The Student Room Group

Your first day as a doctor

Scroll to see replies

Original post by sidewalkwhenshewalks
durr i hate cxr they all look the same to me.
need to pull back on that tube so it isn't so far in the lung.


I think that counts as an answer... Problem was a right mainstem intubation (EET extended too far into the lung, causing the patient to be unable to breathe properly). So... you pull back on it a bit, fix the lung and leave.

A little while later you are alerted to the fact that the patient's hypostension has worsened to 78/42.

What now?
Original post by sidewalkwhenshewalks
durr i hate cxr they all look the same to me.
need to pull back on that tube so it isn't so far in the lung.


I think that counts as an answer... Problem was a right mainstem intubation (EET extended too far into the lung, causing the patient to be unable to breathe properly). So... you pull back on it a bit, fix the lung and leave.

A little while later you are alerted to the fact that the patient's hypotension has worsened to 78/42.

What now?
Reply 602
Less science, more puzzles and ethics please! :colondollar:
Original post by UpsidedownLandMan
I think that counts as an answer... Problem was a right mainstem intubation (EET extended too far into the lung, causing the patient to be unable to breathe properly). So... you pull back on it a bit, fix the lung and leave.

A little while later you are alerted to the fact that the patient's hypotension has worsened to 78/42.

What now?


is he oedemous? this isn't looking good
I really have no idea, it's been so long since i did HLB...
hang 0.9% saline over 15 minutes and repeat until he dies of shock or decompensates because of fluid load and dies of respiratory failure. quit medicine and become writer.
(edited 12 years ago)
Original post by LaRoar
Less science, more puzzles and ethics please! :colondollar:


Right. Since I now have no idea what to do with the other guy he gets salined etc.

New one...
HISTORY:
An 8 month old male with altered mental status is brought to your emergency department by the mother. He was put down for a nap and when he was checked on, was found to be “breathing funny” and “not acting right.”

There is no reported history of trauma.
There is no viral prodrome.
There is no history of AMS, apnea episodes. The child is healthy.
The child is thought to be a full term child with up to date immunizations.
There are no sick contacts.
The parents and co-habitators deny being on prescription medications or having access to illicit substances.
PMHX none
Meds none
ALL NKDA
Soc Lives with mom, boyfriend sometimes stays over (was babysitting prior to nap), no other kids in house

PHYSICAL EXAM:
Initial State
T 37.0 HR 106 BP 90/50 SPO2 94%
General: drowsy, lethargic
HEENT: atraumatic, normal fontanelle, pupils equal but sluggish, nares normal, TMs normal
Neck: no nuchal ridigity, normal
Chest Shallow Resps, Otherwise clear
Heart regular rhythm no MRG
Abd soft, nontender, ND, NABS
Ext W/WP nl CR
Neuro: drowsy, moves all four spontaneously, normal to decreased tone
Skin: (rashes, turgor, trauma,etc): quarter size bruise to the left upper back, unclear age
Ok here's a tricky one (for the doctors) that I saw a few weeks back.

77year old with 40packyr smoking history. Presents with sob, cough productive of green phlegm and fevers/chills.
On examination wheeze bilaterally, creps bibasally. Working hard with breathing.
Temp35, bp200/100, p105, sats 92% on 15 litres

From that smidgeon of information tell me what you think is wrong with this lady, what investigations are needed (and how they would help) and what treatment you would start (exact treatment not vague)
O and who to refer to.
(edited 12 years ago)
[
Original post by UpsidedownLandMan
Right. Since I now have no idea what to do with the other guy he gets salined etc.

New one...
HISTORY:
An 8 month old male with altered mental status is brought to your emergency department by the mother. He was put down for a nap and when he was checked on, was found to be “breathing funny” and “not acting right.”

