Medicine Flashcards
Where you are:
You are an FY2 in A&E
Who the patient is:
Mr John Smith, aged 49, presented to the hospital with chest pain.
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of management with the patient.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including routine blood tests, special blood test for your heart enzymes and an ECG.
From my assessment, your chest pain is likely to be from your heart. We did an ECG and fortunately it came back normal. I will confirm it with my seniors as well. We did a special blood test for your heart enzymes and we are waiting for the result.
We will also do some further investigations to see your Blood Cholesterol Level and your liver and kidney function.
We will give you Aspirin, Clopidogrel (Blood thinner) to protect you from further attacks and a spray under your tongue, Glyceryl Trinitrate (GTN), to relieve your pain.
We will keep you in the observation unit and repeat the special blood test after a few hours of your chest pain. If everything goes smoothly, we will send you home.
We may give you some medication for cholesterol or some other medications to protect your heart, if needed.
Please follow up with the heart specialist and your GP.
You need to make some changes in your Lifestyle such as smoking/ alcohol cessation, diet, physical activity because these may lead to the severe complications of your condition.
(Give lifestyle advice accordingly.)
If you develop any sudden severe chest pain, breathlessness, dial 999 and come to the hospital.
D/D Myocardial infarction Angina Pulmonary embolism Pericarditis Pneumonia Gastroesophageal reflux disease
Where you are:
You are an FY2 in A&E.
Who the patient is:
Mr Daniel Smith, aged 30, presented to the hospital with chest pain
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of management with the patient
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including Routine Blood Test, special blood test for your heart (Troponin), CXR and ECG.
From my assessment, your chest pain seems to be pericarditis.
Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart). If all the tests come back normal, we will send you home.
We will give you anti-inflammatory medicines such as Ibuprofen which are usually given to ease the pain and reduce inflammation.
If your symptoms persist for more than 14 days then we may give you a medicine called colchicine, which helps to improve the outcome and reduces the chances of the inflammation coming back.
If the pain is severe and you are not getting better with ibuprofen and
colchicine, steroids may be used to reduce the inflammation. The pain and inflammation usually settle within a few weeks.
We’ll also do routine Blood Tests, a Special Blood Test for your heart (Troponin) & a CXR.
Please Follow Up with the heart specialist and your GP.
Give Lifestyle advice accordingly.
If you develop any sudden severe chest pain or breathlessness, dial 999 and come to the hospital.
If a lot of fluid builds up and causes cardiac tamponade, the fluid needs to be drained with a needle and syringe. If constrictive pericarditis develops and interferes with the heart’s function, the thickened pericardium may need to be removed by an operation. This is called a pericardectomy.
D/D Myocardial infarction Angina Pulmonary embolism Pericarditis Pneumonia Gastroesophageal reflux disease
Where you are:
You are an FY2 in A&E
Who the patient is:
Mr David Smith, aged 27, presented to the hospital with chest pain.
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take history, and discuss your initial plan of management with the patient
Special note:
None
I would like to check your vitals and examine your chest. I will also examine the upper chest area for any tenderness.
Examination:
Inspection: Chest is moving bilateral symmetrical. There is no sign of any trauma or injury. There is no flail chest. No engorged neck veins.
Palpation: There is no tracheal deviation, trachea is central in position. Patient
cannot breathe in because of pain. Tenderness on both sides of the chest.
Percussion: There is no dullness or hyper-resonance.
Auscultation: Chest sounds are normal vesicular. There is no added sound.
I would like to send for some initial investigations including Routine Blood Test, Special blood test for your heart enzymes (Troponin), CXR (pneumothorax) and ECG (MI).
From my assessment, your chest pain is likely to be musculoskeletal pain or we call it Costochondritis, which is the inflammation of the cartilage that joins your ribs to your breastbone (sternum).
Costochondritis often gets better after a few weeks, but self-help measures and medication can manage the symptoms.
We can give you some Painkillers, such as Paracetamol to ease your pain.
Taking a type of medication called a Non Steroidal Anti-Inflammatory Drug (NSAID) — such as ibuprofen, two or three times a day can also help control the pain and swelling.
Self-help:
Costochondritis can be aggravated by any activity that places stress on your chest area, such as strenuous exercise or even simple movements.
You can use an Ice Pack (after wrapping in a cloth) to improve your pain.
Any activity that makes the pain in your chest area worse should be avoided until the inflammation in your ribs and cartilage has subsided.
