acute medical unit cases

Acute Medical Unit Cases

Open Question: Please give three differential diagnoses

Answered: infection, allergy, seconday bacterial infection, viral infection

Feedback: 1. Meningitis (viral or bacterial)2. Encephalitis (viral – usually herpetic)3. Recreational drug toxicity

These are the main 3 likely causes to be invetsigated and managed initially.Sepsis from another origin is also acceptable but there are reasonable clinical clues to suggest cerebral infection and he isan at risk patient living in multiple occupancy accommodation. Acute cerebral irritation from ingested drugs could presentwith confusion depending on the drug taken and what it may have been cut with but consequences of drug use such ascerebral oedema or neuroleptic malignant syndrome should also be considered.

Multiple Choice Question: What is the first thing you are going to do? (please choose one)

Possible answers:

1. Order an urgent CT head.

2. Complete the clerk-in document detail (as much as you can).

3. Tell the registrar/consultant about him and ask them to come and review him ASAP. Selected answer.

Feedback: Correct. Remember although you are a qualified doctor you are not experienced enough to deal with anurgently unwell adult without help from a senior colleague. Informing your senior team as soon as possible is paramount.They should respond by coming to immediately help you or by giving you strict instructions on what to immediately do foryour patient until they can be there to help you. You can do this yourself or ask a member of nursing staff to do it for youwhile to continue to assess.

4. Get IV access and administer IV antibiotics and steroids.

5. Baseline bloods and blood cultures.

Multiple Choice Question: After telling the registrar, your senior tells you they will help as soon as they can but just to getcracking and treat as suspected meningitis.What should you do next? (please choose one)

Possible answers:

1. Urgent CT head

2. Complete the clerk-in document (as much as you can)

3. Gain IV access and administer antibiotics and steroids? Selected answer.

Feedback: Correct. With meningitis as a strong contender in our differentials we need to treat this immediately. When thepossibility of meningococcal meningitis is raised treatment comes before investigations.

4. Tell your senior team member

5. Baseline bloods and blood cultures

Acute Medical Unit Cases page 1 of 19

Open Question: What is the antibiotic regime for suspected meningitis in adults under 50 in Tayside?

Answered: ceftriaxone 2mg bd iv, dexamethsone 0.15mg/kg for 4 days,

Feedback: Ceftriaxone 2 grams IV twice daily. This is a third generation cephalosporin antibiotic of sufficiently broadspectrum to cover for all potential pathogens in the young adult particularly meningococcal. The most common organismcausing meningitis in adults is Streptococcus pneumoniae, but Neisseria meningitidis is often associated with outbreaks incrowded accommodation such as student halls of residence or military barracks. Ceftriaxone will not treat listeria which is apotential pathogen in the very old and the very young. In patients over 50 (although strictly speaking not very old!) we alsoadminister 2 grams IV 4 times daily to cover for this.

Incidentally we would also administer anti-virals in the form of acyclovir until the diagnosis of encephalitis had beenexcluded or meningitis/another pathology confirmed.

Open Question: What important question must you attempt to achieve an answer for before you administer this/these (inany patient)?

Answered: allergies, other medication, what time of allergic reaction?

Feedback: “Do you have any known drug allergies?” This is of vital importance in any patient before you administertreatment especially antibiotic therapy. Although ceftriaxone is not a penicillin it has similar properties and literaturesuggests that up to 10% of patients with a true penicillin-allergy will also be allergic to cephalosprins. If a patient states anallergy you must always ask them to describe the reaction where possible. People often mistake nausea, diarrhoea andvomiting as allergic reactions which is incorrect. Drug eruption rashes are also important to note but are usually indicativeof a type IV hypersensitivity reaction and not an anaphylactic allergic response (type I hypersensitivity). In a life-threateningsituation a penicillin or penicillin-related antibiotic could be administered if no type 1 reaction has been described.

When patients or their carers are unable to provide a reliable answer to this question an electronic database can beaccessed in some hospitals. With no documented or available history the appropriate antibiotic should be administered asthe clinical situation dictates.

Open Question: Why does the guideline ask staff to consider IV steroids?

Answered: already on steroids, adrenal disturbance

Feedback: IV steroids are administered as they have been shown to reduce morbidity & mortality in bacterial meningitis inseveral studies published since the 1990s. They work by inhibiting release of proinflammatory cytokines triggered byantibiotic-induced bacterial lysis.

Open Question: When should steroids be given?

Answered: with or just before initial dose of antibiotics

Feedback: All evidence suggests they are most effective when given before or immediately after the first dose of antibiotics.

Open Question: Do you think this patient has meningococcal meningitis? Please explain your clinical reasoning.

