F1 "On Call"

F1 On-Call
An Interactive Case Scenario

Congratulations, you have graduated from medical school!
You have had a month’s holiday to relax, change your title to “Dr”
on all your bank cards and prepare for your first job.
Tonight, its your first night on call and you are the surgical F1!
With your SHO, you are going to be looking after 8 surgical wards
throughout the night. It is down to you to deal appropriately with
any medical issues including emergencies.
Don’t forget, you can always bleep the on call registrar if you get
stuck, but try not to call them unnecessarily otherwise you may
become very unpopular!
Good Luck
Continue …

Time: 21:34
Place: Doctor’s Mess
Your first night on call is going very smoothly. You are just about
to reward yourself with a well deserved sandwich, but as you sit
down in the doctors mess and unwrap your lunch box, your
bleep goes off loudly. You check the number and see that it
belongs to one of the surgical wards. As look at your sandwich, it
looks at you… mocking you.
A) Answer the bleep quickly, it could be urgent!
B) Eat the sandwich and take a 15 minute break, It
almost definitely isn’t urgent.
Back to Beginning
Call the registrar! I don’t know what I’m doing!

Place: Doctor’s Mess Back
You ring the ward, the nurse on the phone tells you that she is
concerned about Mrs M, a 70 year old lady who underwent an
open cholecystectomy this afternoon. Mrs M was doing well
initially after her operation, but she has now got worse, with
an early warning score of 5. She has dropped her blood
pressure and seems a little confused. She is catheterized but
has not passed any urine in 4 hours.
You head down to the ward. As you do, you consider what could
cause a drop in blood pressure in the post operative patient.
To the ward……

Place: Doctor’s Mess Back
You ignore the bleep for the time being, and enjoy your
sandwich. As you sit back on the comfortable sofa your head
begins to nod….
You violently awake to the sound of your bleep! You run to
answer the phone, the registrar is very annoyed with you. You
are on call and it is your duty to answer your bleep quickly, once
you know what you’ve been called for, you can then decide how
urgent it is!

You call the registrar for help…
The registrar is angry that you have called him for something so
simple as answering your bleep. He asks you if you are really
cut out for this job.
Well? Are you?
Back
Image taken from http://www.ncbusinesslitigationreport.com/tags/statute-of-limitations/

Time: 21:40
Place: The Ward Back
You arrive on the ward and the nurse hands you Mrs M’s notes
and her observation chart. She explains that Mrs M was due for
surgery at 9.00 am, but due to a couple of emergencies, her
surgery was pushed back to 3:00 pm and she came out of
surgery at 4:40pm. Over the last couple of hours her
observations have been declining and she has not passed any
urine in 4 hours.
See initial clerking
See observations chart
See drugs chart
See recent pathology tests
Go and see Mrs M….
See fluid balance chart

Clerking on Admission for Mrs M, 70
years old
PC
Recurrent biliary colic
HxPC
3/12 Hx abdo pain
Pain in the epigastric region
Sudden Onset.
Pain is colicky.
Pain sometimes radiates to the right shoulder tip
The pain is usually brought on after eating fatty food
Pain usually lasts for about 3-5 hours at a time and occurs increasingly frequently
Pain is exacerbated by movement.
She rates the pain at about 8/10 at its worst
Nausea and vomiting associated with episodes of pain.
No Hx fever
She has noticed no change in bowel habit, stool colour, urinary habit or urine colour.
PMHx
Cholecystitis 2/12 ago
Asthma, mild intermittent
Hypercholesterolaemia
Appendicitis 10 years ago
Menorrhagia 20 years ago
PSHx
Appendicectomy 10 years
ago
Hysterectomy 20 years ago
Current Medication
NKDA
Simvastatin 40mg OD PO
Salbutamol 150 micrograms PRN Inhaled
Family History
Mother had Gall
Stones
Social History
Retired sweet shop owner, lives with her husband in Tiverton. Fully
mobile and enjoys walking. Ex Smoker since 15 years. Used to
smoke 20/day since 16 years old.
Drinks small amounts of alcohol at weekends.
Back
Next

