Friday, February 6, y Introduction to Clinical Medicine SCENARIO 1: Multidrug therapy The scenario presents a patient with hypertension, type 2 diabetes and new symptoms of dry cough and shortness of breath. The student should identify the cause of new symptoms, implement the new treatment, and check whether currently used treatment is appropriate. Proper management includes collect medical history and physical examination of the patient, order and interpret additional tests, make the diagnosis of bronchial obstruction and the inclusion of appropriate treatment. List of medications to prepare by students prior to the lab: • carvedilol • acetylsalicylic acid • hydrochlorothiazide • enalapril maleate • potassium chloride • metformin • estazolam • ibuprofen, paracetamol, ketoprofen, tramadol • clarithromycin, amoxicillin /clavulanic acid • Salbutamol nebuliser solution • Hydrocortisone 1
Transcript
Friday, February 6, y
Introduction to Clinical Medicine
SCENARIO 1:
Multidrug therapyThe scenario presents a patient with hypertension, type 2 diabetes and new symptoms of dry cough and shortness of breath. The student should identify the cause of new symptoms, implement the new treatment, and check whether currently used treatment is appropriate. Proper management includes collect medical history and physical examination of the patient, order and interpret additional tests, make the diagnosis of bronchial obstruction and the inclusion of appropriate treatment.
List of medications to prepare by students prior to the lab:• carvedilol• acetylsalicylic acid• hydrochlorothiazide• enalapril maleate• potassium chloride• metformin• estazolam• ibuprofen, paracetamol, ketoprofen, tramadol• clarithromycin, amoxicillin /clavulanic acid• Salbutamol nebuliser solution• Hydrocortisone• Magnesium sulfate• Theophylline• Budesonide• 500 ml multielectrolyte fluid
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- 80 years
- kristina
- severe shortness breath
- ER b/c breathing problem starting in morning
- dry, exhausting cough
- carvedilol 6.25
- acetylsalicylic (aspirin) 75 mg
- hydrochlorothiozide 25 mg
- enalapril maleate 5 mg (2 xs/day)
- potassium chloride
- metformin 2xs a day 500 mg
- pain killers taken on own:
• ibuprofen 200 mg
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• paracetamol 500 mg
• ketoprofen 100 mg
• tramadol 100 mg
- clarithromycin 500 g ended 2 days ago; amoxicillin & clavulanic acid 850 + 150 mg ended 2 days ago
1. give oxygen
2. Breathing problem
1. auscultate patient: heard wheezing and restriction
2. had constriction so give a bronchodilator
3. should elevate bed = easier to expand lungs
3. heart rate was high
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4. concerns about heart failure, reactions to new medications, pneumonia not cured
5. PROBLEM:
1. enalapril: ACE inhibitor --> prevents break down of bradykinin and produces cough
2. carvedilol: non-selective beta blocker --> constriction of lungs
6. give oxygen, auscultate, bronchodilator & raise bed, re-assess and auscultate again to check is breathing improves
7. KNOW EVERYTHING ABOUT PT. MEDICATION
SCENARIO 2:
Injuries - care and treatmentThe scenario presents a patient after an injury of the hip additionally with persistent atrial fibrillation. The student has to exclude fractures and apply appropriate analgesic therapy. Proper conduction includes collecting medical history and physical examination of the patient, ordering and interpretation of diagnostic imaging studies, injury management and to formulate a course of treatment.
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List of medications to prepare by students prior to the lab:• Acenocumarol/warfarin according to INR• Bisoprolol fumarate• Enalapril maleate• potassium chloride• Dipyron hydrate, Methapyrone, Metamizol• Tramadol [Ultram, Ralivia flashtab, Ralivia ER, Tramal]• Ketoprofen [Orudis, Profenid, Actron, Oruvail]• Paracetamol [Tylenol, APAP, Datril, Acetaminofen]• 500 ml r-r Ringer’s or Multi electrolyte fluid (Isolyte)
Patient: slippery sidewalk, 86 year old woman slipped and fell on right hip on curb, wound on R. hip, little bit elevated HR, feels pain on r. hip and brought to ER
1. stop bleeding and check vitals
1. HR = very high >160
2. BP high
• due to pain
2. give painkillers; always assess id successful or not by asking pt. grade 1 - 10 before & after the medication (remember to give dosage accordingly to age)
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1. normal to become sleepy after morphine; start at 2mg and then assess and adjust dose accordingly to avoid them becoming unconscious
2. check saturation and respiratory rate because opioids can cause suppression of respiratory system
3. give oxygen mask to continue oxygenate patient
4. reverse opioid excess with naloxone
3. X Ray to see if fracture or not; if fracture don't move leg
4. Clean the wound and for infections
1. give antibiotics (IV) incase of bacterial infection before suturing; give oral dose later to take at home
2. give antivirals (IV) incase of viral infection; ex. incase of rabies, check tetanus status
5. pt. had been taking warfarin which increased bleeding; reverse this effect
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1. give fresh frozen plasma
2. vitamin K
***always check for allergies to medications; ex. ibuprofen and aspirin allergies
- give a small amount and check for allergic reaction before admin full dose
SCENARIO 3:
Rating respiratory and circulatory condition of patients, preoperative assessment
The scenario presents a patient being prepared for elective left knee replacement surgery. The patient had myocardial infarction 5 years ago, suffers from recurrent venous thromboembolism, takes anticoagulation from 8 months, 9 months ago the patient was implanted pacemaker system due to third-degree atrioventricular block. In addition, the patient has hypertension and chronic obstructive pulmonary disease.
