MSO case discussion!

[frootloop]

Ok, so I've got med school finals at the end of the year, so I need a semk-legitimate excuse for the amount of time I spend on here

So, come up with clinical vignettes, and then ask everyone questions based on them.

A few quick rules:

- Don't post actual cases. But if you remove all identifiable information and modify enough aspects of the case that, it should be fine to loosely base scenarios on things you've actually seen.

- For each scenario, make sure you post a question or two for preclinical students to answer as well. Just so we can get as many people as we can in on the discussion, and it can help the preclins tie what they're learning into clinical stuff.

- Write your own cases. Don't just copy-paste out of textbooks or stuff your med school has given you or any other copyrighted material.

- Underneath each of your questions, post your own replies in an offtopic box.

- Try not to just google the answers. It's far more useful if we try and reason stuff out ourselves and then discuss it.

- Finally, and this is aimed mostly at the schoolkids out there, I'll delete any trolling and s**tposts on this thread.

Gogogogo!

 

[frootloop]

I'm on orthopaedics at the moment, so we'll start with a straightforward one:

(Nb, if anyone wants to critique how I write this up, please feel free. After a year out I've gotten a touch rusty in pretty much every area)

A 68-year-old Caucasian female presents to the ED with severe (9/10) left ankle pain. She stood up from a seated position, and her foot slid out from underneath her, resulting in an audible 'crack' from her ankle. She has been brought in in a wheelchair, as she is unable to weight-bear on the left side.

On inspection, the ankle and the dorsal aspect of the foot are severely swollen, but the foot is not grossly displaced. There are no lacerations or abrasions, and the colour and temperature of the left foot and ankle are normal. She has bimalleolar tenderness, but her foot and lower leg are non-tender. She is unable to actively perform any ankle or foot movements on the left side, and has lost sensation over the dorsum of the foot. She sustained no other injuries during her fall. She is otherwise well, and reported no abnormal symptoms prior to her fall. Her only significant history is of a radial fracture after a FOOSH 7/12 ago.

X-rays reveal a trimalleolar fracture.

1) List the bones and major ligaments involved in the ankle joint

2) What are some possible complications to watch for following this type of injury, and how would you monitor these?

3) What other injuries commonly co-occur with ankle injuries caused by rotational forces?

4) Management plan and rationale. Go. Include in your answer why surgery is/isn't likely to be required for this type of injury.

5) This is her second fracture in the past year. What are her risk factors for osteoporosis, and how (if at all) would you test her for it?

6) Both of her recent fractures occured following falls. List 5 possible factors which may have contributed to these falls, keeping in mind her demographic factors and the mechanism of the fall given in the vignette. Outline how you would go about determining which (if any) may have been responsible, and how these could be managed going forward.

I'm on my phone, so I can't be bothered typing out my answers. I'll edit them in later.

 

[Benjamin]

Just quickly - instead of using my offtopic box I made (which has currently broken!) use the insert spoiler button. It's on the top of the text editor as what looks like a newspaper article (3 right from the smiley face button). Alternatively you can use the following BB code

[SPOILER] Your hidden text here [/SPOILER]

Here's a case from me, discuss at will/ask any question you want and I'll try get you an answer. My cases will all be aimed at ED presentations from initial work-up to referral/discharge because that's where I'm at currently.

Vignette:
75+ year old male with sudden onset of continuous vertigo, nausea & diaphoresis at 0500hrs this AM which he still has when you see him in the ED at 0900hrs but resolves by 0930hrs. He describes his vertigo as being "unable to walk properly, like I had to hold onto things so I wouldn't fall over" but denies any weakness, sensation changes or speech disturbances. He has a significant past medical history of coronary artery bypass grafting (CABG) in 2012 & a transient ischaemic attack 6 months prior.

He has had no chest pain or abdominal pain & is unable to give you a list of his regular medications other than to say he takes "one for fat in my blood, one for my blood pressure and one to keep my blood thin"

His observations are as follows: HR 85 regular / BP 180/105 / RR 14 / SpO2 98% on RA / Afebrile

What are your main differentials for this patient/what do you need to exclude?

Spoiler

For most cases of vertigo & nausea the main differentials depend on whether the cause is peripheral or central - i.e. in the brain or outside the CNS.

1. Posterior circulation cerebrovascular event given continuous nature of vertigo + past history of TIA 6/12 ago. A full cerebellar examination is vital in this case of vertigo.
2. Myocardial ischaemia/infarct. Sudden onset of his symptoms + PMHx + diaphoresis make this potentially a silent MI with cerebral ischaemia. Excluded with investigations.
4. Electrolyte or metabolic abnormalities - i.e. hypoglycaemia etc.
5. Acute vestibular syndromes - vestibular neuritis, labyrinthitis etc. causing the vertigo would be peripheral causes. These would typically have a more gradual onset and be found on a HiNTs examination with abnormal head impulse/loss of vestibular-ocular reflex +/- horizontal nystagmus beating in one direction + no eye skew.
6. Benign paroxysmal positional vertigo - only if the vertigo is intermittent and positional!

What are you going to look for on examination or what other history would you like to exclude/include these differentials?

Spoiler

There is a lot of history missing from this case but by far the most important is whether the vertigo is continuous or intermittent. A diagnosis of benign positional paroxysmal vertigo (BPPV) should NEVER be given to a patient that has vertigo persisting when their head is still or not worsened by changing position. BPPV is vertigo that worsens with head movement but settles when the head is not moving & eyes are closed. If the vertigo is continuous and not relieved by sitting still then a posterior CVA/stroke should be excluded. Thankfully this can be done with the HiNTS exam which is explained succintly by Scott Weingat here (originally from this paper) and a great review article on the topic is here. It wasn't until I actually read that paper that I realised you want an ABNORMAL head impulse test to exclude a posterior circulation stroke - i.e. an ABNORMAL head impulse test indicates the issue is within the vestibular nerve and not central in origin.

In this case the patient had unrelenting vertigo even when laying still with their eyes closed. They also had a normal head impulse but direction changing nystagmus.

