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CST Interview > Clinical Scenarios > Flashcards

Clinical Scenarios Flashcards

1
Q

You are the CT1 covering the orthopaedic wards on a night shift. A 30-year old gentleman has had surgery to his right tibia and fibula following a motorcycle accident and is now complaining of pain and numbness in his lower limb and foot. How would you proceed?

A
  1. I would be worried about a compartment syndrome.
  2. Differentials:
    - DVT
    - Ischaemic Limb
    - Rhabdomyalsis
  3. A-E + Focused exemption of limb + hx
  4. 6 Ps
    - Palor
    - Pain
    - Parasthesia
    - pulselessness
    - pressures (>40mmHg diagnostic)
    - paralysis

NB: remove cast or dressings!!

  1. management
    - IVI (rhabdo and renal failure)
    - Discuss with seniors
    - Prep for theatre
    - Consent if able
    - inform patient and relative
    - urine myoglobin
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2
Q

what is compartment syndrome

A

this is when there is swelling or bleeding in within a compartment. because the fascia does not stretch this can cause increased pressure on the vessels and nerves, disrupting the blood flow and can cause nerve and muscle cell damage.

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3
Q

You are the orthopaedic CT1 on call. You have been called to A&E to see a 24-year-old man who sustained a right lower limb injury after a slide tackle whilst playing football. You are shown the picture below. How would you proceed?

(Xray shows transverse tibia and fibula fracture)

A

potential surgical emergency - ATLS approach

  1. Trauma call and in Resus
  2. Primary Survey A-E including
    - C Spine
    - FAST Scan
    - Thoracic, pelvic, abdominal, long bone bone and peripheral bleeding
  3. Focused history
  4. Secondary Survey
    - inspect the limb (swelling, trauma, open fractures)
    - palpate (tense compartment, joint above and below)
    - Neurovascular status (Pulse, Sensation, motor function with passive and active movement)
  5. Escalate to senior + ? Prep for theatre. + ?CT Trauma series including CTA ?splint
    - Abx + Tetnus booster if open
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4
Q

what is a secondary survey

A 
a head to toe examination of a patient following the initial primary surgery, comprising of: 
Head / skull 
Maxillofacial  
cervical spine 
chest 
abdo 
pelvis 
perineum 
orifaces (PV/PR) 
Neurological 
MSK 
Diagnostic care / definitive management
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5
Q

You are the orthopaedic CT1 on call at a major trauma centre. You have been called to A&E to see a 35-year old female equestrian who fell off her horse. She is complaining of hip pain but not much else. The A&E doctor suspects she has a pelvic fracture. How would you proceed?

A

ATLS + Resus + 2222

A-E + Sepcific pelvic examination

  • Inspection
  • Palpation PS and Iliac crests (gentle - I WOULD NOT ROCK THE PELVIS)
  • DRE +/- PV
  • lower limb length discrepancy
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6
Q

what is the indication for a trauma series CT

A

generally:
- High speed RTA
- if there was a death at the scene
- fall from >2m
- concerning mechanism of injury
- abnormal imaging
- abnormal vital signs

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7
Q

You are the CT1 covering all surgical specialities at a rural district general hospital. You have been called to A&E to see a 24-year old climber who fell 10 meters down the side of a rock face. A&E had performed a CT head which was normal. He was complaining of left sided chest pain, so a chest x-ray was performed but has not yet been reviewed. How would you proceed?

5th rib fracture seen on x ray

A

ATLS approach + Resus + 2222 trauma call

A-E + specific focused chest examination

  • Flail chest segments
  • trachea deviation
  • pneumothorax

Nb: patient may need discussion with ITU / HDU for higher level of care
- PCA / thoracic epidural

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8
Q

You are the orthopaedic CT1 called to A&E to assess a 75-year old lady who has had a fall whilst out shopping. She is complaining of pain in her right hip and the ambulance crew tell you she is unable to weight bear at the scene. The busy A&E doctor has ordered an x-ray of the pelvis and given analgesia. How would you proceed?

