Clinical Flashcards
What to do when you answer the bleep?
9 point
i) Ask for patient name, DOB, Hospital Number and location
ii) NEWS score –> Trend of the NEWS score
iii) Why is the patient in hospital?
iv) How long have they been in hospital
v) Who are they under the care of?
vi) What medications are they on? anything been added/changed recently?
vii) Have fluids and oxygen been perscribed?
viii) Ask nurse to —> Cannulate, ECG, Take bloods, Check catheter, flush catheter, check BM
ix) Im on my way –> can you get drug chart, patient notes, fluid chart and relevant investigations
What can you ask the nurse to do over the phone?
6 points
i) Rudimentary A-E assessment
ii) Cannulatea
iii) ECG
iv) Take bloods
v) Check and flush catehter
vi) Check BM
What do you do before / after A to E assessment?
1 point
5 points
Before
Talk to the patient to see if they are able to give a history or if they’re acutely unwell
Skim the patient’s notes before you see them if this is possible
After
i) review drug and fluid charts
ii) Document asessment in the notes
iii) Who has been contacted
iv) Current management plan and when review time is (put this on jobs list)
v) Put re-assessment frequency in the notes too (doctors and nurses) Every fifteen minutes if acute and advise to bleep if NEWS score shanges
Questions for all patients being fluid monitored
3 points
Have they been eating and drinking?
If so, how much?
Has that been recorded? (if not to be recorded)
Elderly patients not eating and drinking?
1L bag of NS over 4 hours and monitor for improvement every hour
Fluid monitoring for the next few days
Oral Intake monitoring
Delirum Screen
Think about Sepsis
Think about Stroke
Continuous nursing monitoring
Withold nephrotoxic medication if cocerned about kidney injury –> document in notes and assess four hourly. (pt. to be reviewed next day)
If concerned about bleeding?
5 points
i) Serial ABGs
ii) FAST Scan
iii) HDU monitoring
iv) look for PR bleeding
v) G&S
ST Depression in V2-V3 and R wave is bigger than S wave
Posterior wall MI/ Posterio-lateral wall MI
- confirmed with 15 lead ECG
- posterior wall MI is usually accompanied by inferior MI
- 3-5% of MI is posterior wall
Key investigations for breathlessness (5)
Baseline Obs - O2, Sats, Pulse, Temp, Peak Flow
ABG If sats <94%
ECG
CXR (Portable if sick on ward)
Bloods –> Glucose, FBC, U &E , Drugs?
Key Investigations for Chest Pain (3)
CXR
ECG
FBC, U&E, Trop
Consdier D- Dminer
Define Coma
Causes of Coma
Immediate management
Coma is Unrousable Unresponsiveness
Causes:
Metabolic - Drugs/posioning, Hypoglycaemia/hyper, Hypoxia, Septic, Hypothermia, Myxoedema, Addisons, hepatic/Uraemic encephalopathy
Neurological - Trauma, Infection, Tumour, Vascular (including hypertensive encephalopathy), Epieltpic (non-convulsive state, post-ictal)
Immediate management:
A-E
Stabilise C Spine
O2 + Seizure treatment if necessary
Check BM - 20% 50 ml glucose IV stat
Drugs - Iv Nalaxone 0.4-2.0 mg, Iv flumanezil, IV Thiamine, IV Cefotaxime (meninigits 2g/12 hour IV) IV Aciclovir)
Bloods - FBC, U and E, CRP, LFT, Clotting, blood cultures, blood ethanol, drug screen
CXR
CT Head
Immediate management of septic shock
A-E
Sepsis 6:
In - oxygen,
fluids 20-30 ml/kg (1-2L0 crystalloid over 30 - 60 mins (IF SBP <90 or lactate >4 mmol/L then ICU referral)
Antibiotics - Tazocin (4.5g tds), Gentamicin (5mg/kg OD) + Vanc (MRSA, 1g/12h IV)
Out
Blood cultures, urine culture, CXR , sputum culture
Lactate
urine output
Anaphylaxis management
Secure airway + 100% oxygen. Consider Intubation if doubts about patency.
IM Adrenaline 0.5 ml (1:1000).
IV: Chlorphenamine 10 mg iv. Hydrocortisone 200mg IV
0.9% Saline titrated against blood pressure. 500 ml( 1/4 hour but may eed up to 2L )
Consider nebulised salbutamol for wheeze
Persistent hypotension—> ICU admission (IV Adrenaline and aminophylline).
Mast Cell Tryptase at 0 hours, 2 hours and 24 hours
Time frame for PCI in STEMI?
Indications for thrombolysis
120 mins from onset.
Thrombolysis:
STEMI can’t be given PCI within 120 minutes ( Should be transferred to PCI unit after thrombolysis anyway)
>1mm in 2 or more limb leeds or >2mm in 2 or more chest leads.
New LBBB
Posterior changes (ST Depression in V1-V3 with tall r waves in leads v1 - v3)
BASH MONA
Doses
B - beta blockers - if hypertensive, LVF, tachycardic (Carvedilol / metoprolol - 50 mg 12 hourly ) / (can also give verapamil 80-120 mg or dilitazem 60-120 mg 8 hourly)
A - Ace inibitors
s - statin
H - heparin (1st line fondapainox 2.5 mg OD) (Enoxoparin - NSTEMI - 1 mg/kg every 12 hours for 2-8days. STEMI - 30 mg + 1 mg/kg every 12 hours)
M - morphine (5-10 mg IV + Metoclopramide 10mg IV) (cyclizine 50 mg IV okay too)
O - oxygen (if sats <95%, breathless or in LVF)
N - nitrates (Use if patient is hypertensive or in pain) / IV nitrate 50 mg in 50 ml of NS)
A - aspirin (300mg + clopidogrel 300mg )
When to give NSTEMI patients angiography
Trop rise
Dynamic st or t wave changes
secondary criteria - diabetes, ckd, LVF,
Infuse GPIIb/IIIA antagonist (tirofiban) and do inpatient angiography
