Monday [23/5/22] Flashcards
(100 cards)
What’s in a ReSPECAT conversation? [5]
ReSPECT conversations follow the ReSPECT process by:
- discussing and reaching a shared understanding of the person’s current state of health and how it may change in the foreseeable future,
- identifying the person’s preferences for and goals of care in the event of a future emergency,
- using that to record an agreed focus of care (either more towards life-sustaining treatments or more towards prioritising comfort over efforts to sustain life),
- making and recording shared decisions about specific types of care and realistic treatment that they would want considered, or that they would not want, and explaining sensitively advance decisions about treatments that clearly would not work in their situation,
- making and recording a shared decision about whether or not CPR is recommended.
How to verify a death [9]
To perform death confirmation:
- Wash your hands and don PPE if appropriate.
- Confirm the identity of the patient by checking their wrist band.
- Inspect for obvious signs of life such as movement and respiratory effort.
- Assess the patient’s response to verbal stimuli (e.g. “Hello, Mr Smith, can you hear me?”).
- Assess the patient’s response to pain using one of the following methods:
Apply pressure to the patient’s fingernail.
Perform a trapezius squeeze.
Apply supraorbital pressure.
6. Assess the patient’s pupillary reflexes using a pen torch: after death, the pupils become fixed and dilated.
- Palpate the carotid artery for a pulse: after death, this will be absent.
- Perform auscultation in an attempt to identify any heart or respiratory sounds:
Listen for heart sounds for at least 2 minutes.
Listen for respiratory sounds for at least 3 minutes.
The recommended amount of time to listen for heart and respiratory sounds can vary, but it is generally accepted that a minimum of five minutes of auscultation is required to establish that irreversible cardiorespiratory arrest has occurred. 1
- Wash your hands, dispose of PPE appropriately and exit the room, making sure the relevant doors and/or curtains are closed/drawn behind you
reasons to refer to the coroner for a death [10]
The cause of death is unknown.
The death was sudden or unexpected (inclusive of all deaths less than 24 hours after admission to hospital).
The deceased person had not seen a doctor within the 14 days before their death.
The death is considered suspicious, unnatural or violent.
The death may be due to an accident, self-neglect or neglect on the behalf of others.
The death is/could be due to the deceased’s prior employment (including industrial disease).
The death may be due to an abortion.
The death occurred during an operation or before recovery from anaesthetic.
The death occurred during or shortly after a period of police custody.
The death may be suicide
The 2 parts of the death certificate
Part 1 = cause of death [1a direct disease leading to death, 1b is the disease leading to 1a, 1c to 1b etc.]
Part 2 = conditions that may have contributed to the death
Families wish to get the patient cremated, what should you fill in?
Cremation form 4
Mrs June Morbid was an 87-year-old lady, whom you last attended to yesterday on the ward round with the consultant (Dr Spot). She had advanced Parkinson’s disease and was admitted 4 days previously with aspiration pneumonia. Unfortunately, the pneumonia did not respond to antibiotic treatment and the decision to palliate was made by the consultant after discussion with the family. Mrs Morbid peacefully passed away last night with her family around her, and her death was verified by your colleague on the night shift. You have been asked to fill in the death certificate after your ward round
1a] aspiration pneumonia
b] parkinsons disease
Mr Clive Matchstick (86-years-old) was admitted to the ward a week ago from a local nursing home having vomited and whilst in hospital, he developed urinary incontinence and sepsis. He was treated for urosepsis, under the care of Dr Johnson, but unfortunately, he passed away. You confirmed his death this morning and you had also reviewed him last night before going home. He has a past history of ischaemic heart disease, type 2 diabetes mellitus, Charcot’s deformity of the left foot and amputation of the big toe on the right foot
1a] urinary sepsis
2] IHD, T2Dm
Mr Samuel Clock (75-years-old) had been an in-patient on the ward you are working on for 2 weeks. He was being treated for community-acquired pneumonia (CURB-65 score of 4). His condition had progressively worsened when you reviewed him with his consultant Dr Tyvand last night and the decision was made to switch to a palliative approach of management. He passed away this morning, with his wife by his side. You confirmed his death on the ward. He has a past medical history of ischemic heart disease, hypertension, mesothelioma, type 2 diabetes and benign prostate hypertrophy
1a] CAP
b] pleural mesothelioma
2] IHD, T2DM
most common age acute appendicitis
10-20y/o
Pathogenesis of appendicitis [4]
lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation
Type of abdo pain seen in appendicitis [3]
- peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
- the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis
- patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
other features of appendicitis [4]
- vomit once or twice but marked and persistent vomiting is unusual
- diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
- mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
- anorexia is very common. It is very unusual for patients with appendicitis to be hungry. Around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
What is the Rovsing’s and psoas signs? [2]
Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
psoas sign: pain on extending hip if retrocaecal appendix
other general signs on examination of appendicits patient [3]
generalised peritonitis if perforation has occurred or localised peritonism
rebound and percussion tenderness, guarding and rigidity
retrocaecal appendicitis may have relatively few signs
digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
Dx appendicitis [4]
- raised inflammatory markers with history and examinations findings often enough to justify an appendicectomy
- neutrophil-predominant leucoytosis seen in 80-90%
- urine analysis to r/o pregnancy, renal colic and UTI
- no definitive imaging techniques, often US if F
Mx of appendicitis 3[]
Appendicectomy [open or laparoscopic approach]
administration of prophylactic IV Abx
patients with perforated appendicitis [typically around 15-20%] require copious abdominal lavage
Research for just Abx with appendicitis [1]
trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months
Causes of ALF [4]
- paracetamol
- alcohol
- viral hepatitis
- AFL disease of pregnancy
Features of ALD [5]
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')Most common causes of acute upper GI bleed [2]
Varicies or peptic ulcer
Clinical features of acute upper GI bleed [3]
haematemesis
the most common presenting feature
often bright red but may sometimes be described as ‘coffee gound’
melena
the passage of altered blood per rectum
typically black and ‘tarry’
a raised urea may be seen due to the ‘protein meal’ of the blood
Differentiate between varicies presentation and peptic ulcer disease presentation
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain
Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed
oesophageal varicies
Usually small volume of blood, except as a preterminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until managed
cancer