A

ATLS + specific lower limb examination + focused history

  • inspect - discrepancy in leg length
  • grain pain
  • alive and passive range of movement
  • neuromuscular status of the limb
  • examination of joint above and below

Mx:

  • ?femoral nerve block
  • foam splint to relieve pressure from heel
  • why did they fall?
  • AP and Lateral of the hip
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9
Q

You are the orthopaedic CT1 called to A&E to assess a 55-year old man who fell out of his sports car. He had a left hip operation a week ago but is unsure what it was. He is not currently in pain. A&E have performed an x-ray which confirms a dislocated hip replacement. How would you proceed?

A

requires urgent closed reduction under sedation or in theatre

A-E + Specific lower limb examination:
- Neurovascular status
Active and passive movement, sensation and pulses

  • discuss with senior ?NBM ?Theatre ?AP and lateral
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10
Q

You are the orthopaedic CT1. The paediatric ST5 asks you to see an overweight 6-year old boy on the paediatric assessment unit who attended with groin pain and limping. He is afebrile. On closer questioning this has been going on for the past 4 months but today the pain has worsened after playing outside with his friends. How would you proceed?

A

Main differential would be Perthes / SUFE. Be mindful of a testicular torsion

A-E examination + focused lower limb examination (paediatric)
Gait – limping
Pain on internal rotation and abduction of the hip
Muscle atrophy
Leg length discrepancy

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11
Q

You are the orthopaedic CT1. The paediatric ST5 calls you from the children’s assessment unit to see a 4-year old child who has presented with acute onset right knee pain, limping and fever. How would you proceed?

A

septic arthritis

A-E, Focused paediatric lower limb examination

  • ESR
  • Gait – limping
  • Pain on internal rotation and abduction of the hip
  • Muscle atrophy
  • Leg length discrepancy

Kocher criteria is a screening tool to differentiate septic arthritis

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12
Q

You are the General Surgery CT1 and are asked to see a 40 year old patient who has been admitted on the general surgery ward for investigation of abdominal pain. He has been taking regular ibuprofen. The nurse bleeps you as the patient is vomiting fresh blood.

A

Concerned about a GI bleed - assess imediately using CRISP principles.

  1. A-E, focused abdo exam + Hx
    - look for signs of liver disease
    - signs of substantial blood loss
    - CXR Pneumperitineum
  2. Management:
    - Endoscopy
    - ?Angiography to identify bleeding point + embolisation (gastroduodenal artery)
    - ?Surgical management if endoscopy unable to control bleeding
    - H-Pylori eradication once tolerating oral fluids
    - NBM
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13
Q

What endoscopic techniques can be used to stop ulcer bleeding?

A

adrenaline
heated probes
clips

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14
Q

what features of the ulcer are associated with further bleeding

A

bleeding from ulcer base
presence of a visible vessel
adherent clot overlying the ulcer

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15
Q

what scoring system is used for upper GI bleeds?

A

Rockall Score

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16
Q

You are the urology CT1 who is asked to review a 60 lady who is day 4 post left nephrectomy. She is spiking temperatures and the nurse is concerned that her bedside blood glucose level is 20. She is an insulin dependent diabetic.

A

Concerned about DKA (precipitated by infection)

  • Chest infection
  • Wound Infection
  • Abdominal Collection
  1. A-E
    - urine and blood cultures if spiking a temperature
  2. focused ample history
  3. systems review
    - look for signs of infection chest / abdo / Wounds / UTI
  4. Investigations
    - Bloods +/- cultures
    - Urine dip for ketones
  5. Treatment
    - treat as per DKA guidelines
    - Sliding scale + IV with potassium, catheter to monitor output
    - Abx for infection
    - monitor BMs
17
Q

what are the principles of preoperative diabetes manamgnet?

A
  1. maintain stable circulating blood glucose

2. Hypoglycemia is more dangerous than hyperglycaemia so maintaining mild hyperglycaemia is acceptable

18
Q

You are the General Surgery CT1 and are asked to see a 35 year old patient who is day 1 post laparotomy. The nurses call you as he is complaining of a lot of pain. His temperature is 38.1oC and saturations are 92%.

A

concerned about Chest infection e.g. atelectasis

  1. A-E + Hx + focused chest examination
    - look for signs of pulmonary collapse
    - check patients pain control as this can increase respiratory rate
  2. Examine patients wounds and drain
  3. Mx
    - Sit patient up
    - 15L O2
    - consider PCA
    - Chest PT
    - ABx
    - ?Salbutamol Nebs
    - DVT prophalazis
19
Q

Describe peri-operative measures that can reduce the risk of atelectasis and pulmonary collapse.

