Blood tubes Flashcards
Your next patient is a 40 year old man who has presented to the emergency department with a nosebleed which started 2 hours ago. Vitals have been checked and BP is 140/90 and PR 84.
Initial Tasks:
Demonstrate how to do initial management
Old cases: Demonstrate how to use a Merocel (nasal pack)
Tasks:
Take history
Explain diagnosis and differentials
Counsel regarding the management
Hemodynamic Stability
D: May I know if my patient is alert or drowsy?
D: May I know the BP, PR and O2 sat?
Introduction
D: Hi, my name is ____. May I know your name?
D: I’m here to help you stop the bleeding and that’s our first priority. Once we control the bleeding, I’ll be asking you a few questions, is that okay with you?
Regular Method
D: I want you to stay seated and relax. Lean forward with your head slightly tilted down
D: I want you to pinch the soft part of your nose and apply firm and steady pressure for 10 - 15 minutes. Don’t release it to check if the bleeding has stopped.
D: Try to spit out the blood rather than swallowing it
Merocel Method
Pick up the Merocel from the table
D: I’m going to show you how we’ll be stopping the bleeding with this device called Merocel. This is a sponge which expands when it gets wet and by putting pressure on the blood tubes, it stops the bleeding.
D: I want you to blow your nose gently. I will use a spray called co-phenylcaine (phenylephrine and lidocaine: vasoconstrictor), and this spray will numb the area and help stop the bleeding.
D: I will lubricate the Merocel with some antibiotic ointment, then slide it in your nostril horizontally towards the back along the floor of your nose. This will be slightly uncomfortable. I will wet the end with some normal saline or water. We’re going to leave it there for about 24 hours.
History
D: May I ask you a few questions now?
D: Can you tell me more about your nosebleed?
Explore the nosebleed
Timing
D: When did it start?
D: Is the bleeding on/off or it’s been continuously happening?
D: Is it getting worse?
D: Is it the first time that you’re experiencing this?
Pattern
D: Is the blood coming from one nostril or both?
D: Do you feel blood dripping behind your throat?
D: Was there any incident or trigger before this started?
Rule out Red Flags
Anemia
D: Are you feeling dizzy?
D: Any chest pain or shortness of breath?
GI Bleeding
D: Have you vomited any blood?
D: Do you have any dark stools?
Tumors
D: Any headaches?
D: Any pain in the face or the ears?
D: Any long term blocking of your nose?
D: Any recent loss of weight?
Rule out Differentials
Trauma
D: Any recent trauma or injury to your nose or to your head?
D: Any recent surgery on your nose?
D: Any nose picking?
D: Did it start after sneezing or blowing your nose?
Inflammation & Dryness
D: Have you had any recent flu-like symptoms? Any runny nose?
D: Do you have any fever?
D: Are you using any nasal steroids or sprays?
Bleeding disorders
D: Are you on any medications especially blood thinners?
R: Yes, I’m on Apixaban
D: Any history of easy bruising?
D: Any family history of bleeding disorders?
Chronic Liver Disease
D: Any previous history of liver disease?
D: Any yellowish discoloration of your skin?
SADMA
D: Do you smoke?
D: Do you use drugs?
Past Medical/Family history
D: Do you have a past medical history or family history of other diseases?
(Usually they show you a script and you will see they’re on ACE inhibitors)
Diagnosis & Differentials
You have a condition called epistaxis, also known as a nosebleed. It happens because of bleeding of the small blood tubes in your nose. The most likely cause in your case is the side effect of the nasal steroid sprays that you are using. These sprays cause dryness in your nose and increase the risk of a nosebleed.
The blood thinner is not the cause of bleeding, but it can make the bleeding more severe or hard to control.
Other causes may be due to trauma, surgeries to the nose, nose picking, strong sneezing or blowing of the nose. Bleeding disorders, chronic liver disease, hay fever, viral infection can increase the risk of a nosebleed.
Tumors inside the nose can also be the cause.
Management
If the bleeding doesn’t stop, we have a few options:
If I see the bleeding vessel, I can burn it off using a medication called silver nitrate. I will use co-phenylcaine before to numb your nose. We’ll put this medication on the tip of a stick that I will gently rub on the bleeding vessel to stop the bleeding.
There is a small risk or perforation of the septum which is the wall int the midline.
We can also use other methods of packing and use a tube called Rapid Rhino. This is an inflatable tube/balloon and stops the bleeding by putting pressure on the blood tubes and the medication that it has on the surface.
If we pack the nose or cauterize the bleeding vessel, I will give you antibiotics to prevent infection called toxic shock syndrome.
I want you to stop the nasal steroids for now. Instead use some moisturizer and gently rub it in your nose. We can look into other options of treating hay fever later on.
If we are unable to stop the bleeding, no matter what we do, we’ll stop your blood thinners temporarily.
I’ll do a full blood examination just to make sure you have not lost excessive blood.