Answered: no, rashs blanches, no neck stiffness, just temperature and previous history of head cold

Feedback: No - Continue for further information

Multiple Choice Question: Presuming baseline bloods & cultures have been taken which investigation/s is warranted next?

Possible answers:

1. CT head

2. Lumbar puncture


Selected answer.

Feedback: Correct. A diagnosis needs to be established for this unwell adult. If the lumbar puncture confirms meningitisthen treatment can continue but if it’s negative the team may have to initiate further urgent investigations. Also the longerthe LP is delayed the more chance of yielding a falsely negative result as the antibiotics work.

3. CT head then lumbar puncture

Open Question: What is her pre-test probability of PE based on the AMU guidance.

Answered: past history of dvt, pregnancy, high probablity

Feedback: High probability (score 9)

Open Question: Please explain how this risk for PE was calculated.

Answered: wells score

Feedback: Heart rate > 100/min = 1.5Clinical signs of DVT = 3Previous VTE = 1.5Other diagnosis less likely = 3

The Modified Wells Score is a clinical decision rule (CDR) used to determine the likelihood of acute pulmonary embolismand help to guide further investigation. There are several available internationally (e.g. Geneva score). CDRs can only beused for patients with suspected pulmonary embolism and are only valid for patients referred from the community. They canextremely useful tools to rule-out PE when used in conjunction with D-dimer assays. This is their main function. A patientwith a low probability & a negative d-dimer is highly unlikely to have a pulmonary embolism. It is then up to the clinicianassessing them to decide what is causing their symptoms.

An intermediate or high score does not diagnose a PE but it means we cannot rule it out without further investigation.

Multiple Choice Question: What baseline investigations does this patient need? (please select all that apply)

Possible answers:

1. CXR Selected answer.

Feedback: Correct. There may be evidence of an alternative pathology to explain the presentation.

2. ECG Selected answer.

Feedback: Correct. We need to assess her tachycardia.

3. D-dimer

4. Baseline INR Selected answer.

Feedback: Correct. She may require anticoagulation. A baseline level is required to make sure she is notauto-anticoagulating for another reason

5. Doppler ultrasound of the left leg Selected answer.

Feedback: Correct. This is a relatively easy investigation to do with no radiation exposure to the mother & baby unit. Shehas signs of a DVT. If positive the treatment and course of treatment would be exactly the same allowing you to avoidfurther investigation.

Overall feedback: Well done you have correctly selected all the baseline investiagtion which this patient needs.


Open Question: Explain your clinical reasoning on whether or not you would do a CXR.

Answered: changes are generally not seen in PE on cxr until late/never, although want to exclude other possible causes,

Feedback: Radiation risk to the foetus is thought to be insignificant at (cumulative) radiation doses less than 10mGy. A CXRwill give, at most, a radiation dose of 0.1mGy to the foetus and is therefore not clinically significant.

(see radiological imaging in pregnancy guidance in the AMU guideline section)

A CXR is necessary to rule out other pathology (such as pneumonia) and also to determine any further appropriate imaging.

Open Question: At what point of pregnancy is the risk of radiation exposure to the foetus greatest?

Answered: 3rd trimester....out of pelvis

Feedback: The biggest risk for foetal death, growth retardation, mental retardation or malformation occurs in the first andsecond trimesters: • • 0-12 weeks First Trimester - rapid stage of embryonic growth/development • 13-28 weeks Second Trimester - organ development

Open Question: From your reading and understanding would the risk of radiation exposure to the foetus from a CXR in thisclinical scenario outweigh the diagnostic benefits for the mother and baby unit’s health?

Answered: no

Feedback: No. as discussed the radiation exposure is very low. If we chose not to do appropriate investigations and get thediagnosis wrong the mother may become more unwell then the baby does too.

Multiple Choice Question: What would be the best form of imaging modality to use in this particular patient to confirm thesuspicion of venous thromboembolic disease? (Presuming either CXR was not done or was done & was normal)

Choose one answer

Possible answers:

1. Doppler ultrasound left leg Selected answer.

Feedback: Correct. This would negate the need for further radiation exposure as discussed. If it was negative you wouldstill have to investigate the lungs so pick another option to do in this case and a perfusion V/Q scan would be the best forthis.

2. Full V/Q scan

3. Perfusion only V/Q scan

4. Ventilation only V/Q scan

5. CTPA

Overall feedback: Correct,as both doppler ultrasound left leg and full V/Q scan can be done - try again selecting theseresponses to see the feedback.

Open Question: Can you explain the clinical reasoning behind your choice of imaging modality to use in this particularpateint?