There is no reported history of trauma.
There is no viral prodrome.
There is no history of AMS, apnea episodes. The child is healthy.
The child is thought to be a full term child with up to date immunizations.
There are no sick contacts.
The parents and co-habitators deny being on prescription medications or having access to illicit substances.
PMHX none
Meds none
ALL NKDA
Soc Lives with mom, boyfriend sometimes stays over (was babysitting prior to nap), no other kids in house

PHYSICAL EXAM:
Initial State
T 37.0 HR 106 BP 90/50 SPO2 94%
General: drowsy, lethargic
HEENT: atraumatic, normal fontanelle, pupils equal but sluggish, nares normal, TMs normal
Neck: no nuchal ridigity, normal
Chest Shallow Resps, Otherwise clear
Heart regular rhythm no MRG
Abd soft, nontender, ND, NABS
Ext W/WP nl CR
Neuro: drowsy, moves all four spontaneously, normal to decreased tone
Skin: (rashes, turgor, trauma,etc): quarter size bruise to the left upper back, unclear age


Sadly common presentation of shaken baby syndrome vs meningitis vs 'something else'
Ct head and take it from there. Intubate first if required.
Original post by Jamie
[

Sadly common presentation of shaken baby syndrome vs meningitis vs 'something else'
Ct head and take it from there. Intubate first if required.


Yep, sounds spot on. (Do a BM as well unless I missed it and you'd already given the result of one).
Original post by Jamie
Ok here's a tricky one (for the doctors) that I saw a few weeks back.

77year old with 40packyr smoking history. Presents with sob, cough productive of green phlegm and fevers/chills.
On examination wheeze bilaterally, creps bibasally. Working hard with breathing.
Temp35, bp200/100, p105, sats 92% on 15 litres

From that smidgeon of information tell me what you think is wrong with this lady, what investigations are needed (and how they would help) and what treatment you would start (exact treatment not vague)
O and who to refer to.


Ok, end of bed snap assessment would be that this pt is sick. Therefore ABC assessment alongside concise hx.

Assume she is managing A herself, at the moment at least.

B = worrying that only managing 92% on 15L. Can add in a further 4L via nasal specs under the mask. Resp rate? Known hx of COPD? Home nebs or O2? Any other resp hx? Assume there is AE throughout and not considering pneumothorax. ABG needed - if temp is 35 it might be that cool peripheries = sats probe dodgy reading. Would also give CO2 and pH / metabolic state. Also get portable CXR (hurrah, bring on the argument with the radiographer) to look for consolidation, effusion... Examine neck nodes for lymphadenopathy.

C = Tachycardic and hypertensive. Has she had salbutamol yet, has this caused the tachycardia? 2x IV access, take bloods at the same time and blood cultures 9I know she is currently febrile but given the hx I think it is appropriate as she is sick and has had fevers.) FBC to look at WCC, UE for renal func, CRP, LFTs as part of general septic screen. BM whilst you've got some blood there to do it. Any hx of heart failure? Any peripheral oedema on examination? Once IV access in, start fluids. Do an ECG - can asssess the tachycardia - is it regular, is it new AF secondary to infection? Can also look at R wave progression (PE sounds unlikely to be what's causing hypoxia here but not impossible).

D = GCS / rapid assessment of confusional state? Should already have a BM now and we've got a temp. Rapid exam of abdomen. Ask nurse to catheterise and monitor strict fluid balance (dip urine at same time). Complete the focussed hx - any foreign travel, haemoptysis, weight loss, TB contacts or previous TB? Known immunocompromise? (HIV / cancer). Allergies / usual meds / significant PMHx. VTE risk factors - doesn't sound likely in this case but could be contributor.

Imp. 1. ?Type 1 or 2 (would know CO2 from gas) resp failure secondary to pneumonia - calculate CURB65 once each bit known, with poss background of COPD given smoking hx, ??underlying malignancy. Has 2 SIRS criteria plus source of infection chest) therefore would meet sepsis criteria so start broad spectrum IV abx early (tazocin if not pen allergic). Fluids are running, bloods are taken, ABG and CR are in progress, ECG and catheter will follow. Urine legionella antigen and sputum culture if you're feeling keen but probably less appropriate in this very acute phase whilst she's so sick, needs stabilising first. Monitored bay.

The ABG / CXR would tell you quite a lot more useful information, at the same time I would also call senior support / possibly an anaesthetist. This lady is struggling on 15L and is tiring. She will probably need either NIV or CPAP depending on gases and therefore call bed management / whoever to check availability of beds for this (in our hosp it's only ITU / the monitored MAU bay that can do this)
Original post by junior.doctor
Ok, end of bed snap assessment would be that this pt is sick. Therefore ABC assessment alongside concise hx.

Assume she is managing A herself, at the moment at least.