Examination on admission
CVS
BP 124/80
HS I----II----0
No signs of cyanosis/ anaemia
RS
RR: 14
Inspection: Breathing easily, no chest
scars seen.
Palpation: No lymph nodes felt, Chest
expansion normal.
Percussion: Normal and equal both sides.
Auscultation: Normal breath sounds.
Abdominal Exam
Inspection: Abdomen looks normal, with no obvious masses or liver
signs. 2 Scars present. Hernial orifices clear.
Palpation: Tenderness in RUQ, no masses felt. Liver edge not felt,
gall bladder not palpable. Kidneys not felt.
Percussion: normal, no hepatomegaly or splenomegaly.
Auscultation: Bowel Sounds Normal.
Neuro
CN I-XII OK
PERL
RUL LUL RLL LLL
Power 5 5 5 5
Tone Ok Ok Ok Ok
Reflexes N N N N
Sensation Ok Ok Ok Ok
OBS
Pulse: 76
BP: 124/80
RR: 14
SaO2: 98% OA
Temp: 36.8
Back

Medication chart
Back
Turn over to see
analgesia…

22/2/11
08:00 18:00 20:00
Hb 12.4
MCV 86
WBC 11.6
Platelets 245
Neutrophils 3.5
Total Bili 20
ALT 46
AST 34
ALP 40
GGT 30
Albumin 44
Na 142
K 3.9
Cl 105
Urea 4.4
Creat 100
C-reactive
protein
10
Back

Place: Ward
Back
You make your way to see Mrs M, she is lying in bed with her eyes closed.
She seems drowsy and confused. She says she is not in any pain and is
feeling better thanks to the patient controlled analgesia.
When you examine her, you find that she has a regular pulse of 90/min
and a blood pressure of 94/52. Her respiratory rate is about 16/min and
her oxygen saturation is 97% without oxygen. Capillary refill time is 3
seconds and there is an apparent loss of skin turgor. Her pupils are small
and sluggish to react to light. Her mouth looks dry and her tongue is a
healthy pink. Her lungs are clear and her cardiovascular exam is normal.
You inspect her abdomen. She has a dressing on the RUQ and 2 drains
which have produced a small amount of blood as well as 2 old scars from
previous surgery. She is catheterised with approximately 130ml of urine in
the bag. On palpation of her abdomen, there is tenderness over the sight
of the wound and you can palpate a mass in the suprapubic region. There
is some dullness to percussion over this area. Otherwise her examination
is normal.
You check her fluid charts and find that she has not produced any urine in
the last 4 hours.
Next

Place: Ward Back
What are you going to do first?
A) Give 1 litre of normal saline IV and review in 1 hour
B) Flush the catheter
C) Give Naloxone 10mg IV Stat.
D) Ask for 15 minute obs and review in 1 hour.
Check clerking
Check obs chart
Check medication chart
Check bloods
Check fluid balance

Oh Dear! After half an hour you are bleeped, the nurse tells you
that Mrs M’s blood pressure and heart rate have picked up
slightly, but she is still anuric.
When you see her, She is still confused and is beginning to
become agitated. You wonder what you have done wrong. The
question is what do you do now?
A) Give another litre of fluid
B) Give 20mg IM furosemide
C) Flush the catheter
D) Give Naloxone 10mg Stat
Back
Place: Ward
Image taken from http://www.choicehow.com/2009/02/how-
to-calculate-dextrose-when.html

Place: Ward Back
Good thinking! You flush the catheter which produces a few
hundred millilitres of relatively dark urine. You find that the lump
in her abdomen is no longer palpable and percussion is no longer
dull in that area. You decide to take some blood to investigate
her renal function. What else can you do?
A) Record the volume drained and
take a sample for testing
B) Request plain film KUB
C) Request urgent renal ultrasound
Image taken from
http://www.lifelinesupply.co.uk/UrineCollectionBag.ht
ml
INFO
Student BMJ article on Post operative Oliguria:
http://archive.student.bmj.com/issues/08/01/education/028.php

Place: Ward Back
You give 10mg Naloxone IV. After a short period Mrs M sits bolt
upright in bed and screams. She then falls back into bed clutching
her abdomen in pain. Her respiratory rate increases to 20 breaths
per minute but her other observations do not change. She tells
you that she feels like her bladder is about to burst. You realise
that her catheter must be blocked.
You flush her catheter and give her a bolus of morphine to calm
her down.
Continue… Image taken from
http://www.atforum.com/newslette
rs/2007summer.php