Red flags: if you get fever, thick green sticky discharge from your nose, if bleeding happens again
Avoid nose picking, avoid hot food for now, avoid heavy exercise, don’t blow your nose too hard
Your next patient is a 25 year old lady who has presented to the ED complaining of pain and swelling in her right lower leg. She returned to Australia 2 days ago and had a flight back from USA to Sydney. She took a diazepam tablet on her flight and slept all the way.
A venous Doppler USD has been done and it shows a visible clot can be seen in the soleal and gastrocnemius vein extending to the popliteal vein.
Tasks:
Take history for 3 minutes
Explain possible causes
Counsel regarding the management plan
Open-ended Question
D: Hi, my name is ____. I’ll be taking care of you today. How may I help you today?
D: Do you have any specific concern that you want me to address?
Explore the Flight
D: Did you walk or stretch your legs during the flight?
D: Were you drinking water during that flight?
Rule out Red Flags
Pulmonary Embolism
D: Do you have any shortness of breath?
D: Any chest pain?
D: Any cough?
Risk Factors
D: Are you using any contraception pills?
D: Can you tell me the name or the type? (COCP vs POP –if it is a girl’s name, it’s most likely a COCP)
D: Are you overweight?
D: Have you had any recent surgeries?
D: Do you have any dilated blood tubes on your legs?
D: Have you had any recent loss of weight?
D: Any lumps and bumps around your body?
D: When was your last menstrual period?
D: Any family history of clotting?
Positive findings: on COCP, mom and aunt also had clots
Contraindications for starting Anticoagulants
D: Any history of kidney disease?
D: Any history of liver disease?
Diagnosis
You have a condition called deep vein thrombosis. This means that there is a clot in the blood tubes of your leg.
The main provoking factor has been your immobility during your recent flight. Sitting for a long time causes the blood flow to slow down and increase the risk of forming a clot.
Other risk factors are: you are on oral contraceptive pills, and this medication increase the risk for clotting, and you have a family history of clotting.
Other possible causes are: having a recent surgery, being overweight, having varicose veins, pregnancy, and malignancies.
Management
I want you to please stop the oral contraceptives for now. As you have had a clot, these contraceptive pills are contraindicated and we need to stop them. I’ll book another consultation to talk about your options like IUD, implants or progesterone only pills.
I will request for some investigations:
UEC, eGFR
LFT
Beta HCG
Coagulation studies: APTT, INR
Thrombophilia screening for clotting disorders
Pharmacological Management
Our preferred medication is called a NOAC like apixaban. They do not need monitoring, they start working quickly. But if you have a kidney disease or a low kidney function, we are not able to use this medication.
Our second option is to start warfarin + heparin. We will start you on both of these medications until your INR blood test is above 2. then we’ll stop heparin and continue warfarin. However, this is contraindicated in pregnancy, we’ll need to do routine monitoring: blood test every 1-2 days in the initial days, then every 4-6 weeks once it’s stable, and it has interactions with food, medications.
In some cases, the specialist may decide to do a mechanical thrombectomy, which means removing the clot with a small tube that we pass through the blood tubes
Duration:
The duration that we want to continue the blood thinner depends on whether there was a provoking factor, and the site of the clot.
Distal provoked: 6 weeks
Distal unprovoked: 3 months
Proximal/surgery or trauma: 3 months
Proximal unprovoked/transient factors: 3-6 months
General advice:
Please take the exact dose at the same time every day.
Watch out for any bleeding: nose, gum, stools, heavy periods.
Watch out for any shortness of breath, chest pain, dizziness, please go to the emergency department.
If you go on your next flight:
Walk and stretch your legs
Wear compression socks
You can see your GP before travelling to get a dose of a blood thinner
Reading materials from Better health channel
Your next patient is a 68 year old lady who has come to you complaining of right leg pain which is getting worse. The pain is worse on walking uphill. She had a history of DVT 10 years ago. She is a known case of hypertension and is on propranolol. She is a smoker and smokes 20 cigarettes per day. ABI is 0.7 (N: 0.9 - 1) on the right leg.
Tasks:
Explain the diagnosis and differentials to the patient
Request further investigations
Explain your management to the patient
Complications
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you today?
D: Do you have any concerns before I tell you the management plan?
Diagnosis
Based on the information given to me in the notes, you have a condition called peripheral arterial disease. In this condition, the blood tubes in your leg are damaged and they are not functioning properly and this means that you have an impaired blood flow in your leg. The reasons I came to this are: you have pain in your leg while walking especially uphill; on examination I found that your blood pressure in your ankle is lower than in your arm; you also have a high blood pressure which is an important risk factor of this condition.
Differentials:
Neurogenic claudication –> Spinal canal stenosis, lumbar radiculopathy. In this condition, the nerves and the spine are under pressure and they cause pain
Post thrombotic syndrome which is a complication of having clots in your leg.