A

Preoperatively
​
cessation of smoking
physiotherapy if co-existing chest disease e.g. COPD
Deferring elective surgery for at least 2 weeks in patients with chest infection

Postoperative
​
Encouraging deep breaths, cough
Early mobilisation
Adequate analgesia
Regular chest physio
20
Q

You are the General Surgery CT1 and are asked to see a 65year old patient who is day 4 post anterior resection. The nurses call you as he is sounds ‘chesty’ and is pyrexial and saturations are 92%.

A

concerned about a potential chest sepsis.

  1. A-E + Hx + Focused system examination looking for signs fo infection
    - chest
    - abdo
    - wounds
    - DVT / PE
21
Q

in patients with post operative chest problems / low saturations who should you escalate to?

A

Surgical Reg
?Med Reg
Critical care if the person is not responding

22
Q

You are the cardiothoracic CT1 and are asked to see a 60year old gentleman who underwent recent CABG. He is tachycardic at 120bpm and complaining of shortness of breath and one of the nurses asks for you to review the patient.

A

tachycardia post operatively ?AF

  1. A-E + focused cardiac exam + Hx
    - assess for compromise e.g. shock
    - look for precipitant I.e. check for sources of infection (chest, wound, abdomen)

If New AF, you would:

  1. look for a reversible case
  2. contact cardiothoracic reg +/- med reg or cardiology
23
Q

what are the causes of AF

A 
Pulmonary 
Iatrogenic 
Rheumatic heart disease 
Atherosclerotic 
Thyroid 
Endocardiitis 
Sick SInus Syndrome
24
Q

You are the General Surgery CT1 and are asked to see a 65 year old gentleman who is day 3 post splenectomy. The operation was challenging and took longer than expected. The patient initially recovered well, however is now becoming increasingly confused. The nurse also reports that the patient has been borderline pyrexial and is now requiring some oxygen via nasal cannulae as his saturations have dropped slightly.

A

post operative delirium

  1. A-E + systems review for source of infection + Hx
    - think chest infection because they were intubated for a long time.
    - Check abdo for post operative collection and wound infection
    - in history want to know the indication for surgery, review operation notes, review drug chart.
    - in history want to know if he has had any medication which might have caused delirium
  2. Ix - cultures if spiking temperatures
25
Q

What are some common causes for post operative delirium

A
  • Pain
  • sepsis / infection
  • atelectasis / HAP
  • Over medication with sedative
  • electrolyte imbalance
  • ## alcohol withdrawal
26
Q

You are the General Surgery CT1 and are asked to see a 55 year old gentleman who is currently on the general surgery ward following recent laparotomy. He is tachycardic and complaining of chest pain and one of the nurses asks for you to review the patient.

A

I would be concerned about a post operative cardiac event such as an MI

  1. A-E + focused cardiac and respiratory examination + hx
    - in history you want to know about indication for surgery and review operation notes.
    - order a troponin

If evidence of MI discuss with Surgical reg and Medical Reg / Cardiology reg.

27
Q

You are the General Surgery CT1 and are asked to see a 65year old gentleman who is day 5 post right hemi colectomy who is complaining of abdominal pain and has a temperature of 39oC .The nurse asks you to review the patient.

A

I would be concerned about a post operative infection ?collection.

  1. A-E + Focused abdominal and chest examination + Focused hx
    - examine all wounds and drains
    - look for signs of infection (chest, abdo, wounds and drains)
    - cultures if septic
    - consider talking to anaesthetics and theatres if collection that might need draining
    ?CT
28
Q

what are the common causes of post operative pyrexia and the timings of these

A 
Days 0-2
Physiological as response to tissue injury: low grade
Pulmonary collapse, atelectasis
Blood transfusion
Thrombophlebitis
Days 3–5
Sepsis: wound infection
Biliary or urinary infection: catheter
Intra-abdominal collection
Pneumonia
Day 5–7
Deep-vein thrombosis (DVT)
Enteric anastomotic leak 
​​
>7 days
Intra-abdominal collection
DVT
Septicaemia.

CST Interview (4 decks)

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