Steroid injection
TENS (Transcutaneous electrical nerve stimulation)
If you develop any sudden severe chest pain or breathlessness, dial 999 and come to the hospital.
D/D Myocardial infarction Angina Pulmonary embolism Pneumothorax Pericarditis Pneumonia MSK pain
Where you are:
You are an FY2 in GP practice
Who the patient is:
A Mrs Hayley Smith, aged 34, has presented to you with a complaint
of breathlessness
Other information you have about the patient:
None
What you must do:
Talk to the patient, assess and give her the plan of management
Special note:
None
I would like to check your vitals & examine your chest.
From what you’ve told me & from my examination, I suspect that you have a condition called pulmonary embolism.
In this condition, a blood clot forms in one of the veins of the lungs & blocks the veins. We would however do some investigations to confirm this. We’II do the routine blood tests, urine dip (have to rule out pregnancy), ABGs & check the levels of chemicals in your body. We’II also check your blood for d-dimers, which is a special test for this condition. We’ll also do an ECG to see if
there’s any problem that can be causing this. We would also do a chest X-ray to see the lungs.
It can be serious, that is why we are going to investigate to confirm it & rule other conditions out. For now, we’re going to give you oxygen & do basic management to ease your breathing & send for tests. We’ll start specific treatment as soon as the results come out.
Management:
- Initial resuscitation w Oxygen 100%.
- Obtain IV access, monitor closely, start baseline investigations.
- Give analgesia if necessary (e.g. morphine).
- Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40 mm Hg for 15 minutes, not due to other causes.
- Low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed PE.
- Vitamin K antagonist (VKA) to patients with confirmed PE within 24 hours of diagnosis and continue the VKA for three months. At three months, assess the risks and benefits of continuing VKA treatment.
D/D Pulmonary Embolism TB Asthma Pneumonia Heart Failure PCP Lung cancer
Where you are:
You are FY2 in GP
Who the patient is:
Mr Peter Smith aged 40, has presented to the clinic with chest pain
Other information you have about the patient:
Other information you have about the patient:
None
What you must do:
Talk to the patient, assess him and discuss the plan of management.
Special note:
None
I would like to do GPE, Vitals, and want to examine your skin lesion.
From our assessment, you might have this chest pain because of a skin ailment called shingles.
Shingles is a painful, blistery rash in one specific area of your body. Most of us get chickenpox in our lives, usually when we are children. Shingles is a deactivation of that chickenpox virus but only in one nerve root. So instead of getting spots all over the place like in chickenpox, you get them just in one area of your body.
We can prescribe some antiviral medicine to help speed up your recovery and avoid longer- lasting problems.
You can catch chickenpox from someone with shingles if you have not had chickenpox before. But most adults and older children have already had chickenpox and so are immune from catching chickenpox again. You cannot get shingles from someone who has shingles.
Do:
- take paracetamol to ease pain.
- keep the rash clean and dry to reduce the risk of infection
- wear loose-fitting clothing
- use a cool compress (a bag of frozen vegetables wrapped in a towel or a wet cloth) a few times a day.
Don’t
- let dressings or plasters stick to the rash
- use antibiotic cream — this slows healing
General Advice.-
1. Try to avoid pregnant women who have not had chickenpox before, people with a weakened immune system and babies less than 1 month old (unless it’s your own baby), as they should be protected from the virus by your immune system.
- Stay off work or school if the rash is still oozing fluid and can’t be covered or until the rash has dried out.
Where you are:
You are FY2 in Medicine
Who the patient is:
Mr. David Parker, aged 69, presented to the hospital with breathlessness
Other information you have about the patient:
Patient has been referred by the GP. Patient had an MI 7 years ago. Patient is not regular with the GP.
What you must do:
Please take history, assess his condition, discuss management and address his concern
Special note:
None
I would like to check your vitals and examine your chest, heart and lungs.
I would like to send for some initial investigations like routine blood tests including Cardiac Enzymes, CXR and an ECG.
Examiner: News Chart: Temperature: 37, Pulse Rate: 67bpm, 02 Sats: 92%, BP: 130/90 mmHg, RR: 12-20 Decreased air entry bilaterally CXR: Cardiomegaly. ECG: Normal/Might find Q waves.
From my assessment, you seem to have a condition called heart failure. This means that the heart is unable to pump blood around the body properly. It usually occurs because the heart has become too weak or stiff.
