Bill Flashcards
(163 cards)
1
Q
What do we learn from Bill’s patient persona?
A
He has been sleeping rough for 4 years
Smoker
He has been receiving lesser coin recently
2
Q
What do the paramedics say in the handover?
A
Picked up from local Homeless centre Went to sleep and was very difficult to rouse after fire alarm at 2:30am non-verbal Drowsy GCS E3 V4 M6 Reactive pupils 37.4 temperature HR 97 BP 89/65 Sats 90% now 94% on oxygen 14 resp rate Mildy wheezy Abdomen distended Blood sugar 4.2
3
Q
What had the paramedics done before his admission to hospital?
A
500 ml of fluid Bought is systolic up to 105 Glucogel given One cannula in the right AVF Oxygen
4
Q
What did the paramedic find?
A
Smoking papers
Papers with number on
Smells of alcohol
5
Q
What do we see in Bill?
A
Altered mental state
6
Q
How would you work our what is happening with Bill?
A
Symptom sieve
7
Q
What is the symptom sieve used by Bill’s doctor?
A
Primary neurological Infection Cardiorespiratory Gastro-intestinal Metabolic\Endocrine Toxins Psychiatric
8
Q
What is GCS?
A
Glasgow Coma Scale
9
Q
What are the possibilities for primary neurological symptoms?
A
Trauma
10
Q
What Infection’s could be present?
A
COPD
Asthma
TB
11
Q
What are possible GI issues?
A
Alcohol poisoning
Pancreatitis
Distended abdomen
12
Q
What toxins could be present?
A
Drugs
Alcohol
13
Q
What psychiatric problems could be present?
A
Depression
Anxiety
14
Q
What comprises an A - E assesment?
A
Airways
15
Q
What would an Airways assessment show in Bill
A
Verbalising intermittently
No foreign objects in mouth or excessive secretions
No snoring / stridor
No mouth or tongue swelling
16
Q
Who could you call when examining airways?
A
An anaesthetist who are experts in airway management
17
Q
What observations can you make about Bill’s breathing?
A
Normal resp. rate (14 breaths per min) Slight wheeze (stridor) when examining abdomen He was distressed 90% sats but 94% on 2L oxygen Smoker
18
Q
What can you exclude when assessing breathing?
A
Exclude trauma to neck
C3,C4,C5 keeps the diaphragm alive
Look at the neck muscles
19
Q
What should you look at in regards to smoker?
A
Nicotine stained fingernails
20
Q
What was Dr. Patel’s C assessment?
A
Blood pressure - 86/64 mm Hg
Heart rate - 110 bpm
Heart sounds - normal
12 lead ECG - sinus tachycardia nil. ischaemic changes
Peripheral capillary refil brisk bilaterally ( more than 3-4 secs)
Warm peripheries, looks flushed
21
Q
What is most concerning about the circulation assessment?
A
Blood pressure is low
High heart rate is normal response
Worry about shock and its consequences
22
Q
How do you conduct a capillary refill test?
A
Lift patients hand to heart level
Place pressure on the fingernail see how long it takes for colour to return
23
Q
What are the 4 types of shock?
A
Hypovolemic
Cardiogenic
Obstructive
Distributive
24
Q
What is the most common form of shock?
A
Hypovolemic shock
25
What causes cardiogenic shock?
Anything that impairs the heart generating pressure
Inadequate tissue perfusion causes shock
26
What causes obstructive shock?
Something physically obstructs the vessels preventing perfusion
27
What are the three types of distributive shock?
Septic
Anaphylactic
Neurogenic
28
How does distributive shock come about?
Vasodilation
TPR falls
Blood pressure falls
Inadequate perfusion
29
Disability, what is his mental state?
```
Blood glucose - 5.7
Temperature - 38.2
Confused
GCS E3 V4 M5
Moving four limbs normally
PEARL - 3mm
Smells of alchol
```
30
What comprises the GCS?
Eyes
Verbal response
Motor
31
What is the exposure?