Answered: no radiation exposure to fetus

Feedback: If the ultrasound is negative (or not available) then imaging of the pulmonary perfusion needs to be performed.Both CTPA and V/Q scan will subject the feotus to further radiation. It is the ventilatory component of the V/Q scan which


has the most radiation so perfusion only will reduce this to the same level as that experienced with a CTPA (0.001- 0.1mGy)and can be accurately interpreted with a good quality X-ray.

The concern in this situation is with the radiation exposure to the mother or, more specifically, the mother’s breast tissue.Estimated exposure of breast tissue during CT chest (CTPA) is 35mGy per breast which may have a significant carcinogeniceffect on proliferative, radiologically sensitive breast tissue during pregnancy. Estimated breast tissue exposure to ‘halfdose’ V/Q scan is 0.25mGy.

See radiological imaging in pregnancy guidance below.

Open Question: Is it safe to agree to allow this? Can you explain your reasoning?

Answered: no, ecg shows PE, need to observe

Feedback: This is tricky and depends on your assessment. In Ninewells hospital we use the Pulmonary Embolism SeverityIndex (PESI) score to determine if someone is appropriate to be investigated as an urgent out-patient. Sadly this score hasnever been validated in pregnant patients (because no one has done the studies!). The ECG will tell us if there is anyevidence of right heart strain (‘S1 QT3’ pattern or right bundle branch block - see images below) which would definitelymean she was unsafe to go home. Her ECG on arrival showed only sinus tachycardia.

This is ultimately a decision for the senior team to make. Her PESI score is low and given her very early pregnancy state, herhaemodynamic stability and her normal ECG (sinus tachycardia allowing) she may be allowed to go home and return thefollowing day for investigation.

The chance of further PE is very low but the risk of subsequent embolism and risks of morbidity/mortality should beexplained to her to allow her to make an informed decision, but ultimately we cannot force a patient to stay in hospital ifthey have capacity to make the decision themselves, but we can give them advice and information to help deal with anyconsequences that arise.

Open Question: Regardless of whether she requires to be admitted to the unit or safely discharged to return tomorrow, whattreatment does she require and at what dose?

Answered: thrombolysisation

Feedback: Low molecular weight heparin (dalteparin in Ninewells) dependent on her early pregnancy weight given as twicedaily dosing. This is the recommendation of the Royal College of Obstetricians and reflects the reduced half-life of LMWH inthe pregnant state.

Multiple Choice Question: What is your FIRST action? (please choose one)

Possible answers:

1. Gain IV access

2. Nebulised salbutamol

3. Inform or get someone to inform your middle-grade/consultant about him? Selected answer.

Feedback: Correct. While all of these answers are important we need to emphasise that getting senior help to managethis patients is priority here.

4. Antibiotics

Open Question: What is his CURB 65 score (based on the information you have)?

Answered: 5

Feedback: 4 so far – confused, hypotensive, over 65 years old and respiratory rate >30/min


Open Question: How would you grade the severity of his Pneumonia?

Answered: severe

Feedback: Severe community acquired pneumonia

Multiple Choice Question: What initial management should you ask the nurse to help you administer? (please select all thatapply)

Possible answers:

1. Oral Amoxycillin 1g within 1 hour

2. IV dextrose 5% stat

3. IV amoxicillin 1 g within 1 hour

4. Nebulised Salbutamol 5mg stat Selected answer.

5. IV Co-amoxiclav 1.2g and IV clarithromycin 500mg within 4 hours

6. IV hydrocortisone 200mg stat

7. Inhaled salbutamol 2 puffs via spacer or aerochamber stat

8. IV saline 0.9% over 1 hour

9. IV co-amoxiclav 1.2g and IV clarithromycin 500mg within 1 hour Selected answer.

10. IV saline 0.9% stat Selected answer.

Overall feedback: Correct! He needs: - Active resuscitation - dextrose is not an appropriate fluid for resuscitation as it quickly leaves the intravascularcompartment. Isotonic saline (0.9%) is the most appropriate and easily available fluid at this point and should be given

- Urgent bronchodilator therapy – based on you examination findings and his hypoxia

- Antibiotic therapy within 1 hour – severe pneumonia is treated with co-amoxiclav & clarithromycin in NHS Tayside(provided no allergies are reported). Although national community acquired pneumonia guidance recommendsantimicrobials within 4 hours, this man is severely septic.