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List of medications to prepare by students prior to the lab:
- assess respiratory system and then medication should have been changed
• spirometry: to check tidal volume; if very low then patient won't be able to come off anesthesia to breathe on own
• x ray of chest should have been done
• re-assess clotting factors after stoping warfarin in 3/4 days
- give heparin instead b/c lower duration of action and less risk for surgery
SCENARIO 4:
Analgesic therapy
The scenario presents a patient who came to the Hospital Emergency Department because of severe pain of the lower back and numbness of the right lower limb. The student should order analgetic treatment, diagnose the cause of acute pain, to administrate long-term analgesia and refer the patient to the appropriate treatment. Proper conduct
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includes medical history, physical examination of the patient, administration of an appropriate analgesic treatment, order diagnostic imaging studies, diagnosis of disc herniation of the nucleus pulposus protrusion at the lumbar spine and referring the patient to the Neurosurgical Clinic for treatment.
List of medications to prepare by students prior to the lab:
- CT = faster thus better in acute situations and patient presents right after injury
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- MRI = 40 minutes thus everything may change; do it if you have time
• L3/4 and L4/5 nucleus pulposus is affected
• elevated leg to see if suddenly pain appears; if can arise leg very high pressing on nerves is not very severe but if only arise small amount must be a huge compression of the nerve
• @ home took 100mg ketoprofen (NSAID)
• gave morphine in hospital
• trying not to breath to exacerbate pain thus shallow breathing
SCENARIO 5:
Intensive medical care for an elderly person
The scenario presents the unconscious patient breathing spontaneously. The student should to protect the patient's airway, get the stabilisation of the patient's cardiovascular parameters and direct the patient to the appropriate ward. Proper conduct includes monitoring of the patient, intubation, administration of drugs to lower BP and HR, laboratory tests and diagnostic imaging studies, and directing the patient to the Department of Neurology.
List of medications to prepare by students prior to the lab:
• reports headache and at dinner lost consciousness and fell to ground
• ambulance brought to ER
• family tells has some sort of heart problem for many years
• had cold for many days and was using some home remedies like aspirin & garlic in large quantities
• why did he fall unconscious
- decreased oxygen to brain
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• check his pupils: one pupil was dilated thus stroke
• CT scan to see what part of brain was affected
- lot of blood in ventricle and subarachnoid space
- no surgical possibility according to neurosurgeon
- increased pressure in skull => may lead to compression of brain stem and thus heart and respiratory problems
- decrease the pressure by giving 20% mannitol with furosemide
• mannitol moves water back into veins and then the diuretic will move the fluid into the urine
• would decrease the BP enough
- should raise head of pt to help with drainage from head
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• Glasgow coma scale = 3; anything less than 8 intubate
• high heart rate = more dangerous
- working very fast and not getting enough oxygen thus leading to infarction
- give beta blocker (selective type)
• BP should be higher in order to perfuse the compressed vessels in the brain
• monitor and control the vitals as well as intracranial pressure
• **** treat patient first
• do full trauma CT
SCENARIO 6:
Prevention and treatment of delirium
The scenario presents alcohol abused patient, after an episode of
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bleeding from the upper gastrointestinal tract. The student has to assess the loss of blood, exclude cranio-cerebral injury, make up deficiencies and refer the patient to the appropriate department. Proper procedure includes taking a laboratory tests, diagnostic imaging study of the head, adequate hydration of patients, supplementing electrolytes, Vitamin K and RBC. Subsequently, after obtaining a negative result for the presence of alcohol in the blood, turn neuroleptic treatment and transfer to the Department of Gastroenterology.
