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    Ok...but only cause I'm bored..! I'll try something abut simpler for the applicants.

    58yr old female on neurosurgical ward. Admitted following a fall, subdural haematoma with surgery for evacuation 2 days ago. She's been talking about a Christmas pudding in the washing machine and asking who else lives in this flat for the past half hour. She has IV access, catheter was removed this morning as she has been out of bed and walking to toilet, although the sheets are now wet, and her pillow case. Wound to right side of head with clips, and PMH of diabetes type 2. What would you first do?

    Obs 4 hours ago:
    Respiratory rate: 18
    Sats 97% on room air
    Heart rate: 82
    Temp: 37.2
    BP: 117/66
    Blood glucose: 6.4
    Eating and drinking well and independantly.
    GCS: 15, pupils equal and reacting to light, no limb deficits.
    Urine output: 110mls per hour, although catheter then removed
    Bowels not yet open.
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    (Original post by Subcutaneous)
    58yr old female on neurosurgical ward. Admitted following a fall, subdural haematoma with surgery for evacuation 2 days ago. She's been talking about a Christmas pudding in the washing machine and asking who else lives in this flat for the past half hour. She has IV access, catheter was removed this morning as she has been out of bed and walking to toilet, although the sheets are now wet, and her pillow case. Wound to right side of head with clips, and PMH of diabetes type 2. What would you first do?
    more IV fluids? BP seems low, HR seems high, urine output seems low. not sure why she is wetting the sheets - she's just had a catheter out, may just be irritation, or a possible UTI?

    check creatinines and get a neutrophil count?
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    Obs were 4 hours ago- wouldn't you like more recent obs? Both for comparison and also for your current information?
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    (Original post by Tech)
    more IV fluids? BP seems low, HR seems high, urine output seems low. not sure why she is wetting the sheets - she's just had a catheter out, may just be irritation, or a possible UTI?

    check creatinines and get a neutrophil count?
    Ok, what fluids would you prescribe? Her BP & HR seem to hover around those ranges when you glance on past observations, staff nurse was not concerned back then. Although they were done 4 hours ago...

    Bloods sent off for creatinine & neutrophils...

    Sheets changed, nurse thinks it wasn't urine..
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    (Original post by birduk)
    Obs were 4 hours ago- wouldn't you like more recent obs? Both for comparison and also for your current information?
    Good idea, always a good place to start!

    Pulse: 110
    BP: 94/56
    temp: 38.5
    RR: 20
    GCS: 14 due to disorientation
    Sats: 93% on room air
    BM: 6.3

    What do you make of this, and plan of action next?

    Patient is getting agitated and anxiou
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    Let's see-
    Obs 4 hours ago:
    Respiratory rate: 18
    Sats 97% on room air
    Heart rate: 82
    Temp: 37.2
    BP: 117/66
    Blood glucose: 6.4
    Eating and drinking well and independantly.
    GCS: 15, pupils equal and reacting to light, no limb deficits.
    Urine output: 110mls per hour, although catheter then removed
    Bowels not yet open


    Now-Pulse: 110
    BP: 94/56
    temp: 38.5
    RR: 20
    GCS: 14 due to disorientation
    Sats: 93% on room air

    So rapid, weak pulse right now? Seems to me this lady is running out of fluid in her body- most probably sweat as it is on the pillow, not just on her sheets. Temp also going up. I think we need to cool this lady down and get more fluids into her. Also a nice oxgen mask would be a good start.
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    Just a thought now- something is causing her to not be able to regulate her temperature. Would that be something to do with the brain injury? Could we get a CT scan to investigate?
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    (Original post by electricjon)
    Honestly Subcutaneous you need to lighten up a bit. I'm not trying to wind anyone up here. Yes I'm playing devil's advocate. There aren't really any right or wrong answers. I'm not forcing anyone to take part in the discussion, and if you take offence to my answers then I do apologise, but then my suggestion would be to not contribute, particularly if you are going to make resentful comments.