Multiple Choice Question: Which investigations need to be performed as soon as possible? (please select ALL that apply)

Possible answers:

1. Departmental CXR Selected answer.

2. ABG on air Selected answer.

3. Us and Es

4. FBC Selected answer.

5. Legionella urinary antigen

6. LFTS


7. Portable CXR Selected answer.

8. Urinalysis

9. Lactate Selected answer.

10. Coagulation screen

11. anca

12. Throat swab

13. ABG on oxygen

14. ECG

15. Avian precepitants

16. Blood cultures x1 pair Selected answer.

17. Blood cultures x2 pairs

Overall feedback: While all of these tests may need to be done (with the exception of anca) the most immediate are the onesyou will need to assess & manage him in the urgent setting.He is far too unstable to travel down to the X-ray department for a CXR. A portable film, while of lower quality, will provideyou with all the important information you will need to manage him in the next few hours.He is hypoxic. He requires oxygen.Never remove oxygen to check an arterial blood gas on an urgently unwell, hypoxic patient. You can roughly gauge theirtrue pO2 on air with this simple method: - In normal respiratory function the FiO2 (ie the percentage to oxygen given) should be roughly equal to the partial pressureof O2 on the ABG minus 10 e.g. 60% oxygen should give a PaO2 of 50kPascals. If the PO2 is 20kPascals then you knowthere is a degree of hypoxaemia without the need to remove the supplementary oxygen to prove it!Lactate is a marker oftissue perfusion. We need to know his baseline lactate to ascertain the severity of his hypoperfused state and to judgeimprovement in perfusion as we resuscitate him.2 sets of blood cultures are required to improve yield and limitcontamination.

Open Question: His mean arterial pressure (MAP) on admission is 64mmHg. What would you like it to be?

Answered: at least 90

Feedback: 65mmHg. This is the MINIMUM required to adequately perfuse the brain & coronary arteries in an adult patient.This is the MAP goal set by the international sepsis management based on early goal-directed therapy in resuscitation ofseptic patients. See the sepsis guidelines or ference below for more details.

Multiple Choice Question: How are you going to achieve this initially? (Choose one)

Possible answers:

1. IV saline 0.9% 20ml/kg over 1 hour

2. IV dextrose 5% 20ml/kg over 1 hour

3. IV saline 0.9% 20ml/kg stat Selected answer.

Feedback: Correct - In an average adult patient this is roughly 1.5 litres stat (based on 70kg adult)

4. IV dextrose 5% 20ml/kg stat

5. IV saline 0.9% 20ml/kg over 2 hours


6. IV dextrose 5% 20ml/kg over 2 hours

7. IV saline 0.45% 20ml/kg stat

Multiple Choice Question: Approximately what FiO? is he currently receiving?

Possible answers:

1. 50%

2. 30%

3. 65-85% Selected answer.

Feedback: A non-rebreath mask is uncontrolled oxygen therapy and is a LOW FLOW device. The oxygen coming from thewall is 100% but this will be diluted by inevitable leaks, mask fit and any other air the patient is managing to get in to treattheir flow needs. The UK resuscitation council guidelines state that you will receive 85% oxygen through this device. Inreality it is probably a bit lower.

Multiple Choice Question: Does he have?

Possible answers:

1. Respiratory acidosis with compensation

2. Respiratory acidosis without compensation

3. Mixed respiratory and metabolic acidosis Selected answer.

Feedback: Correct. His pH is low indicating acidaemia, his pCO2 is high which leads to increased hydrogen ions and hisbicarbonate is all used up or lost. The base excess tells us he is in a metabolic acidosis. Compensation occurs when thenon-faulty or upset system is compensated for by the alternative. The key to being in a compensated state is the pH. If thepH is normal then compensation is occurring.

4. Metabolic acidosis with compensation

Multiple Choice Question: Where should this man be cared for?

Possible answers:

1. Level 1 care bed (such as AMU/ward 15)

2. Level 2 care bed (such as medical high dependency) Selected answer.

Feedback: Correct - He is severely septic requiring aggressive resuscitation and regular monitoring – potentiallyinvasive monitoring such as central venous pressures. His observational and basic care needs cannot be met in a level 1bed where the ratio of staff to patients to too high to be able to recognise deterioration in a timely manner.

Multiple Choice Question: On transfer the nursing staff ask you what type of observations he requires. What will you tellthem?

Possible answers:

1. Full SEWS every hour


2. Full SEWS every 2-4 hours

3. BP every hour with other observations hourly

4. Full SEWS every hour wit hourly urine output Selected answer.

Feedback: At the very least this should pick up any deterioration and let us know how he is responding to ourresuscitative measures. If he continues to deteriorate it should be even more frequent. It is vitally important that youcommunicate your concerns to your nursing colleagues so they can be aware of the situation and provide good care.Although many nursing staff are trained to deal with urgently unwell adults they need to know your thinking andmanagement plan for the team to work effectively.

Multiple Choice Question: Bearing in mind his blood gas results & clinical state, which of his systems are in failure? (choose as many as appropriate)

Possible answers:

1. Respiratory Selected answer.

2. Renal Selected answer.

3. Tissue/perfusion Selected answer.

4. Cerebral

5. Liver

6. Clotting cascade

Overall feedback: You should have selected all as every organ is failing! His urea & creatinine indicate acute kidney injurymost likely secondary to hypovolaemia. His ALT indicates poor hepatic perfusion (‘shock liver’), his lactate indicates poortissue perfusion, his platelets/PT/APTT suggest he is developing a disseminated intravascular coagulopathy.