This causes fluid to accumulate in the peripheries and lungs, that explains the swelling in your legs and shortness of breath. This is one of the complications of heart attack.
We did a CXR and as you can see here, this white area here is your heart and this shows that the size of your heart is enlarged.
Fortunately, your ECG looks okay, I will confirm it with my senior. (There is minor abnormality in your ECG (Q waves) this might be because of your previous heart attack; I will confirm it with my senior.
This is a complication of heart attack, after an attack some part of your heart muscle is dead and your heart will strain more to pump blood. This strain has caused the enlargement of your heart. We call this re-modeling of the heart.
In order to prevent this, we usually give some medication called beta blockers to reduce the strain on your heart and ACE inhibitors to decrease your blood pressure. As you have not been taking these medications, this could be one of the causes for your heart enlargement.
We will keep you in the hospital till your symptoms improve.
We will do further blood tests to check if you have anaemia and the function of your liver and kidneys.
We will do US of your heart (Echo) to assess the structure of your heart. We will also assess the function of your lungs.
We will give you Oxygen and medication to decrease the fluid in your lungs and your legs (Furosemide), so that your breathing improves. We will prescribe you Beta Blockers to reduce the strain on your heart and ACE inhibitors to decrease your blood pressure.
Hopefully, your condition should get better with these medications. If not, you may have to have a procedure done for your heart or for your heart beatWe might refer you to a Cardiac Rehabilitation service led by healthcare professionals for people with heart conditions, if needed.
The programme covers the following:
• exercise
• education
• relaxation and emotional support
D: We will discharge you once your symptoms improve.
You need to take all your medications regularly and as prescribed to prevent further re- modelling of your heart.
Address lifestyle accordingly: Smoking Alcohol Diet - Cut the amount of salt & fluid intake Physical activity.
You need to come for follow ups regularly. You should also see your GP regularly. He can assess your condition before it gets too bad.
If your symptoms get worse or if you need any help, please come back to us.
Where you are:
You are FY2 in a GP clinic
Who the patient is:
Mr. Alexander Dukov, aged 57, presented to the hospital complaining of
chest discomfort
Other information you have about the patient:
This is the patient’s first visit
What you must do:
Please talk to the patient, take a focused history, and discuss your initial plan of management with the patient.
Special note:
None
I would like to check your vitals and examine your heart and lungs. I would like to send for some initial investigations including routine blood tests, a special blood test for your heart enzymes and ECG.
From my assessment, you seem to have a problem in your heart called Arrhythmia, which is an irregular beating of your heart. The heart rhythm is controlled by electrical signals and arrhythmia is an abnormality of the heart
rhythm and sometimes rate. It may beat too slowly, too quickly or irregularly.
I am so sorry for what happened to your dad and brother. I can imagine how worried you are. We are here to help you. We are going to do some investigations to confirm the diagnosis and understand what is exactly going on.
We will refer you to a specialist. We will do some blood tests to see if you have anaemia, to check your kidneys, liver and thyroid gland function and also to check your blood sugar and cholesterol levels. We may need to do an x-ray of your chest.
The most effective way to diagnose an arrhythmia is with an electrical recording of your heart rhythm called an electrocardiogram (ECG). If the ECG doesn’t find a problem, you may need further monitoring of your heart.
This may involve wearing a small portable ECG recording device for 24 hours or longer. This is called a Holter monitor or ambulatory ECG monitoring.
If your symptoms seem to be triggered by exercise, an exercise ECG may be needed to record your heart rhythm while you are using a treadmill or exercise bike.
You should request a copy of your ECG. Take it with you to see the cardiologist or heart rhythm specialist and always keep a copy for future use.
Other tests used in diagnosing arrhythmias include:
cardiac event recorder — a device to record occasional symptoms over a period of time whenever you have them
echocardiogram (echo) —an ultrasound scan of your heart
Treatment for arrhythmias:
How your arrhythmia will be treated will depend on whether it is a fast or slow arrhythmia or heart block. Any underlying causes of your arrhythmia, such as heart failure, will need to be treated as well.
The treatments used for arrhythmias include giving medication — to stop or prevent an arrhythmia or control the rate of an arrhythmia
Arrhythmia/ heart racing has many causes, but to find out the exact cause in your case, we will run the tests and treat it accordingly. Sometimes having a family history of heart disease can also lead to this condition.
If you experience any heart racing, especially if it is fast and irregular accompanied by shortness of breath, dizziness or fainting, please come to the A&E immediately.