B = worrying that only managing 92% on 15L. Can add in a further 4L via nasal specs under the mask. Resp rate? Known hx of COPD? Home nebs or O2? Any other resp hx? Assume there is AE throughout and not considering pneumothorax. ABG needed - if temp is 35 it might be that cool peripheries = sats probe dodgy reading. Would also give CO2 and pH / metabolic state. Also get portable CXR (hurrah, bring on the argument with the radiographer) to look for consolidation, effusion... Examine neck nodes for lymphadenopathy.

C = Tachycardic and hypertensive. Has she had salbutamol yet, has this caused the tachycardia? 2x IV access, take bloods at the same time and blood cultures 9I know she is currently febrile but given the hx I think it is appropriate as she is sick and has had fevers.) FBC to look at WCC, UE for renal func, CRP, LFTs as part of general septic screen. BM whilst you've got some blood there to do it. Any hx of heart failure? Any peripheral oedema on examination? Once IV access in, start fluids. Do an ECG - can asssess the tachycardia - is it regular, is it new AF secondary to infection? Can also look at R wave progression (PE sounds unlikely to be what's causing hypoxia here but not impossible).

D = GCS / rapid assessment of confusional state? Should already have a BM now and we've got a temp. Rapid exam of abdomen. Ask nurse to catheterise and monitor strict fluid balance (dip urine at same time). Complete the focussed hx - any foreign travel, haemoptysis, weight loss, TB contacts or previous TB? Known immunocompromise? (HIV / cancer). Allergies / usual meds / significant PMHx. VTE risk factors - doesn't sound likely in this case but could be contributor.

Imp. 1. ?Type 1 or 2 (would know CO2 from gas) resp failure secondary to pneumonia - calculate CURB65 once each bit known, with poss background of COPD given smoking hx, ??underlying malignancy. Has 2 SIRS criteria plus source of infection chest) therefore would meet sepsis criteria so start broad spectrum IV abx early (tazocin if not pen allergic). Fluids are running, bloods are taken, ABG and CR are in progress, ECG and catheter will follow. Urine legionella antigen and sputum culture if you're feeling keen but probably less appropriate in this very acute phase whilst she's so sick, needs stabilising first. Monitored bay.

The ABG / CXR would tell you quite a lot more useful information, at the same time I would also call senior support / possibly an anaesthetist. This lady is struggling on 15L and is tiring. She will probably need either NIV or CPAP depending on gases and therefore call bed management / whoever to check availability of beds for this (in our hosp it's only ITU / the monitored MAU bay that can do this)


Okely dokely, so

Good
-Great format of your assessment (ITU style, like it). Thinking about things in depth and properly and reasoning out rather than blindly shouting tests.
-Well spotted with the SIRS and observing that this is a septic patient (despite hypothermia which throws some people)
-Consideration of a plan and level of escalation. Plus thinking about patient safety in terms of nursing is always good (remembering that on some wards you cannot safely manage acutely unwell patients)
-Correct diagnosis with respiratory failure secondary to pneumonia
- You didn't jump to the COPD on high flow oxygen = loss of hypoxic drive so stop the oxygen conclusion. Hate it, its always wrong. Oxygen is good. Retention is rare and not treated by inducing hypoxia.

THink about
-Oxygenation. THink about when you would use nasal prongs. 2 situations strike me (aside from just using nasal prongs). One is when giving air driven nebuliser to someone requiring a little oxygen. THe other is giving oxygen driven nebuliser to someone needing LOTS of oxygen.
Pointless to add nasal prongs if using 15l non-rebreather as they will never be breathing in more than 15l.

CPAP is a but poo. No longer really used. Even for pulmonary oedema it has been realised that BiPaP is just as efficous but much better tolerated.
When dealing with septic patient never forget the value of a venous gas. Can do it whilst takin bloods, and from that get blood glucose, pH and upper limit of CO2. (cos arterial will only ever be lower than venous!)
Will also get the magical LACTATE (didn't see you mention it).


Really good effort, have a star.
Original post by Jamie


Really good effort, have a star.


Why thank you :biggrin: Can I stick it in my eportfolio? (bah, wretched thing, day off pre-Easter weekend nights = quarterly portfolio mass update)

Am realising more and more the value of lactate now I'm doing ITU - sometimes it's not so easy outside of ITU to get a lactate easily, especially when it's only the ITU gas machine that does them and ITU are understandably precious about their machine being used by other people. Altho a formal one doesn't take that long I suppose. Thankd for your feedback, v useful.
Original post by junior.doctor
Ok, end of bed snap assessment would be that this pt is sick. Therefore ABC assessment alongside concise hx.

