Abdominal pain
Presentation of the acute abdomen
Tender RUQ with tachycardia and hypotension, rebound tenderness in RUQ, not peritonitic.
Background
Admitted with RUQ pain, deranged LFTs, ?choledocolithiasis. Scheduled for cholecystectomy. Released on day leave, NBM 0200 tomorrow for MOT.
Call
From charge nurse with clinical concern. Patient looks unwell, 10/10 pain.
Review of patient
Appears unwell, reports severe pain in RUQ. Tachycardic, hypotensive, tachypnoeic, hypoxic, afebrile. Tenderness in RUQ +rebound, not guarded, not peritonitic. Bloods pending.
Suggested management plan
Investigations
- Bloods (inc. FBC, U&Es, amylase, LFTs, group and hold, clotting; bonus points for bloods for Glasgow score – Ca2+, LDH, glucose)
- ABG
- AXR/CXR
- ECG Rx
- Analgesia
- Fluid challenge (crystalloid)
- Follow-up fluids
- Catheterise Follow-up
- Senior review (urgently)
- Regular repeat observations
- Fluid balance chart
- Call if deteriorates
Discussion points
- Relative urgency (senior sister calling, previously well patient now ?acutely unwell, obs currently quite stable)
- Differential diagnosis (pancreatitis, ascending cholangitis, peptic ulcer perforation, ECG to rule out chest causes etc. etc.)
- Pancreatitis clues – aetiology (gallstones), epigastric tenderness, pain radiating to back, hypotension
- Appropriate plan
Hyperkalaemia
Presentation
Serum potassium = 7.0
Background
UKNOWN
Call
From biochemistry lab regarding potassium result - 7.0.
Review of patient
NOT SEEN
Suggested management plan
Investigations
- Possibly VBG for repeat K to confirm hyperkalaemia
- ECG Rx
- Appropriate treatment – insulin/dextrose, salbutamol nebs, calcium gluconate Follow-up
- Senior review
- Repeat K within 6 hours
- Repeat ECG
Discussion points
- Hospital protocol for treatment of hyperkalaemia may be available on intranet
- Possibility of haemolysis, erroneous result
- Cause of hyperkalaemia
Analgesia for potential bowel obstruction
Presentation
Severe pain following admission for ? bowel obstruction
Background
Post-operative - hartmanns.
Call
From nurse for sever pain and now medications charted on admission
Review of patient
Severe pain, bilious vomit, no flatus or bowel motion.
Suggested management plan
Investigations
- Bloods
- ABG
- Chase AXR
- CT Tx
- Analgesia
- NG tube
- Anti-emetic
- IV fluids Follow-up
- Senior review
- Regular repeat observations
- Fluid balance chart
- Call if deteriorates
Prescriptions
- Appropriate choice of drug
- Analgesia (using WHO pain ladder – e.g. regular paracetamol and opioid, PRN sevredol)
- Anti-emetic (NOT metoclopramide/domperidone as ?obstruction)
- IV fluids
Discussion points
- Relative urgency (obstruction as emergency, reg already aware, danger of aspiration w/ recurrent vomiting)
- Differential diagnosis (likely obstruction, any other potentials?)
- Appropriate plan
Low urine output
Presentation
370mL of urine in the last 24 hours.
Background
Post-operative - hartmanns.
Call
From nurse for reduced urine output. Patient otherwise stable.
Review of patient
NOT SEEN
Suggested management plan
Investigations
- Bloods – U&Es
- Bladder scan
Rx
- Fluid challenge
- Reassessment
Follow-up
- Senior review
- Regular repeat observations
- Fluid balance chart
- Bleep if deteriorates
Discussion points
- Classification of renal failure – this being most likely pre-renal
- Differentials for cause – reduced oral intake, high-output stoma, bleed
- Importance of reassessment following fluid challenge
- Usefulness of accurate fluid balance chart
Warfarin dose “missed”
Presentation
Warfarin dose “missed”, likely withheld
Background
UNKNOWN
Call
From nurse for missed warfarin dose.
Review of patient
NOT SEEN
Suggested management plan
Investigations
- Bloods – INR
Tx
- Withhold warfarin (INR4.8)
- Repeat INR mane
Follow-up
- Monitor INR to titrate warfarin
Discussion points
- Narrow therapeutic range of warfarin
- Possible causes of increased INR (antibiotic interaction)
- When to use vitamin K
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