This patient should have at least a full cardiac, abdominal & neurological examination + an ear examination. A summary of pertinent examination findings are below:

VITALS:
HR 85 regular / BP 180/105 / RR 14 / SpO2 98% on RA / Afebrile

GENERAL:
Alert + oriented x 3, GCS 15.
Laying comfortably in bed at 45 degrees, no obvious respiratory distress.
No obvious pain or discomfort.

CARDIO:
Radial pulses regular + strong bilaterally. Capillary refill time <3 seconds
No radial-radial, radial-femoral delay.
BP 180/105 in both arms.

Heart sounds S1 + S2, nil added.
JVP not elevated

RESP:
Vesicular breath sounds throughout chest posteriorly. Percussion resonant throughout.
Air entry R = L
Chest expansion R = L

ABDO:
Abdomen soft & non-tender throughout.
No percussion or rebound tenderness.
No palpable hepatosplenomegaly or masses.

NEURO:
GCS 15, no gross neurological deficit.
Cranial nerves II-XII intact. Visual acuity not formally assessed.
Pupils equal & reactive to light & accomodation

Tone normal & R = L
Reflexes 1+, R = L & UL = LL
Babinski normal. No clonus.
Motor 5/5 in all movements
Sensation grossly intact (formal sharp + light touch not conducted prior to imaging)

Dysdiadokinesis evident with hand-to-hand.
Heel-shin test normal. No ataxia, past pointing or intention tremor with finger-nose
Rhombergs -ve. Gait normal.
Head impulse normal. Direction changing nystagmus to both R & L. Eye skew normal.

EARS:
Tympanic membranes clear bilaterally, nil effusion or inflammation.

Please interpret his ECG (attached at bottom). It is unchanged from a previous ECG in 2016.

Spoiler

Use the following format:
Axis: 1 +ve, AVF -ve: Left axis deviation
Rate: ~85bpm
Rhythm: 1st degree heart block
P waves: normal p waves
PR segment: prolonged (>0.2s/5 small squares)
QRS waves: wide QRS waves (<0.12s/3 small squares) evident of left bundle branch block + ?RBBB given prolonged PR segment
ST segment: difficult to interpret in view of heart block, correlate with previous ECG or use Modified Sgarbossa criteria
T waves: nil significant abnormalities
Other: nil
Summary: LBBB with first degree heart block, though it could also be an incomplete trifasicular block (left anterior + left posterior + right bundle) given prolonged PR segment may represent a RBBB abnormality associated with the + LBBB pattern

What other investigations would you like to order?

Spoiler

Full blood count //
Hb 97 w/ MCV 78
WCC 8.2
Plt 377

CHEM20 //
Electrolytes: Na 136 / K 4.8 / Cl 105 / Ca 2.10 (corr) / Mg 0.9 / BSL 6.2
Renal: eGFR 47 w/ creat 110 & urea 10.8. Similar to previous Ix
LFT's: All within normal limits
Other: All within normal limits

Initial Cardiac Troponin I (4hrs post onset of symptoms) //
0.032 (ref: <0.04)

Troponin in 2hrs time //
0.036 (ref: <0.04)

CHEST X RAY //


CT Head non-contrast

Please interpret the above ordered investigations.

Spoiler

FBC - microcytic anaemia

CHEM20 - Chronic kidney disease w/ eGFR ~50 on previous studies.

Troponins - below the cut-off limit for normal (0.04), no evidence of acute myocardial injury.

CT HEAD:
No midline shift. No intracranial haemorrhages or masses.
Periventricular ischaemia with deep white matter hypoattenuation/bilateral white matter hypodensity surrounding the ventricles.
Correlated with previous films which appeared unchanged.

Please summarise the case so far

Spoiler

75+ year old male with vertigo, nausea & diaphoresis OBO CABG 2012 + TIA in 2016 + LBBB with 1st degree heart block. Significant neurological findings of dysdiadokinesia, normal head impulse & direction changing nystagmus suggesting possible posterior circulation ischaemia. Given the symptoms have currently resolved + appear central in origin this is considered a transient ischaemic attack and thus the ABCD2 score can be used to calculate their risk of a future CVA.

The score can be calculated here, with this patient having a score of 4 for:

• Age: >60 years old - 1
• Blood pressure: >140/80 - 1
• Clinical features other than speech disturbance or weakness - 0
• Duration >60 minutes - 2

This gives them a moderate risk of a CVA occurring in the next 2, 7 & 90 days with respective risks of 4.1, 5.9 & 9.8%. They should be referred to the neurology/medical team depending on how your hospital runs potential stroke referrals.

 

[govpop]

You're on your surgical run and get called to the ward after hours to review two different patients. These are the handovers you get from nursing staff.

1. Mrs A is 1 days post anterior resection. Her urine output is 25mls per hour. Vitals HR 85 BP 120/70 sats 95% on 1L Rr 18 afebrile. Please review.

2. Mr B is 3 days post Ivor-Lewis oesophagectomy. He desaturated to 80% this evening so I have changed his nasal prongs to face mask and he is on 6L now. Resp rate is also 30. Please review.

How would you approach these patients? Ask for any further information, hx, exam findings etc. Updates and progress will come based on your management plan. Attempt to provide a differential whenever you can.

Eta: preclinical years feel free to have a stab. Will throw in some simpler preclinical qs along the way.

 

[Benjamin]

Great cases! Here's how I would genuinely approach the patients described & how I would go about my notes:

1. Mrs A is 1 days post anterior resection. Her urine output is 25mls per hour. Vitals HR 85 BP 120/70 sats 95% on 1L Rr 18 afebrile. Please review.

