HOOH cases Flashcards
89 year old man with recurrent falls.
- HPC - Fallen 3-4 times in the last few days. LOC for about 1 second and quickly re-orientates. Usually occurs after standing and taking a couple of steps with his frame. Once from sitting when turning and reaching for his cup of coffee.
- PMHx - multiple comorbidities, including CCF, previous CABG and ruptured AAA, aortic stenosis and antral resection for GAVE. History of IDA
- DHx - furosemide, ramipril, bisoprolol, spironolactone, ferrous sulphate
- Obs: Lying BP: 92/47, HR 63 and regular, temp 36.0, RR 18, SpO2 99%
- O/E: ESM audible, CRT 4 seconds, peripherally cool, no signs of fluid overload
a) Main differentials
b) Management plan
a) - Aortic stenosis
- Postural hypotension
- Vasovagal syncope
- Subclavian steal syndrome
b) - Assess for postural drop (lying and standing BP: drop of > 20/10 after 3 mins)
- IV fluids: NaCl - 1L over 8 hours (normal rate)
- Cardiology referral to determine if candidate for TAVI
- Medication review: consider omitting furosemide if BP doesn’t pick up on 1L
- Repeat U+Es tomorrow to observe for creatinine reduction on fluids
52 year old lady with asthma, admitted with increasing SOB, cough, wheeze and chest tightness.
- HPC - started this morning, at rest, given some salbutamol nebs and now improved. Never admitted with asthma before. Mild scattered wheeze. Not breathless at rest.
- SpO2 90%, so ABG requested.
- ABG: PaO2 8.9, PaCO2 4.6, HCO3 26, pH 7.41
a) Interpret the ABG
b) Main differential
c) Management plan
a) Hypoxia, but not quite T1RF and CO2 unaffected, no acidosis.
b) Acute viral exacerbation of asthma
c) - Oxygen 2L via NC
- Observe for increase in sats, and wean off oxygen
- If breathless or more wheezy, give salbutamol nebs
- Oral prednisolone - 40 mg OD for 5 days
- Assess peak flow - ensure > 75% of best
- INB - consider CXR to exclude pneumonia
- Asthma nurse review with safety netting, check inhaler technique and compliance, give spacer, etc.
42 year old woman admitted with anaemia.
- HPC - Hb 79 on routine blood test at GP, ongoing on/off IDA for 11 years, not currently on supplements. Menorrhagia - heavy flow and 2 periods per month, lasting ~ 7 days. Changes pads every 30 mins when severe. Also has RIF that peaks during menses, and some urinary symptoms. TVUS in August found bulky uterus with fibroids.
- All obs stable, patient well. Overweight. NAD o/e.
a) Differentials
b) Management plan
a) - Fibroids
- Dysfunctional uterine bleeding
- Adenomyosis/endometriosis
- Endometrial hyperplasia/cancer
b) - Gynae review
- GP to restart iron supplementation - lifelong
88 year old man with absolute dysphagia
HPC - oesophageal Ca, inoperable but not metastasised. Dysphagia to solids and liquids, vomits everything back up. Stent has been discussed in the past
- All obs stable, patient otherwise well
a) Management plan
a) - Gastro review - discuss stenting and feeding options
18 year old male with 6/7 melaena ?UGIB
- HPC: 6 days of black tarry stool, some dyspepsia, no change in bowel habit, no haematemesis, otherwise fit + well. No PMHx, no regular meds.
a) Impression
b) What score must be calculated to determine management?
c) What else should form part of the management?
a) UGIB - probably secondary to PUD (no aspirin or NSAID use so possibly h. pylori)
b) Glasgow-Blatchford score:
- Risk stratifies patients who have had an UGIB to determine who will need OGD
- Score > 0 indicates need for intervention
- Score 6+ indicates high risk and urgent intervention needed
c) - NBM + IVI
- PPI - IV panteprazole
- Gastro review for ?OGD
58 year old female with paracetamol OD.
- HPC: staggered overdose taken, so treatment commenced in ED, then transferred to ward.
- O/E: tachycardic, but otherwise stable. Vomiting and has RUQ pain. Also agitated.
a) What treatment is needed? And what doses?
b) What fluid should it be given in?
c) How many mg of NAC is in 1 ml
a) NAC:
- 1st infusion - 150 mg/kg over 1 hour
- 2nd infusion - 50 mg/kg over 4 hours
- 3rd infusion - 100 mg/kg over 16 hours
b) Administer in bag of 5% dextrose:
- 1st - 200 ml
- 2nd - 500 ml
- 3rd - 1000 ml
c) 200mg / mL
63 year old male in Resus with ?CAP - on 15L/min via NRB but SpO2 only 92%.
- HPC: feeling generally unwell for 1/52, feverish, SOB, productive cough and some pleuritic L-sided CP. Has had oxygen, 1L NaCl, salbutamol nebs and stat dose of co-amoxiclav so far.
O/E.
- Airway - patent,
- Breathing - SpO2 92% on 15L, crackles LMZ,
- Circulation - HR 145, intermittently in AF, BP 124/78 CRT < 2s, appears dry and has AKI, not catheterised
- Disability - GCS 15, PEARL, glucose 7.1, no neurology
- Exposure - some back pain, calves SNT, abdomen SNT, no rashes, wounds or ulcers.
