med viva/revision for anaes m.med part 2
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Med viva/revision for Anaes M.Med Part 2TRANSCRIPT
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Medical Viva
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Diagnosis?
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Define QT interval
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Define QT intervalTime from the start of the Q wave to the end of the T wave.
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What does the QT interval represent?
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What does the QT interval represent?
It represents the time taken for ventricular depolarisation and repolarisation.
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How does QT relate to the heart rate?
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How does QT relate to the heart rate?
QT interval is inversely proportional to heart rate
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Why does QT needs to be corrected?
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Why does QT needs to be corrected?
This allows comparison of QT values at different heart rates and improves detection of patients at increased risk of arrhythmias.
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So what is it corrected to?
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So what is it corrected to?
Corrected QT interval (QTc) estimates the QT interval at a heart rate of 60 bpm.
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What is the problem with prolonged QTc?
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What is the problem with prolonged QTc?
An abnormally prolonged QT is associated with an increased risk of ventricular arrhythmias, especially Torsades de Pointes.
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What is normal QTc?
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What is normal QTc?< 440ms in men
< 460ms in women
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Name me a formula for calculation.
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Name me a formula for calculation.
QTC = QT / √ RR
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What is the formula called?
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What is the formula called?Bazett’s formula
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What is the limitation of Bazett’s formula?
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What is the limitation of Bazett’s formula?
It over-corrects at heart rates > 100 bpm under-corrects at heart rates < 60 bpm,
(but provides an adequate correction for heart rates ranging from 60 – 100 bpm).
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Name some causes of prolonged QTc
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Name some causes of prolonged QTc
Hypo-MCTMI
High ICPDrugs
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Does hypokalemia cause prolonged QTc?
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Does hypokalemia cause prolonged QTc?
Technically no. U wave may cause apparent proloned QTc.
But risk of TdP not there. Severe hypokalemia = asystole, remember?
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Name some drugs which cause
prolonged QTc.
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Name some drugs which cause
prolonged QTc.OndansetronDroperidol
DiphenhydramineErythromycinAmiodarone
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What is shortened QTc?
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What is shortened QTc?
< 350ms
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Names some causes
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Name some causesHypercalcaemia
DigoxinCongential short QT syndrome
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Any problems with short QT?
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Any problems with short QT?
increased risk of paroxysmal atrial and ventricular fibrillationsudden cardiac death.
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BREAK
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Diagnosis?
70 year old male. Hypertension. Otherwise asymptomatic.
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Brugada
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Problem with Brugada?
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Problem with Brugada?
Sudden cardiac death
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Brugada SignCoved ST segment elevation >2mm in >1 of
V1-V3
followed by a negative T wave
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How many types of Brugada?
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How many types of Brugada?
3 types:
Type 1: Brugada Sign + Clinical criteria(Documented VT or VF. Family history of sudden cardiac death at <45 years old .Coved-type ECGs in family members. Inducibility of VT with
programmed electrical stimulation. Syncope. Nocturnal agonal respiration.)
Type 2: Type 2 has >2mm of saddleback shaped ST elevation
Type 3: morphology of either type 1 or type 2, but with <2mm of ST segment elevation
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Pathophysiology of Brugada?
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Pathophysiology of Brugada?
Mutation in the cardiac sodium channel gene.
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Treatment of Brugada?
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Treatment of Brugada?
AICD implantation
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What anaesthetic drug to use with
caution in Brugada?
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What anaesthetic drug to use with
caution in Brugada?Propofol!
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BREAK
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Diagnosis
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Inferior infarct + posterior infarct
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What else should you look out for?
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What else should you look out for?
RV infarct and heart block
Inferior infarct: must look for posterior infarct (V1-3)Inferior infarct: must look for RV infarct
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How to diagnose RV infarct with ECG?
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How to diagnose RV infarct with ECG?
rV4
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Describe the position of rV4
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Describe the position of rV4
V4 position on right side
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What is significant change in rV4 to be called an RV STEMI?
