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Acute stations. Ardit Begaj. Learning objectives. How to approach the acute station Possible scenarios. Approaching the station. 1 min reading, 6 min hx + exam, 2 min questions
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Acute stations Ardit Begaj
Learning objectives • How to approach the acute station • Possible scenarios
Approaching the station • 1 min reading, 6 min hx + exam, 2 min questions • Important to read the story before you go in so you know who you are and in which setting you are in (ward, GP, A&E) • Wash your hands • Introduce yourself • Confirm patient’s identification • If the patient is speaking to you, explain you might be speaking to the examiner in the room
Mention to the examiner that you would approach as ABCDE • Patient talking so you will take a history first • 2 options • Continue with the history • Ask to see obs chart • Check if haemodynamically stable
History • Allocate around 3-4 minutes • Will guide your examination • Be systematic and focused • PC, HPC, FH etc • Do not forget allergies
Examination • Allocate around 2-3 minutes • Look at obs chart • Comment on findings • Focused exam • Important things to comment • General observations (end of the bed) • CRT
Most likely scenarios • Acute chest pain • MI • PE • Shortness of breath • Asthma • COPD • PE • Acute Abdominal pain • Pancreatitis • Appendicitis • Ectopic
Acute chest pain • Make sure he is haemodynamically stable at the start • SOCRATES for the pain • Family hx is important • Drug use • Cocaine • Social • Stressful job
On examination • Comment if any respiratory distress • Mixed cardio + respiratory exam • Check for JVP – heart failure • Central cyanosis • Radial radial delay and offer radiofemoral – dissection • Check for a AAA • Check the calves and feel for tenderness- PE
Question time • What investigations would you do? • FBC, UE, LFT, Troponin, D-dimer (if suspected PE), ABG for PE • ECG • Echo • Chest X-rayfind • Wells score for PE - CTPA
Management • Acute MI • Morphine • Aspirin • Clopidogrel • GTN • Antiemetic • Speak to Senior • If <90 min onset of pain – primary PCI (STEMI only)
Management • PE • If wells score >4 –CTPA • If CTPA cannot be arranged immediately – LMWH • If wells score <4 – D-Dimer • If D-Dimer +ve – CTPA • If –ve – alternate diagnosis • Oxygen • If pregnant – V/Q mismatch
Acute shortness of breath • Asthma • HPC- SOB + wheeze • Ask about • Previous admissions/attacks/ICU admissions • Asthma control • Best PEF • Current medication if any • PMH- atopy/asthma
On examination • Comment on respiratory distress • Comment if can complete full sentences • Severe • Unable to complete sentences • RR>25 • HR >110 • PEF < 50% predicted/best • Life threatening • Silent chest/cyanosis • Brady/hypotension • Fatigue, confusion, coma • PEF<33%
Investigations • FBC, UE, LFT • ABG + lactate • Chest x-ray- rule out consolidation/pneumothorax • Peek flow if able
Management • Oxygen – high flow • Salbutamol 5 mg nebs back to back • Prednisolone 40 mg po • Repeat ABG • Senior • If normal or retaining CO2 – ICU/critical care outreach • For COPD • Salbutamol • Prednisolone 30 mg • Abx • NIV
Acute abdomen • Pancreatitis • Epigastric pain going to the back • Nausea and vomiting • Hx of alcohol abuse • Hx of ERCP • Appendicitis • Umbilical pain – radiating to RIF • Previously fit and healthy • Bowels – constipation/diarrhoea • No appetite
On examination • Pancreatitis • Look for signs of steroid use (bruising, stretch marks, gynecomastia) • Comment on guarding, peritonism, Gray turner sign • Offer PR • Appendicitis • Guarding, peritonism, Rovsing’s sign, rebound tenderness
Investigations • Pancreatitis • FBC, UE, LFT, CRP, Amylase, LDH, Bone profile • Glasgow score • CT abdo • ABG+ lactate • Appendicitis • FBC, UE, LFT, CRP, cogulation, G&S • Echo • Erect chest x-ray + abdo X-ray for both + urine dip
Management • Pancreatitis • NBM • IV fluids • If vomits – NG + aspirate • Appendicitis • NBM • Fluids • Theatre • ABX
Ectopic • Hx of recent unprotected sex • Abdominal pain localizing in RIF or LIF • No periods • PV bleed • Shoulder tip pain • Tachycardic/ hypotensive
Investigations • FBC, UE, LFT, Coag, G&S • bHCG • TVUS • Progesterone • Management • Expectant- serial • Medical – methotrexate • Surgical