```
No rashes
No sites of infection / track marks
No evidence of trauma to limbs or head
No evidence of external bleeding
Abdominal examination - abdomen distended, tender in left illiac fossa
```
32
What are Dr. Patels impressions?
Sepsis
Altered mental state
Likely due to sepsis however need to consider alcohol, delirium, drugs and intra-cranial pathology
33
Why do we think it is sepsis?
```
Developing high temperature (may or may not have in sepsis)
Difficult to wake/Sleepier than normal
Altered mental state
Oxygen to maintain above 92% sats
Low blood pressure
From shelter/streets - poor hygiene
```
34
What is Dr. Patel's plan?
Sepsis management
Need to investigate the source of sepsis
CT head to rule out intra-cranial pathology
35
What is important about observations?
They are not static
Must be reviewed regularly
Compared to previous
36
How do you diagnose SIRS?
2 or more of
37
What is the flowchart for septic shock?
SIRS
Sepsis
Severe Sepsis
Septic Shock
38
What are the SEPSIS 6?
```
Give O2 to keep sats above 94%
Take blood cultures
Give IV antibiotics
Give a fluid challenge
Measure lactate
Measure urine output
```
39
What biochemical tests do Dr. Patel order?
```
CRP
Creatinine
Urea
Na
K
ALT
ALP
GGT
Bili
Amylase
Lactate
```
40
What haematology test do Dr. Patel order?
Hb
WCC
Neut
PLT
41
What other test does Dr. Patel order?
Toxicology screen
| Blood culture
42
What can you tell from the blood results
```
High CRP (marker of inflammation)
High Lactate (tissue ischaemia)
High WBC and Neut (infection)
Creatinine (poor kidney function/muscle breakdown)
Blood ethanol is positive
Hyponatremic (possible dehydration)
High urea (kidney problems)
```
43
Which abnormal bloods are most relevant?
```
CRP
Creatinine + Urea (kidney problems)
Lactate
WBC
Neut
```
44
What is Dr. Patel's clinical update?
```
CT head normal
Blood tests are keeping with sepsis
Blood cultures sent
IV AB given
Patient improving clinically with AB and fluids
Less confused
Reporting severe pain in his abdomen
Patient tender in left iliac fossa
Abdomen soft to palpitation
```
45
What is his NEWS2 score?
Systolic BP 1
Pulse 1
Consciousness 3
Temperature 1
6 Medium risk, key threshold for urgent response
46
What antibiotic do you give after taking cultures?
Best guess antibiotics immediately after taking cultures
'empirical antibiotics'
When culture results come in 24 hours antibiotic treatment can be fine tuned
47
What is the timescale for the Sepsis 6?
Should be done within an hour
48
What is Dr. Patel's second clinical plan?
Analgesia
CT abdomen/pelvis
Continue intravenous fluids and antibiotics
49
What his is new NEWS 2 score?
Now less confused
| so is now 3
50
After more information what symptom sieve categories are most likely to be causing his confusion?
Infection
GI
Toxins
Psychiatric
51
What organs could be causing Bill's pain?
Descending and sigmoid colon
52
What are the radiologist's observations?
Normally positioned liver with evidence of mild parenchymal nodularity and fatty infiltration
No portal vein enlargement
The intra- and extra-hepatic billiard ducts and gallbladder are unremarkable
The spleen is of normal size. There is no ascites.
53
What is Bill most likely to have?
Sigmoid diverticulitis
54
What is sigmoid diverticulitis?
Constant abdominal pain
Signs of systemic upset
Common cause of sepsis
55
What is diverticulitis?
Out-pouching with infection/inflammation
56
What is diverticulosis?
Out-pouching without inflammation
57
What are diverticula>
Abnormal out-pouching of the mucosa
58
When does it become diverticular disease?
Intermittent abdominal pain
Changes in bowel pain
Related to a high fat, low fibre diet
59
What is important to know about tests?
They are there to confirm your suspicions
In this case palpating would have given you the diagnosis and test confirmed it.
