Clinical Scenarios Flashcards

Question

Explaining SDH to patient?

Answer 1

I would start by making sure that we are in a quiet room where we will not be disturbed. I would ask the patient and daughter if there is anyone else that needs to be present. WARNING SHOT!!!!!!! I would start by explaining that the CT head scan has shown a cause for the worsening confusion. (This is the warning shot). I would then explain that the scan has shown a bleed around the outside of her brain. Explain that the blood is likely exerting some pressure on the brain which is why Mrs Redbridge is more confused. The bleeding is likely secondary to her use of rivaroxaban which increases her risk of haematoma formation after head injury. I would explain that the scans have been reviewed by my surgical colleagues who do not think that surgery is required. Explain that Mrs Redbridge will be admitted for a short period to monitor and assess the impact of the bleed before being discharged home. I would then make sure that the patient and family had time to ask questions.

Answer 2

The surgeons have reviewed the scans. Decisions on surgery are made based on the presentation of the patient (is the bleed causing a threat to life), the success of surgery balanced against the risks. In this case, the risks of surgery would be high. The subdural haematoma will be resorbed slowly. We are monitoring to make sure that Mrs Redbridge remains stable. Yes, we will stop the rivaroxaban today. This will reduce the likelihood of the bleed getting any bigger. A decision on restarting the rivaroxaban will be made with the senior clinician based on the risks and benefits of continuing to take it. Your mother will be assessed by our inpatient therapy team during the admission to assess her current level of mobility and self-care. Based on this we make recommendations about her safety to go home on her own. She may need a reablement package of care for example depending on the outcome of the assessment.

Answer 3

I would initially start with open questions followed by more closed questioning to help me narrow my differential diagnosis. I would make sure that I use appropriate language and try to avoid medical jargon in my questions. - when did it happen (time of day) and how long did it last - exactly what symptoms occurred - weakness - distribution, difficulty with speech, slurring of words, change in sensation, visual impairment, impaired mobility, balance issues - how long did they symptoms last - have the symptoms completely resolved - any warning symptoms - what were they doing when it came one and events leading up to it - any head trauma - any change in consciousness - any associated pain - similar precious episodes PMH diabetes and HTN - are they well controlled SH smoking alcohol medications FH of stroke Important to ask if patient drives finally I would finish with a systems review to identify any symptoms that the patient may have forgotten to say Ask about ICE

Answer 4

determined by the history and examination Full set of observations L/S BP ECG Bloods - FBC, Renal profile, HbA1c, lipid profile further include 24 hour ECG, echo, carotid USS and MRI head I would want to discuss with my consultant

Answer 5

Toxic/metabolic disturbance - hypoglycaemia, drug and alcohol toxicity Neurological - seizure, migraine with aura, MS, peripheral neuropathies such as Bell's palsy Systemic or local infection - central nervous system abscess, encephalitis, sepsis Space occupying lesion - tumour, subdural haematoma Conditions which can cause dizziness or disturbed balance such as: Syncope. Labyrinthine disorders — vertigo, Meniere's disease, labyrinthitis. Encephalopathies such as: Hypertensive encephalopathy. Wernicke’s encephalopathy. Others - acute confusional state, dementia, vasculitis, somatoform or conversion disorder

Answer 6

I would begin by explaining to the patient what a TIA is. I would explain that a transient ischaemic attack (TIA) is often a herald of a stroke. The mainstay of treatment is about prevention of a stroke following the TIA. The patient should be advised on lifestyle measures including encouraging physical activity; advice around stopping smoking and referral to smoking cessation services if indicated; advice on a healthy diet – low salt, reduced intake of saturated fats. Advice should be given about drinking alcohol with consumption limited to less than 14 units a week. With regards to treatment, antiplatelet therapy should be started if the patient is not already on it. Currently, dual antiplateley therapy is recommended of clopidogrel and aspirin for 21 days, followed by monotherapy with clopidogrel. Other options are available if this is not tolerated. Unless contraindicated, treatment with a high intensity statin should be initiated, such as atorvastatin 80mg OD. Cholesterol should be checked three months after initiating this to check the response to medication. The patient is likely already on anti-hypertensive medication but if not this should be considered in the clinic with a target systolic blood pressure of below 130 mmHg (unless there is severe bilateral carotid stenosis). Making sure his diabetes is well managed will also be an important part of his stroke prevention I would make sure that I discuss all medication decisions with my clinical supervisor in the clinic.

