Clinical station Flashcards
1
Q
what to note down in 5 min review period?
A
- differential diagnoses (most likely, most dangerous)
- investigations (written as bedside, bloods, imaging)
- management points
2
Q
airway assessment
A
- patient vocalising - assume airway is patent
- feel for expired air
- listen for sounds suggestive of obstruction
- look inside mouth for loose objects/dentures
- protect cervical spine is injury is possible
3
Q
airway actions
A
- consider using wide bore suction under direct vision if secretions
- if concerns about airway establish sing manoeuvres or adjuncts
- if concerns about airway/reducing GCS –> 2222
4
Q
breathing assessment
A
- LOOK for chest expansion (?equal ?fogging of mask), cyanosis
- LISTEN for air entry (?equal ?added sounds)
- FEEL for expansion and percussion (?equal), any tracheal deviation
5
Q
breathing investigations
A
monitor sats and RR
CXR/ABG
6
Q
breathing actions
A
- if concerns –> 15L oxygen via NRM
- if absent or poor resp effort use bag valve mask
- no resp effort –> 2222 for I&V
7
Q
circulation assessment
A
- look for pallor, cyanosis, distended neck veins (JVP)
- feel for central pulse (carotid/femoral) - rate/rhythm
8
Q
circulation investigations
A
- monitor defib ECG and BP
- 12 lead ECG
- gain venous access and send bloods
9
Q
circulation actions
A
- treat shock (500ml saline over 10-15 mins –> watch to see response
- if no cardiac output = arrest call
10
Q
disability assessment
A
- level of consciousness (AVPU, GCS)
- check pupil size (PEARL?)
- check tone in all 4 limbs
- check CBG
11
Q
disability actions
A
if unresponsive or GCS <8 = call anaesthetist
12
Q
key points in exposure
A
- undress patient
- check temp
- look for rashes, bleeding, surgical site
- perform brief abdo exam
- cover patient with blanket
13
Q
other useful information to gain
A
- events surrounding illness
- PMH
- medication
- allergies
14
Q
acute abdomen work up
A
- bedside: urinalysis, bladder scan
- bloods: FBC, U&E, LFT, amylase/lipase, clotting, G&S, CRP
- imaging: Erect CXR, CT, USS
15
Q
acute abdomen management
A
- keep NBM (?VRII for diabetics)
- IV fluids
- IV Abx (if infectious process suspected)
- IV analgesia
- urgent discussion with surgical team
16
Q
acute asthma work up
A
- bedside: PEFR, ECG, ABG, SaO2
- bloods: FBC, U&E
- imaging: CXR
17
Q
acute asthma general management
A
- warn ICU if severe or life threatening asthma attack
- bronchodilation: salbutamol nebs 5mg with high flow oxygen
- steroids: IV hydrocortisone 100mg or PO pred 40-50mg
- oxygen: 15L NRM is sats <92%
18
Q
what to add if life threatening
A
- add nebulised ipratropium bromide 500mcg 6 hrly
- IV Mag Sulphate 2g over 20 mins
19
Q
what to do next if the asthma is responding to treatment?
A
- 4 hrly salbutamol nebs
- pred 40-50mg OD for 5-7 days
- monitor PEFR and sats
20
Q
what to do if not responding to treatment?
