Infection Cardiorespiratory Gastro-intestinal Metabolic/Endocrine Toxins Psychiatric
What are the most likely categories from the symptom sieve that apply to Bill?
Neurological - trauma
Infection - has been sleeping rough for 4 years
Cardio-resp - low BP and sats
Toxins likely - alcoholism, may use drugs
Psychiatric - disorientated, letter stated low confidence
GI - alcohol poisoning, poor diet, distended abdomen, pancreatitis, appendicitis
What is GCS?
So then what is meant by - E3 V4 M6?
Glasgow Coma Scale E = eye-opening response V = verbal response to commands M = motor response The higher the number, the more responsive
What is an A-E assessment? What does it look at?
Carried out on unwell patients to assess their vitals A - Airway B - Breathing C - Circulation D - Disability E - Exposure
What would an Airways assessment show in Bill?
Who could you call when examining airways?
Verbalising intermittently
No foreign objects in mouth or excessive secretions
No snoring / stridor
No mouth or tongue swelling
An anaesthetist who are experts in airway management
What observations can you make about Bill’s breathing?
What do you look at in the neck as a part of the breathing assessment?
Normal resp. rate (14 breaths per min) Slight wheeze (stridor) when examining abdomen He was distressed 90% sats but 94% on 2L oxygen Smoker
Look at the muscles in the neck e.g. scalene
What can you exclude when assessing breathing?
Exclude trauma to neck
C3,C4,C5 keeps the diaphragm alive
What else is important when assessing breathing and how can this be noticed?
Smoking history - nicotine stained fingernails
What did the circulation assessment show in Bill?
Blood pressure - 89/64 mm Hg
Heart rate - 110 bpm
Heart sounds - normal
12 lead ECG - sinus tachycardia nil. ischaemic changes
Peripheral capillary refil brisk bilaterally ( more than 3-4 secs)
Warm peripheries, looks flushed
What is most concerning about the circulation assessment?
Blood pressure is low
High heart rate is normal response
Worry about shock and its consequences
How do you conduct a capillary refill test?
Lift patients hand to heart level
Place pressure on the fingernail see how long it takes for colour to return
Why does Bill look warm and flushed?
Perhaps alcohol increasing blood in the peripheries
Infection / sepsis
What are the 4 types of shock and how are they characterised?
Which is most common?
Hypovolemic - too low blood volume
Cardiogenic - anything (e.g. pressure issue, cardiomyopathy, infarction) that impairs the heart generating pressure leading to inadequate tissue perfusion, which causes shock
Obstructive - Something physically obstructs the vessels preventing perfusion
Distributive - excessive vasodilation (Pressure = CO x total peripheral resistance), anything that causes massive vasodilation = fall in total peripherial resistance = fall in pressure
Hypovolemic shock = most common
What are the three types of distributive shock?
Septic
Anaphylactic - anaphylaxis = histamine release = vasodilation
Neurogenic
How does distributive shock come about?
Vasodilation
TPR (total peripheral resistance) falls
Blood pressure falls
Inadequate perfusion
How does shock lead to death?
Tissues not adequately perfused = organ failure = death
What did the disability assessment show in Bill?
Blood glucose - 5.7 Temperature - 38.2 ACVPU (alert, confusion, voice, pain, unresponsive) = confusion GCS: E3 V4 M5 (adds up to 12) Moving four limbs normally PEARL - 3mm Smells of alcohol
What did the exposure assessment show in Bill?
No rashes No sites of infection / track marks No evidence of trauma to limbs or head No evidence of external bleeding Abdominal examination - abdomen distended, tender in left illiac fossa
Dr Patel wrote in her notes:
Impression - sepsis, altered mental state likely due to that but need to consider alcohol, delirium, drugs and intracranial pathology
Plan - sepsis management, investigate source of sepsis, CT to rule out intracranial pathology
Why does Dr Patel think Bill has sepsis?
Developing high temperature (may or may not have in sepsis) Difficult to wake/Sleepier than normal Altered mental state Oxygen to maintain above 92% sats Low blood pressure From shelter/streets - poor hygiene
All other shocks = pale and weak, and not much change in temp
What is important about observations?
They are not static
Must be reviewed regularly
Compared to previous
Bill's labs show: Raised CRP - 203 (normal = <5) Raised creatinine - 145 (normal = 59-104) Raised urea - 9.2 (normal = 2.5-7.8) Raised GGT - 74 (normal = 0-60) Raised lactate - 3.1 (normal = 0.5-2.2) Ethanol - positive in serum Raised WBC - 15.3 (normal = 4.2-10.6) Raised neut - 9.8 (normal = 2.0-7.1)
Which of these abnormal results are indicative of sepsis?