Answer 7

Direct oral anticoagulants (DOACs) are drugs which prevent harmful blood clots from forming in your blood vessels. They do this by slowing down the clotting process. They have a similar effect on thinning the blood as warfarin. The medication is taken each day. It is important to take the medication at the same time each day to ensure that they work properly. If you miss a dose, you should take the medication as soon as you remember if on the same day, however, you should not take two tablets on the same day. There are several side effects associated with a DOAC that it is important for you to be aware of. If you experience these, you should seek medical attention: prolonged nosebleed; bleeding from cuts; blood in your stool/vomit/sputum/urine; spontaneous bruising; persistent headache. You should seek emergency medical attention if you suffer any major trauma or head injury. DOACs do not need monitoring (in the same way as warfarin). However, kidney function should be checked prior to starting the medication and may need to be reviewed if there is any change in this. DOACs do not interact with alcohol. However, I would advise minimal alcohol intake when taking a DOAC because of alcohol on your balance/walking and the increased likelihood of head injury when intoxicated. I’m happy to provide you with written information on the drug so that you can read it at your own pace prior to starting the medication so that you can make an informed choice. If you choose not to take the medication the risk of further cerebrovascular events because of the atrial fibrillation will be higher - taking blood thinners reduces your risk by as much of two-thirds (https://pubmed.ncbi.nlm.nih.gov/22514252/) Use of the DOAC tablets in patients with AF reduces the risk of a severe stroke by about 50% compared to those taking warfarin, which is the older drug. (https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025554)

Answer 8

Anticoagulation should be initiated in patients who present with TIA who are found to have persistent or paroxysmal atrial fibrillation. Treatment can start as soon as imaging has confirmed no presence of haemorrhage or factors that may be contraindicated – for example the presence of microhaemorrhages in cerebral amyloid angiopathy. The risk of bleeding when considering starting anticoagulation can be assessed using the ORBIT bleeding risk tool The choice of anticoagulant is likely to be determined by local policy and I would discuss this with my clinical supervisor in the clinic.

Answer 9

People who have had a TIA must not drive for one month, but they do not need to inform the DVLA. If the patient has a further TIA, then they should stop driving for 3 months and inform the DVLA at this point.

Answer 10

S: I have just assessed Mr Adene, a 69-year-old gentleman, who was referred to clinic following a transient episode of right hemiparesis and word finding difficulty. B: He has a background of hypertension, type two diabetes, and COPD. A: Based on my assessment I believe that the presentation is consistent with a transient Ischaemic Attack. I have arranged several investigations to help identify the source of the TIA and based on an ECG in clinic we have also confirmed a diagnosis of atrial fibrillation. I have spoken with Mr Adene about prevention of future stroke including lifestyle measures and have started him on high dose statin. Because of the atrial fibrillation I believe that Mr Adene would benefit from being on long term anticoagulation and have discussed this with the patient. I have spoken with him about driving and when he can return to this. R: Mr Adene should be followed up in this clinic to check his response to the medications initiated today and to review the outcome of further investigations that I have arranged including his prolonged ECG monitoring and his MRI head so that a DOAC can be started safely. I have made sure to safety net and informed Mr Adene to present back to hospital should he have any recurrence of his presenting symptoms.