List of medications to prepare by students prior to the lab:
• phospholipid essential (Essentiale Forte) – 2 caps x 3• Pantoprazole (Controloc) 20 mg x 1• phytomenadione (Vitacon) 10 mg x 1• Potassium chloride x 1 1000 ml multielectrolyte solution (Isolyte) 500 ml Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection) Ephedryne 2 j PRBCs (packed red blood cells) Haloperidol
• rescue team brings in patient b/c blood vomiting and loss of consciousness in front of house
• lack logical contact
• can smell alcohol on patient
• pale and sweaty skin
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• marks of blood clots in angles of mouth
• 60 years old
• esophageal varices ruptured; perhaps b/c of alcoholic
• help patient when vomiting to remove it, should move patient on to side
• check level of alcohol in blood and assess type of alcohol consumed
- if consumed methanol; could cause blindness and later death
• BP was low; loss of blood via vomit and should lab test for hemoglobin, CBC, level of RBCs
- Hb = 6 (far too low)
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- give blood transfusion b/c huge loss; don't give just fresh frozen plasma in this case (is good for bleeding b/c has albumin and clotting factors)
• wall of stomach was thick = could be due to cancer as a result of alcoholism
vomiting = loss of electrolytes as well
SCENARIO 7:
Rehabilitation after surgery
The scenario presents a patient after surgery, arthroplasty of the right hip. The patient reported severe pain of the right hip after falling down. The student is to conduct the medical history and physical examination, give analgesics and perform the necessary tests. Proper action (based on research) includes directing patient to the Department of Orthopaedic for the operation and further rehabilitation.
List of medications to prepare by students prior to the lab:
• Acenocumarol due to INR• Bisoprolol 5 mg x 1• Enalapril 10 mg 2x1• Potassium chloride• Ketoprofen
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• 500 ml 0,9% NaCl (Normal Saline)• Tramadol• MetamizolParacetamol (acetaminophen)
• brought by ambulance to ER
• found injury of right hip because of fall
• broken femoral neck
• had surgery to fix it
• one hour post-op; decide if everything is okay with patient
- has epidural anesthesia and asking why can't move legs
• BP 140/90 usually
• after surgery check wound and do physical examination
• wait a few hours before giving anticoagulant because epidural and wound needs coagulation
SCENARIO 8:
Anatomical and physiological processes associated with aging
The scenario presents conscious patient suffered dysarthria, paresis of the upper and lower left limbs. The student should take care of the patient properly, diagnose the cause of the deterioration of his condition. Proper conduct includes: monitoring, neurological examination, diagnostic imaging studies and adequate treatment.
List of medications to prepare by students prior to the lab:
• Clopidogrel (Plavix) 75 mg• Acetylsalicylic acid (Acard/Aspirin) 150 mg• Ramipril (Vivace) 5 mg• 500 ml 0,9% normal saline (NaCl)• Nootropil (Piracetam) tabl. 1,2 g x 2• Antihypertensive therapy (diuretics and ACE-inhibitors)
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• statins in the reduction of LDL less than 100 mg % [ mg / dl ] - e.g. 20 Zocor (simvastatin) x once in the evening• anticoagulants (per os) - Warfarin - recommended the INR should be 2-3
• conscious pt
• came in b/c abdominal pain, diarrhea and weakness
• sigmoid colon resected
- 3 courses of chemotherapy
• 3 months after last course
• has metastases in liver, lungs, and abdominal lymph nodes
• feel pain and is very weak
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• 80 years old
• very low oxygen and BP with high HR
- gave oxygen and fluids
• BP did not rise enough
• HR increased further
• terminal patient: metastases, pain, etc.
- give opioids to relieve pain
- can only control vitals and pain
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• heart stopped because of illness
- check pulse and if none start CPR chest compressions
- may revive but will have complications again in future
- check for DNR!
• if none then start CPR; if asystole will be very hard to revive
• if not responding to CPR consider stopping after 3 cycles as pt is terminal
SCENARIO 9:
Acute abdominal pain
The scenario presents a patient with patient with acute abdominal pain, nausea and difficulties with breathing. The student should identify the cause of symptoms, implement the treatment. Proper management includes collect medical history and physical examination of the patient, order and interpret additional tests, make the diagnosis
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of abdominal pain and the inclusion of appropriate treatment.
List of medications to prepare by students prior to the lab:
• oxygen• acetylsalicylic acid• nitroglicerin• morphine• 500 ml multielectrolyte fluid
• acute abdominal pain, nausea and difficulty breathing
- started 30 min ago during physical activity
• 40 years old
• first time in life feeling this pain
• recent MI
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- do lab work for CBC, troponin, CK-MB, etc.
- do physical for hernia and other abnormalities in abdomen
The scenario presents a patient with patient with patient with acute pain in the lumbar region. The student should identify the cause of symptoms, implement the treatment. Proper management includes collect medical history and physical examination of the patient, order and interpret additional tests, make the diagnosis of pain and the inclusion of appropriate treatment.
List of medications to prepare by students prior to the lab:
• Codeine/acetaminophen• 500 ml multielectrolyte fluid• Doxazosin• Tamsulosin
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• Nifedipine (Procardia, sustained release)
• feels acute lumbar pain for 2 hours
• found fresh blood in urine
• increased BP and HR
• assess pain on 1-10 scale
- give codeine for pain
- re-assess pain level
• did USG and found bilateral stones
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- 10 mm stone needed to get it to pass and breakdown
- 5 mm may just pass
- do CT because not always sure if correct
• around stone is constriction of the muscles; give muscle relaxants (alpha blocker)
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