Venous insufficiency which happens because of damage in the gateways in your veins
Other differentials:
Joint inflammation: Arthritis
Soft tissue problems: bursitis, tendonitis, plantar fasciitis
Malignancies: bone tumors
Medications: statin-induced myopathy
Investigations
This condition has some risk factors which are similar to the risk factors of heart disease. Smoking, alcohol drinking, overweight, high blood sugar level, high fats in the blood, kidney disease.
Arterial Doppler ultrasound: this is an imaging that checks your blood tubes more accurately; CT angio, MR angio if needed
FBS
Lipid profile
eGFR, urine ACR
Management
Pharmacological:
Aspirin 100mg daily
Statins to decrease the fat in your blood and decrease the risk of this condition getting worse and prevent heart disease
The medication that you are taking for your high blood pressure can make the pain worse. I’ll talk to your GP/cardiologist since I prefer to change it to another ACE inhibitors like perindopril
Non-pharmacological:
Graduated walking program & exercise plan
I’ll refer you an exercise physiologist and physiotherapist. They will make a regular, individualized walking plan starting from the intensity and duration which you can tolerate, and gradually increasing it
Foot care
I’ll refer you to a podiatrist
Check your feet daily for ulcers, cuts, cracks or if any redness is there
Wear well-fitting shoes which are comfortable for you
Trim your toenails gently and properly
Keep your leg clean and well-moisturized
Lifestyle modifications
Stop smoking. I’ll refer you to quitline and to control your cravings we can start NPT
Cut down on alcohol
Healthy diet: avoid salt
Regular exercise
Weight loss
General Advice
Red flags: if you have any ulcers, cracks, redness, come back to me for a check; if your pain gets worse, we’ll repeat our tests and our ABI, if it goes below 0.3-0.4, we may need a surgery and refer you to a vascular surgeon
Reading materials from heart foundation
Review you regularly
Complications
This condition can get worse, and if not treated it can lead to an amputation. It also increases the risk of heart disease like heart attack, stroke.
Your next patient is a 45 year old man who has come to your GP to discuss his USD/CT scan reports. He is a known case of hypertension and is a chronic smoker. (He is planning to go on a caravan trip).
Ultrasound: 3.6cm AAA can be seen (some cases it’s 5cm). Kidneys, pancreas and liver are normal.
Tasks:
Explain results to the patient
Explain contributing factors and complications
Counsel regarding further management
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How can I help you?
D: Do you have any specific concerns before we start?
Explain Investigations
D: On your ultrasound, I can see that the kidneys, liver and pancreas, all of which are organs in your stomach, are all normal.
D: The main blood tube that carries blood out of the heart is called the aorta. This blood tube crosses the abdomen. In a condition called aortic aneurysm, the wall of the blood tube weaken and bulge out, and this is called an aneurysm. This is considered as a vascular disease and the risk factors are similar to the risk factors of heart disease, like smoking, high blood pressure, high fats in blood, high sugar, diet, lack of exercise, overweight, and it can also run in families.
D: This condition can be life threatening as it can continue to grow and increase in size and it can suddenly burst and lead to a rupture, which is an urgent life threatening condition that needs urgent surgery.
Investigations
I’ll request some blood tests: lipid profile, FBS, eGFR
Management
Pharmacological:
Aspirin: which is a blood thinner
Medication to lower the blood pressure: ACEI to decrease the risk of heart disease and vascular disease
Medication to lower the fats in the blood: Statins
Non-Pharmacological
We want to aim for a healthy lifestyle
Healthy diet, send to dietician
Exercise, send to exercise physiologist
Please avoid sports that have a risk of trauma and injury to the abdomen
Lose weight
Avoid smoking, refer to Quitline, NRT
Cut down alcohol
Monitoring
3 - 3.9cm: 2 years
4 - 4.5cm : annually
4.6 - 5cm : 6 months
> 5cm : 3 months
I want you to notify your first-degree family members, we would like to screen them for AAA with an ultrasound for men and women older than 65 years old.
If the size go above 5.5cm in a man (>5cm in a woman), or if there is rapid growth of >1cm/year or if you become symptomatic, you have back pain or abdominal pain, I will refer you to the vascular surgeon for possible surgery.
Notify the driving license authority (VICROADS) that you have this condition
I will examine you for other vascular diseases
Leg: PAD
Knee: popliteal artery aneurysm
CVS risk assessment: predicts the risk of heart disease in 5 years
Reading material from heart foundation
Red flags: abdominal pain, back pain
Address Concern: Caravan trip
If 3.6cm AAA:
I will consider the risks, in the event of a rupture, you need immediate medical attention and surgery and in case that you are in a rural area with no medical help close to you, this condition can be life threatening.
If 5cm AAA:
You have a 5cm AAA which is considered a large aneurysm. The larger the aneurysm, the higher risk of rupture.
I will consider the risks, in the event of a rupture, you need immediate medical attention and surgery and in case that you are in a rural area with no medical help close to you, this condition can be life threatening.
I would prefer you to see the vascular surgeon first and make a plan together.