Answer 11

he balance of training vs service provision can often fall unfavourably There is a moral and practical obligation to ensure juniors such as yourself are trained appropriately to form the next generation of senior doctors. Missing regular teaching opportunities could result in a lack of personal and professional development and ultimately prevent you from performing at the expected level of a registrar at the end of your training. This of course needs to be balanced against the short-term patient safety issues that could be raised by you leaving what sounds like a very busy ward. If this situation has arisen due to a genuine medical emergency then clearly it would be inappropriate to leave the ward for teaching but this is unlikely to be the case on multiple occasions and instead likely represents a cultural or staffing issue in the department.

Answer 12

You need to immediately raise your concerns with the consultant in question and if they are not willing to help, it may need to go further and involve other external figures such as your clinical supervisor (if this is a separate person) or your educational supervisor. If this is unsuccessful or the situation remains unresolved despite this, further escalation to your training programme director or head of department may help to resolve the situation. It may be that the consultant themself has been under considerable pressure and has neglected to think of how the situation has affected you, in which case simply explaining why it is inappropriate could help. You can also submit an ‘exception report’ to make a paper trail of missed training opportunities (in addition to staying late at work) which would highlight the issue at an organisational level.

Answer 13

It is a professional and contractual requirement for consultants working in areas with trainees to help facilitate their education and training. Many consultants will understand this and be keen to help contribute to your learning but in other cases may need stronger reminders of the importance of teaching.

Answer 14

observations sputum sample ECG Bloods (raised Hb in response to chronic hypoxia) renal function CRP CXR (in COPD may have hyper inflated lungs and flattened diaphragm) PEF Spirometry Echo CT chest

Answer 15

Asthma Bronchiectasis Lung cancer Tuberculosis Congestive heart failure Medication induced] Gastro-oesophageal reflux disease

Answer 16

COPD is a long-term lung condition that makes it hard to breathe. It happens because the airways (the tubes that carry air in and out of your lungs) become inflamed, damaged, and narrowed, and the air sacs in your lungs (which help transfer oxygen to your blood) don’t work as well as they should.

Answer 17

Bronchiectasis is a chronic lung condition characterized by irreversible dilation and damage to the bronchi, the airways responsible for carrying air to and from the lungs. This structural abnormality leads to impaired clearance of mucus, recurrent infections, and inflammation.

Answer 18

Hi Mrs Bruth. I wanted to talk to you about the results of the investigations that we have ordered. These have come back and shown the reason for your cough, wheeze and shortness of breath. The scans have confirmed a diagnosis of Chronic Obstructive Pulmonary Disorder. Have you ever heard of this before? Some people will also refer to this as emphysema or chronic bronchitis (It is worth giving the patient time – they may want to respond or will indicate time for you to keep going. Pausing and giving the patient time to take in your words is an important part of communication). Would you like me to explain a little bit about what this diagnosis means? Chronic Obstructive Pulmonary disorder (or COPD for short) is a disease of the lungs which results in damage and inflammation to the airways that makes it harder for you to get air in and out which results in feeling short of breath. It is a progressive disorder and the inflammation of the airways is not reversible (such as in asthma). COPD is common in the UK. The majority of cases are caused by long term smoking, although air pollution is also a common causative factor. Symptoms can be managed with a combination of inhalers which we will start today and I will ask the respiratory CNS to talk to you in more detail about inhaler technique. The main thing that you can do which will help with slowing the progression of disease is to stop smoking. Exercise and losing weight will also help the condition. COPD is a chronic condition, but you can experience exacerbations of your symptoms which may be prompted by viral infections for example. Exacerbations may require management with antibiotics and in extreme cases oxygen. Does what I have told you make sense? Do you have any questions? Depending on what you have said, you may be asked various follow up questions. These could range from treatment advice to asking about cancer to long term prognosis. Remember, you are not expected to know everything. All you are being judged on is your ability to communicate, so stay calm and answer in a polite way. Anything you don’t know you can say and demonstrate how you would go about finding the answer. Finally: I will provide you with written information on COPD. I will be referring you to the community respiratory team who will be responsible for your ongoing management of COPD and they along with your GP will be good points of contact moving forward.