What should be investigated with the raised creatinine?
He has a high neutrophil count, high WBC, high creatinine – muscle damage can raise it, or indicative or kidney failure
Check for muscle damage, and intracranial bleeds
What is SIRS?
How is it diagnosed?
Systemic inflammatory response syndrome
By two or more symptoms including fever or hypothermia, tachycardia, tachypnoea (abnormally rapid breathing) and change in WBC count
What is the flowchart for septic shock?
SIRS
Sepsis
Severe Sepsis
Septic Shock
What are the SEPSIS 6 for treating sepsis?
HINT: give 3, take 3
Give O2 to keep sats above 94% Take blood cultures Give IV antibiotics Give a fluid challenge Take / Measure lactate Take / Measure urine output
What biochemical tests do Dr. Patel order?
CRP Creatinine Urea Na K ALT ALP GGT Bili Amylase Lactate
What haematology test do Dr. Patel order?
Hb
WCC
Neut
PLT
What other test does Dr. Patel order?
Toxicology screen
Blood culture
What can you tell from the blood results?
High CRP (marker of inflammation) High Lactate (tissue ischaemia) High WBC and Neut (infection) Creatinine (poor kidney function/muscle breakdown) Blood ethanol is positive Hyponatremic (possible dehydration) High urea (kidney problems)
Which abnormal bloods are most relevant?
CRP Creatinine + Urea (kidney problems) Lactate WBC Neut
What is Dr. Patel’s clinical update?
CT head normal Blood tests are keeping with sepsis Blood cultures sent IV AB given Patient improving clinically with AB and fluids Less confused Reporting severe pain in his abdomen Patient tender in left iliac fossa Abdomen soft to palpitation
What is his NEWS2 score?
Systolic BP 1
Pulse 1
Consciousness 3
Temperature 1
6 Medium risk, key threshold for urgent response
What antibiotic do you give after taking cultures?
Best guess antibiotics immediately after taking cultures
‘empirical antibiotics’
When culture results come in 24 hours antibiotic treatment can be fine tuned
What is the timescale for the Sepsis 6?
Should be done within an hour
What is Dr. Patel’s second clinical plan?
Analgesia
CT abdomen/pelvis
Continue intravenous fluids and antibiotics
What his is new NEWS 2 score?
Now less confused
so is now 3
After more information what symptom sieve categories are most likely to be causing his confusion?
Infection
GI
Toxins
Psychiatric (not alert enough to do a psychiatric assessment though)
What organs are found in the abdomen that could be causing pain?
What conditions / organs could be causing Bill’s pain?
Bladder = central abdomen, kidney = higher up, or descending and sigmoid colon (in a female, the ovaries, uterus and womb are important to take into consideration)
Appendicitis Sigmoid diverculitis Colorectal adenocarcinoma Acute kidney injury Descending and sigmoid colon
What are the radiologist’s observations?
Liver = normal position
No portal vein enlargement
The intra- and extra-hepatic billiard ducts and gallbladder = normal
Spleen = normal size. There are no ascites.
Pancreas = normal size
Kidneys = normal size and position
Multiple diverticulae in the colonic segments, sigmoid colon = thickened walls, small fluid filled mass at anterior sigmoid colon perhaps abscess formation
Free fluid within lower left quadrant
What is Bill most likely to have? And why not the others?
Sigmoid diverticulitis
Appendicitis = unlikely at his age, usually seen in extremes of ages (young or old)
colorectal adenocarcinoma = can be seen on ct images, but not bill’s presentation
Acute kidney injury = biochemical diagnosis
What is Sigmoid diverticulitis?
How is it diagnosed?
Constant abdominal pain due to overgrowth of gut bacteria
Signs of systemic upset
Common cause of sepsis
Diagnosed = clinical examination blood tests and ct scan (or sometimes ultrasound)
What is diverticulitis?
Out-pouching with infection/inflammation - often due to poor diet results in change in bowel movements
What is diverticulosis?
Out-pouching without inflammation
What are diverticula?
Abnormal out-pouching of the mucosa
When does it become diverticular disease?
Intermittent abdominal pain
Changes in bowel pain
Related to a high fat, low fibre diet
BMJ soundcloud:
What is the iceberg of homelessness?
How is this a public health issue?
Iceberg of homelessness:
- Obvious homelessness (street sleepers) - increase from 2000 to 4800
- Hidden homelessness - sleeping in car parks, couch surfing etc.
- People on the edge of becoming homeless
Homelessness = public health issue:
Most affects 1. - cold, drug use, infections, etc.