60
What is the main aim of the A-E approach?
Buy time for further treatment and making a diagnosis
61
What is the SBAR approach?
Situation
Background
Assessment Recommendation
62
What is the homelessness iceberg?
Most obvious is homelessness on the street increased from 2000 in 2010 to 4800 in 2018
People in tents/carparks
On the edge of homelessness e.g. living with a friend
People in hostels
63
Why does homelessness cause a public health issue?
Those sleeping rough have average age of death of 47
High drug use
The effects of being in rentery's is equivalent to becoming redundant
Affects skin, breathing, mental health
64
What is RSVP approach?
Reason
Story
Vital signs
Plan
65
What causes homelessness?
Eviction from private tenancies
You can evict someone with only 8 week notice in UK
66
How many children live in houses where they can be evicted?
1/3
67
Why is there now a lot of housing that is not being used?
More people are buying houses to rent
Makes housing market inefficient
E.g. a 2 bed maisonette would usually house a 4 people family
Now a private landlord will rent it out to a single working professional
68
What might airway obstruction cause if untreated?
Hypoxia
Risks organ damage
Cardiac arrest
Death
69
Where is homelessness less prevalent?
Scotland e.g. Edinburgh and Glasgow
70
Give examples of airway problems
- Decreased GCS (GCS ≤8 usually requires intubation)
- Excessive secretions
- Foreign body
- Airway swelling / inflammation
- Trauma
71
How can airway obstruction present?
- There may be paradoxical chest and abdominal movements
- There may be use of accessory muscles
- In partial obstruction there may be noisy breathing (snoring, stridor, wheeze) with diminished air entry
- In total obstruction there will be no breath sounds at the nose or mouth
- Central cyanosis is a late sign
72
What actions can you take to treat an airway obstruction?
Airway opening manoeuvres - head tilt and chin lift, or jaw thrust
- Suction to remove debris (don’t ever use your fingers!)
- Simple airway adjuncts – nasopharyngeal airway, oropharyngeal airway (aka Guedel)
- Supraglottic airway (eg iGel)
- Advanced airway interventions – intubation, emergency surgical airway
- Then give oxygen at high concentration
73
Give some examples of respiratory pathologies the can cause problems with breathing
- Reduced GCS
- Acute severe asthma or COPD
- Pneumonia or lung infection
- Pulmonary oedema
- Pneumothorax or tension pneumothorax
- Pulmonary embolism
- Haemothorax (blood in the pleural cavity, often secondary to trauma)
- Respiratory depression (e.g. secondary to drug toxicity)
74
How do you assess someone's breathing?
- Oxygen sats
- Can they talk?
- Use of respiratory muscles, central cyanosis, sweating?
- Look / feel for symmetry of chest movement and for chest deformity
- Feel for the trachea deviation
- Percuss the chest - hyper-resonance
- Listen to the chest – for air entry and any added sounds (crackles, wheeze, stridor)
- Look at the calves for any signs of DVT
75
What may tracheal deviation indicate?
to one side may indicate a tension pneumothorax or large effusion on the
contralateral side
or collapse on the ipsilateral side
76
What might hyper-resonance suggest?
pneumothorax; dullness usually indicates consolidation or
| pleural fluid
77
What might absent or reduced breath sounds suggest?
a pneumothorax or pleural fluid or lung consolidation caused by complete obstruction to that region.
78
What would DVT possibly indicate?
possibility of PE
79
What action do you take when someone's breathing is compromised?
Specific treatment depends on cause
Sit the patient up if possible
Give oxygen to meet sat target of >94%
80
What would you give to treat breathing in anaphylaxis?
Adrenaline
81
What would you do to treat breathing in a pneumothorax?
Chest drainage
82
What do you give to treat breathing due to an opioid overdose?
Naloxone
83
What do you used to treat breathing in airway disease?