A
refer to ITU for intensified therapy (I&V, aminophylline)
21
Q
exacerbation of COPD work up
A
bedside: ECG, ABG
bloods: FBC, U&E, CRP, sputum culture
imaging: CXR
22
Q
exacerbation of COPD work up
A
- bronchodilator (neb salbutamol 5mg/4 hr, neb ipratropium bromide 500mcg/ 6hr)
- oxygen (if hypoxic = high flow, after ABG can monitor target sats)
- steroids: IV hydrocortisone 200mg
- ABx: follow trust guidelines
23
Q
management if no response to treatment
A
refer to ITU
consider:
- IV aminophylline
- consider NIV
- cosnider I&V
24
Q
ACS work up
A
bedside: 12 lead ECG, CBG
bloods: troponin, FBC, U&E, blood glucose, cholesterol
imaging: CXR
25
immediate management of ACS
- IV morphine 5-10mg
- IV metoclopramide 10mg
- oxygen if hypoxic
- aspirin 300mg and clopidogrel 300mg/ticagrelor 180mg
26
further treatment for a STEMI
- PCI if able to reach centre within 120mins of first medical contact
- fibrinolysis (alteplase) within 30 mins of admission if PCI unavailable
27
NSTEMI treatment
SC fondaparinux 2.5mg OD
assess risk and need for angiography (GRACE score)
28
drugs patients need to take on discharge
- DAPT
- ACEi
- Statin
- beta blocker
29
work up for acute HF
-bedside: ECG, ABG
- bloods: troponin, U&E, BNP
- imaging: CXR, echo
30
management of acute heart failure
- sit upright
- 15L oxygen via NRB mask
- gain IV access
- diamorphine 1.25mg IV (caution in liver failure/COPD)
- furosemide 40-80mg IV STAT
- GTN spray 2 puffs
31
if no response to above treatment, next steps?
- repeat furosemide dose
- consider CPAP
- consider nitrate infusion
- consider ITU
32
if acute HF now stable following response to treatment, next steps?
- daily weights
- repeat CXR
- switch to oral diuretics
33
which medications to take away on discharge?
- ACEi
- beta blocker
- consider spiro
34
work up for AKI
- Bedside: ECG (K+), urinalysis, urine sample for MC&S and ACR, ABG (acidosis), bladder scan
- Bloods: U&E, calcium, phosphate, FBC, CRP, LFTs, CK, renal screen
- Imaging: USS, CXR
35
management of AKI
- treat high K if present (10ml 10% calcium gluconate, 10U Actrapid with 100ml 20% glucose, consider salbutamol nebs)
- treat cause
36
indications for urgent dialsysi
- refractory hyperkalaemia
- refractory pulmonary oedema
- uraemic complications
- severe metabolic acidosis (pH <7.2)
37
aims of anaesthetic pre-assessment
- establish rapport with patient
- check that optimized for surgery
- formulate anaesthetic plan
38
aspects of preoperative visit
- discuss patient with consultant first, type of case they are likely to undergo
- history
- examine airway
- examine Cardiorespiratory system
- review any investigations (ECG/CXR)
- make a problem list
- formulate anaesthetic plan (type of anaesthetic, monitoring, analgesia, anti-emetics, post-op care)
39
workup for anaphylaxis
if suspected, go straight to management
40
initial management of anaphylaxis
- if airway compromised, secure airway, give high flow
- administer 0.5mg adrenaline 1:1000
- repeat every 5 mins if needed
- secure IV access
- administer IV fluid bolus if shocked
41
refractory anaphylaxis treatment
- if no improvement after 2 dose of IM adrenaline
- give IV adrenaline infusion
42
ongoing management of anaphylaxis
- allergy clinic to identify allergen
- discharge with 2 adrenaline auto-ejectors
- teach how to self inject
43
AF work up
Bedside: ECG
Bloods: U&E, bone profile, Mg, TFT, troponin
Scoring system: CHADS-Vasc, ORBIT
44
management of AF
- adverse features (MI/shock/pulmonary oedema) = DC cardiovert
- rhythm control with new onset AF with clear precipitant (cardiovert/amiodarone)
- rate control (beta blocker, digoxin)
45
decompensated CLD work up
bedside: urinalysis, BM
bloods: VBG, U&E, LFT, clotting, G&S, CRP, blood cultures
imaging: CXR, US Abdo, ascitic tap
46
management of ascites
perform tap to diagnose SBP
if SBP --> Tazocin
47
manage alcohol excess
CIWA scoring and chlordiazepoxide
IV pabrinex
48
management of variceal bleeding
- resus with fluids and blood products
- Vit K for coagulopathy
- IV terlipressin and prophylactic abx
- discuss OGD with GI Bleed SpR on call
49
management of hepatic encephalopathy
- consider precipitants e.g. GI bleed, constipation, dehydration, infection
- lactulose
- rifaximin
- aim for 2-3 soft stools per day
50
DKA work up
- bedside: CBG and ketones, urine dup, ECG
- bloods: lab glucose and ketones, U&E, VBG, FBC, blood culture, amylase
- imagine: CXR to r/o pneumonia as precipitant
51
management of DKA
- fixed rate actrapid infusion (0.1U/kg/hour)
- aim for fall in ketones of 0.5 mmol/L/hour
OR
- aim for rise in bicarb of 3mmol/L/hr with fall in glucose of 3 mmol/L/hr
- check VBG at 1 hr, 2 hr and 2hrly thereafter
- once BM <14m start 10% glucose 8 hrly
- fluid replacement 100ml/kg, over 48 hrs
- add K to bag if K in normal range
52
when to stop fixed rate?