Primary concern - limited urine output (normal is >0.5mL/kg/hr) ?acute kidney injury + ?need for supplemental O2
Things I want to know before I get there/before I walk in to see the patient:

• Background Hx & reason for anterior resection - could either be elective for rectal Ca or an emergency Hartmann's procedure for diverticulitis perforation/other emergent cause. The two patients/situations would be approached very differently.
• Recent bloods specifically renal function/electrolyte status - do they normally have an eGFR ~15 and minimal urine output is normal for them or are they normally eGFR >90 and otherwise healthy?
• Recent fluids/current oral intake status/stoma output status - still on clear fluid diet because BNO/stoma not functioning / unable to tolerate PO intake 2' nausea & vomiting / stoma is outputting 2L of water every 6hrs.
• Current meds - has Mrs A been getting a bunch of nephrotoxic drugs and no fluids + a diuretic? Better check!
• Duration of limited urine output - has it been 25mLs since the catheter bag was changed an hour ago (because it was full!) or has it been 25mLs/hour since the operation yesterday at 0800hrs.
• Do they have a urinary catheter? (usually they do)
• O2 supplementation - when was it started / is it being weaned / what does she desaturate to without it?

My actual reviews of patients run basically the same as an intern regardless of what I'm seeing. Every patient will get a documented ABCD + cardio + resp + abdominal exam + ins/outs + wound assessments primarily because I feel as an intern the process of overassessing patients is comforting/I'm bound to miss stuff if I don't look.

Lets assume a few things:
Mrs A is a 72 year old independent female who came in for an elective ultra-low anterior resection for rectosigmoid cancer. She is otherwise well & has no other significant co-morbidities. She had been charted for 1L 0.9% NaCl on Friday and was planned to be nil by mouth from 0000hrs that night for an operation on Saturday morning. Unfortunately the consultant doing her operation got called into emergency surgery & so her operation was delayed until Sunday. There were no fluids charted beyond that initial bag.

Her operation went well, there was ~600mL of blood loss after an arterial bleed but this was managed intraoperatively and her abdomen is soft & appropriately tender post-operatively. Her wound looks clean & she has a normal cardiovascular & respiratory examination. Her colostomy is not yet functioning.

Post-operatively she has been put on a clear fluid diet until her stoma functions but has had issues with ongoing nausea & vomiting. She has been unable to keep anything down. She feels very thirsty and her tongue looks like sandpaper. Her JVP is not visible and her capillary refill time is delayed.

A urinary catheter is inserted after a bladder scan shows ~50mLs and a small amount of urine is drained.

Her investigations are as follows:

FBC //
Hb 98
WCC 12.2 w/ 9.2 neutrophils
Plt 300

CHEM20 (our U/E/LFT panel)
Electrolytes: Na 131 / K 4.2 / Cl 100
Renal: eGFR 22 w/ creat 260 & urea 11.2
LFT: All WNL
Other: Mg 0.6 / Phos 0.4

AXR //

Marked distension of large & small bowel / No obvious transition point / Likely ileus given Hx.
Full radiopaedia discussion: Paralytic ileus | Radiology Case | Radiopaedia.org

Old bloods demonstrate that pre-operatively Mrs A had normal renal function.

Impression
72F with acute kidney injury (creat 260 / eGFR 22 / urea 11.2) on the background of ultralow anterior resection for rectosigmoid Ca & minimal hydration over the last 72/24hrs.
Likely pre-renal acute kidney injury given dehydration
Need to exclude: nephrotoxic medications / post-renal obstruction / ureteric injury intraoperatively

Plan from initial review
- Bladder scan + catheter if not already done. Strict fluid balance monitoring.
- Bloods: Full blood count (if not done that AM) + electrolytes/urea/creat/LFT's. Usually I'll get a VBG if I'm concerned about the patient because it'll take me 5 minutes to get the result rather than an hour.
- Urine sent off for MCS + ask lab to hold a sample (renal might want albumin creat ratios etc)
- Fluids: As long as they aren't clinically overloaded I'd be pretty comfortable putting a litre of 0.9% NaCl up to run over 2-3 hours & I would come reassess them throughout this time. If they still don't establish a urine output with this in the next few hours I'd probably give another bag after excluding an obstructive cause.
- Cease all nephrotoxic drugs & make sure her current drugs are changed to renally adjusted dosages as per her creatinine clearance.
- Discuss with my surgical registrar to run my plan by them.
- Check history to ensure no significant Hx of renal calculi/other post-renal obstructive cause. If at all concerned get an ultrasound request in for KUB to check for hydronephrosis + (if I have time) grab a probe myself to flick it over their kidneys ... I'd still get a formal USS but if it's barn door hydronephrosis that I can demonstrate on USS then it might expedite a urology referral.
- Check op notes - did they use flexible cystoscopy + ureteric stents to help identify the ureters during the resection? Is there any mention of a potential ureteric injury? This is an unlikely cause but definitely on the list.
- Pending all the above (i.e. no increase in urine output w/ fluids + no sign of post-renal obstruction) I'd contact the renal team for consideration of potential renal causes + advice further. I would contact renal earlier if:

• normal fluid status (i.e. has been getting adequate fluids) & likely 2' nephrotoxic drugs that may require dialysis - i.e. likely intrinsic renal cause
• no evidence of post-renal obstruction or surgical injury to ureters - i.e. doesn't need a urology referral
• known chronic kidney disease w/ low baseline eGFR &/or has been previously reviewed by the renal team in our hospital
• they had indications for dialysis (unlikely this early!) - these are: severe acidosis / severe electrolyte abnormalities (K+ / Na + /Ca 2+) / Intoxicants/nephrotoxins that need to be dialysed off / Severe fluid overload & minimal/no urine output/ Uraemia with symptoms (i.e. nausea/pericarditis/seizures/bleeding)

Other things that are helpful to do but not absolutely essential:
- ECG if she doesn't have a baseline one so that when/if her K rises you have something to compare to for ?hyperkalemic changes. This sounds silly because hyperkalemic changes are supposed to be "clear-cut" but it's not as easy as it sounds & having an earlier ECG makes it a lot easier.
- Sending off albumin/creatinine ratios / random urine Na / other renal investigations ... in principle its reasonable but in practice unless a registrar requests them you might well just be ordering expensive, unneccesary tests.

 

[Benjamin]

2. Mr B is 3 days post Ivor-Lewis oesophagectomy. He desaturated to 80% this evening so I have changed his nasal prongs to face mask and he is on 6L now. Resp rate is also 30. Please review.