If you develop any sudden chest pain which is heavy and radiating to your left arm, shoulder, neck or jaw, please come to the A&E.
Please cut down tea or coffee.
Differentials
- Arrhythmia
- ACS
- Angina
- Pheochromocytoma
- Hyperthyroidism
Where you are:
You are an FY2 in A&E
Who the patient is:
Mrs. Dianna Pattinson, aged 60, presented to the hospital with pain in her
leg
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take history, assess her and discuss your initial plan of management with the patient.
Special note:
None
I would like to do GPE, vitals including distal pulses and examination of the leg. I would like to do some blood tests (FBC, VBG, U&E, TFT, LFT, Troponin). I would like to order a chest x-ray and ECG.
Examiner: Vitals (B.P- 120/70, PR- 80, Spo2- 96%, RR- 18), ECG- AF
From my assessment, you have a condition called Peripheral arterial disease (PAD) which is a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It’s also known as Peripheral Vascular Disease (PVD).
The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assess how well you’re responding to treatment.
I will discuss the case with my senior. I will give painkiller (Morphine) to my patient. We may have to give oxygen to our patient.
I would like to give my patient a medication to control the rate of heartbeat as the first line management, such as a beta blocker (metoprolol) or a calcium channel blocker (verapamil or digoxin)
If symptoms continue after heart rate has been controlled or if the rate control strategy has not been successful, rhythm control may be considered to restore a normal heart rhythm using
(A) medication such as flecainide
(B) cardioversion.
We may consider giving clopidogrel which prevents the formation of blood clots in your arteries.
We may consider anticoagulation based on CHADVAS and HAS-BLED scoring system We may consider further investigations like ECHO, Holter monitoring (24-48hrs) and Ultrasound scan where sound waves can identify exactly where in your arteries there are blockages or narrowed areas. We may consider doing an angiogram for detailed image of your arteries.
Give lifestyle advice to the patient.
If you develop any sudden severe chest pain, breathlessness dial 999 and come to the
hospital.
ABPI:
While you rest on your back, your GP or practice nurse will measure the blood pressure in your upper arms and your ankles. These measurements are taken with a Doppler probe, which uses sound waves to determine the blood flow in your arteries. They then divide the second result (from your ankle) by the first result (from your arm).If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same, and the result of your ABPI would be one. However, if you have PAD, the blood pressure in your ankle will be lower because of a reduction in blood supply, so the results of the ABPI would be less than one.
D/D Peripheral Arterial Disease Acute Limb Ischaemia Cellulitis DVT
Where you are:
You are FY2 in the respiratory department
Who the patient is:
Mr Peter Smith, aged 70, has come to you with a cough
for the past few months
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take history, and assess the patient’s
condition. After 6 minutes, discuss differential diagnosis with the examiner and discuss the management plan with the patient.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including a routine blood test, CXR.
Examiner:
All the examinations are normal/ Reduced breath sounds on the right side.
From my assessment, you seem to have a problem in your lungs. It is very difficult for us to give you a definitive diagnosis about what’s wrong with you because all the symptoms you presented with can have many causes.
We are going to run further tests to confirm what is going on.
We will do further blood tests to check if you have anaemia or any infection and to check your blood gases.
We will do ECG (Tracing of your heart). We will do a chest CXR (If chest X-ray is not done already) and check your lung function. If there is any fluid in the lining around your lungs, we will take a sample by introducing a needle and analyse it in the lab.
We need to examine your phlegm, but as you said you don’t have any phlegm/ sputum along with cough, we may have to do a procedure to get some sputum/phlegm out (saline nebulisation and
chest physiotherapy). If we are not able to get a sample of your sputum, then we will do bronchoscopy and lavage (BAL) to
get a sample. The sputum sample will then be sent to the lab for examination to check for any bugs using a special dye. We may also grow some bugs if there are any.
We may have to do a procedure called thoracoscopy to have a better look inside your lungs. We may even take a sample of your lung. The sample will then be sent to the lab to have a closer look.
D/D
TB - (Night sweats, weight loss, fatigue, fever, loss of appetite, contact with son)
Lung cancer - (Weight Loss, Fatigue, Occupational, Loss of Appetite)
Asthma - (Gardening)
Pneumonia - (Fever)
Heart failure - (SOB on lying down)
Where you are:
You are FY2 in medicine.
