HAP data interpretation

Setting: Orthopaedics ward 1A. You are the night shit covering doctor.

Patient: Ethel Rodgers is a 82 year old female patient with no past medical history who is not on any regular medications. She has been admitted to orthopaedics with a neck of femur fracture. She had a total hip replacement yesterday. The nurse looking after the patient has contacted you because she is concerned by the patients observations.

Observations: RR22, BP 106/78, HR 138, Saturations 89% on air, temperature 38.3, GCS 15

Task: This is a data interpretation station. You will be presented information by the examiner.

There is no patient present in this station.
The examiner will present information to the candidate. Please give information in a neutral manor and do not probe or question answers given.

Category	Question	Done	Excellent
Investigations	Given the history presented, which investigations would you like to request? Chest x-ray Arterial blood gas Electrocardiogram (ECG) Blood tests (FBC, U&E, CRP, LFT) Blood cultures Urine culture
CXR	photo_camera The patient's chest radiograph is shown. Please comment on the film. Notes name, hospital number and date missing Assesses film adequacy - Rotation, Inspiration, Area, and Exposure Airway - trachea central Breathing - consolidation in left mid-zone Circulation - no cardiomegaly Diaphragm - no costaphrenic angle blunting/effusions Extras - no rib fractures/soft tissue swelling
CXR	What is your overall impression of the chest x-ray? Left-sided pneumonia
Mx	What treatments would you consider based on the information so far? Intravenous antibiotics for HAP (based on local guideline) Oxygen (target saturations 92-96% or 94-98%) Paracetamol Consider IV fluids depending on clinical fluid status review
ECG	photo_camera An ECG is performed because of her tachycardia. Please review the patient's ECG. Notes name, hospital number and date missing Calibration voltage correct (10mm/mV), but paper speed not present HR = 132bpm (total R waves on ECG multiplied by 6) Rhythm = irregular + p waves absent (atrial fibrillation) QRS normal Mild anterolateral ST depression No T wave inversion
ECG	What is your overall impression of the ECG? Atrial fibrillation with fast ventricular response Rate related ischaemic changes
Mx	What further management would you consider based on this? Rate control (bisoprolol 2.5mg PO or Digoxin 500 micrograms IV) Consider IV fluids if hypotensive Anticoagulation to be considered (but unlikely to be appropriate currently given recent operation)
Further events	You initiate the above treatments. Later in the night, she deteriorates and is now requiring 15L oxygen via non-rebreather mask to maintain her oxygen saturations. What actions would you take now? Repeat arterial blood gas Repeat chest x-ray Ask for urgent senior help (your registrar/medical registrar/ICU registrar) Consider resuscitation status and whether patient is appropriate for escalation to ICU Contact family