We already know from his ABG he is in respiratory failure and his confusion indicates cerebral failure.

Multiple Choice Question: How would you describe his current clinical state?

Possible answers:

1. Sepsis secondary to severe community acquired pneumonia

2. Severe sepsis secondary to community acquired pneumonia

3. Severe septic shock secondary to community acquired pneumonia Selected answer.

Feedback: This is the definition of septic shock – failure to respond to an appropriate fluid challenge.

This patients is in multi-organ failure and his prognosis is very poor even with aggressive and timely resuscitativemeasures, but this shouldn’t stop us trying. If he fails to respond to our management decisions about maximumappropriate treatment and resuscitation status will have to be made.

Multiple Choice Question: Which of the following does he need immediately (choose all that apply)

Possible answers:

1. Upper GI endoscopy


2. Peripheral cannula for IV access (size and site not important)

3. 1 large bore peripheral cannula

4. 1 large bore peripheral cannula in each antecubital fossa Selected answer.

5. Group and save blood sample (with option to cross-match later)

6. Full blood count Selected answer.

7. Calcium

8. Cross-matched blood 6 units Selected answer.

9. Us and Es Selected answer.

10. Coagulation screen Selected answer.

11. Blood alcohol level

12. Gamma GT

13. LFTs Selected answer.

14. Portable erect CXR

15. IV dextrose 50% 50 ml stat Selected answer.

Overall feedback: This man has clinical evidence of haemodynamic instability plus evidence of acute GI blood loss (meleanaconfirmed on PR and present since the previous evening). He is also taking an oral anti-coagulant while continuing to drinkheavily which will affect the half-life and may lead to excessive anti-coagulation.

This is an acute upper GI bleed until proven otherwise and requires resuscitation. He needs large bore IVaccess (times 2) inhis antecubital fossae to allow rapid resuscitation should he lose more volume with further bleeding and he needs to becross-matched for 6 units immediately. With his history plus your examination the likelihood of transfusion is very high;with the anti-coagulated state the likelihood of ongoing bleeding is high therefore X-matching in preparation for transfusionbefore you have his full blood count is entirely appropriate in this scenario.

We need to know baseline parameters for his clinical state and a PT ratio to determine the need for urgent reversal ofanti-coagulation.

With mild epigastric tenderness and no guarding an urgent portable CXR will not add to his care. There is no clinicalevidence of perforation and CXR changes are not seen in the majority of cases of perforation. If he develops an acuteabdomen (peritonitis/guarding/rigidity) then this can be reconsidered.

Did you notice his BM was low?

Open Question: What is his Blatchford score (based on information you have) & what does this mean?

Answered: high, may rebled

Feedback: His score is 3: • Systolic BP 100-109mmHg = 1 • Pulse >100/min = 1 • Presentation with meleana = 1

Blatchford is a clinical scoring system that allows us to determine a patients risk of having suffered an acute GI bleed and


aids our further investigation & management. Like all clinical tools it is an aid and should be used in conjunction withclinical acumen. His score of 3 indicates indeterminate risk of GI bleed. This is without his urea or haemoglobin levels. Withour current clinical information this score (with current information) appears to be vastly underestimating his risk of GIbleed.

The recommendations are to continue monitoring (hourly) and consider urgent treatment of his potential pathology and anycausative factors (such as anti-coagulation). Decision for endoscopy will be made after observation but remember this iswithout the full information required and his score may be higher once his blood results are known.

(see NHS Tayside Guidance for management of Upper GI Bleed)

Open Question: Where could you find this (remembering you work in AMU Ninewells)?

Answered: on the wall, tayside area formulary, staffnet

Feedback: In the AMU clinical guideline folder or on the intranet on the Acute Medicine Unit webpage on the hospitalintranet.

Multiple Choice Question: Do you prescribe ... (please choose one)

Possible answers:

1. IV omeprazole 80mg stat bolus (then wait for further advice/instruction)

2. IV esomeprazole 80mg stat bolus followed by infusion Selected answer.

Feedback: Correct. This man has evidence of significant upper GI bleed as shown by haemodynamic compromise &meleana. The local guidance for these patients is commencement on an IV PPI infusion which will aid acid suppression andhealing for presumed gastric mucosal origin of his GI bleed. This is a local recommendation based on the evidence that IVPPI infusion aids healing in the acute setting and reduces morbidity and mortality. It mostly in patients who have undergoneendoscopic treatment as well but there is a growing body of evidence suggesting patients also benefit from this treatmentpre-endoscopy.