Place: Ward
Back
You are bleeped by the nurse after 45 minutes. Mrs M’s Obs are
declining and she now has an early warning score of 7.
The registrar is reviewing the patient and would like a word with
you... Outside…
Image taken from
http://brawl247thebook.com/2010/12
/can-you-fight-cancer-or-any-illness/
INFO

You bleep the registrar who calls back shortly. To your
embarrassment he diagnoses the problem over the phone and
suggests that you take a little more time to reflect on the
findings of your examination.
Go back to the ward…
INFO
Image taken from
http://nps.cardinal.com/nps/co
ntent/nucpharm/complex/inde
x.asp

You give another litre of saline and leave. 1 hour later you are bleeped
again and return to the ward. The registrar is waiting for you. He asks
you why you thought it appropriate to give this lady 2 litres of fluid when
she was obviously in urinary retention. In a completely anuric patient,
you should always consider urinary outflow obstruction. In this case a
blockage in the patient’s Foley catheter is the most likely cause. In men,
prostatic hyperplasia can also cause acute urinary retention. If this is not
treated promptly, patients can become hydronephrotic, which can lead
to acute renal failure!
Clues to look for-
No urine output
Palpable bladder
Discomfort
Remember!
When the urine output is low, always check for lower urinary tract
obstruction. Palpating the bladder will give you an idea.
Place: Ward Back
INFO

You give her 20 mg of IM furosemide. One hour later, you are
bleeped again and return to the ward. The registrar is already
there. He asks why you gave furosemide to an anuric,
hypovolaemic patient. You explain that you were concerned
about the patients poor urine output. He tells you that the
patient’s urine output was poor because of a blocked catheter
and because you had failed to recognise this the patient is now
in danger of developing renal failure.
He tells you to go home and read up on post operative care. You
are clearly not competent enough to be allowed to deal with
patients on your own.
Place: Ward Back
INFO
http://archive.student.bmj.com/issues/08/01/education/028.php Image taken from
http://well.blogs.nytimes.com/2010/10/07/whe
n-doctors-get-depressed/

You call the registrar and tell him about Mrs M’s anuric state. He
asks you if you have checked to see if Mrs M has a urinary
outflow obstruction.
“It’s quite simple, can you palpate her bladder? If so she’s
probably got a blocked catheter. You need to flush it quickly!”
Feeling a little foolish, you return to the ward.
Back to the ward….

Correct!
You need to record the volume drained and to collect a sample for
microscopy and culture.
Measuring the volume will help you to decide if this is just a
simple “one off” case of acute urinary retention caused by a
blocked catheter or if this is an acute on chronic episode.
Culture and microscopy will help you to exclude any serious
causes of acute urinary retention as well as urinary tract
infections (common in a catheterised patient), haematuria and
markers of renal failure.
Continue...
Back
INFO
Map of Medicine, NHS. Guidance for acute urinary retention.
http://eng.mapofmedicine.com/evidence/map/acute_urinary_retention_aur_in_
adult_males1.html

Incorrect!
A KUB X-ray is helpful in diagnosing the presence of ureteric calculi (or
kidney stones) and can be useful if a bowel obstruction is suspected.
However, we have no reason to suspect either of these events based
on our patient’s history and examination.
You should measure the volume of urine drained to help you to decide
if this is just a simple “one off” case of acute urinary retention caused
by a blocked catheter or if this is an acute on chronic episode.
You should also take a sample for culture and microscopy. This will help
you to exclude any serious causes of acute urinary retention as well as
urinary tract infections (common in a catheterised patient),
haematuria and markers of renal failure.
Continue...
Back
INFO
http://eng.mapofmedicine.com/evidence/map/acute_urinary_retention_aur_
in_adult_males1.html

Incorrect!
A renal ultrasound would be necessary if prolonged high volume
urinary retention had occurred. You may yet need to order one if the
renal function tests come back as deranged.
You should measure the volume of urine drained to help you to
decide if this is just a simple “one off” case of acute urinary retention
caused by a blocked catheter or if this is an acute on chronic episode.
You should also take a sample for culture and microscopy. This will
help you to exclude any serious causes of acute urinary retention as
well as urinary tract infections (common in a catheterised patient),
haematuria and markers of renal failure.
Continue....
Back
INFO
http://eng.mapofmedicine.com/evidence/map/acute_urinary_retention_aur_in
_adult_males1.html