Who the patient is:
Mr. Michael Smith, aged 24, presented to the hospital with cough and
shortness of breath for the past few weeks.
Other information you have about the patient:
Patient is homeless and losing weight
What you must do:
Please talk to the patient, assess the patient, do relevant examinations and discuss initial management with the patient.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including routine blood tests, ABG and CXR.
Findings:
NEWS Chart: Temperature - 38’C, O2 Sats - 90%
Auscultation: Bilateral reduced air entry/Bi-basal crepitations.
CXR finding: CXR shows pneumonia/Not done yet.
From my assessment, it seems you have a chest infection, as your temperature is high and oxygen in your blood is low. Your chest X-ray also suggests the same.
We will do further blood tests to check for any bug and to check your blood gases. We will do a Chest X-ray (If chest X-ray is not done already) and check your lung function. We need to examine your phlegm, as you said you don*t have any phlegm/ sputum along with cough. We may have to do a
procedure to get some sputum/ phlegm out (saline nebulisation and chest physiotherapy). If we are not able to get a sample of your sputum, then we will do bronchoscopy and lavage (BAL) to get a sample. We may have to do a biopsy of your lung to get the sample. The sample will then be
sent to the lab for a procedure called PCR (Polymerase Chain Reaction) to identify the cause of your chest infection.
This type of infection is sometimes caused by HIV. HIV spreads by unsafe sex and sharing needles. We may test for HIV infection in you, so that we can treat HIV also if you are positive.
We will admit you and treat you with Antibiotics (Co-trimoxazole) through your blood vessels. We will give you steroids as well to prevent damage to your lungs. We will then taper down the dose of steroids in the next 21 days and stop. We will monitor you regularly by doing blood tests, checking your pulse, blood pressure, temperature and oxygen in your blood.
Please come back to us if your symptoms worsen.
Please practice safe sex and also avoid sharing needles. We have a needle exchange programme if you want to enroll in it.
We will talk to social services and try to arrange accommodation for you.
D/D PCP Lung cancer TB Asthma Pneumonia
Where you are:
You are FY2 in A&E
Who the patient is:
Mr Thomas Johnson, aged 29, presented with a cough and SOB
Other information you have about the patient:
None
What you must do:
Talk to the patient, take relevant history, assess the patient and outline the plan of management with him.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including a routine blood test, CXR.
Examiner: All the examinations are Normal/ Reduced breath sounds on the right side. NEWS CHART: Temperature 38 Pulse Rate 100 02 Sat BP 110/80 mmHg, RR >25/min AVPU Alert NEWS Score 6
X-Ray:
Increased bronchoalveolar marking in the hilar region in both the lungs predominantly on the right side.
Tuberculosis (TB) is caused by a type of bacterium called Mycobacterium Tuberculosis. It spreads when a person with active TB in the lungs coughs or sneezes and someone else inhales the expelled droplets, which contain TB bacteria.
From my assessment, you seem to have Pulmonary Tuberculosis in your lungs. We are going to run further tests to confirm the diagnosis.
We will do further blood tests to check if you have anaemia or any infection and to check your blood gases.
We will do a chest X-Ray (If chest X-ray is not done already) and check your lung function. If there is any fluid in the lining around your lungs, we will take a sample by introducing a needle and analyse it in the lab. We need to examine your phlegm with a special dye to look for TB bacteria (If patient says there is
no phlegm - as you said you don’t have any phlegm/ sputum along with cough, we may have to do a procedure to get some sputum/ phlegm out(saline nebulisation and chest physiotherapy). If we are not able to get a sample of your sputum, then we will do bronchoscopy and lavage (BAL) to
get a sample). We will also grow TB bugs in the lab, if there are any.
You’ll be prescribed at least a six-month course of a combination of antibiotics if you’re diagnosed with active pulmonary TB, where your lungs are affected and you have symptoms.
The usual treatment is:
-two antibiotics (isoniazid and rifampicin) for six months
-two additional antibiotics (pyrazinamide and ethambutol) for the first two months of the six-month treatment period
It may be several weeks before you start to feel better. The exact length of time will depend on your overall health and the severity of your TB.
After taking antibiotics for two weeks, most people are no longer infectious and feel better. However, it’s important to continue taking your medicine exactly as prescribed and to complete the whole course of antibiotics. Taking medication for six months is the best way to ensure the TB bacteria are killed.