    I'm not pretending I'm above anyone. But as someone who has had to deal with these situations in one form or another, however arbitrary or modified, I find your comments quite offensive.
    I'll be honest mate, I don't see where some people are getting this 'arrogance' thing from. These cases are absolutely fascinating and have certainly given me a massive amount of food for thought. I think it's less your arrogance than certain inexperienced members who don't like realising how much they've still got to learn.
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    (Original post by birduk)
    Just a thought now- something is causing her to not be able to regulate her temperature. Would that be something to do with the brain injury? Could we get a CT scan to investigate?
    There are much more common reasons why someone might have a raised temperature. She may well need another CT at some point soon but it's not what you should be doing first.

    What does the wound look like, apart from having clips in?

    (I'm not going to give too much away though, as it's not really fair on the applicants/students)
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    Oh oh oh oh! Infection????
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    (Original post by birduk)
    Just a thought now- something is causing her to not be able to regulate her temperature. Would that be something to do with the brain injury? Could we get a CT scan to investigate?
    Ct ordered..although nurse queries it and asks if you're sure..

    What rate oxygen would you give and what type of mask? How'd you regulate her temperature? IV fluid prescription?

    Wound has exudate on dressing, erythema and slightly swollen, patient keeps wanting to touch her head too...
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    (Original post by birduk)
    Oh oh oh oh! Infection????


    One possibility...ways to find out...

    Although the nurse (who lacks a bit of initative) is waiting for fluids to be prescribed, what rate oxygen/mask and how she can regulate the temperature...
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    (Original post by Subcutaneous)
    One possibility...ways to find out...

    Although the nurse (who lacks a bit of initative) is waiting for fluids to be prescribed, what rate oxygen/mask and how she can regulate the temperature...
    nurse turns out to be Batman's Joker. C4 is planted in hospital, set to go off in 2.30 minutes.
    Do you
    a) Get out of there
    b) help the crippled boy and lose a leg and an arm to backdraft
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    No idea about oxygen rate and mask to be honest- I am just applying for med school (but to be honest I hope I learn that in the next 5 years).

    Ice packs on the back of your neck, remove sheets, chilled saline?

    I'll step out of this one now and bow down to a med student.
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    (Original post by birduk)
    No idea about oxygen rate and mask to be honest- I am just applying for med school (but to be honest I hope I learn that in the next 5 years).

    Ice packs on the back of your neck, remove sheets, chilled saline?

    I'll step out of this one now and bow down to a med student.
    *is consumed by backdraft
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    (Original post by birduk)
    No idea about oxygen rate and mask to be honest- I am just applying for med school (but to be honest I hope I learn that in the next 5 years).

    Ice packs on the back of your neck, remove sheets, chilled saline?

    I'll step out of this one now and bow down to a med student.
    Youve done well, taking sheets off is an excellent way to help temperature and although obvious not one many think of initially, ice packs too may help!

    Ok well the nurse has removed sheets, opened a window and popped a fan on the side. She decided to give 02 at 4l on nasal cannulas and repeat obs...Could do with a suggestion for fluids, colloid/crystalloid..blood?

    HR: 124, irregular and 'bounding'
    BP: 83/45
    Sats: 91% on 4l oxygen via nasal cannulas
    Resps: 26
    GCS: 14
    Blood glucose: 6.4
    Temp: 38.7

    There's a very simple and easy to get drug which is also an antipyrexial aswell as good for pain relief which you could prescribe...
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    I said I'd step out but....

    asprin?
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    Can we give her paracetemol?
    Also I'd get her an ECG- high heart rate and low BP could mean she has something like atrial fibrillation
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    (Original post by ihaveyourcat)
    Can we give her paracetemol?
    Also I'd get her an ECG- high heart rate and low BP could mean she has something like atrial fibrillation
    Good idea, paracetamol 1g IV is given, 30mins later temp goes too 38.1, although patient isn't clutching her head so much..you touch her and she's feeling rather cool and clammy

    ECG is done, shows 126 rate, sinus rhythm.
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    Anything like NSAIDs, or as the users above have pointed out aspirin and paracetemol would also lower the fever.

    EDIT: Nevermind, too slow :cry:
 
 
 
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