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What is significant change in rV4 to be called an RV STEMI?
0.5 mm or half a square.
Why?
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How does the management of RV infarct differ from LV
infarct?
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How does the management of RV infarct differ from LV
infarct?Fluid responsive therefore fluid loading may help BP.
Avoid nitrates.
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Describe other lead positions you can
place
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Describe other lead positions you can
placeV7,8,9
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Where are V7,8 and 9 placed?
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Where are V7,8 and 9 placed?
Posterior, below scapula along 6th IC space
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What is V7,8,9 good for?
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What is V7,8,9 good for?
Diagnosis of posterior infarct.
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What is the recommended door
to balloon time?
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What is the recommended door
to balloon time?60 min
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What is the difference between BMS and
DES?
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What is the difference between BMS and
DES?Bare metal – more thrombogenic but epithelization more rapid.
Earlier thrombosisDual anti-platelet shorter.
DES – less thrombogenic but epithelization slowerLess thrombosis
Dual anti-platelet longer.
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Recommended BMS DAP duration
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Recommended BMS DAP duration
4 weeks
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BREAK
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Diagnosis?
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Patient’s asymptomatic. Management?
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Patient’s asymptomatic. Management?
Refer EPS
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ECG repeated: BP 120/80. Tx?
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StableVagal maneuvers
AmiodaroneFleclanide
Procainamide
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ECG repeated: BP 70/40. Tx?
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UnstableSynchronized cardioversion
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Data Intepretation34 yo female intubated and ventilated following
a prolonged generalized tonic-clonic seizure. Initial non-contrast CT brain shows bilateral intracerebral haemorrhages. ABG and GBC post intubation:
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Data IntepretationList the abnormalities on the ABG and give the
most likely cause in each case.
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Data Intepretation Metabolic acidosis – lactic acidosis induced by
prolonged seizure Respiratory acidosis / inadequate compensation –
inappropriate mechanical ventilation Increased A-a gradient – aspiration pneumonitis
or neurogenic pulmonary oedema
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Data Intepretation Give three possible diagnoses for her
presentation based on the history and investigations.
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Data Intepretation TTP / HUS Eclampsia Vasculitis
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Difference between TTP and HUS?
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Difference between TTP and HUS?
TTP : more brain, adult female
HUS: more kidneys, kids, related to E. coli
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BREAK
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likely diagnosis?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likely diagnosis? Supratherapeutic warfarinisation
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What are possible causes of supratherapeutic warfarinisation?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What are possible causes of supratherapeutic warfarinisation? Overdose Drug interaction Change in diet
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What are possible drug interactions causing high INR in this patient?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What are possible drug interactions causing high INR in this patient? Antibiotics Omeprazole Amiodarone
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likeliest mechanism for antibiotics to cause high INR in this patient?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likeliest mechanism for antibiotics to cause high INR in this patient?
Vitamin K metabolism altered due to change in gut flora.
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likeliest mechanism for omeprazole to cause high INR in this patient?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
What is the likeliest mechanism for omeprazole to cause high INR in this patient?
Liver enzyme inhibition
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
Outline your management of this patient if not bleeding.
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
Outline your management of this patient if not bleeding. Stop warfarin Vitamin K in as low a dose as possible Consider FFP or factor concentrate if high risk of
bleeding
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
How much FFP should be given?
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Data Intepretation68-year-old male with chronic AF is noted to
have the following coagulation profile:
How much FFP should be given? At least 10-15ml/kg.
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
What anomaly do you notice in the blood gas report?
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
What anomaly do you notice in the blood gas report? Hypercapnia / resp acidosis. Metabolic acidosis
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
Anything about the P50?
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
Anything about the P50? A left shifted curve despite a high PCO2 and a low
pH.
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
List 2 other investigations you would perform to elucidate the cause of the anomaly.
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Data IntepretationABG obtained from a patient admitted to the ICU
after a suicide attempt.