Place: The Ward
Congratulations! You have solved the problem of Mrs M’s
anuric state. But you’re not finished yet....
You review Mrs M’s observations:
Pulse: 96 Regular
BP: 92/50
RR: 16
Temp: 36.8
SaO2: 97% without oxygen
What is the most likely cause of her deranged observations?
A) Hypovolaemia
B) Sepsis
C) Pulmonary embolism
D) Opiate toxicity
Back

Correct!
A tachycardia and hypotension after surgery strongly suggest a low
blood volume. This can be due to bleeding and dehydration. In this
case dehydration is the most likely cause because:
•Mrs M’s operation was scheduled for 9am and then pushed back to
4pm which means she will have been nil by mouth since midnight the
night before. Although patients are allowed to drink water at this
time, they often don’t drink enough to stop them becoming
dehydrated.
•Mrs M is showing classic signs of dehydration:- loss of skin turgor,
dry mucous membranes and slow capillary refill (>2 seconds).
•You have already checked Mrs M’s wound and drains which have
shown no signs of significant blood loss and there is no sign of
bruising or blood leaking from the wound.
However, you MUST always consider bleeding in the postoperative
patient with hypovolaemia. If you suspect bleeding or are unsure in
any way, call for senior assistance!!!
Continue
Back

Incorrect!
Mrs M has only come out of surgery a few hours ago and is
apyrexial. It is very unlikely she will be in septic shock. Infection is a
rare complication of most general surgical procedures and doesn’t
tend to present until at least a day later.
Early signs of infection can be seen at the sight of surgery. Look for
any signs of inflammation including redness, swelling, heat and
pain.
Try again....
INFO
More information on the symptoms, signs and management of septic shock:
http://emedicine.medscape.com/article/786058-overview

Incorrect!
Massive pulmonary embolism can cause hypovolaemia due to a
cor pulmonale however it is very unlikely. You would expect to
see signs of breathlessness, reduced SaO2 and chest pain.
Try again...
INFO
More information about the symptoms, signs and management of a massive PE
here
British Thoracic Society Guidelines on management of a suspected massive PE
here

Incorrect!
This lady has a tachycardia and hypotension. Opiate toxicity
would present with pupillary miosis, respiratory depression
and drowsiness.
Try Again...
INFO
Information on opioid overdose:
http://eng.mapofmedicine.com/evidence/map/opioid_overdose2.html

Place: The Ward
How should you address her apparent hypovolaemia??
A) Give 2 litres of saline over 8 hours
B) Give a fluid challenge
C) Refer to ICU for central venous pressure
monitoring.
D) Encourage oral fluids over night and review
in the morning.
Call the registrar! I don’t know what I’m doing!!
Back

Place: Ward Back
You prescribe 2 litres of saline with instruction for this to be given
slowly over 8 hours. You are called back half an hour later as her
observations are getting worse.
Her obs are
Pulse: 122
BP: 90/50
RR:16
Urine output (last hour)- 10ml
Temp: 36.3
SaO2: 96%
You call your registrar, who suggests you give a bolus of fluid to
replace the deficit. You are currently giving too little too slowly.
He tells you to give a fluid challenge.
Continue…

What is a fluid challenge?
A) 1 litre of Saline given over 30 minutes followed by re-
assessment.
B) 250 ml of Colloid over 10 minutes followed by re-
assessment.
C) 500 ml of Hartmann’s given over 45 minutes followed by re-
assessment.
D) A pint of water to be downed in the fewest number of gulps
possible.
Back
Picture taken from
http://www.hamovhotov.com/fun/?m=20070
730&paged=2

You phone ICU and explain your situation to the SHO on the
receiving end. To your embarrassment, he tells you to that F1
doctors on their first night on call should not be making ICU
referrals without having consulted their seniors. He suggests you
administer a fluid challenge.
Back…
Image taken from
http://www.alcoholics-
information.com/Alcoholic_Rehab_Cent
er.html

Despite a lot of encouragement, Mrs M does not manage to
consume much water. She is now delirious, agitated extremely
dehydrated. You need to give her more fluid more quickly!!
Back…
Image taken from
http://www.sciencemadesimple.co.uk/page72g.
html