If you stop taking your antibiotics before you complete the course or you skip a dose, the TB infection may become resistant to the antibiotics. This is potentially serious because it can be difficult to treat and will require a longer course of treatment with different, and possibly more toxic, therapies.
If you find it difficult to take your medication every day, your treatment team can work with you to find a solution.
If your symptoms get worse or if you develop persistent swollen glands, any abdominal pain or pain and loss of movement in an affected bone or joint, confusion, any persistent headache or fits (seizures) please come back to us.
Preventing the spread of infection
If you’re diagnosed with pulmonary TB, you’ll be contagious up to about two to three weeks into your course of treatment. You won’t usually need to be isolated during this time, but it’s important to take some basic
precautions to stop TB from spreading to your family and friends.
You should:
1. Stay away from work, school or college until your TB treatment team advises you it’s safe to return.
2. Always cover your mouth — preferably with a disposable tissue — when coughing, sneezing or laughing.
3. Carefully dispose of any used tissues in a sealed plastic bag.
4. Open windows, when possible, to ensure a good supply of fresh air in the areas where you spend time.
5. Not sleep in the same room as other people — you could cough or sneeze in your sleep without realising it.
D/D TB PCP Lung cancer Asthma Pneumonia
Where you are:
You are FY2 in A&E
Who the patient is:
Mr Daniel McCormick, aged 72, presented with cough and shortness of breath.
Other information you have about the patient:
He has been referred by his GP. Nurse colleague has seen the patient. The vitals have been recorded in an observation chart. Chest X-Ray has been taken. You can find the NEWS chart and CXR inside of the cubicle
What you must do:
Talk to the patient, take relevant history, assess the patient, and discuss the
initial management plan with the patient.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including a routine bloodtest, CXR.
Examiner:
All the examination is normal/ Reduced breath sounds on the right side.
News chart:
Temperature: 38-39 Pulse Rate: 110/min 02 Sat: S91 % or 90%
BP: 110/80 mmHg RR: 25/min Blood Sugar: 8
CXR:
Prominent hilar markings in the central area. Round opacity in the right upper lobe.
From my assessment, you seem to have a chest infection.
We will do further blood tests to check if you have anaemia and to check your blood gases.
We will do a Chest X-ray (If chest X-ray is not done already) and check your lung function. We need to examine your phlegm. The sputum sample will then be sent to the lab for close examination for any bugs using a dye. We may also grow some bugs if there are any. We need to examine your urine
and check your urine output as well.
We need to keep you in the hospital. We will give you oxygen as oxygen levels are low in your blood. We will give you fluids through your blood vessel (vein) as a drip.We will give you antibiotics (dual antibiotic therapy) through your blood vessel(vein).
(Co-AmoxicIav 1.2 g TDS IV and Clarithromycin 500 mg BD PO or IV for 5-10 days)
If vitals are okay and you are sending the patient home- Please take rest and drink plenty of fluids.If your symptoms get worse or if you develop any confusion or drowsiness, please come back to us.
We will arrange a follow up with your GP in 4-6 weeks.
CURB65 score is calculated by giving 1 point for each of the following prognostic features:
- Confusion (abbreviated Mental Test score 8 or less, or new disorientation in person,place or time)
- Raised blood Urea nitrogen (over 7 mmol/litre)
- Raised Respiratory rate (30 breaths per minute or more)
- Low Blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
- Age 65 years or more.
Patients are stratified for risk of death as follows:
• 0 or 1: low risk (less than 3% mortality risk)
• 2: intermediate risk (3-1S% mortality risk)
• 3 to 5: high risk (more than 1S% mortality risk).
Use clinical judgement in conjunction with the CURB6S score to guide the management of community acquired pneumonia, as follows:
• consider home based care for patients with a CURB6S score of 0 or 1
• consider hospital-based care for patients with a CURB65 score of 2 or more
• consider intensive care assessment for patients with a CURB6S score of 3 or more.
Where you are:
You are FY2 in Acute Medical Unit.
Who the patient is:
Mrs. Olive Green, aged 85, has been referred to the hospital from a care home.
Other information you have about the patient:
Patient is confused and agitated. You are not able to talk to her to take any
history. There is no medical record or reference letter from the care home. You are not able to examine her. Vitals have been recorded and are as follows.
BP: 90/60 mmHg, Pulse: 20/min, RR: 24/min, Temp: 38.5, 02 Stat: 88%
What you must do:
Call the care home and talk to a member of care home and take history about the patient. After 6 mins, talk to the examiner regarding the provisional diagnosis and discuss the management in the best interest of the patient.