3. - anxiety, fear
BMJ soundcloud:
What are the causes of homelessness?
Superficial = private renting and evictions (fams with children need to live in private renting - 8 weeks notice)
Inequality in wealth - amount of housing not being used by well-off people
Family homes still in use by older generation - leaves rooms entry
Most expensive and least well-regulated housing
Mostly an issue in London, not so much in rural areas (homelessness clearing)
What could be done in this country to help homelessness?
Cuts to local authority funding = lack of hostels
Requisition of empty warehouses, put in bunk beds for the homeless
Change rent regulations - landlords should not be able to evict you with just an 8 weeks notice and not to put up rent whenever they feel like it
Lower the house prices, lower rent (sometimes rent is double a mortgage)
What could help the homeless in terms of medical provisions?
Practices = deals exclusively with homeless people
GPs need to recognise: many symptoms of people = underlying stress from housing
Stigma with homelessness = do not seek help
What does the ABCDE approach stand for and why is it used?
A = Airway, B = Breathing, C = Circulation, D = Disability, E = Exposure
Used to recognise life threatening issues to buy time for further treatment and diagnosis
What are the problems, assessments and actions for the Airways?
Is the patient’s airway secure or compromised? Untreated = hypoxia and risks organ damage, cardiac arrest, and death.
Problems:- Decreased GCS (GCS ≤8 usually requires intubation), excessive secretions, airway swelling / inflammation, trauma
Assessment:- Paradoxical chest and abdominal movements, use of accessory muscles, noisy breathing, no breath sounds at the nose or mouth, central cyanosis (blue)
Action:- head tilt and chin lift, or jaw thrust, suction to remove debris, intubation, emergency surgical airway, give oxygen at high concentration
What are the problems, assessments and actions for Breathing?
Problems:- reduced GCS, acute severe asthma / COPD, pneumonia / lung infection, pulmonary oedema, pneumothorax, pulmonary embolism, haemothorax (blood in the pleural cavity, often secondary to trauma), respiratory depression (e.g. secondary to drug toxicity)
Assessment:- Obtain oxygen saturations, count RR, talking ability, use of respiratory muscles, central cyanosis, sweating, look for symmetry of chest movement and for chest deformity, feel trachea for deviation = tension pneumothorax or large effusion on the contralateral side or collapse on the ipsilateral side, percuss the chest, hyper-resonance = pneumothorax, dullness = pleural fluid, listen to air entry and added sounds (crackles, wheeze, stridor)
consolidationcaused by complete obstruction to that region, DVT (deep vein thrombosis)
Action:- Specific treatment will depend on cause (e.g. adrenaline in anaphylaxis, chest drainage in pneumothorax, Naloxone in opioid overdose, bronchodilators in airway disease), arterial blood gas analysis is likely to be useful, sit patient up if possible and they’re short of breath, give oxygen (target >94%), use bag-mask or pocket mask ventilation to improve oxygenation and ventilation, non-invasive ventilation or intubation and ventilation
What are the problems, assessments and actions for Circulation?
All emergencies = hypovolaemia is primary cause of circulatory failure (shock) until proven otherwise, breathing issues affect circulation
Problems:- hypovolaemia (bleeding, burns, diarrhoea / vomiting, dehydration), pump failure cardiogenic (e.g heart failure, myocardial infarction, arrhythmia) or non-cardiogenic (e.g cardiac tamponade, tension pneumothorax, PE), vasodilation (sepsis, anaphylaxis)
Assessment:- colour of hands, limb temperature, measure capillary refill time (normal CRT < 2 s), prolonged CRT = poor peripheral perfusion (or cold env. and old age), HR, 3-lead cardiac monitoring (or 12-lead ECG), jugular venous pressure (elevated JVP = heart failure or fluid overload), palpate pulses for quality regularity and equality, (barely palpable = poor CO), Abounding pulse = sepsis, measure BP, auscultate the heart (murmur? difficult to hear = cardiac tamponade), look for evidence of bleed
Action:- insert IV, take blood for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching. Lactate level = tissue perfusion, low BP = give fluid, monitor HR and BP, if the patient is bleeding, replace blood with blood, if BP does not improve stimulate vasoconstriction
What are the problems, assessments and actions for Disability?
Disability = consciousness, neurological function
Problems:- hypoxia or hypercapnoea, drugs –sedatives, opioids, toxins, poisons, cerebral hypoperfusion (e.g. from hypotension), raised intracranial pressure, CVA, metabolic dysfunction (e.g. hypoglycaemia)
Assessment:-
ABC-DEFG, check glucose, temperature, assess neurological status (rapid assessment ACVPU and formal assessment GCS), check pupils for size equality and reactivity to light, assess for pain, check drug chart
Action:- Provide glucose if needed, analgesia for pain (Specific e.g. treat seizures, treat opioid toxicity with Naloxone, seek specialist input if raised intracranial pressure)
What are the problems, assessments and actions for Exposure?