Answer 19

Send serum potassium (U&E) and ask for ECG (although this should not delay treatment) Calcium gluconate (stabilise cardiac myocytes) Salbutamol nebs Insulin/dextrose infusion Cardiac monitoring Look for a cause… (renal failure, exogenous potassium, spironolactone) Calcium resonium not required for immediate management

Answer 20

Causes of AKI can be split into pre-renal, renal and post-renal Pre-renal: volume depletion (most common), heart failure, liver failure, low BP Renal: RTA, trauma, contrast induced nephropathy, glomerulonephritis Post-renal: stones, BPH, malignancy, BOO, catheter problems

Answer 21

State your recognition of the refractory hyperkalaemia. Say you would reassess the patient A to E. Has treatment been given? Is the cannula working? Is there any exogenous potassium being given to the patient? Send repeat serum sample to confirm diagnosis. -could consider sending a slow spin. Involve medical registrar – seeking senior support is essential as this patient is not improving but also is at risk of further deterioration Move patient to HDU/resus setting Involve ITU registrar

Answer 22

Refractory hyperkalaemia Metabolic acidosis CKD Stage 5 Fluid overload unresponsive to treatment Symptoms of uraemia

Answer 23

VITAMIN CDEF useful aide-memoire (V-vascular I-infective T-trauma A-autoimmune M-metabolic I-iatrogenic N-neoplastic C-congenital D-degenerative E-endocrine F-functional)

Answer 24

Causes of PR bleeding can be broken down into local and systemic. Local causes include haemorrhoids, anal fissures and fistulas. More proximal causes can then be divided according to their underlying aetiology: Vascular: mesenteric ischaemia, angiodysplasia Infective: gastroenteritis Neoplastic: anal cancer, colorectal cancer Inflammatory: diverticulitis, Crohn’s disease, Ulcerative colitis

Answer 25

Given the patient's age and her past medical history of atrial fibrillation, from the list of differentials I am immediately concerned about mesenteric ischaemia. Her age also puts her at risk of diverticulitis and colorectal cancer.

Answer 26

I would begin with a detailed history of the presenting complaint: onset, nature (colour, volume, etc) which may provide an indication as to the severity and aetiology. I would also ask how the patient has been in herself recent (recent infection, systemic symptoms- weight loss, fever, lethargy) or any previous similar episodes. If concerned about gastroenteritis I may also enquire about infective contacts (i.e. other residents), any potential food sources or recent antibiotics courses (clostridium difficile). PMH: I would ask specifically about past gastrointestinal conditions such as previous diagnoses of diverticulitis or IBD. Dx: I would check if she takes antiplatelets or anticoagulants especially as these may be indicated from the PMH. Other risk factors for the differentials would include a family history of clotting disorders or gastrointestinal conditions with familial components to the aetiology (colorectal cancer, IBD) and general social history (smoking history, diet/lifestyle- risk factors for malignancy). An important consideration would also be a social history, to provide more information about this patient’s functional status. This is important because she is at risk of becoming critically unwell, and if so there may need to be conversations with the critical care team about escalation to ITU, and whether this would be appropriate.

Answer 27

Bedside - ECG, PR exam, stool cultures, ABG/VBG Bloods - FBC, U&E's, LFTs, clotting profile, group and save Imaging - if any concerns about obstruction or toxic mega colon I could consider abdominal XR (risk in UC and C.diff) Erect CXR if any concerns about perforation. If haemodynamically unstable - urgent CT angiogram once the patient has been resuscitated. I would discuss this with my seniors

Answer 28

The arterial blood gas shows a metabolic acidosis with a raised lactate. There is acid base disturbance with signs of hypoperfusion. This is immediately concerning. I would begin the patient on fluids if she is not already on fluids. Providing there are no contraindications I would initiate a fluid challenge starting with 500ml of a crystalloid fluid such as Normal Saline 0.9% ran STAT and would then reassess, continuing as necessary.

