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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



Submit your answers to get your score.

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