3. IV esomprazole 80mg stat (then wait for further advice/instruction)

4. PO omeprazole 80mg stat

5. IV Terlipressin 2mg stat then 1mg QID

Open Question: Your senior team member is also concerned about him receiving a large bolus of dextrose and asks if youprescribed stat IV vitamins as well. Why?

Answered: alcohol abuse usually low in b12 and thiamine,

Feedback: With a history of significant alcohol intake and his clinical appearance of general cachexia the suggestion is thathe is deficient in basic elemental nutrition and vitamins (most notably thiamine). This has obviously been of concern beforenow as he has been prescribed regular supplemental thiamine but he admits to not taking them.

Patients with a chronic thiamine deficiency are at risk of developing Wernicke’s encephalopathy. This pathology can beacutely precipitated by large, sudden carbohydrate loads in the form of food or IV dextrose. The dose of dextrose requiredto correct his presenting hypoglycaemia could be sufficient to precipitate this but it is clearly necessary to preventlong-term cerebral damage from prolonged hypoglycaemia. Administration of IV thiamine (in the form of Pabrinex) is a wayto try and prevent this.

This is, incidentally, also the reason why we give nutritionally deplete patients (particularly alcoholics) IV pabrinex for 2-3days during initial hospital stay. It is assumed that their food intake will be substantially better that it would ordinarily andthe carbohydrate loads in hospital food could precipitate Wernicke’s. It is important to consider this in all nutritionallydeplete patients and not just those with chronic alcohol abuse. IV vitamins have no role in preventing re-feeding syndrome(acute disruption of electrolytes) - a common misconception.


Open Question: Give 2 plausible reasons why he is agitated/distracted.

Answered: pain, alcohol withdrawl,

Feedback: 1. Hypoglycaemia2. Acute alcohol withdrawal

Open Question: Give 2 plausible reasons why he is tachycardic.

Answered: alcohol withdrawl, hypovolaemic

Feedback: 1. Hypovolaemia (due to bleeding)2. Acute alcohol withdrawal

He has abruptly reduced his usual alcohol intake. The resultant withdrawal state usually takes 12-24 hours to manifest andmay not be obvious on initial assessment. Any patient who has a history of alcohol abuse must be carefully monitored forwithdrawal which can be a life-threatening condition if not addressed promptly.

Multiple Choice Question: Given his history and presentation, which of the following would you also like to do? (Pleaseselect all that apply)

Possible answers:

1. Re-prescribe his thiamine and forceval orally

2. Give IV pabrinex 4 vials TDS

3. Give IV pabrinex 2 vials TDS Selected answer.

Feedback: Correct. This is the appropriate dose and regime for urgent thiamine replacement in the ‘at risk’ patient.

4. Give IV diazepam 10mg stat and 10mg orally QID

5. Ask the nurse to perform an alcohol withdrawal assessment and prescribe PRN diazepam to be used in conjunction withit. Selected answer.

Feedback: Correct. This is the best way of ensuring the patient is getting sufficient medication to alleviate his withdrawalstate. Constant assessment will ensure he is not being under-treated.

Overall feedback: Well done - you selected the correct responses.

Multiple Choice Question: Based on these results what additional treatment does he now need urgently? (choose all thatapply)

Possible answers:

1. Transfusion of 2 units with 40mg furosemide cover

2. Transfusion of 4 units with 80mg furosemide cover

3. Transfusion of 2-4 units stat without furosemide cover Selected answer.

4. IV vitamin K 10mg

5. IV vitamin K 2mg

6. Prothrombin Complex Concentrate (PCC) according to weight

7. 2 units of fresh frozen plasma


Overall feedback: This patient has suffered acute blood loss leading to reduction in his circulating volume. We suspectedthis on his initial assessment and now his blood results confirm this. He requires replacement of his blood loss in the formof red blood cells BUT as loss is acute he has had no time to compensate for the overall loss in circulating volume.Prescribing diuretic with his transfusion will lead to on-going volume loss which could exacerbate his situation. In states ofchronic, slow blood loss patients often have time to compensate for the loss and maintain a euvolaemic state. In thesecircumstances diuretic treatment in conjunction with transfusion helps to prevent volume overload. This is not a concern inour patient.His prothrombin time is severely prolonged which is exacerbating his blood loss as it prevents naturalcoagulation. This needs to be urgently reversed. Vitamin K takes, on average, 6 hours to take effect. A high dose needs tobe administered to completely reverse the warfarin but if the patient is unstable and at risk of further bleeding a faster actingagent is also required. PCC is the preferred method of urgent warfarin reversal in Tayside but this is not necessarily thecase nationally and policy may alter from hospital to hospital. Fresh frozen plasma (FFP) is still sometimes used but as thisrelies on regular donation and is a finite resource it is avoided. Both FFP and PCC contain blood products which may beagainst the patients express wishes if they are a Jehovah's Witness, something which we can often overlook in theemergency situation.The only pathology that requires careful control of thrombotic state (even in a life-threatening bleed) isa mechanical heart valve. These patients are at high risk of thrombus formation on the replaced valve and required verycareful control of anti-coagulation under specialist care to balance the risks of blood loss against the risks of valvethrombus. In these cases a 2mg dose of vitamin K is administered to prevent complete, long-term warfarin inhibition. Inevery other pathology urgent PT reversal is indicated.