Bronchodialtors
84
What do you do if the patient's rate or depth of breathing is insufficient or absent?
use bag-mask or pocket mask ventilation to
improve oxygenation and ventilation
whilst calling immediately for expert help
85
What do you do if breathing still has not improved after intervention?
Non-invasive ventilation
OR
Intubation and ventilation may be required
86
In those with COPD what can high conc/ of O2 do?
May depress breathing
87
What do patients with COPD often have?
Chronic hypercarbia
88
What does chronic hypercarbia mean they do?
Start to rely upon hypoxia (rather than CO2 levels) to stimulate ventilation
'hypoxic drive'
high flow oxygen care remove their driving factor for respiration
89
Why can you not let patients with COPD have a low sats rate?
They might sustain end-organ damage or cardiac arrest
90
What do you aim for when treating the breathing of COPD patients?
target SpO2 of 88–92% in
most COPD patients
evaluate this based on the patient’s arterial blood gas measurements
91
In almost all emergencies what should you consider to be the primary cause of circulatory failure?
Hypovolaemia
92
What are the basic aims of treating cardiovascular collapse?
Fluid replacement
Haemorrhage control
Restoration of tissue perfusion
93
What life threatening conditions must you look for when assessing circulation?
Cardiac tamponade
Massive haemorrhage
Septic Shock
94
What could be causing problems in circulation?
Hypovolaemia (bleeding, burns, diarrhoea / vomiting, dehydration)
- Pump failure
- Cardiogenic eg heart failure, myocardial infarction, arrhythmia
- Non-cardiogenic eg cardiac tamponade, tension pneumothorax, PE
- Vasodilation (sepsis, anaphylaxis)
95
How do you assess circulation?
Look at the colour of the hands and digits: are they blue, pink, pale or mottled?
- Assess the limb temperature by feeling the patient’s hands: are they cool or warm?
- Measure the capillary refill time (CRT).
- Take the heart rate
- Apply 3-lead cardiac monitoring (you should also ask for a 12-lead ECG).
- Look at the neck for the height of the jugular venous pressure (JVP).
- Palpate peripheral and central pulses, assessing for rate, quality, regularity and equality.
- Measure the blood pressure.
- Auscultate the heart. Is there a murmur? Are the heart sounds difficult to hear (such as may be seen in cardiac
tamponade) ?
- Look thoroughly for evidence of bleeding
96
How to you measure CRT?
Apply cutaneous pressure for 5 seconds on a fingertip held at heart
level to cause blanching. Time how long it takes for the skin to return to its previous colour after releasing. A
normal CRT is < 2 s. A prolonged CRT suggests poor peripheral perfusion (but can also be due to cold
surroundings and old age).
97
What can elevated jugular venous pressure indicate?
An elevated JVP may indicate heart failure
| or fluid overload
98
What might differences in use indicate?
Barely palpable
central pulses suggest poor cardiac output
A bounding pulse may indicate sepsis.
99
Why might blood pressure in circulatory shock be normal?
Even in circulatory failure (shock), the blood pressure may be normal, because
compensatory mechanisms increase peripheral resistance in response to reduced cardiac output.
100
What actions do you take to treat circulatory issues?
- Insert one or more large intravenous cannulae
- Take blood from the cannula for routine checks
- If the BP is low, give a fluid challenge
- If the patient is bleeding, replace blood with blood
101
What investigations are carried out with blood sample?
haematological
biochemical
coagulation
cross-matching
102
What can lactate level indicate?
A lactate level can give an indication as to tissue perfusion.
103
How do you conduct a fluid challenge?
250ml up to 1000ml of Crystalloid fluid
depending on the
patient and the situation (use less if the patient is elderly or known to have heart failure)
Monitor the heart
rate and BP in response to the fluid
104
What might the patient benefit from if BP does not improve despite fluid resuscitation?
If BP does not improve despite IV fluid resuscitation, the patient may benefit from specific drug infusions on
intensive care to improve the function of their heart or to stimulate vasoconstriction
105
What does disability look at?
Level of consciousness and neurological functioning
106
What problems would cause disability?