Special note:
None
From our assessment, it looks like she is having septic shock due to the chest infection as she is confused, has tachycardia, hypotension and high temperature and her 02 Sats are low. She also has shortness of breath.
I would like to do necessary investigations like Bloods (FBC/U&E/LFT/Glucose/ABG/Clotting
Screen/Blood Culture), Urine test, ECG, Imaging (CXR/Abdominal USG)
SEPSIS SIX: (within one hour)
Give High flow 02, IV Antibiotics, IV Fluids to the patient. Take Blood Culture, Serum Lactate, and Hourly Urine Output.
I will discuss with my senior and use a broad-spectrum antibiotic based on the hospital protocol.
We may consider Co-AmoxicIav 1-2g TDS IV & Clarithromycin 500mg BD IV.
Where you are:
You are FY2 in the respiratory department
Who the patient is:
Mr Jacob Murphy, aged 85, has come to the clinic because
of cough and haemoptysis.
Other information you have about the patient:
None
What you must do:
Please talk to the patient, take relevant history, assess the patient,
discuss the initial management plan with the patient and address his concern
Special note:
X-ray has been done and you can find it in the cubicle.
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including Routine Blood Test, Sputum and CXR.
Examiner:
On Inspection of Hands- clubbing and nicotine stains
On Palpation: Fullness in supra-clavicular area.
On Auscultation: Decreased breath sounds on the right side.
CXR finding:
Pleural effusion in the right lung (mesothelioma). Round shaped opacity on the upper lobe of the left lung, about 5cm diameter (lung cancer).
Explain the CXR to the patient.
From our assessment, you seem to have a condition in your lungs.
We have examined you, conducted blood tests and chest X-ray and from that, we suspect your condition could be a serious one.
As you can see the chest X-ray, these are your lungs and heart. Your normal lungs appear black because of the air in them.
- But can you see the round opacity here, this could be because of many causes like TB, infections or lung cancer.
- But can you see the white shade in this part of your lungs, this is called Pleural Effusion. This could be because of many causes like pneumonia, heart, liver and kidney problems or cancer (lung and mesothelioma - cancer of lining of lungs).
From the history you have given us and from the chest X-ray, it looks like cancer, but it is very difficult for us to confirm it at this stage before doing all the tests.
We need to do further investigations to make sure what exactly is going on. We need to do further blood tests, check your lung function(spirometry), CT scan of your chest and we may have to take a sample from your lung if needed.If we find any abnormality in the CT of your chest, then we may have to do a bronchoscopy. We will be able to take some samples during the procedure if needed.
We will refer you to a specialist (pulmonologist) and a team of doctors (multi-disciplinary team) who will do the necessary tests and confirm the diagnosis and start treatment depending upon the condition. We will refer you to the specialist in 2 weeks time.
If it is cancer, then the treatment depends not onIy on the type, size, position and stage of cancer and also your overall health. We have surgical options for resection of some tumors (lung cancer). But in some cases (mesothelioma), we have to give chemotherapy and radiotherapy to extend the quality and quantity of life.
Advice for smoking cessation.
Advice for changing the occupation (if exposed to Asbestos)
In the meantime, if you have any concerns before meeting the specialist, please come back to us at any time.
Please come back to us if your symptoms worsen or if you have severe breathlessness, coughing up large amounts of blood, any swelling in the face, any weakness of arms or if you are unable to swallow food.
D/D Pulmonary embolism Pneumonia Tuberculosis Bronchiectasis Bronchogenic carcinoma Mesothelioma Bleeding disorders Blood thinners Instrumentation
Cancer Pathway
GP: 2 Weeks Urgent Referral to Specialist
Specialist: Admit & Investigate
Where you are:
You are FY2 in GP
Who the patient is:
Mr Adam Jakes, aged 22, presented to the hospital with wheeze and chest
tightness
Other information you have about the patient:
None
What you must do:
Take a focused history, assess the patient, discuss diagnosis and the management plan.
Special note:
None
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including a routine blood test, CXR.
This is peak flow meter, it is used to take Peak flow readings. We use this device to perform a test in which we can assess how well your lungs are functioning. By doing this test, we can measure how quickly you can blow air out of your lungs. If your airways are tight and inflamed, you won*t be able to blow out quickly.
Normal Peak flow readings depend on your gender, and height. We can find out your normal value on this chart (explain the chart and how to take the reading to the patient).