Answer 29

Senior colleague and ask them to review ensure the team looking after her are aware - ED consultant and nurse Discuss with the surgical team If not deteriorating - discuss with ITU If rapidly deteriorating discuss - 2222/MET team

Answer 30

Situation: I am concerned about this 82 year old lady with a raised lactate and metabolic acidosis secondary to hypoperfusion as a result of a significant PR-bleed. Background: She has a history of persistent pr-bleeding and is also known to have AF. Her drug history is not known. Assessment: Fluid resuscitation has been started and a group and save ad crossmatch has been urgently sent to the lab. She is tachycardiac and hypotensive. Recommendations: I am worried that this patient could quickly deteriorate. I have recommended that she is moved to the Resus department in A+E where she can be closely monitored. She needs an urgent senior review. I have asked the team to urgently request her drug history from the nursing home. If she is on anticoagulation for her AF she may need a reversal agent or discussion with haematology. In the event of a further deterioration she should be given O-negative blood from the transfusion fridge pending her formal cross-matched sample. Given the presentation and her continued deterioration, she may benefit from being reviewed by the general surgical team.

Answer 31

remember - If appears severely breathless - immediately start 15L NRB Remember to assess for effort of breathing and respiratory distress C - JVP and skin turgor assess fluid status monitor urine output - may require catheterisation At the end - if I had any concerns I would want to escalate this to a senior

Answer 32

REMEMBER SEPSIS COMMENCE SEPSIS 6 I am concerned that this patient may be septic. I would therefore ensure a sepsis six is completed. This includes checking a lactate, and taking blood cultures. I would also ensure urine output is monitored (with a catheter if necessary), and that fluids, IV antibiotics and oxygen are administered. Bloods ABG ECG CXR Sputum sample Urine dip - for atypical antigens

Answer 33

The bloods demonstrated a high white cell count which is predominantly a neutrophilia, supporting the diagnosis of a bacterial infection such as community acquired pneumonia. Both platelets and CRP are elevated, also indicating an inflammatory response. The elevated urea suggests her hypotension is causing poor kidney flow. The D-dimer is elevated, which can suggest DVT or PE however can be elevated for several reasons and may be in keeping with pneumonia. CXR is again supportive of pneumonia. The results are supportive of community acquired pneumonia so I would continue to treat this, and continue fluid resuscitation. The elevated dimer is a complication which I would discuss with my registrar for consideration of a CTPA to rule out a PE.

Answer 34

A D-dimer may not initially be helpful as it has a low specificity of 45%, i.e. can be positive for many reasons, e.g. obstetrics, peripheral vascular disease, cancer, inflammatory diseases and increasing age. However, it can be used in conjunction with the modified Wells’ score. A patient can be scored and if they are low risk a (negative) D-dimer may be used to rule out a pulmonary embolism. Patients at higher risk of PE should not have a D-dimer and a CTPA should be performed as the first line investigation In this case I would therefore consider performing a CTPA to rule out a pulmonary embolism.

Answer 35

Intensive care would be able to provide a higher level of care with intensive nursing and closer monitoring and management from clinicians. In the acute phase ITU may be able to provide an arterial line to facilitate frequent arterial gas sampling for lactate monitoring, and venous lines for intensive fluid replacement and monitoring. If required they would be able to facilitate use of vasopressors or intubation and ventilation.

Answer 36

each score one confusion BUN > 19/> 7 RR >. 30 BP < 90 or diastolic < 50 Age > 65

Answer 37

- ensure privacy -- introduce myself and my role - ask if there was anyone else she wanted there - explain in simple language that we are treating for a bad chest infection and that she needs to stay in hospital - treating with Abx and fluids - ask if she had any questions at any point - ask if she wanted me call anyone and inform them

Answer 38

qSOFA A bedside screening tool that consists of three simple tests: Altered mental status Systolic blood pressure less than or equal to 100 mm Hg Respiratory rate greater than or equal to 22 breaths per minute Patients with two or more of these findings should be examined for organ dysfunction.