List 2 other investigations you would perform to elucidate the cause of the anomaly. CoHb Measure temperature Measure 2,3 DPG
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
How can you treat carbon monoxide poisoning?
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Data IntepretationABG obtained from a patient admitted to the
ICU after a suicide attempt.
How can you treat carbon monoxide poisoning? Supportive 100% oxygen
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BREAK
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Diagnosis?55 year old man presents with chest pain and
shortness of breath following vomiting four hours earlier.
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\
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Pneumothorax and pleural effusion on
right side.
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This CXR and history: diagnosis?
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This CXR and history: diagnosis?
Boerhaave’s syndrome
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Management?
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Management?supplementary oxygen, IV fluid resuscitation,
appropriate IV antibiotics, an appropriate size chest drain,
urgent surgical referral
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BREAK
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Diagnosis?
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What is the classical description of the
patient?
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What is the classical description of the
patient?Lucid interval
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Management?
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BREAK
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Case Scenerio68 year-old man who had cardiac surgery 4
days previously.
He is intubated and ventilated and developed an increasing FiO2 requirement over the course of the day.
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Xray yesterday
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Xray todayDiagnosis?
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Left consolidationBut did you see the right pneumothorax?
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BREAK
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For Fun:
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Situs inversus
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BREAK
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Case19 year old male admitted after a severe TBI.
Due to refractory intracranial hypertension he has been intubated, sedated and paralysed
You are called to the bedside because he has desaturated to 85% on 100% oxygen.
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Describe?Diagnosis?
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Left upper, Right lower collapse
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Why is the patient hypoxic despite
administration of 100% oxygen?
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Why is the patient hypoxic despite
administration of 100% oxygen?
Shunt
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How to manage?
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How to manage?Bronchoscopy Recruitment manoeuvres
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Describe how you recruit?
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What are the complications of
recruitment maneuvers?
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What are the complications of
recruitment maneuvers?
PneumothoraxHypotension
HypoxiaRaised intracranial pressure
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Long Case
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Story30 year old male.
ASA 2 smoker. History of childhood respiratory disorder but well since.
Admitted for right ankle fracture following mountain bike accident.
Underwent ORIF of right ankle fracture.
POD1: informs nurse of acute breathlessness and you are contacted for an assessment.
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StoryParameters
BP 115 / 75 mmHg HR 95 / min SpO2 97% on room air Temperature 37.5 C
Medication chart PO Paracetamol 1g qds prn PO Synflex 550 mg bd prn PO Oxycodone 5 mg q2h prn IV Ondansetron 4 mg tds prn
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What are your differentials?
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Describe your approach
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Describe your approach
My primary approach is to treat the underlying pathophysiology by first elucidating the cause.
I will d0 so by reassessing the History, performing a directed Physical Examination and ordering targeted
Investigations.
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What would you like to know about the
history?
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What will you be looking for in the
your physical examination?
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What will you be looking for in the
your physical examination?Starting from the Head, I will look for …
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How would you investigate this
patient?
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Data IntepretationABG (room air)
pH 7.47 pCO2 31 pO2 85 BE -2 HCO3 23 SpO2 97%
Interpret the ABG
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Data IntepretationFBC
TWC 12k Hb 12g/dL Platelets 151K
UE Cr 65 K 4.3
Lactate 1
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Data Intepretation
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Story changesPatient is progressively breathless. Unable to
speak.
Wheezing worsens.
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What treatments will you start?
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What treatments will you start?
Beta agonistAnticholinergics
MagnesiumAminophylline
KetamineVolatile agents
Steriods
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Data IntepretationABG repeated:
pH 7.25 pCO2 52 pO2 65 BE -8 HCO3 23 SpO2 92%
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Story continuesPatient worsens and consciousness drops.
You decide to intubate the patient.
Describe your intubation technique and choice of drugs.
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Story continuesAfter intubation, describe you would ventilate
this patient?
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Data InterpretationFBC
TWC 15 k Hb 11.9 g/dL Platelets 255 K
UE Cr 65 K 3.2
Lactate 8
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END
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