continue fixed rate insulin until ketones <0.3mmol/L, venous pH >7.3 and venous bicarb >18
53
head injury work up
- bedside: neuro exam, BM
- bloods: FBC, U&E, blood alcohol, toxicology screen, VBG, clotting, G&S
- imaging: CT Head
54
management of head injury
- oxygen if low sats
- if concerns about ICP, patients may need hyperventilation
- immobilise C-spine
- treat seizures with benzo
- check for CSF leak
- involve neurosurgeon early if concerns about raised ICP
55
indication for major haemorrhage protocol
clinical concern that patient is bleeding and requires multiple blood products
56
who comes to major haemorrhage and what is important to do
med reg, surgical reg, porter
ask one person to liaise with blood bank
57
pnemothorax work up
- bedside: ECG
- bloods: FBC, clotting, G&S
- imaging: CXR
58
types of pneumothroax
- primary (congenital weakness of pleural bleb)
- secondary (underlying lung disease)
- iatrogenic (pleural biopsy, central line, VAP)
- trauma (penetrating chest injury)
59
work up in post operative pyrexia
- bedside: urinalysis
- bloods: FBC, U&E, CRP, LFT, blood cultures
- imaging: CXR, CR
60
main sources of post op pyrexia to consider
- chest
- urine
- surgical site infections
- intra-abdominal infection
- collections/anastomotic leaks
61
sepsis 6
- high flow oxygen
- IV fluids
- IV Abx
- UO monitoring
- VBG for lactate
- blood cultures
62
work up for PE
- bedside: ECG, ABG
- bloods: FBC, U&E, clotting, D-dimer, troponin, BNP
- imaging: CXR, CTPA
63
management of PE
- high flow oxygen if hypoxic
- morphine with metaclopramide
- treatment dose anti-coag
- if ill with massive PE --> thrombolysis
64
work up for seizures
- Bedside: ECG, BM
- Bloods: FBC, U&E, bone profile, Mg, VBG (lactate), anticonvulsant levels
- Imaging: CT Head
65
management of seizure during
- surrounding space clear of anything
- start timer
- gain IV access and blood (inc VBG)
If IV access:
- IV lorazepam 4mg after 5-10 mins, repeat, keppra/phenytoin if no response
If no IV access:
- consider IO
- buccal midazolam, rectal diazepam
66
management following the seizure
reassess patient using A-E approach
correct potential precipitants (hypoglycaemia, electrolyte imbalance)
67
work up of sepsis
- bedside: ECG
- blood: FBC, U&E, VBG (lactate), glucose, blood culture
- imaging: depending on cause (e.g. CXR)
68
stroke work up
- bedside: ECG, cap glucose
- bloods: FBC, U&E, lipids, clotting, cardiac enzymes, G&S
- imaging: CT head, carotid doppler
69
management of stroke
- oxygen if hypoxic
- NBM
- treat arrhythmia and low glucose id present
- URGENT CT head
- 300mg PO stat if hemorrhagic stroke ruled out
- physio and SALT inpt long term
70
when to consider thrombolysis in stroke?