The registrar thanks you for phoning him. He also
congratulates you on spotting the blocked catheter! He
explains that the patient is most likely hypovolaemic as she
has been nil by mouth all day as her surgery was delayed
until the afternoon. He suggests you give her a fluid
challenge.
Back…

Incorrect!
A fluid challenge is a useful thing to know about! It is the first port of
call for when dealing with a patient with evidence of volume
depletion. A 250ml bolus of colloid should be given over 10-30
minutes depending on which guidelines you follow. The patient
should then be reassessed. If the blood pressure does not increase,
or increases and then returns shortly, the patient is hypovolaemic
and further 250ml boluses of fluid should be given until
normovolaemia is reached. If the blood pressure increases and
remains increased, this suggests the patient is already
normovolaemic and an alternate cause of their apparent
hypovolaemia should be investigated. If the patient fails to respond
to 2 fluid challenges, call senior help as they may require Central
Venous Pressure monitoring.
INFO
http://archive.student.bmj.com/issues/04/04/education/144.php (Student
BMJ : Acute care, Volume resuscitation)
http://www.sign.ac.uk/pdf/sign77.pdf (Sign Guidlines for post operative
management in adults. Page 31 covers fluid challenges)
Continue….

Correct!
This is indeed the guidance set out for administering a fluid
challenge. Fluid challenge is the first port of call for when dealing
with a patient with evidence of volume depletion. A 250ml bolus of
colloid should be given over 10-30 minutes depending on which
guidelines you follow. The patient should then be reassessed. If the
blood pressure does not increase, or increases and then returns
shortly, the patient is hypovolaemic and further 250ml boluses of
fluid should be given until normovolaemia is reached. If the blood
pressure increases and remains increased, this suggests the patient
is already normovolaemic and an alternate cause of their apparent
hypovolaemia should be investigated. If the patient fails to respond
to 2 fluid challenges, call senior help as they may require Central
Venous Pressure monitoring.
INFO
http://archive.student.bmj.com/issues/04/04/education/144.php (Student BMJ :
Acute care, Volume resuscitation)
Continue….

Incorrect!
Not quite, but you’ve got the right idea. A 250ml bolus of colloid
should be given over 10-30 minutes depending on which
guidelines you follow. The patient should then be reassessed. If
the blood pressure does not increase, or increases and then
returns shortly, the patient is hypovolaemic and further 250ml
boluses of fluid should be given until normovolaemia is reached.
If the blood pressure increases and remains increased, this
suggests the patient is already normovolaemic and an alternate
cause of their apparent hypovolaemia should be investigated. If
the patient fails to respond to 2 fluid challenges, call senior help
as they may require Central Venous Pressure monitoring.
INFO
http://archive.student.bmj.com/issues/04/04/education/144.php (Student BMJ :
Acute care, Volume resuscitation)
Continue…

Well obviously not!
Med School is over, this is not the time or place to play pub golf.
Try again…

You give Mrs M 250ml Colloid solution and re-assess her. There is
no change in her blood pressure and heart rate yet. You repeat
the fluid challenge and her heart rate begins to decrease and
blood pressure picks up to 100/60. You give 2 more fluid boluses
over next hour and then start her on some maintenance fluids.
You notice that she is still drowsy and her respiratory rate has
dropped to approx 8 breaths/minute. Her SaO2 is now 93%. You
give high flow oxygen which increases her saturation to 97% but
her respiratory rate is still very low. What should you do?
A) Give IV Naloxone 2mg
B) Remove PCA and replace with a 75 mcg fentanyl patch
C) Give IV Naloxone 100 mcg and re-assess
D) Call the crash team
Back

You give Mrs M a 10mg bolus of Naloxone. She jump sits up
suddenly, screams in pain and punches you in the face. As you
hold onto your bleeding nose, she collapses back into bed
clutching her abdomen in pain. You do notice that her
respiratory rate has now increased to 22 breaths per minute. As
you approach her to give some more pain relief, she swears at
you and tells you to leave her alone as you’ve done enough
damage already! The next morning on the ward round, she
points you out to your consultant and asks him not to let you
treat her any more.
What a shame! You were doing so well…….
Back...
INFO
Management guidelines on opioid toxicity:

You remove the PCA and give Mrs M a 75mcg fentanyl patch.
When you return to the ward 3 hours later you find the crash
team trying to resuscitate Mrs M, but with little success! The
Anaesthetist in charge asks you why you thought it suitable to
give Mrs M such a high dose of fentanyl when she had developed
no opioid tolerance at all!
The crash team fail to bring Mrs M round and it is down to you to
explain to her relatives what happened.
Good luck
Back
INFO

You give Mrs M 100 mcg of Naloxone and re-assess, after 300
mg her respiratory rate picks up to 14 and she seems less
drowsy. He pupils are equal and reactive to light. You quickly
assess her cognitive state and find she is fully orientated. You
halve the bolus dose of morphine.
Continue...
Back
INFO

The crash team arrive and assess Mrs M. They quickly realise that
she is showing signs of opioid toxicity. The anaesthetist in charge
asks you what the signs of opioid toxicity are and how you manage
it.
Back...
INFO

You call the registrar, who is very impressed with your
management of the patient so far. He suggests that the patient
may be taking to high a dose of morphine. He recommends
that you give Naloxone to the patient, but slowly a bit at a time
otherwise she will suddenly come round in pain. He then
suggests you decrease the patients morphine bolus as she is
obviously on too much. He asks you to call him earlier next
time! He tells you that he is on his way down to check on your
progress.
Back

The registrar asks you to make sure you add Naloxone PRN on
Mrs M’s drug chart. He also asks “Why is this necessary?”
The Ward
A) In her already delicate state, Mrs M is more susceptible to
opiate toxicity, even when the dose has been halved.
B) Mrs M’s renal function will have been compromised by her
hypovolaemia, leading to a more rapid excretion of naloxone
from the kidneys.
C) Naloxone has a shorter half life than morphine.
D) It is purely a precaution and is to save you from being called
back to prescribe more should she need it.
Back

Incorrect!
The registrar is not impressed with your rather vague
explanation and asks you to try again.
Try again....

Incorrect!
The registrar is very unimpressed with your completely
incorrect explanation.
“Firstly, its unlikely she is in renal failure, secondly renal failure
would not increase her rate of excretion!”
He asks you to have another go- and not to make stuff up!
Try Again...

Correct!
INFO
For more information about treatment of opiate toxicity:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726910/
pdf/v022p00612.pdf
The registrar is impressed with your knowledge, he expands:
“The half life of Naloxone is 64 minutes compared to the half
life of morphine which is around 2-3 hours. Subsequently
patients who have been treated for opiate toxicity should be
observed for 2-3 hours and it is wise to prescribe Naloxone
PRN (as required). If this is not done, opiate toxicity could
reoccur. This is most often occurs in emergency departments
where heroin addicts self discharge after being treated with
naloxone. They are often found dead the next morning.”
Continue...
Back

Incorrect!
The registrar shakes his head. “No there is actually a reason....
Think about it!”
Try again...

CONGRATULATIONS!!!!
You have survived your first night on call and successfully
managed a patient with several common post operative
complications! Of course this only covers a few of the problems
you will come across as a surgical F1, but hopefully it should
help you get into the appropriate mindset for tackling similar
problems in the future.
Remember, when in doubt always ask for help!
Try some short cases...

Short Case 1
You are called to the ward at 4.30 am to see Steve, a 25 year old man
with persistent vomiting. He has been recovering from an emergency
laparotomy which was carried out 3 days ago. One of your colleagues
has seen him already and prescribed anti-emetics, but no examination is
documented.
You see in Steve’s notes that he underwent an emergency laparotomy
for trauma, the bowel was examined thoroughly, but no injury was
found. NG tube was not placed after surgery and following an apparently
good recovery, his catheter was removed and he has recently started
oral fluids.
On examination, Steve is very distressed. His pulse is 116 and BP is
122/80mmHg, he is apyrexial and his SaO2 is 9 There is a midline incision
which is covered with a dressing. His abdomen is distended and tender
to palpation. Bowel sounds are not present on auscultation.
You request an urgent abdominal X-ray.
Continue....
Back

What is the most likely cause of Steve discomfort?
A) Ischemic bowel stricture
B) Gallstone Ileus
C) Bowel Rupture into the Peritoneal cavity
D) Paralytic Ileus
E) Strangulated Hernia
Back
Image taken from
http://www.ganfyd.org/index.php?title=Ileus

Bowel ischemia is unlikely in a 25 year old man. No
complications were mentioned in his operation notes and if
surgery had caused ischemia, he would probably have
presented sooner!
Try again...
Incorrect!