This one is a little simpler than the above. My answer to this phone call is:

• Are their sats still 80% & tachypneoic (30) on 6L face mask? If so, please put on a non-rebreather mask + crank it all the way on the wall (i.e. 16L+) & MET call this - I am on my way.
• Have their sats come above 85% and RR coming down with non-rebreather? I am on my way, they may not need a met call but will need a surg +/- med reg review at least.

The Ivor-Lewis oesphagectomy method is essentially video-assisted thoracotomy + abdominal incision. In terms of airway complications the primary concern is related to the thoracotomy. I've written the below with other methods in view as well - i.e. higher oesophagectomy incisions.

Airway/breathing issues aren't to be messed with & as an intern there isn't a lot you can do other than throw on some oxygen, listen to the chest & ask for some investigations. It's far easier to call a reg early for advice and say you are starting initial investigations + have started O2 + puffers and want help than it is to call them 10 minutes later when they've been hypoxic the whole time. My general rule is that if I walk in and the patient looks scared then I should be scared and a MET call is probably on the cards ... this worked reasonably well in ED and hasn't let me down yet on the wards.

Regardless, general stuff I want to know:

• Other obs / full set of vitals
• Baseline SpO2/lung function - if they have chronic COPD and are on home oxygen with SpO2 normally 80-85 its far less concerning. If they normally jog to work every morning you should be scared.
• Recent CXR/lung imaging?
• Rapid deterioration in minutes or over last 12-24 hours / current work of breathing
• What was their oesophagectomy approach? If they have a neck wound is there an expanding haematoma / is this an immediate surgical complication that needs immediate OT? Do they have stridor or other signs of ?airway obstruction.
• Do they/did they have a chest drain in post video assisted thoracotomy?
• What meds are they on / have they just been narced by excessive opioids?

As above any emergent situation on the wards I approach the same way: Airway, Breathing, Circulation, Disability, Exposure. In this case most of the specific things I am concerned about are things that I am not going to start any management for as an intern / they are all at least registrar level interventions:

• Surgical complication w/ airway obstruction 2' haematoma/swelling/pneumothorax. If I am concerned about this at all I immediately MET call & contact the surg reg on call/any surgical registrar I can get a hold of in the hospital.
• Pulmonary embolism
• Pneumonia (D3 post potentially but unlikely if absolutely sudden deterioration & no other signs of infection)
• Narced 2' opiods

Things I need/will try get done before the MET/Med reg gets there if they look dreadful & I'm scared.

• Listen to patients chest + heart + crank up O2 + read their PHx so I can hand over to the MET/Med Reg when they arrive
• ECG
• VBG for a quick electrolyte panel + bicarb. ABG could be argued for to differentiate type 1 vs type 2 resp failure but I'm not going to get one before initiating interventions/can't do ABG's with my eyes close while a nurse can grab a VBG for me/I can do it without thinking & can focus on other things
• Request a mobile CXR if they look too sick to get down to radiology on a bed
• Ask for a CPAP/BiPAP/portable mechanical ventilator to be sent down from the respiratory ward - most wards don't just have them laying around and its much better to have one and not need it than the other way around.
• If they look septic and I think an infection is the cause of their issues then I'll usually try drag a blood culture or two off as well as a full set of other bloods.

Almost none of that will get done before the MET team gets there in a few minutes time but at least things will be semi-in motion.

 

[govpop]

Case 1 (83 yr old)

Wow, excellent approach and summary. I would just ask what is it you are looking for in sending off the urine M/C/S?

Nice illustration of a direction this case could have taken. I will however take it in a slightly different direction and answer the questions posed at the top.

1. This is an elective laparoscopic rectal Ca case. The patients other history includes GORD, OA, hypertension and aortic sclerosis.
2. Baseline renal function is normal.
3. Operation was yesterday midday and received 3L plasmalyte intraop. No significant intraop events noted. Post operatively received 1L Dex-Saline at 100mls/hr. Currently on FOFs and had 1.5L oral intake today. Operation done without diverting stoma.
4. Meds are omeprazole 20 bd, paracetamol QID, Amlodipine 5mg od, PRN tramadol, morphine, ondansetron
5. Urine output has been 25-30mls/hour since operation. IDC is in situ.
6. She came out of the op on 2L. Now on 1L. Nobody knows what her sats are off O2 nor is it documented anywhere.

Exam that you have asked for
ABCD: intact
Cardio: HS dual, warm peripheries, no murmurs
Resp: No distress, chest clear, good AE
Abdo: Tender lower abdomen but soft, non peritonitic, no distension, bruising.
Ins/outs: as mentioned plus rectal tube/pelvic drain: scant serous output
Laparoscopic wounds look good.

How to proceed?

 

[govpop]

2nd case (75 year old)

- sats are now 92% on 6L. RR still 30.
- BP 160/100, HR 90, afebrile, GCS 15/15
- no background of lung conditions. Other comorbidities are hypertension, obesity, previous R MCA with full recovery, previous R TKJR, T2DM on metformin alone
- last CXR POD 1 in ICU (routine post op admission) - expected appearance post oesophagectomy
- he was on 3L yesterday and his O2 requirement has progressed over about 24 hours.
- Your current observation of his WOB is that he is taking short sharp shallow breaths and tachypneic at a RR of 30. Accessory muscle use is minimal.
- it was upper abdo + lateral thoracotomy approach
- he is on cilazapril 2.5, aspirin 100, metformin 500 BD, regular panadol, PRN IV morphine which he is using 2mg about every hour

A: own, no stridor, no neck swelling
B: as mentioned above plus globally quiet breath sounds and dullness at left base.
C: warm, well perfused, BP as above
D: alert, oriented, answering question appropriately
E: not relevant

You may proceed with further ix or ask for other history/exam findings.

ETA: chest drain removed POD 2 in ICU prior to ward transfer

 

[Benjamin]

Case 1 (83 yr old)

Wow, excellent approach and summary. I would just ask what is it you are looking for in sending off the urine M/C/S?

How to proceed?

Urine M/C/S is less for the culture and more the microscopy. Specifically does she have red cell casts / hyaline casts / haematuria suggesting ureteric injury/dehydration etc. A completely normal Urine MCS is reassuring.

