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Objectives
- To develop a thorough system for diagnosing and managing common problems
- To develop a list of differential diagnosis for each presentation.
- Identify the most likely causes
- Identify the critical causes not to be misses
Introduction
Internship will be one of the most difficult transitions you’ll have to do as a medical doctor. Clinical practice is very different to being a student in university or on the wards.
The major challenges that I believe most interns face are
- Lack of knowledge in very specialized units
- Many high priority tasks
- Limited time
- Many patients to look after
One way that you can tackle this is to become competent and efficient at those tasks that will be commonly asked of you. This includes
- Practical skills such as IV cannulation, urinary catheter insertion, and obtaining arterial blood gas
- And the ability to solve common problems.
By competently and safely solving the common problems, you will not only have more time to learn the knowledge and specialized skills of your particular unit but also give your patients better care.
The common problems that we solve daily in anaesthetics in very unwell patients with significantly altered physiology, have remarkable overlap with the problems you will be asked to solve for ward patients.
What are the common problems?
- Hypoxaemia
- Tachypnea
- Bradypnoea (slow resp rate)
- Hypertension
- Hypotension
- Tachycardia
- Bradycardia
- Oliguria
- Decreased conscious state
Complete the following exercise to diagnose and manage the common problems
Hypoxaemia
You get a call from the nurse stating your 60yo male patient has decreased oxygen saturations to 92% 1 day after his total knee replacement.
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Request the patient sit up to improve lung mechanics and functional residual capacity
- Repeat a set of vitals
On the way to the patient you consider these broadly classified causes
- Decreased FiO2
- Hypoventilation
- V/Q mismatch – shunt vs dead space
- Diffusion abnormality
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Relevant positives on Hx/Ex/Ix | Specific causes | Treatment | |
| Low FiO2 | Administer oxygen | ||
| Hypoventilation | Hx: Drugs, Acquired or preexisting, CNS pathology, myopathy, rib fractures
Ex: Slow RR Ix: éPaCO2. êpH
|
Opioids and benzodiazepines, CNS depression
Pathology of neurotransmission Muscle paralysis or fatigue Chest wall pathology Pain
|
Naloxone
Flumazenil Ventilate patient |
| Shunt | Hx: smoking.
Ex: additional sounds on auscultation Ix: êPa02. A-a gradient CXR signs of APO, pneumonia, malignancy |
Sputum plugging
Atelectasis Aspiration Bronchospasm Pulmonary oedema Pneumonia Malignancy |
Chest physio/encourage deep breathe and cough
Salbutamol Lasix,nitrates. Antibiotics |
| Dead space | Risk factors for PE/DVT
Ix: VQ scan or CTPA |
Pulmonary embolism | Anticoagulation and supportive |
| Diffusion abnormality | Hx
Ex Ix:CXR. Lung fn tests |
Emphysema
Interstitial fibrosis Infiltrative conditions |
Optimise preexisting illness management |
What are the most likely causes in this patient?
- Hypoventilation secondary to opioids
- Sputum plugging in a smoker
- Atelectasis post surgery
What critical diagnoses are not to be missed?
- Pulmonary embolism
- Drug error/overdose
- Pneumonia
- Pulmonary oedema
Tachypnoea
You get a call from the nurse because your 80yo male patient admitted to gen med for foot cellulitis has a resp rate of 36 (PHx: CCF and renal failure)
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Request the patient sit up to improve lung mechanics and functional residual capacity
- Repeat a set of vitals
On the way to the patient you consider these broadly classified causes
- Pain
- Resp disease
- CVS
- Metabolic acidosis
- Respiratory alkalosis
- Drug/overdose
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Slow resp rate (bradypnoea)
You get a call from the nurse stating a 40yo female patient has decreased resp rate of 8 post thymectomy for myasthenia gravis.
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Request the patient sit up to improve lung mechanics and functional residual capacity
- Repeat a set of vitals
On the way to the patient you consider these broadly classified causes
- CNS
- Drug
- Neurotransmission
- Lung mechanics/chest wall
- Neuromuscular junction
- Muscle pathology
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Hypotension
You get a call from the nurse stating your 50yo male patient has a BP of 90/40 day 1 post anterior resection
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Request the patients legs elevated and with head slightly up
- Repeat a set of vitals
- If inadequate access – IV trolley at bedside and fluid line set up
On the way to the patient you consider these broadly classified causes
- Preload
- Rate and rhythm
- Contractility
- Afterload
- Obstructive
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Hypertension
You get a call from the nurse stating your 70yo patient is hypertensive post a long mastoidectomy.
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Repeat a set of vitals
- Repeat BP on both arms
On the way to the patient you consider these broadly classified causes
- Preexisting
- Pharmacological
- Pain (somatic, visceral)
- Physiological (CVS, resp, CNS, endo)
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Tachycardia
You get a call from the nurse stating your 60yo male patient has decreased oxygen saturations to 92% 1 day after his total knee replacement.
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Repeat a set of vitals
- ECG
On the way to the patient you consider these broadly classified causes
- Primary tachycardia (SVT, AF, Atrial Flutter, VT!)
- Secondary
- Physiological (resp, CVS, CNS, metabolic/endo)
- Pharmacological
- Pain (somatic, visceral, anxiety)
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Bradycardia
You get a call from the nurse stating your 70yo male patient is bradycardic at 36bpm after being admitted with a NSTEMI
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Repeat a set of vitals
- ECG
On the way to the patient you consider these broadly classified causes
- Primary bradycardia (HB)
- Secondary
- Vagal tone (baroreceptor, Cushings reflex)
- Pharmacological
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Oliguria
You get a call from the nurse stating your 60yo male patient is making 20ml/hr or urine day 1 post right hemicolectomy.
Before you attend, over the phone you
- Request bladder scan
- If inadequate access – IV trolley at bedside and fluid line set up
On the way to the patient you consider these broadly classified causes
- Prerenal
- Renal
- Post renal
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
Decreased conscious state
You get a call from the nurse stating your 50yo male patient is minimally rouseable post scleral buckle surgery for vitreo retinal haemorrhage
Before you attend, over the phone you
- Ask if a code blue or MET call needs to be called
- Request high flow oxygen via Hudson mask
- Repeat a set of vitals
- If inadequate access – IV trolley at bedside and fluid line set up
On the way to the patient you consider these broadly classified causes
- Physiological
- Pharmacological
- Neurological
- Other
At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?
| Differentials | Relevant positives on Hx/Ex/Ix | Specific causes | Treatment |
What are the most likely causes in this patient?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
What critical diagnoses are not to be missed?
- ____________________________________________________________________________________
- ____________________________________________________________________________________
- ____________________________________________________________________________________