Multiple Choice Question: You inform your middle-grade immediately. What do you think is the next best action? (pleaseselect one response)

Possible answers:

1. Give continuous gelofusion and wait for type specific bags to arrive

2. Given continuous gelofusion and ask for group only to be sent

3. Give 1 further stat gelofusion and wait for type specific or group specific

4. Give 1 further stat gelofusion and ask a member of staff to urgently collect 2 units of O negative bags from the nearestemergency blood bank Selected answer.

Feedback: While our patient is haemodynamically compromised his fluid loss is blood. Giving boluses of isotonic fluidwill help to correct his volaemic state but will also dilute the remaining haemoglobin. If his haemoglobin is reduced he is atrisk of lactic acidosis from reduced oxygenation of his mitochondriae and coronary ischaemia. Cross-matching ofappropriate bloods can take some time depending on the patients pre-existing antibodies but all hospitals will haveO-negative blood available for acute massive bleeds where there is not time to wait for the cross match. It would be entirelyappropriate to use the emergency supply in this situation but you must inform the transfusion lab that you've used it so itcan be urgently replaced.

Open Question: While you are arranging the immediate resuscitation, the middle-grade doctor contacts the transfusionlaboratory to ask for a ‘Shock Pack’.

Please explain what this is.

Answered: o neg, fresh froxen plasma, clotting factors

Feedback: Shock pack is an emergency supply of 2 units of O-negative red blood cells (RBC) plus 1 unit of fresh frozenplasma and 1 unit of cryoprecipitates. Massive replacement of blood loss does not account for the massive loss ofcoagulants that accompanies this situation. Remember RBC units have been ‘cleansed’ of all other blood constituents andreplacement of 6 units or more will require replacement of natural anti-coagulants.

Multiple Choice Question: What do you think is the next best management startegy for this man? (please choose one)

Possible answers:

1. Transfer to medical HDU for ongoing treatment and urgent endoscopy tomorrow when stable

2. Sengstaken-Blakemore tube insertion


3. Urgent surgical referral for consideration of endoscopy or surgical intervention ASAP Selected answer.

Feedback: There is little that can be done for this man at the bedside if his bleeding continues. If we cannot control isongoing bleeding with PCC then he will need direct control of it via endoscopy (e.g. adrenaline injection or diathermy) orinvasive surgical procedure. Once referred to the surgical team he will need to be monitored in a level 2 care bed until activeintervention is initiated but this should be in a surgical high dependency unit.A Sengstaken-Blakemore tube is an oesophageal & gastric tube which inflates to provide direct, physical haemostasis foracute variceal bleeds. It is of no use in acute gastric, non-variceal bleeds.


Assessment Summary

Case 1

Open Question: Please give three differential diagnoses

Answered

infection, allergy, seconday bacterial infection, viral infection

Multiple Choice Question: What is the first thing you are going to do? (please choose one)

Answered Correctness Retries Score

3 correct 0 1 / 1

Multiple Choice Question: After telling the registrar, your senior tells you they will help as soon as they can but just to getcracking and treat as suspected meningitis.What should you do next? (please choose one)


3 correct 0 1 / 1

Open Question: What is the antibiotic regime for suspected meningitis in adults under 50 in Tayside?

Answered

ceftriaxone 2mg bd iv, dexamethsone 0.15mg/kg for 4 days,

Open Question: What important question must you attempt to achieve an answer for before you administer this/these (inany patient)?

Answered

allergies, other medication, what time of allergic reaction?

Open Question: Why does the guideline ask staff to consider IV steroids?

Answered

already on steroids, adrenal disturbance

Open Question: When should steroids be given?

Answered

with or just before initial dose of antibiotics

Open Question: Do you think this patient has meningococcal meningitis? Please explain your clinical reasoning.

Answered

no, rashs blanches, no neck stiffness, just temperature and previous history of head cold

Multiple Choice Question: Presuming baseline bloods & cultures have been taken which investigation/s is warranted next?


2 correct 1 1 / 1

Case 2

Open Question: What is her pre-test probability of PE based on the AMU guidance.