At this point it looks like she is clinically well & that she has had adequate fluids. I'm slightly unsure why she would have needed 3L intra-operatively - this seems like a fair whack to me unless she had significant blood loss or was hypotensive throughout the surgery but I note there weren't any significant intra-operative issues. Perhaps it's just that our anaesthetics at my hospital tend to run people dry.

With a reassuring clinical exam, adequate fluid intake & no signs of overload given that input there isn't much I would do prior to getting bloods back. A urine output of 25mls/hour is only really just on the cusp of at risk of an acute kidney injury (0.5ml/kg/hr for a 60kg lady is ~30mLs/hr).

She isn't on any nephrotoxic drugs other than the amlodopine. I'm a bit sketchy about 1g QID paracetamol in anyone >70 or anyone that "looks old" though; geriatrics has always told me to head towards TDS.

My approach would likely be:
- Continue maintenance fluids as previously charted since these seem appropriate. I'm not a fan of Dex-Saline mixtures but if this is what the treating team had her on I'm probably not going to change it drastically.
- Continue strict fluid balance
- Withhold amlodopine until bloods back
- Await bloods before further intervention: if significant AKI then USS to exclude post-renal obstructive cause (just demonstrate no hydronephrosis) and then discuss with my reg & likely medical/renal team depending on how your hospital runs speciality referrals.

Realistically if it's a mild AKI then it is probably something that the surgical team should manage on their own, but some teams prefer to get specialist advice early so I'd run it by my reg to see how comfortable they are with the situation. I'd probably be comfortable sitting on a mild AKI for a day or so and if it doesn't resolve then considering a renal consult but that depends on how much I feel like I can identify a cause.

2nd case (75 year old)
Esophagectomy w/ SpO2 drop & high O2 requirement

To summarise:
D3 post thoracotamy + abdominal approach esophagectomy. Progressively deteriorating respiratory function with SpO2 ~92% on 6L via facemask & ~80% without.
Examination findings suggesting localized pathology in left lower base (assuming this is the side of VATS lap) + quiet breath sounds globally

Primary concerns are ?haemopneumothorax/pleural effusion/need to qualify with imaging. Priority is getting a CXR & an ECG. An ultrasound could again be useful here in the right hands to identify a large pleural collection quickly, but realistically a CXR is going to be needed so the ultrasound would largely be academic.

His numbers have improved enough that I'm not going to call a MET immediately but would if he started to show any signs of haemodynamic compromise or dropped further (concerned for potential 2' iatrogenic tension pneumothorax post chest drain removal). I would still call my surgical registrar to let them know my plans because I'm probably going to need their assistance putting a chest drain in if its heading the direction I think it is.

I'm happy that they aren't likely to be narced with a good going resp rate when I get there / a pneumonia is unlikely & would be demonstrated on CXR if its bad enough to cause this / a PE is also still on my differential given he has had a previous middle cerebral artery stroke & is only on aspirin post-operatively. If a CXR didn't demonstrate a significant cause (i.e. lungs completely clear, no pneumothorax or pleural collection, no interstital fluid, no consolidation or collapse) then I'd head down the PE pathway & he would certainly be high risk on a Wells score unless his esophagectomy was for a stricture and not Ca. Also on the list is an MI (hence the ECG) given T2DM + HTN + previous stroke (?evidence of macrovascular disease) + obesity ... this could precipitate a heart failure / APO picture but is still lower down & hopefully the combination of clinical exam + CXR + ECG would help exclude it.

Not sure what else to think of!

Your thoughts?

 

[chinaski]

My actual reviews of patients run basically the same as an intern regardless of what I'm seeing. Every patient will get a documented ABCD + cardio + resp + abdominal exam + ins/outs + wound assessments primarily because I feel as an intern the process of overassessing patients is comforting/I'm bound to miss stuff if I don't look.

That, there is perfect. Please clone yourself. You'd be shocked at how comparatively few interns bother with being thorough and switched on.

Airway/breathing issues aren't to be messed with & as an intern there isn't a lot you can do other than throw on some oxygen, listen to the chest & ask for some investigations. It's far easier to call a reg early for advice and say you are starting initial investigations + have started O2 + puffers and want help than it is to call them 10 minutes later when they've been hypoxic the whole time. My general rule is that if I walk in and the patient looks scared then I should be scared and a MET call is probably on the cards ... this worked reasonably well in ED and hasn't let me down yet on the wards.

This kind of common sense is what your bosses and registrars will love. Great approaches, all over.

 

[govpop]

Case 1

I should add under exam findings that JVP, MM, signs of hydration etc are all normal.

With a reassuring clinical exam, adequate fluid intake & no signs of overload given that input there isn't much I would do prior to getting bloods back

Good stuff. The key point of this case is to demonstrate that urine output in the immediate post operative period is not correlated well with hydration status. Surgical stress results in an antidiuresis and release of hormones such as ADH and aldosterone which will conserve sodium and water. This is why sometimes elderly patients will get fluid overloaded in the post operative period. You've correctly identified that the overall clinical picture is what is important. In fact, one study has been done which has shown that in the first 48hours post op a urine output target of 0.2mls/kg/hr is not inferior to 0.5.

Always important to think of ureteric injury as a cause of post renal injury in pelvic surgery. However I wouldn't investigate for this unless there was intraoperative concern of injury or other signs at the bedside e.g. progressively decreasing urine output, significant pain, haematuria, etc.

Completely reasonable to ask for bloods, however my question is would you feel comfortable managing this patient without repeat blood tests?

Specifically does she have red cell casts / hyaline casts / haematuria suggesting ureteric

It may be difficult to interpret microscopic haematuria in the context of an IDC. Also, what will your red cell casts/hyaline casts tell you that you that will change your management? Not saying its wrong, just playing Devils advocate.

I'm a bit sketchy about 1g QID paracetamol in anyone >70 or anyone that "looks old"

I agree that in someone with deranged LFTs or low body weight reduced dosing is appropriate, but Im not sure I would do it based on age alone.