Profound hypoxia or hypercapnoea
- Drugs – sedatives, opioids, toxins, poisons
- Cerebral hypoperfusion (eg from profound hypotension)
- Raised intracranial pressure
- CVA
- Metabolic dysfunction eg hypoglycaemia
107
How do you assess disability?
Check the Glucose
- Take the temperature
- Assess the neurological status
- Check the pupils for size, equality and reactivity to light
- Assess for pain
- Check the drug chart for possible culprits / reversible causes of depressed consciousness
108
How do you conduct a rapid neurological assessment?
ACVPU (Alert – confused – respond to voice – respond to pain – unresponsive)
109
How do you conduct a formal neurological assessment?
GCS
110
What actions do you take against disability?
- Provide oral or parenteral glucose if needed (follow local protocols)
- Provide analgesia for pain
- Specific action for specific problems eg treat seizures, treat opioid toxicity with Naloxone, seek specialist input
if raised intracranial pressure
111
What does exposure mean?
To examine the patient properly full exposure of the body may be necessary. Respect the patient’s dignity and
minimise heat loss.
112
What do you examine in the exposure stage?
head to toe, front and back. Look for bleeding, swellings, rashes, sores, wounds, catheters etc
Perform a focused exam of any relevant systems eg the abdomen
113
What steps should you take during the exposure assessment?
Take a full clinical history from the patient, any relatives or friends, and other staff.
- Review the patient’s notes and charts
- Review the results of laboratory or radiological investigations
114
What does a NEWS2 score of 0-4 indicate?
Low clinical risk
Ward based response
115
What does a NEWS2 score of 5-6 indicate?
Medium clinical risk
Key threshold for urgent response
116
What does a score of three in any individual parameter mean?
Low-medium clinical risk
Urgent ward-based response
117
What does a NEWS2 score of 7 or more indicate?
High clinical risk
Urgent or emergency response
118
What is the clinical response for a NEWS of 0?
Minimum 12 hourly
| Continue routine NEWS monitoring
119
What is the clinical response for a NEWS of 1-4?
Minimum 4-6 hourly
Inform registered nurse who must assess the patient
Nurse decides whether increased frequency of monitoring or escalation of care in required
120
What is the clinical response for a NEWS of 3 in a single parameter?
Minimum 1 hourly
| Registered nurse to inform medical team who will review and decide whether escalation of care in necessary
121
What is the clinical response for a NEWS of 5 or more?
Minimum 1 hourly
Registered nurse inform medical team immediately
Nurse to request urgent assessment by clinician or team with acute core competencies
Care to be provided in an environments with monitoring facilities
122
What is the clinical response for a NEWS of 7 or more?
Registered nurse immediately inform someone of specialist registrar level or above
Emergency assessment by a team with critical care competencies
Consider transfer of care to level 2/3 clinical care facility e.g. ICU
Clinical care with monitoring facilities
123
What can the abdominopelvic cavity be divided into?
4 quadrants
9 areas
124
What are the 4 quadrants?
Right upper
Right lower
Left upper
Left lower
125
What are the 9 areas?
```
right hypochondriac
right lumbar
right illiac
epigastric
umbilical
hypogastric/pubic
left hypochondriac
left lumbar
left illiac
```
126
What is considered to be the 10th division?
Perineum
127
What is in the left upper quadrant?
```
Left portion of liver
Larger portion of stomach
Pancreas
Left kidney
Spleen
Bits of transverse and descending colon
Bits of small intestine
```
128
What is in the right upper quadrant?
```
Right portion of the liver
Gallbladder
Right kidney
Small portion of stomach
Bits of ascending and transverse colon
Bits of small intestine
```
129
What is in the left lower quadrant?
Majority of small intestine
Some of the large intestine
Left female reproductive organs
Left ureter
130
What is in the right lower quadrant?
