FY1s please help - common medical presentations

Just wanted advice on how you tend to approach common scenarios and the questions you will ask the nurses when they tell you these things, for example the below:

1) Patient with low urine output
2) Patient who's catheter is not flushing
3) Patient who's sats are dropping
4) Patient with high potassium
5) Patient with low sodium

Reply 1

Helenia

20

Original post by BreatheDeep

Just wanted advice on how you tend to approach common scenarios and the questions you will ask the nurses when they tell you these things, for example the below:

1) Patient with low urine output
2) Patient who's catheter is not flushing
3) Patient who's sats are dropping
4) Patient with high potassium
5) Patient with low sodium

Not an F1, but nobody else has volunteered so far. Tell me what ideas you have already, and we'll help you out if you get stuck.

OP

Anyone?

Original post by BreatheDeep

Anyone?

See the above post.

Reply 4

BreatheDeep

OP

12

Original post by Helenia

Not an F1, but nobody else has volunteered so far. Tell me what ideas you have already, and we'll help you out if you get stuck.

Thank you - first one with low urine output - normal I try to check their blood results to check U+Es and ask for a bladder scan and decide whether to insert a catheter...

Reply 5

Da CorrupteD KiD

9

Original post by BreatheDeep

Thank you - first one with low urine output - normal I try to check their blood results to check U+Es and ask for a bladder scan and decide whether to insert a catheter...

That's a good start. When you're on call you will devise your own ways to filter through the requests from nurses. In this case I would check exactly how much is the patient passing over the last few hours and how much has gone in. What has the patient come in with? What are the obs like. If they have a catheter, has the nurse flushed it? If you're worried about retention then do a bladder scan as you right suggested. Last but not least, ask about how the patient is clinically. Are they in agony (?acute retention), drowsy (severe AKI with uraemia?) or up and about chatting with their neighbour whilst sipping tea. It helps with your prioritisation.

I'm curious as to how the other more senior doctors here would approach this too.

Reply 6

themedicalgeek

12

Original post by BreatheDeep

Just wanted advice on how you tend to approach common scenarios and the questions you will ask the nurses when they tell you these things, for example the below:

1) Patient with low urine output
2) Patient who's catheter is not flushing
3) Patient who's sats are dropping
4) Patient with high potassium
5) Patient with low sodium

There are really good flow charts in the Oxford Handbook of Clinical Medicine for the electrolyte abnormalities. They are in the clinical chemistry chapter.

The Student BMJ also did quite a good series 'You've been bleeped' which took you through a scenario like the ones above from the point of view of a FY1 and a registrar which was quite informative.

I guess for the dropping SATS you would start with ABCDE and ring senior if things don't look good after initial interventions. Im only a 3rd yr so if any FY1s disagree with me on that plan then ok :smile:

Reply 7

Helenia

20

Original post by BreatheDeep

Thank you - first one with low urine output - normal I try to check their blood results to check U+Es and ask for a bladder scan and decide whether to insert a catheter...

OK, both reasonable options. What is your system for approaching this problem? What potential causes are you thinking of?

Reply 8

BreatheDeep

OP

12

Original post by Helenia

OK, both reasonable options. What is your system for approaching this problem? What potential causes are you thinking of?

Just making notes now :smile:

My problem is I don't have a structure on the wards so I just remember things haphazardly..

Reply 9

Helenia

20

Original post by BreatheDeep

Just making notes now :smile:

My problem is I don't have a structure on the wards so I just remember things haphazardly..

It's the structure that will keep you sane and your patients safe. Think about why something is happening, classify that into possible causes, and then approach each problem that way.

For example, patient with low urine output. First of all, there are two options for why the urine output is low: they aren't making urine, or the urine is being made but not getting out.

The latter is probably simplest to address - if they are not catheterised, then put one in. Patients can quite easily go into urinary retention for all sorts of reasons when they are acutely unwell, and may not feel the urge to pee, so examine them and put in a catheter. If they already have a catheter, flush it, make sure it is not kinked etc, and put on a proper urometer bag to enable accurate measurements. You may want to do a dipstick +/- MCS on a sample if you can get one. Don't forget possible obstructive causes higher up the urinary tract.

If that doesn't seem to be the problem, then you have to think about why they're not making urine. Is it a pre-renal or intrinsic renal cause? Pre-renal: What is their blood pressure? Is it adequate for them? Examine for signs of dehydration, check their history, medications and recent blood results. Consider a trial of IV fluids - if the BP is on the low side or the patient looks dry, consider starting with a bolus of 250-500ml followed by maintenance, which will have a quicker effect than just starting a maintenance regime. If appropriate, encourage the patient to drink as well. Renal: are their U&Es deteriorating? Any nephrotoxic drugs? Current/past medical history? There may not be much you can do to treat many of the causes in this group, but stopping drugs like NSAIDs will at least prevent things from getting worse, and ensuring adequate renal perfusion and drainage will help with recovery. If you think the patient actually looks overloaded rather than dry, consider diuretics, but ONLY once you have ruled everything else out, and even then some places will want you to get your seniors to review before starting them.

If the above hasn't helped, and their renal function is poor or worsening, you may want to think about imaging - US is first choice to look at the kidneys themselves, but in a surgical patient your bosses may want a CT in case anything else is going on in the abdomen. At this point, enlisting senior assistance is a good idea. You may need a medical/renal review, plus possibly ICU if they may need haemofiltration, but that's a long way down the line and isn't a call for an FY1 to be making on their own, generally.

Reply 10

Dexa

1

Original post by BreatheDeep

Just wanted advice on how you tend to approach common scenarios and the questions you will ask the nurses when they tell you these things, for example the below:

1) Patient with low urine output
2) Patient who's catheter is not flushing
3) Patient who's sats are dropping
4) Patient with high potassium
5) Patient with low sodium

As an FY1 approach any inpatient in the same way (generally):

1) Are they acutely unwell? If Yes, do an ABCDE assessment before going to step 2:
2) If stable take a full Hx, examination, construct DDx
3) If you believe you're competent enough to deal with the situation then go ahead, otherwise at this point discuss the patient with your senior on the right course of action. They will be in charge of definitive management so don't worry too much if you're not completely sure on that.
4) Organise appropriate investigations e.g. bloods, cultures (blood, urine), scans etc
5) In the meantime, see if there is any immediate management necessary e.g. do they need any analgesia, cannulation + fluids, antiemetics, catheters. Prescribe as necessary and inform the nurse looking after the patient.
6) Document what you've done, what you've requested, who you've made aware etc in the patient notes so whoever is on-call and the ward team the next morning know what's going on.
7) Handover the patient to the on-call team before going home.

FY1s please help - common medical presentations

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