 

[govpop]

To summarise:
D3 post thoracotamy + abdominal approach esophagectomy. Progressively deteriorating respiratory function with SpO2 ~92% on 6L via facemask & ~80% without.
Examination findings suggesting localized pathology in left lower base (assuming this is the side of VATS lap) + quiet breath sounds globally

Primary concerns are ?haemopneumothorax/pleural effusion/need to qualify with imaging. Priority is getting a CXR & an ECG. An ultrasound could again be useful here in the right hands to identify a large pleural collection quickly, but realistically a CXR is going to be needed so the ultrasound would largely be academic.

His numbers have improved enough that I'm not going to call a MET immediately but would if he started to show any signs of haemodynamic compromise or dropped further (concerned for potential 2' iatrogenic tension pneumothorax post chest drain removal). I would still call my surgical registrar to let them know my plans because I'm probably going to need their assistance putting a chest drain in if its heading the direction I think it is.

I'm happy that they aren't likely to be narced with a good going resp rate when I get there / a pneumonia is unlikely & would be demonstrated on CXR if its bad enough to cause this / a PE is also still on my differential given he has had a previous middle cerebral artery stroke & is only on aspirin post-operatively. If a CXR didn't demonstrate a significant cause (i.e. lungs completely clear, no pneumothorax or pleural collection, no interstital fluid, no consolidation or collapse) then I'd head down the PE pathway & he would certainly be high risk on a Wells score unless his esophagectomy was for a stricture and not Ca. Also on the list is an MI (hence the ECG) given T2DM + HTN + previous stroke (?evidence of macrovascular disease) + obesity ... this could precipitate a heart failure / APO picture but is still lower down & hopefully the combination of clinical exam + CXR + ECG would help exclude it.

Not sure what else to think of!

Your thoughts?

The thoracotomy for this operation is on the right side

Additional hx; The patient tells you "doc i've been sore as since they took out my epidural yesterday", meanwhile pointing at his incisions. He otherwise denies other symptoms other than some mild lightheadedness

Additional exam: Dual HS, good pulse, JVP 3cm, tender over upper abdominal incision but soft and non-peritonitic, abdomen distended with fat, normal resonance, Calves SNT, no peripheral edema. He appears to be in significant pain.

You request the bedside USS. Unfortunately the coordinator informs you it has been broken for two weeks.

You request ECG and CXR which are as follows.

The nurse pages you after the patient returns to ward; doctor, Ive looked at the CXR and I think he has a pneumomediastinum!

Proceed.

Ignore for the moment that there is a CVL visible on the CXR (and also breasts)

 

[Benjamin]

Completely reasonable to ask for bloods, however my question is would you feel comfortable managing this patient without repeat blood tests?

It may be difficult to interpret microscopic haematuria in the context of an IDC. Also, what will your red cell casts/hyaline casts tell you that you that will change your management? Not saying its wrong, just playing Devils advocate.

With this lady looking clinically well I'd probably not be overly concerned and wouldn't say that I definitely need bloods, but at the same time I have a realistically low threshold for ordering electrolytes/renal function in any post-bowel resection patient. Not as necessary in ultra low anterior resections but certainly in a R hemicolectomy or an extended R hemi I'd be getting post-op renal function/electrolytes in most cases, especially if its a busy week.

The reality is that if I have a lot of patients to look after I'm more likely to order bloods because I'll have less time to clinically assess everyone, it's a bit of a rubbish justification but I'll stick with it for the moment. Similarly if the nurse is overly concerned and I know that they'll keep calling me without an objective response/bloods I'll probably order them, again a rubbish indication but I've certainly done it to avoid confrontation.

Similarly with the urine my point was that a completely normal urine is reassuring. My understanding is that most ureteric injuries have some haematuria and the absence of it on an MCS would probably help cross it off my list.

The thoracotomy for this operation is on the right side

The nurse pages you after the patient returns to ward; doctor, Ive looked at the CXR and I think he has a pneumomediastinum!

ECG:
Rate - ~70
Rhythm - normal sinus
Axis - 1+ / AVf + / normal axis
Acute changes - I dont think there isn't any definite ST elevation/T wave changes. Regardless, I'm a proponent of "if I want an ECG then I need to show a reg" even if that means sending a photo of the ECG through WhatsApp

CXR:
Not a pneumomediastinum. Cardiac contour is clear & there is no line of gas tracking between layers of pericardium.

I've never actually seen a post Ivor-Lewis CXR but I imagine this is what it looks like - the procedure is essentially cutting out the distal oesophagus and dragging the stomach up through the diaphragm to meet the shorted oesophagus.

There is a air-fluid level overlying the right heart and there are small metallic density ?surgical clips directly superior to this. The trachea & carina can barely be made out but are visible & a seperate structure. The left lung has a small pleural effusion but is otherwise clear. The right lung has an area of increased density in the lower lobe likely 2' collapse but is otherwise clear & the costophrenic angle is sharp. No evidence of pneumothorax.

Additionally, the CVL is in good position.

At this point I think it's fair to say that other than ?pain I probably don't know what's causing this guys tachypneoa and O2 requirement. If he's in pain & has a high RR I'd probably be comfortable with throwing a smidge more morphine his way while I figure out what's going on - usually this is one of the first things I'll ask when I get called to see a patient as theres not point trying to assess an abdomen/etc when someone is writhing around in pain. With an ECG and a CXR in hand I'd head to a reg and run the story by them since as far as I'm concerned this is a D3 post-op with a developing O2 requirement & no barn-door obvious reason.

 

[govpop]

With this lady looking clinically well I'd probably not be overly concerned and wouldn't say that I definitely need bloods, but at the same time I have a realistically low threshold for ordering electrolytes/renal function in any post-bowel resection patient. Not as necessary in ultra low anterior resections but certainly in a R hemicolectomy or an extended R hemi I'd be getting post-op renal function/electrolytes in most cases, especially if its a busy week.

The reality is that if I have a lot of patients to look after I'm more likely to order bloods because I'll have less time to clinically assess everyone, it's a bit of a rubbish justification but I'll stick with it for the moment. Similarly if the nurse is overly concerned and I know that they'll keep calling me without an objective response/bloods I'll probably order them, again a rubbish indication but I've certainly done it to avoid confrontation.