Answered

past history of dvt, pregnancy, high probablity

Open Question: Please explain how this risk for PE was calculated.

Answered


wells score

Multiple Choice Question: What baseline investigations does this patient need? (please select all that apply)


1, 2, 4, 5 correct 1 1 / 1

Open Question: Explain your clinical reasoning on whether or not you would do a CXR.

Answered

changes are generally not seen in PE on cxr until late/never, although want to exclude other possible causes,

Open Question: At what point of pregnancy is the risk of radiation exposure to the foetus greatest?

Answered

3rd trimester....out of pelvis

Open Question: From your reading and understanding would the risk of radiation exposure to the foetus from a CXR in thisclinical scenario outweigh the diagnostic benefits for the mother and baby unit’s health?

Answered

no

Multiple Choice Question: What would be the best form of imaging modality to use in this particular patient to confirm thesuspicion of venous thromboembolic disease? (Presuming either CXR was not done or was done & was normal)

Choose one answer


1 neutral 2 0.5 / 1

Open Question: Can you explain the clinical reasoning behind your choice of imaging modality to use in this particularpateint?

Answered

no radiation exposure to fetus

Open Question: Is it safe to agree to allow this? Can you explain your reasoning?

Answered

no, ecg shows PE, need to observe

Open Question: Regardless of whether she requires to be admitted to the unit or safely discharged to return tomorrow, whattreatment does she require and at what dose?

Answered

thrombolysisation

Case 3

Multiple Choice Question: What is your FIRST action? (please choose one)


3 correct 0 1 / 1

Open Question: What is his CURB 65 score (based on the information you have)?

Answered

5

Open Question: How would you grade the severity of his Pneumonia?


Answered

severe

Multiple Choice Question: What initial management should you ask the nurse to help you administer? (please select all thatapply)


4, 9, 10 correct 1 1 / 1

Multiple Choice Question: Which investigations need to be performed as soon as possible? (please select ALL that apply)


1, 2, 4, 7, 9, 16 neutral 1 0.5 / 1

Open Question: His mean arterial pressure (MAP) on admission is 64mmHg. What would you like it to be?

Answered

at least 90

Multiple Choice Question: How are you going to achieve this initially? (Choose one)


3 correct 3 1 / 1

Multiple Choice Question: Approximately what FiO? is he currently receiving?


3 correct 0 1 / 1

Multiple Choice Question: Does he have?


3 correct 2 1 / 1

Multiple Choice Question: Where should this man be cared for?


2 correct 0 1 / 1

Multiple Choice Question: On transfer the nursing staff ask you what type of observations he requires. What will you tellthem?


4 correct 0 1 / 1

Multiple Choice Question: Bearing in mind his blood gas results & clinical state, which of his systems are in failure? (choose as many as appropriate)


1, 2, 3 neutral 0 0.5 / 1

Multiple Choice Question: How would you describe his current clinical state?


3 correct 0 1 / 1

Case 4

Multiple Choice Question: Which of the following does he need immediately (choose all that apply)



4, 6, 8, 9, 10, 13, 15 correct 1 1 / 1

Open Question: What is his Blatchford score (based on information you have) & what does this mean?

Answered

high, may rebled

Open Question: Where could you find this (remembering you work in AMU Ninewells)?

Answered

on the wall, tayside area formulary, staffnet

Multiple Choice Question: Do you prescribe ... (please choose one)


2 correct 1 1 / 1

Open Question: Your senior team member is also concerned about him receiving a large bolus of dextrose and asks if youprescribed stat IV vitamins as well. Why?

Answered

alcohol abuse usually low in b12 and thiamine,

Open Question: Give 2 plausible reasons why he is agitated/distracted.

Answered

pain, alcohol withdrawl,

Open Question: Give 2 plausible reasons why he is tachycardic.

Answered

alcohol withdrawl, hypovolaemic

Multiple Choice Question: Given his history and presentation, which of the following would you also like to do? (Pleaseselect all that apply)


3, 5 correct 1 1 / 1

Multiple Choice Question: Based on these results what additional treatment does he now need urgently? (choose all thatapply)


3 neutral 0 0.5 / 1

Multiple Choice Question: You inform your middle-grade immediately. What do you think is the next best action? (pleaseselect one response)


4 correct 1 1 / 1

Open Question: While you are arranging the immediate resuscitation, the middle-grade doctor contacts the transfusionlaboratory to ask for a ‘Shock Pack’.

Please explain what this is.

Answered

o neg, fresh froxen plasma, clotting factors

Multiple Choice Question: What do you think is the next best management startegy for this man? (please choose one)



3 correct 0 1 / 1

Total score: 19 / 21 (90%)


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