This is unlikely in a 25 year old man and this was not
mentioned in the history. Remember gallstones typically
present in: Fair, Fat, Forty year old Females!
Try again...
Incorrect!

This would present with fever, rigors and sweating. Also no
complications were mentioned in the operating notes and no
actual surgery took place on the bowel itself.
The X ray shows inflated loops of small bowel, which implies
presence of an obstruction. What could have caused this?
Try again...
Incorrect!

Steve has a post operative paralytic ileus. An ileus is a
disruption in the normal peristaltic motility of the bowel which
can lead to obstruction. Ileus is common after abdominal
surgery, but usually resolves within 2-3 days. If it purists, it
becomes termed a paralytic ileus. Steve’s symptoms have
recently erupted as he has only recently started taking oral
fluids.
Correct!
Continue...
Back

Incorrect!
Although this can cause Steve’s symptoms, there has been no
mention of any hernia in the examination or history.
However, one should always check the hernial orifices during
an abdominal examination.
Try again...

How should Steve initially be managed?
A) Anti-emetics, opioid analgesia and stimulant
laxatives.
B) Nasogastric tube, NSAIDs, Urinary catheter.
C) Call consultant for emergency disimpaction of
bowel.
D) Nasogastric tube, opioid analgesia and IV
fluids.
Back

After an hour of treatment, there is very little change. Steve is
still vomiting and his abdomen is extremely distended.
However he does feel much more relaxed. You call your
registrar for help and he is not impressed with your surgical
knowledge. This is not how you acutely manage a bowel
obstruction!
Incorrect!
Try again...

Correct!
A nasogastric tube is used to decompress the bowel and allow
the contents to flow out without the patient needing to vomit.
Non-steroidal anti-inflammatory drugs (NSAIDs) are used in
preference to opioids as opioids are likely to contribute to
bowel immobility.
A urinary catheter should be placed to monitor fluid output. IV
fluids may be required if Steve is dehydrated.
Blood should also be taken to check for electrolyte imbalance
which can cause an ileus.
Continue...
Back

Incorrect!
The consultant is not amused.
Steve can be managed by more conservative means for the
moment and he is unlikely to require further surgery.
Try again...
Image taken from http://www.mirror.co.uk/news/top-
stories/2009/04/19/bt-are-charging-you-7-for-wake-
up-call-115875-21288732/

Incorrect!
Although a nasogastric tube is needed to decompress the
bowel, opioid analgesia is contraindicated as it is liable to slow
bowel motility further. Although IV fluid may well be
necessary, it is useful to get a measurement of Steve’s urine
output first.
Try again...

Short Case 2
You are called to one of the orthopaedic wards to review Doris,
a 78 year old lady who underwent an elective total hip
replacement 6 days ago.
The Nurse is concerned about Doris as she has become
extremely short of breath in the last hour. When you arrive, you
find Doris sitting up in bed with an oxygen mask on. She tells
you that she gets some sharp pain in her chest when she
breaths in. She struggles to speak in full sentences.
On examination she has a respiratory rate of 32/minute, pulse
of 112/minute and regular and a blood pressure of 102/78. Her
SaO2 is 92% and she is apyrexial. Respiratory examination is
otherwise normal as is cardiovascular and abdominal
examination.
Continue...
Back...

What should you do first?
A) ABG, Peak Flow and Blood
Cultures
B) ECG, Chest X-Ray and ABG
C) V/Q Scan
D) CT Pulmonary Angiogram
E) D-Dimer
Back

Incorrect!
Her Peak flow is within the normal rang but her ABGs show a
decreased partial pressure of oxygen. While you wait for the
results of the blood cultures, Doris dies on the ward. Your
registrar is not happy with you, and neither are Doris’s
relatives!
Consider the clinical picture, what should you be most
concerned about? Is there a quicker way to rule out an
infection?
Try again...
Image taken from http://www.health212.com/too-
many-people-are-dying-in-hospital-against-their-
wishes.html

Correct!
These are the basic initial investigations recommended by the
British Thoracic Society.
Her chest X-ray is shows no obvious abnormality. Her blood
gasses come back as a PaO2 of 7.0 and a PaCO2 of 3.6, but
otherwise normal. Her ECG is shown below.
Continue...
Image taken from
http://www.learntheheart.com/Pulmona
ryEmbolism.html
Back

Incorrect!
The on-call radiologist laughs: “You might want to carry out
some basic tests first and you might want to consult your
seniors before coming straight to me!”
A V/Q scan may be required to confirm a pulmonary embolism,
however it would be wise to rule out other causes of chest
pain and breathlessness before doing this.
Try again....