```
Cecum
Appendix
Parts of small intestine
Right female reproductive organs
Right ureter
```
131
What is pain in the right upper quadrant associated with?
infection and inflammation in the gallbladder and liver
peptic ulcers in the stomach
132
What is pain in the left upper quadrant associated with?
malrotation of the intestine and colon
133
What is pain in the left lower quadrant associated with?
colitis (inflammation of the large intestine)
pelvic inflammatory disease
ovarian cysts in females
134
What is pain in the right lower quadrant associated with?
Appendicitis
135
What does the right hypochondriac contain?
right portion of the liver
the gallbladder
the right kidney
parts of the small intestine
136
What does the left hypochondriac contain?
spleen
left kidney
part of the stomach
the pancreas
parts of the colon
137
What does the epigastric contain?
majority of the stomach
part of the liver
part of the pancreas
part of the duodenum
part of the spleen
adrenal glands
138
What does the right lumbar region contain?
gallbladder
the left kidney
part of the liver
ascending colon
139
What does the left lumbar region contain?
descending colon
left kidney
part of the spleen
140
What does the umbilical region contain?
Umbilicus
Many parts of small intestine (duodenum, jejunum and illeum)
Transverse colon
Bottom portions of both left and right kidneys
141
What does the right iliac contain?
appendix, cecum, and the right iliac fossa
142
What is pain in the right iliac region associated with?
Appendicitis
143
What does the left iliac contain?
descending colon
the sigmoid colon
the left illiac fossa
144
What does the hypogastric region contain?
organs around the pubic bone
bladder
part of the sigmoid colon
the anus
many organs of the reproductive system
145
What are diverticula?
a small pouch with a narrow neck that sticks out from (protrudes from) the wall of the gut
146
Where do diverticula most commonly develop?
Section of colon leading to the rectum
147
When in life do diverticula become more common?
Increasing age
148
What causes diverticula?
Not enough fibre
Gut muscles have to work harder
High pressure develops when it squeezes hard stools
Increased pressure may push the inner lining small area of your gut through the muscle wall
149
What does diverticulosis mean?
Diverticula are present but no symptoms
3 in 4
150
What is diverticular disease?
diverticula cause intermittent, lower tummy (abdominal) pain or bloating
crampy and tends to come and go
pain in the lower left part of abdomen
pain and bloating may ease by passing faeces
some people develop diarrhoea or constipation or pass mucus with stools
151
What are the symptoms of diverticular disease similar to?
IBS but this affects younger people
Early bowel cancer (colonoscopy may be needed)
152
How do you diagnose diverticular disease?
confirm presence of diverticula
rule out all other causes
153
What is diverticulitis?
One or more diverticula become inflamed and infected
154
What can cause diverticulitis?
Faeces stagnates
| Bacteria multiply causing infection
155
What are symptoms of diverticulitis?
Constant pain in the abdomen
High temp
Constipation/diarrhoea
Blood in stools
Nausea and vomiting
156
What are potential complications of diverticulitis?
Blockage of colon
Abscess in abdomen (diagnosed by CT)
Fistula may form to other organs
Perforation in the wall of the bowel which can lead to peritonitis
157
What causes rectal bleeding?
burst blood vessel that sometimes occurs in the wall of a diverticulum
158
What is the treatment for diverticulosis?
Advice high fibre diet
18 - 30g of fibre a day
Stop smoking
Exercise
Lose weight
159
Give examples of high fibre foods?
Whole grains, fruit, veg
Wholemeal/Brown versions
Beans, pulses and legumes
160
When might fibre supplements be advised?
When a high fibre diet does not ease symptoms
e.g. psyllium, methylcellulose or polycarbophil
161
What is the treatment for diverticular disease?
High fibre diet
Plenty of fluids
Paracetamol
Antispasmodics
162
What is the treatments for diverticulitis?
Course of antibiotics
May be admitted to hospital
Painkillers
Surgery for complications
Emergency blood transfusion for bleeding diverticula
163
What scans can be used to diagnose diverticulosis?
Sigmoidoscopy
Colonoscopy
CT scan
Barium X-rays