Assume she is managing A herself, at the moment at least.

B = worrying that only managing 92% on 15L. Can add in a further 4L via nasal specs under the mask. Resp rate? Known hx of COPD? Home nebs or O2? Any other resp hx? Assume there is AE throughout and not considering pneumothorax. ABG needed - if temp is 35 it might be that cool peripheries = sats probe dodgy reading. Would also give CO2 and pH / metabolic state. Also get portable CXR (hurrah, bring on the argument with the radiographer) to look for consolidation, effusion... Examine neck nodes for lymphadenopathy.

C = Tachycardic and hypertensive. Has she had salbutamol yet, has this caused the tachycardia? 2x IV access, take bloods at the same time and blood cultures 9I know she is currently febrile but given the hx I think it is appropriate as she is sick and has had fevers.) FBC to look at WCC, UE for renal func, CRP, LFTs as part of general septic screen. BM whilst you've got some blood there to do it. Any hx of heart failure? Any peripheral oedema on examination? Once IV access in, start fluids. Do an ECG - can asssess the tachycardia - is it regular, is it new AF secondary to infection? Can also look at R wave progression (PE sounds unlikely to be what's causing hypoxia here but not impossible).

D = GCS / rapid assessment of confusional state? Should already have a BM now and we've got a temp. Rapid exam of abdomen. Ask nurse to catheterise and monitor strict fluid balance (dip urine at same time). Complete the focussed hx - any foreign travel, haemoptysis, weight loss, TB contacts or previous TB? Known immunocompromise? (HIV / cancer). Allergies / usual meds / significant PMHx. VTE risk factors - doesn't sound likely in this case but could be contributor.

Imp. 1. ?Type 1 or 2 (would know CO2 from gas) resp failure secondary to pneumonia - calculate CURB65 once each bit known, with poss background of COPD given smoking hx, ??underlying malignancy. Has 2 SIRS criteria plus source of infection chest) therefore would meet sepsis criteria so start broad spectrum IV abx early (tazocin if not pen allergic). Fluids are running, bloods are taken, ABG and CR are in progress, ECG and catheter will follow. Urine legionella antigen and sputum culture if you're feeling keen but probably less appropriate in this very acute phase whilst she's so sick, needs stabilising first. Monitored bay.

The ABG / CXR would tell you quite a lot more useful information, at the same time I would also call senior support / possibly an anaesthetist. This lady is struggling on 15L and is tiring. She will probably need either NIV or CPAP depending on gases and therefore call bed management / whoever to check availability of beds for this (in our hosp it's only ITU / the monitored MAU bay that can do this)


Wow.

Part of me wonders how much of this you learn at medschool and how much is obtained on the job. Would I right to assume that it must be more the latter?
Original post by GodspeedGehenna
Wow.

Part of me wonders how much of this you learn at medschool and how much is obtained on the job. Would I right to assume that it must be more the latter?


You need the theoretical knowledge from medical school to underpin the practical experience. Certainly I got a lot of experience in my later clinical attachments in medical school by being very hands on with the general work of whichever team I was attached to. Someone gave me a very sensible piece of advice when I was in my final year, which was that in a few months' time I'd be doing the work of the people I was currently attached to - therefore to regularly look at the sorts of things they were asked to do, ask myself if I could do it if someone were to ask me, and if I couldn't, to learn how. (Example: prescribing fluids for patients, treating high potassium, doing a pre-op assessment, writing a decent ward-round entry, prioritising jobs and tasks on out-of-hours ward cover).

That said, a huge amount of my practical experience has come from being a junior doctor and having to do this (ie assess people who are varying degrees of 'sick') every day of the week, especially out of hours. Experience teaches you to make a rapid assessment from glancing at the patient, the presenting complaint and the obs chart - how sick are they? Do you need to start instigating immediate treatment alongside an 'ABCDE' assessment, or do you have time for history-examination-impression-management plan? Experience on the job also helps you to discern WHY you're doing certain tests, the value and urgency of them and how they're going to affect both your immediate and subsequent management. (You also learn which boss likes what, heh heh. If the respiratory boss is post-taking, you always ask every patient if they keep pigeons. If it's the ID boss, you send a urine legionella antigen for every LRTI *sigh*)

Quick Reply