Incorrect!
The on-call radiologist laughs: “You might want to carry out
some basic tests first and you might want to consult your seniors
before coming straight to me!”
A CTPA may be required to confirm a pulmonary embolism,
however it would be wise to rule out other causes of chest pain
and breathlessness before doing this.
Try again...

Incorrect!
D-Dimer is a useful test to rule out a pulmonary embolism,
but is not at all specific. You may wish to carry out a few other
more basic tests to rule out other causes of breathlessness
first.
Try again...

You recognise the S1,Q3,T3 pattern on the ECG and suspect a
pulmonary embolism. You call the registrar who asks you to do
a quick “risk assessment” while he makes his way down to you.
How should you assess Doris’s risk?
A) CURB 65 Score
B) CHADS2 Score
C) Well’s Score
D) Modified Glasgow Score
E) ABCD2 Score
Back

Incorrect!
Try again...
CURB 65 is a scoring test to assess severity of pneumonia.
Confusion
Urea>7
Respiratory Rate >30
Blood Pressure <90 Systolic
65 Years +
1pt
1pt
1pt
1pt
1pt
<2 Treat at home
=2 Admit
3-5 Severe- consider intensive care

Incorrect!
Try again...
The CHADS2 score is used to asses a patient for Warfarin
treatment.
Cardiac failure
Hypertension
Age >75
Diabetes
Stroke Hx
1pt
1pt
1pt
1pt
2pts
>2 Warfarin is indicated

Correct! Back
The Wells score is used to give a rough estimate of the risk of
Pulmonary Embolism. It is not a perfect test as part of it is
subjective and relies on your own opinion. The test can be used
to decide what further action can should be taken.
•Clinically Suspected DVT : 3pts
•PE is Clinically Suspected: 3pts
•Tachycardia: 1.5pts
•Hx Immobilization/ Surgery in previous 4
weeks: 1.5 pts
•Haemoptysis: 1pt
•Malignancy: 1pt
Continue...
<2: Mild Risk
2-6: Moderate Risk
>6: High Risk
With no evident DVT, Doris has a score of 6 placing her in the
moderate category, but only just.

Incorrect!
Try again...
The Modified Glasgow Score is to asses the severity of acute
pancreatitis.
PaO2 <8 kPa
Age > 55
Neutrophils (WCC) > 15
Calcium <2 mmol/L
Renal Function (Urea) >16
Enzymes (LDH) >600 iu
Albumin <32g/L
Sugar (Glucose) >10mmol/L
1pt
1pt
1pt
1pt
1pt
1pt
1pt
1pt
>3 predicts severe pancreatitis

Incorrect!
Try again...
The ABCD2 score is used to assess patients for risk of stroke
following a suspected TIA.
Age >60: 1pt
Blood Pressure >140/90: 1pt
Clinical Features, Speech: 1pt, Unilateral Weakness: 2pts
Duration <1 Hr: 1pt, >1Hr: 2pts
Diabetes :1pt
Risk of stroke in 90 days: 0-3 Low, 4-5 Moderate, 6-7 High

The registrar arrives and you present the case to him. He is
impressed with your risk assessment and tells you he will take
it from here.
He suggests you go to the doctors mess and put your feet up
for 20 minutes. You take him up on that offer.
Image taken from
http://maxcdn.fooyoh.com/files/att
ach/images/591/314/413/004/feet-
up-cats.jpg
Back
Useful Resources

Resources
Student BMJ: Managing Post Operative Oliguria
http://archive.student.bmj.com/issues/08/01/education/028.p
hp
SIGN Guidelines in post operative management can be found
here, also available is a quick reference guide.
BTS Guidlines for suspected Pulmonary Embolism
http://www.brit-thoracic.org.uk/Clinical-
Information/Pulmonary-Embolism/Pulmonary-Embolism-
Guidelines.aspx

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