Answer 39

b - it is vital to diagnose and treat immediately life-threatening conditions (e.g. acute severe asthma, pulmonary oedema, tension pneumothorax, and massive haemothorax). c- if septic - start sepsis 6 at this stage - IV abx, fluids, oxygen - lactate, blood cultures, monitor urine output at the end - consideration of escalation status if they are elderly ? do they already have an ACP

Answer 40

Sepsis as a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is a life-threatening condition that arises when the body’s response to an infection causes widespread inflammation, tissue damage, and organ dysfunction Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. Septic shock is a severe form of sepsis characterized by persistent low blood pressure (hypotension) that does not improve with fluid resuscitation and requires vasopressor medications to maintain adequate blood pressure and perfusion.

Answer 41

The sepsis six was a name given to a bundle of therapies designed to reduce the mortality of patients with sepsis. It was not included in the updated version of the Surviving Sepsis Campaign Bundle but was adapted. However, it is still routinely used in hospitals when responding to patients with possible sepsis. It includes: Titrate oxygen to a saturation target of 94% Take blood cultures Administer empiric intravenous antibiotics Measure serum lactate and send full blood count Start intravenous fluid Commence accurate urine output measurement

Answer 42

Key risk factors that would make you more susceptible to sepsis include: underlying malignancy, age older than 65 years, immunocompromise, haemodialysis, alcoholism, and diabetes mellitus. The patient in this case is at risk due to her older age.

Answer 43

The prognosis in patients with sepsis and septic shock is guarded at best. The mortality rate from sepsis has been estimated in a number of studies to be between 28% and 50%. The SOAP study in Europe observed an overall hospital mortality of 36%.

Answer 44

Toxic causes such as opiate use, alcohol, anxiolytics, antidepressants Metabolic causes such as hypoglycaemia or electrolyte disturbance Trauma - i.e.head injury A vascular event – such as an intracranial haemorrhage or large territory infarct Infective causes such as meningitis or encephalitis. Given there is evidence of vomiting he is also at risk of aspiration pneumonia Neurological causes - the patient could be post-ictal following a seizure.

Answer 45

hyponatraemia hyperkalaemia hypoglycaemia

Answer 46

drugs and alcohol are the main causes most common drugs - insulin and sulfonylureas rarer drugs - salicylates, beta blocker, quinine and pentamidine Organ failure, acute liver failure, adrenal failure, myxoedema, hypopituitarism, due to infection e.g. malaria The high potassium and low sodium on the blood gas results would in particular raise suspicion of an acute adrenal crisis If worried about adrenal insufficiency - should decide if IV steroids be given rarely - insulinoma

Answer 47

Glucagon is a hormone that induces conversion of glycogen to glucose in the liver, thereby raising the blood glucose level. The fact that glucagon has not worked would suggest that the process of glycogenolysis is not working. This would indicate that the cause of the hypoglycaemia is due to the inhibition of liver cells, most likely due to acute excessive alcohol consumption. This is the likely cause for the patient’s presentation.

Answer 48

don't drink too much risk of hypoglycaemia alcohol inhibits the liver’s ability to release glucose into the blood. This impairment can last for several hours after drinking alcohol. eat before drinking eat carbs before going to sleep

Answer 49

educating on nutrition checking blood glucose signs and symptoms of hypoglycaemia recognition of early symptoms is important must inform DVLA if they drive and take insulin Patients should always be encouraged to check their blood glucose before driving and take regular breaks to test their blood sugar. If the blood sugar is less than 5.0 mmol/L then patients should not drive. If they have a hypo they should treat it and not drive for at least 45 minutes, until blood sugars have returned to above 5.0 mmol/L.

Answer 50

to reduce preload and afterload, improving cardiac output. Avoid if patients are hypotensive