CCrisp

Question 1

There are two stems the patient will have either pain abdomen or SOB
Present accordingly

Answer 1

This patient presented with acute pleuritic chest pain and shortness of breath 8 days after a hip operation. He is hemodynamically stable, but had saturations of 88% on 2L. This improved with high flow oxygen. They also had a swollen painful left calf. Otherwise examination showed a clear chest with good bilateral air entry and a normal percussion note making a pneumonia and pneumothorax unlikely. An MI is possible but less likely due to the nature of the pain, however I am awaiting an ECG and troponin.

My top differential is a pulmonary embolus.

I examined this patient presented by shortness of breath, Left shoulder tip pain. On general inspection, the patient looks obviously having shortness of breath and generalized abdominal pain. I started by doing light palpation on his right iliac fossa , which showed that the patient was having severe abdominal tenderness, so this patient looked critically ill and therefore I started assessing the patient according to the CCRISP his airway is patent and assessing his breathing: no central cyanosis, equal chest wall movements, percussion note was normal, equal air entry with no added sounds and assessing his circulation: no congested neck veins, no signs of dehydration and normal heart sounds. The patient was alert. There was no any swelling or pain in his calves. His charts showed: rising temp., rising blood pressure, increasing o2 requirements FBC (leukocytosis) and his ECG shows AF.

So, my main diagnosis for that case is generalized peritonitis secondary to anastomotic leakage which caused the patient to have sepsis. Shoulder tip pain in such case may be due to the presence of intrabdominal collection causing irritation of the diaphragm

Question 2

Investigations and management

Answer 2

NBM

• Urinary catheter to monitor output

• NG tube for suction and bowel rest

• May refer the patient to HDU to insert a central line and monitor

• Fluid resuscitation by crystalloids

• IV antibiotics

• Bloods: ABG, U&E

• Chest x-ray to rule out any respiratory problem

• CTPA to rule out PE

• Abdominal ultrasound to detect any abdominal collections

• CT with Gastrografin enema to identify the leaking anastomosis

• This patient will need urgent laparotomy; Hartman’s procedure plus good peritoneal toilet plus drainage

Question 3

Q:DDx? for Abdominal pain

Q:DDx? for soB

Answer 3

Anastomotic leak, subphrenic collection, mesenteric ischemia, Io, volvulous (5)

Pulm embolism,atelectasis,chest inf,MI, pain, ARDS

Question 4

Differential diagnosis? Of sob and chest pain

What investigation would you arrange now?

What is the management of a pulmonary embolism?

If you were scrubbed in the theatre and have been updated with the patient condition, what will you do?

Answer 4

• Pulmonary embolism
• Myocardial infarction

• Assuming renal function was within acceptable limits I would arrange a CTPA to exclude a PE
• Chest x-ray
• D- dimer
• ABG: respiratory alkalosis
• ECG o Right ventricular strain pattern – T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF).
o Right axis deviation o S1, Q3, T3 pattern – deep S wave in lead I, Q wave in III, inverted T wave in III

Management follows the usual ALS sequence of securing the airway before moving on to breathing where high flow oxygen is essential and then circulation. Assuming this was all done, the management can be spilt into massive PE and non-massive PE. Massive PE is characterized by hemodynamic compromise and may require thrombolysis. I would put out a crash call if the patient presented in this way to get urgent help.

If the patient is stable, treatment initially with a therapeutic dose of subcutaneous heparin, followed by warfarin is warranted. I would involve the appropriate medical team to follow this patient up.

I will put a crash call immediately

Question 5

Q:How to prevent PE?

Q:clexane dose?

heparin dose?

Answer 5

-early mobilization
-mechanical prot> TEDS stocking
-pharmacological prot> heparin

LMWH
-prophylactic 40 mg OD S/C
-Therapeutic 1mg/kg/BID

-prophylactic:5000 IU
-Therapeutic:Loading 80U/kg followed by maintenance 18U/kg/hr till reaching APTT from 40-60
SEC