(The patient will have near normal PEFR)
From our assessment, you seem to have a condition called asthma. Asthma is a lung condition that causes occasional breathing difficulties.
It is a condition which affects the smaller airways which carry air in and out of your lungs. That’s why it causes breathing difficulties and other symptoms.
Asthma has many triggers. When Exercise triggers it, we call it Exercise Induced Asthma.
We are going to prescribe you a blue inhaler which is a reliever.
This relaxes your airways very quickly to allow you to breathe easily. You should take 1-2 puffs whenever you have any symptoms.
We will review your condition and tell you how long you should take it for.
Side Effects of Salbutamol:
Headache - Simple Paracetamol
Muscle Cramps
Heart Racing
Hand Shaking
These symptoms usually pass within a few minutes or a few hours at the most and are not dangerous.
If any of these become troublesome, please speak to your GP.
You can also try these practical tips:
• Warm up and warm down for 10-15 minutes before and after exercising.
• If you’re exercising with someone else, make sure they know you have asthma, and that you have a reliever inhaler with you.
• If you have symptoms when you exercise, stop, take your reliever inhaler and wait until you feel better before starting again.
• In colder weather, symptoms are even more likely during exercise because when the air is cold, it can irritate the sensitive airways. One way to avoid this problem is to exercise indoors during the winter months. Or consider doing less vigorous exercises - go for a power walk instead of a run, for example.
• Dress appropriately. If it’s cold, make sure your chest and throat are covered and keep a scarf around your nose.
• If you regularly have asthma symptoms when you exercise, speak to your GP or asthma nurse who can assess your treatment.
I am going to talk about a few important things today: • Your medication and Inhaler • Peak flow meter and reading • Asthma diary • Triggers
This is an inhaler which we are going to prescribe you to take your medication. Let me explain to you how to use this one (explain inhaler technique).
This is an asthma diary which is used to observe the progression of your condition. (Explain Asthma Diary).
You have to record your PEFR readings on this diary twice a day, morning and at night, for two weeks. You need to take 3 readings every time you record your PEFR and plot the highest reading you got here (show it in the diary). You need to do it in the same position every time you do it. For example, if you are sitting upright, you have to continue in the same way all the time. Same if you
are standing.
You have to record in the diary:
Your morning and evening PEFR readings.
You need to tick this box (show it on the chart) if:
1) You use your reliever inhaler
2) You have any symptoms
3) You wake up at night with asthma symptoms
4) You feel that you can*t keep up with your normal day to day activities
Note down anything unusual or different that may be the reason for a lower than usual peak flow score in a week here (show it on the chart).
Example: You were stressed, you were doing exercise.
If we can identify your triggers and try to avoid them, your asthma can be better controlled. As I told you earlier, exercise is a trigger for your asthma.
Usually, you breathe in through your nose, so the air is warmed and moistened. When you exercise, you tend to breathe faster and in through your mouth, so the air you inhale is colder and drier. In some people with asthma, the airways are sensitive to these changes in temperature and humidity and they react by getting narrower.
The best way to avoid exercise triggering asthma symptoms is to manage your asthma well:
• Take your medication exactly as prescribed and discussed with your GP or asthma nurse.
• Check with your GP or asthma nurse whether you’re using your inhaler correctly.
• Use an up-to-date written asthma action plan and keep it where you can see it (on the fridge, for example).
• Go for regular asthma reviews.
Technique for Peak Flow:
• Stand or sit upright (do it the same way all the time) whichever is comfortable for you.
• Hold the device in horizontal position.
• Put the pointer on the first line on the scale (usually 60).
• Take a deep breath.
• Make a tight seal with your lips around the mouth piece.
• Blow out as hard and as fast as you can into the meter.
• Write down the number next to the pointer. This is your score.
• Do it 3 times in a row so you get 3 scores (Record the highest of the 3 scores in your diary).
The common mistakes are:
- Not closing the lips around the mouth piece properly.
- Not blowing out as hard as possible.
- Not holding the device horizontally.
- Bending forward.
Technique for inhaler:
• Check the expiry date.
• Remove the cap.
• Shake the inhaler well.
• Put the mouthpiece in your mouth as you begin to breathe in which should be slow and deep, press the canister down and continue to inhale steadily and deeply.
• Remove the inhaler from your mouth and continue to hold your breath for 10 seconds or as long as it is comfortable.