Similarly with the urine my point was that a completely normal urine is reassuring. My understanding is that most ureteric injuries have some haematuria and the absence of it on an MCS would probably help cross it off my list.

Solid rationale. My experience at the placed ive worked at is that since the lab will automatically culture the urine, any eventual growth (which is likely once the catheter has been in >24 hours) will be firebombed by the surgical team, so i try to avoid taking catheter samples if I can.

 

[govpop]

At this point I think it's fair to say that other than ?pain I probably don't know what's causing this guys tachypneoa and O2 requirement. If he's in pain & has a high RR I'd probably be comfortable with throwing a smidge more morphine his way while I figure out what's going on - usually this is one of the first things I'll ask when I get called to see a patient as theres not point trying to assess an abdomen/etc when someone is writhing around in pain. With an ECG and a CXR in hand I'd head to a reg and run the story by them since as far as I'm concerned this is a D3 post-op with a developing O2 requirement & no barn-door obvious reason.

You tell the nurses to return and give morphine Q5 minutes until the patients is more comfortable. You return after 20 minutes and the patients having received 6mg IV to find him looking alot more comfortable and RR down to 24. He is taking fuller breaths. Face mask oxygen has come down to 4L.

You called your reg who said "im busy draining pus" and advises to obtain an ABG.

This shows pH 7.3, CO2 7kpa, O2 9.5kpa, BE -2, lactate 1, all the other stuff normal.

 

[Kat92]

I'm on orthopaedics at the moment, so we'll start with a straightforward one:

(Nb, if anyone wants to critique how I write this up, please feel free. After a year out I've gotten a touch rusty in pretty much every area)

A 68-year-old Caucasian female presents to the ED with severe (9/10) left ankle pain. She stood up from a seated position, and her foot slid out from underneath her, resulting in an audible 'crack' from her ankle. She has been brought in in a wheelchair, as she is unable to weight-bear on the left side.

On inspection, the ankle and the dorsal aspect of the foot are severely swollen, but the foot is not grossly displaced. There are no lacerations or abrasions, and the colour and temperature of the left foot and ankle are normal. She has bimalleolar tenderness, but her foot and lower leg are non-tender. She is unable to actively perform any ankle or foot movements on the left side, and has lost sensation over the dorsum of the foot. She sustained no other injuries during her fall. She is otherwise well, and reported no abnormal symptoms prior to her fall. Her only significant history is of a radial fracture after a FOOSH 7/12 ago.

X-rays reveal a trimalleolar fracture.

1) List the bones and major ligaments involved in the ankle joint

2) What are some possible complications to watch for following this type of injury, and how would you monitor these?

3) What other injuries commonly co-occur with ankle injuries caused by rotational forces?

4) Management plan and rationale. Go. Include in your answer why surgery is/isn't likely to be required for this type of injury.

5) This is her second fracture in the past year. What are her risk factors for osteoporosis, and how (if at all) would you test her for it?

6) Both of her recent fractures occured following falls. List 5 possible factors which may have contributed to these falls, keeping in mind her demographic factors and the mechanism of the fall given in the vignette. Outline how you would go about determining which (if any) may have been responsible, and how these could be managed going forward.

I'm on my phone, so I can't be bothered typing out my answers. I'll edit them in later.

----
I'll give this a go even though I am going for JMP admission a few yrs down the track due to my own current health. Any feedback is greatly appreciated!

68YO WF presents to ED in W/C with c/o severe L ankle pain after fall. Pain score 9/10. Pt states stood up from a seated position, and her foot slid out from underneath her, resulting in an audible 'crack' from her ankle. NIL WBAT and ankle or foot movements on L side, NIL gross displacement, NIL Lac or abrasions, NIL other injuries.

On inspection, the ankle and the dorsal aspect of the foot are severely swollen, but the colour and Temp of the L foot and ankle are normal. Bimalleolar tenderness noted, but LF and LLL are non-tender. Pt has loss of sensation over the dorsum of LF.

Otherwise well. Reported no abnormal symptoms prior to her fall.

PMH:
Radial fracture after a FOOSH 7/12 ago.


Reflexes normal on right side but reduced movement on L side due to pain.

XR LF and L ankle reveals a trimalleolar fracture.



1) Main bones: talus (in the foot), and the tibia and fibula (in the leg)
Ligaments: medial ligament (or deltoid ligament), lateral ligament, Anterior talofibular, Posterior talofibular, Calcaneofibular.


2) blood clots in the legs—U/S, pt history, D-dimer, MRI, CT, heart/lungs, legs for warmth, swelling, bulging veins, or changes in skin colour.

infection— FBC

malunion— XR, CT, MRI.

osteoarthritis—pt history/family history, swelling and tenderness of the joints, loss of movement in specific joints, or visible joint damage such as bony growths in the surrounding area, Joint aspiration or arthrocentesis, XR, MRI.



3) Tarsal Tunnel Syndrome, Peroneal Tendonitis, Sinus tarsi syndrome, Tibialis Anterior Tendonitis.


4) Plan:
Surgery not suitable for this pt due totoo high of a risk due to other health conditions.
Discharge with advice re analgesia, ankle overuse, falls education and osteoporosis.
Organise PT outpatient appt re suitable exercises
Repeat XR in 6/12 to check healing
Discharge


5) Risk factors:
smoking—GATS survey
alcohol— survey
low weight— BMI
low physical activity— GPAQ, pt questioning.
poor nutrition—NNS

Testing for osteoporosis:
Bone density test.



6) 5 possible factors which may have contributed to these falls:

· Unsafe mobility-- Poor balance and decreased strength

· Visual impairment-- Vision prescription that is out of date

· Medications-- Side effects of some medication

· Home hazards—clutter, poor lighting, unsafe bathrooms, loose mats, holes in carpet, slippery floors, hoses and pets.

· Chronic conditions- long term undiagnosed condition such as osteo/rheumatoid arthritis.