Full exposure of the body may be necessary.
Respect the patient’s dignity and minimise heat loss.
Examine head to toe, front and back. Look for bleeding, swellings, rashes, sores, wounds, catheters etc. Perform focused exam of relevant systems. Take a full clinical history from the patient, any relatives or friends, and other staff. Review the patient’s notes and charts, the results of laboratory or radiological investigation
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What are the 4 quadrants of the abdominopelvic cavity? What organs are found in each?
Right upper = right of the liver, gallbladder, right kidney, a small portion of the stomach, portions of the ascending and transverse colon and small intestine
Right lower = cecum, appendix, part of the small intestines, the right female reproductive organs, and the right ureter
Left upper = left of the liver, stomach, pancreas, left kidney, spleen, parts of the transverse and descending colon and small intestine
Left lower = majority of the small intestine, some of the large intestine, the left female reproductive organs, and the left ureter
What are the 9 regions of the abdominopelvic cavity?
Right hypochondriac, right lumbar, right illiac, epigastric, umbilical, hypogastric (or pubic), left hypochondriac, left lumbar, and left illiac divisions
Perineum = 10th division
What is found each of the 9 abdominal divisions?
RH = right of the liver, the gallbladder, right kidney, and parts of the small intestine LH = part of spleen, left kidney, part of stomach, pancreas, and parts of the colon Epi = majority of stomach, part of the liver and pancreas and duodenum and spleen, and adrenal glands (puffs out due to diaphragm when breathing) RL = gallbladder, left kidney, part of liver, and ascending colon LL = descending colon, left kidney, and part of the spleen Umb = umbilicus (navel), small intestine, part of the duodenum, the jejunum, and the illeum. Transverse colon and the bottom of the kidneys RI = appendix, cecum, and the right iliac fossa LI = descending colon, the sigmoid colon, and the left illiac fossa Hypo = bladder, part of the sigmoid colon, the anus, and organs of the reproductive system e.g. uterus and ovaries in females and prostate in males
What are diverticula? At what age are they common?
Small pouches developed on the colon - more common with increasing age
Why and how do diverticula develop?
Related to not eating enough fibre - harder to push out stools, increased pressure = push the inner lining of a small area of your gut through the muscle wall to form a small diverticulum
Diverticulosis VS Diverticular Disease VS Diverticulitis?
Diverticulosis = diverticula are present by asymptomatic
Diverticular Disease = diverticula cause intermittent pain or bloating without swelling, cramps tend to come and go. Symptom overlap with IBS (more common in young people) or early bowel cancer
Diverticulitis = infection and inflammation of diverticula
How does diverticulitis present?
Constant pain (usually lower left side) of abdomen Fever Constipation / Diarrhoea Mixed blood in stools Nausea / Vomiting
What are some complications of diverticulitis?
Colon obstruction
Collection of pus (abscess)
Fistula (Channel) may form to other organs e.g. bladder
Perforation in the wall of the bowel - can lead to peritonitis (infection inside abdomen)
Why may diverticula bleed? Is it painful?
Bleeding due to burst blood vessel in wall of diverticulum - usually abrupt, painless, blood passes via anus
Severe bleed requires intervention e.g. blood transfusion or surgery
Colonoscopy may be required to determine the cause of bleeding
What is the treatment for diverticulosis?
High-fibre diet advised (18g/day advised), helps make softer and larger stools - helps prevent constipation
May prevent further diverticula forming
Healthy lifestyle = stop smoking, regular exercise, lose weight is obese
What is the treatment for diverticula disease?
High fibre diet - foods including: wholegrains, fruits, vegetables, brown rice, wholewheat pasta, beans, pulses, legumes, wholewheat bread / flour
Drink lots of fluids with high-fibre diet
Paracetamol for pain
Antipasmodics e.g. Mebeverine for persistent abdominal spasms
What is the treatment for diverticulitis?
Course of antibiotics and fluids via IV
Follow high fibre, lots of fluid diet
Stronger painkillers
Surgery to treat complications
Repeated diverticulitis attacks = surgery to remove that portion of the colon
How is diverticulosis diagnosed?
For people without symptoms, found incidentally during evaluations for other conditions e.g. during colonoscopies etc.
How is diverticulitis diagnosed?
CT scan to confirm a diagnosis of diverticulitis
CT scan is required to diagnose complications e.g. an abscess