Ix.
- Bloods: WCC 12, CRP 241, Cr 149
- CXR: shows LMZ consolidation
a) What are the main differentials here?
b) Likely cause of the AF
c) Possible causes of the tachycardia
d) Further management
a) CAP (chest sepsis), PE, or both
b) Sepsis-induced AF
c) - Sepsis
- PE (resistant tachycardia on ABx with no hypotension makes this increasingly more likely)
- Salbutamol nebs
d) - Sepsis 6 (BUFALO): needs blood cultures, ABG, lactate level and catheterisation for fluid balance assessment
- Escalate antibiotics: IV tazocin +/- clari
- CTPA to rule out PE (no need doing a D-dimer as will be raised if septic anyway)
Troponins.
a) What are they?
b) Assessment in MI
c) Other causes of raised trops
a) - Troponins I and T are cardiac muscle proteins.
- Elevated levels indicate myocyte injury
b) - In patients with an acute presentation consistent with an MI, elevated troponin levels can differentiate between NSTEMI and unstable angina
- Look for increasing levels over periods of 3 - 6h intervals
c) - Cardiac: CCF, angina, myocarditis, endocarditis, pericarditis, tachy- or bradyarrhythmias, or heart block,
HTN, cardiac contusion/trauma including surgery, ablation, pacing, aortic dissection, Ao stenosis, HCM
- Non-cardiac: PE, severe pulmonary hypertension, renal failure, COPD, diabetes, acute neurological event, drugs and toxins
D-dimer.
a) What are they?
b) 3 main conditions it can be used to exclude
c) Other causes of raised D-dimer
a) A fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis
b) DVT, PE and DIC
c) Infection (especially sepsis), trauma, heart failure
Lactate.
a) Why is it raised? (physiology)
b) Causes of raised lactate
a) Tissue hypoperfusion, leading to hypoxia and increased anaerobic respiration - increased lactic acid (lactate) production
b) - Systemic hypoperfusion (shock): septic, hypovolaemic, obstructive, anaphylactic, etc.
- Regional hypoperfusion: compartment syndrome, limb ischaemia, mesenteric ischaemia, burns, trauma, necrotising soft tissue infections
- Other: DKA, malignancy, seizures, liver failure, heavy work of breathing, drugs and toxins
60 year old female admitted with ?AECOPD.
- HPC: Increasingly SOB for 1/52, more wheezy than usual also.
- O/E:
a) What clinical findings would indicate bacterial vs viral cause?
b) What investigation might be useful in differentiating bacterial vs viral?
c) What treatment should be commenced?
d) How would you determine appropriate target sats?
e) Why might eosinophil levels be useful?
a) - Increased purulence or volume of sputum
- Focal signs - crackles, effusion, bronchial breathing
b) - Procalcitonin
- Note: also, CRP > 40 often indicates more likely bacterial
c) - Oxygen - titrated accordingly
- Nebulisers - salbutamol, ipratropium
- Oral prednisolone course
- ?antibiotics - if deemed bacterial - based on bloods, cultures, XR findings, etc.
d) - ABG - determine if acutely retaining (raised CO2) and if chronic retainer (raised HCO3-)
e) Eosinophilia may…
- Indicate possible steroid-responsiveness
- Suggest possible asthma-COPD overlap
Sepsis.
a) Define
b) Clinical indicators
c) Lab indicators
a) Dysregulated host response to infection leading to end organ damage
b) - CV - HR > 130, BP < 90/60 or drop of 40+, CRT > 3, urine output < 30 ml/hr, lactate > 2
- Resp - RR > 25, SpO2 < 90%, new oxygen requirement
- Neuro - reduced GCS
c) - Renal - AKI (Cr > 177)
- Haem - APPT > 60, INR > 1.5, platelets < 100
48 year old lady with anorexia, admitted with hypoglycaemia. Recent BM 4.6, all obs stable. Currently inpatient at Riverdale Grange for eating disorders help.
a) What tests should be performed?
b) What treatment may be commenced?
c) What condition is this patient at risk of developing with treatment?
a) - Bedside: ECG, BM + ketones
- Bloods: U+Es, glucose, phosphate
b) Pabrinex (thiamine and vitamin C), supplementation of any deficient vitamins/ minerals
c) Refeeding syndrome
Falls assessment overnight.
- What two things must you focus on?
- Neurosurgical problem? - IC bleed, cord compression, etc.
- Orthopaedic problem? - fracture, dislocation, etc.
Once these two things are ruled out, you can relax.
Focus on the cause of the fall can be done by the day team. Most overnight will be mechanical
Fluids prescribing.
a) For replacement
b) For maintenance
c) Calculating volume and rate
a) 0.9% NaCl, or Hartmann’s
b) Dex/saline (4% dextrose, 0.18% NaCl) with KCl supplementation (if required)
c) - 25 - 30 mls/kg/day
- If requiring 2L per day, rate should be 12 hourly for 1L fluid