- age <80 and <4.5 hours from start of sx
- age >80 and <3 hours from start of sx
71
take away medications for stroke
- after 2 weeks switch from 300mg aspirin to 75mg clopidogrel OD PO
- statin
- BP meds
-anticoag if also AF
72
transfusion reaction work up
bloods: FBC, DAT, ABO testing
Imaging: CXR
Other: send blood products back to lab
73
UGI bleed work up
- bedside: BP ?PR
- bloods: G&S, X-match 6-10 units of blood, clotting screen, LFT, FBC< U&E
- imaging: endoscopy
- scoring system: rockall
74
immediate management of UGI bleed
- protect airway and keep NBM
- 2 large bore cannulas
- rapid IV crystalloid infusion up to 1L
- use O- until X-match if grade 3/4 shock
- correct clotting abnormalities (Vit K/FFP/PCC)
- consider referral to ICU
- insert catheter to monitor UO
- URGENT endoscopy
- if massive may need Sengstaken Blackemore
75
medical management of UGI bleed
- major ulcer bleeding --> consider high dose PPI after endoscopy
- variceal bleeding --> terlipressin 2mg SC/IV QDS
76
what approach should you take when entering clinical scenario?
- who is available to help you/ plan ahead to see who you can request assistance for from wider hospital
- what: differentials
- where: where is the patient and is there somewhere more suitable to manage them, what specialist services are available at the hospital
77
example starting answer
- I would like to start by taking a relevant history while concurrently performing an A-E assessment
- manage any life-threatening abnormalitis as I go along
- I would like to delegate tasks to my team members according to their capabilities and using closed loop communication
- ask HCA to attach routine continuous monitoring (oxygen sats, 3 lead ECG, BP cuff to cycle every 2 mins)
- ask nurse if able to insert a cannula and take bloods at same time
78
if taking a nurse referral to see a patient over the phone, what to ask for
- prepare patient notes
- observation chart
- drug chart
79
example airway answer
if the patient can vocalise, I would feel confident that their airway is patent
80
breathing assessment example answer
- I would assess breathing using look, listen, feel approach
- look for evidence of increased WOB
- listen for equal air entry and added sounds
- would feel for symmetrical chest expansion
- if I am happy with this, I would move on to assess circulation
81
example disability answer
- assess the patient's consciousness using AVPU
- ask a nurse/HCA to check BM
- check the pupils are equal and reactive to light
82
example exposure answer
- would expose patient entirely whilst maintaining dignitity
- check for anything I may have missed e.g. bleeding/surgical scars/rashes
- perform brief abdo exam to check for tenderness
82
when come up with and summarised plan, how could you end it off?
- explain diagnosis to the patient
- convey plan to nursing team
- inform my anesthetics registrar
83
what to say in response to hypotension?
- flatten the bed
- raise patient legs
- call for help
- ensure being managed in suitable location
- establish large bore IV access in both arms and take some blood
- fluid bolus and assess for response
84
what investigations to consider following seizure?
- VBG
- FBC, U&E, CRP, bone profile, Mg, ethanol level, clotting, G&S
- urine sample for drug screen
85
how to manage when someone is having a seizure?
- pull emergency buzzer
- flatten bed, ensure nothing patient can injure themselves on
- ask colleague to start a timer and bring crash trolley
- wait to see if seizure terminates spontaenously
- if persisting >2 minutes, begin preparing medications to terminate seizure
- if IV access --> IV lorazepam
- no IV access --> buccal midazolam or rectal diazepam
- try to identify reversible causes
- fast bleep anaesthetist
86
what measures could be taken if patient showing signs of raised ICP?
- patient sat up
- mannitol, hypertonic saline, dexamethasone
- patient could be intubated and hyperventilated
87
who is involved in trauma call?
- A&E team
- trauma team leader
- major trauma SHO
- ortho
- general surgery
88
general spiel for assessment of circulation
- ask for updated HR and BP
- feel patient's pulses centrally and peripherally
- check JVP and their cap refill time
89
what to do if you notice a patient has an issue with one of A-E
- if identify has an issue with one station arrange investigations and commence some initial management before proceeding
90