Management: Falls education booklet/talk, OT R/v of house, med R/V, optometrist to R/V prescription, GP R/V to see if undiagnosed chronic condition and any associated hearing or BP/postural drop problems that could be causing poor balance.

 

[frootloop]

Considering that, if I've read that right, you're a few years away from even starting medical school, that's a pretty impressive response.

1) Yep, that's about the limit of my ankle anatomy haha.

2) Not bad at all. I didn't really specify a time-frame for the complications, so those are all valid. You'd usually also be looking at CRP/ESR and probably some form of cultures (e.g. blood, joint aspirate) as well as the CBC you've ordered to look for/guide treatment of infection, though.

3) Again, I probably should've been more specific about the time-frame, but I was angling at injuries which would commonly be sustained at the same time as a trimalleolar fracture. Things like acute neurovascular injury or muscle/tendon damage. But you've listed later complications involving those structures, so you've got the general idea.

4) This is about the only thing which really stands out as something I'd disagree with. With no real indications given in the past medical history, or anywhere else in the stem, you've decided you wouldn't surgically repair it. Trimalleolar fractures aren't exactly stable, so in the absence of major contraindications to surgery they're generally repaired. But the plan outline you've given assuming a non-surgical ankle looks alright to me.

5) Yeah pretty much. There's some debate about the how's and when's of bone density testing that I don't remember well enough to outline here, but I'm pretty certain you could justify it in a 68 year old female with two fractures in the last year.

6) Very nice.

 

[Kat92]

Considering that, if I've read that right, you're a few years away from even starting medical school, that's a pretty impressive response.

1) Yep, that's about the limit of my ankle anatomy haha.

2) Not bad at all. I didn't really specify a time-frame for the complications, so those are all valid. You'd usually also be looking at CRP/ESR and probably some form of cultures (e.g. blood, joint aspirate) as well as the CBC you've ordered to look for/guide treatment of infection, though.

3) Again, I probably should've been more specific about the time-frame, but I was angling at injuries which would commonly be sustained at the same time as a trimalleolar fracture. Things like acute neurovascular injury or muscle/tendon damage. But you've listed later complications involving those structures, so you've got the general idea.

4) This is about the only thing which really stands out as something I'd disagree with. With no real indications given in the past medical history, or anywhere else in the stem, you've decided you wouldn't surgically repair it. Trimalleolar fractures aren't exactly stable, so in the absence of major contraindications to surgery they're generally repaired. But the plan outline you've given assuming a non-surgical ankle looks alright to me.

5) Yeah pretty much. There's some debate about the how's and when's of bone density testing that I don't remember well enough to outline here, but I'm pretty certain you could justify it in a 68 year old female with two fractures in the last year.

6) Very nice.

Thanks! Yes, a few years away still but have tagged alongside some doctors when I was doing AIN, AHA (in a physio and TACP role) and MEDASST placements + I am currently studying BDemCare and BBest(Major Psych, Minor Sociology). Ahh my bad I missed the "is" before the isn't. Of course surgery should be done if there are no other complications .

Hmm I'm not sure about the bone density scan testing myself, although my GP intially wanted me to have one until she received the U/S report about adhesive capsulitis, so it must be dependant on symptoms perhaps.

 

[Kat92]

Here's a case from me, discuss at will/ask any question you want and I'll try get you an answer. My cases will all be aimed at ED presentations from initial work-up to referral/discharge because that's where I'm at currently.

Vignette:
75+ year old male with sudden onset of continuous vertigo, nausea & diaphoresis at 0500hrs this AM which he still has when you see him in the ED at 0900hrs but resolves by 0930hrs. He describes his vertigo as being "unable to walk properly, like I had to hold onto things so I wouldn't fall over" but denies any weakness, sensation changes or speech disturbances. He has a significant past medical history of coronary artery bypass grafting (CABG) in 2012 & a transient ischaemic attack 6 months prior.

He has had no chest pain or abdominal pain & is unable to give you a list of his regular medications other than to say he takes "one for fat in my blood, one for my blood pressure and one to keep my blood thin"

His observations are as follows: HR 85 regular / BP 180/105 / RR 14 / SpO2 98% on RA / Afebrile

What are your main differentials for this patient/what do you need to exclude?

· Cerebral problems associated with TIA/CVA/Stroke.

· Myocardial ischaemia/infarct.

· Hypocalcemia

· Hypoglycemia

· Electrolytes

· Ear problems to due with eustachian tubes, vestibular movement.

· Benign paroxysmal positional vertigo

· Orthostatic hypotension as we only have one set of BP readings most likely from the pt on the bed??

· ?? Menieres disease coming and going.

What are you going to look for on examination or what other history would you like to exclude/include these differentials?

· Cardiac assessment i.e. ECG, ECHO.

· Neurological assessment i.e. feelings, reflexes, coordination, tongue and eye muscles.

· Ear examination for any wax, fluid, etc.

Please interpret his ECG (attached at bottom). It is unchanged from a previous ECG in 2016.

This looks like a heart block with a slight murmur. Normal P waves, Rate approx. 78-84bpm. Although, I am not sure what type of heart block as the ECG’s I am used to so far are Sinus, AF, Bradycardia, Tachycardia, Atrial Flutter, and VFib.


What other investigations would you like to order?

*Can’t find the information about what has already been done to answer this.


Please interpret the above ordered investigations.

*Can’t find the information about what has already been done to answer this.


Please summarise the case so far

75YO male presents 0900 to ED with c/o sudden onset of continuous vertigo, nausea & diaphoresis which started 0500 this AM. Pt states his vertigo stops him from walking properly and he must hang onto things to avoid falling. Denies any weakness, sensation changes or speech disturbances.

On inspection, NIL chest or abdominal pain and Obs remarkable except for BP of 180/105 which indicates possible stage 2 hypertension. Pt unable to give a history of regular medications, he can only state what they are for- due this have sent for CT head scan and neurological assessment.

Current ECG shows heart block with ?? a slight murmur. Approx. rate of 75-85 bpm. P waves normal.

PMH:
CABG 2012
TIA 2016

 

[Sam]

how about a pharmacy one?

a doctor forgot to sign the scrip, what do you do?