Acute Medical Unit Cases

Open Question: Please give three differential diagnoses

Answered: infection, allergy, seconday bacterial infection, viral infection
Feedback: 1. Meningitis (viral or bacterial)
2. Encephalitis (viral usually herpetic)
3. Recreational drug toxicity
These are the main 3 likely causes to be invetsigated and managed initially.
Sepsis from another origin is also acceptable but there are reasonable clinical clues to suggest cerebral infection and he is
an at risk patient living in multiple occupancy accommodation. Acute cerebral irritation from ingested drugs could present
with confusion depending on the drug taken and what it may have been cut with but consequences of drug use such as
cerebral oedema or neuroleptic malignant syndrome should also be considered.

Multiple Choice Question: What is the first thing you are going to do? (please choose one)
Possible answers:
1. Order an urgent CT head.
2. Complete the clerk-in document detail (as much as you can).
3. Tell the registrar/consultant about him and ask them to come and review him ASAP.
Selected answer.
Feedback: Correct. Remember although you are a qualified doctor you are not experienced enough to deal with an
urgently unwell adult without help from a senior colleague. Informing your senior team as soon as possible is paramount.
They should respond by coming to immediately help you or by giving you strict instructions on what to immediately do for
your patient until they can be there to help you. You can do this yourself or ask a member of nursing staff to do it for you
while to continue to assess.
4. Get IV access and administer IV antibiotics and steroids.
5. Baseline bloods and blood cultures.

Multiple Choice Question: After telling the registrar, your senior tells you they will help as soon as they can but just to get
cracking and treat as suspected meningitis.
What should you do next? (please choose one)
Possible answers:
1. Urgent CT head
2. Complete the clerk-in document (as much as you can)
3. Gain IV access and administer antibiotics and steroids?
Selected answer.
Feedback: Correct. With meningitis as a strong contender in our differentials we need to treat this immediately. When the
possibility of meningococcal meningitis is raised treatment comes before investigations.
4. Tell your senior team member
5. Baseline bloods and blood cultures

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Open Question: What is the antibiotic regime for suspected meningitis in adults under 50 in Tayside?
Answered: ceftriaxone 2mg bd iv, dexamethsone 0.15mg/kg for 4 days,
Feedback: Ceftriaxone 2 grams IV twice daily. This is a third generation cephalosporin antibiotic of sufficiently broad
spectrum to cover for all potential pathogens in the young adult particularly meningococcal. The most common organism
causing meningitis in adults is Streptococcus pneumoniae, but Neisseria meningitidis is often associated with outbreaks in
crowded accommodation such as student halls of residence or military barracks. Ceftriaxone will not treat listeria which is a
potential pathogen in the very old and the very young. In patients over 50 (although strictly speaking not very old!) we also
administer 2 grams IV 4 times daily to cover for this.
Incidentally we would also administer anti-virals in the form of acyclovir until the diagnosis of encephalitis had been
excluded or meningitis/another pathology confirmed.

Open Question: What important question must you attempt to achieve an answer for before you administer this/these (in
any patient)?
Answered: allergies, other medication, what time of allergic reaction?
Feedback: Do you have any known drug allergies? This is of vital importance in any patient before you administer
treatment especially antibiotic therapy. Although ceftriaxone is not a penicillin it has similar properties and literature
suggests that up to 10% of patients with a true penicillin-allergy will also be allergic to cephalosprins. If a patient states an
allergy you must always ask them to describe the reaction where possible. People often mistake nausea, diarrhoea and
vomiting as allergic reactions which is incorrect. Drug eruption rashes are also important to note but are usually indicative
of a type IV hypersensitivity reaction and not an anaphylactic allergic response (type I hypersensitivity). In a life-threatening
situation a penicillin or penicillin-related antibiotic could be administered if no type 1 reaction has been described.
When patients or their carers are unable to provide a reliable answer to this question an electronic database can be
accessed in some hospitals. With no documented or available history the appropriate antibiotic should be administered as
the clinical situation dictates.

Open Question: Why does the guideline ask staff to consider IV steroids?
Answered: already on steroids, adrenal disturbance
Feedback: IV steroids are administered as they have been shown to reduce morbidity & mortality in bacterial meningitis in
several studies published since the 1990s. They work by inhibiting release of proinflammatory cytokines triggered by
antibiotic-induced bacterial lysis.

Open Question: When should steroids be given?

Answered: with or just before initial dose of antibiotics
Feedback: All evidence suggests they are most effective when given before or immediately after the first dose of antibiotics.

Open Question: Do you think this patient has meningococcal meningitis? Please explain your clinical reasoning.
Answered: no, rashs blanches, no neck stiffness, just temperature and previous history of head cold
Feedback: No - Continue for further information

Multiple Choice Question: Presuming baseline bloods & cultures have been taken which investigation/s is warranted next?
Possible answers:
1. CT head
2. Lumbar puncture

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Selected answer.
Feedback: Correct. A diagnosis needs to be established for this unwell adult. If the lumbar puncture confirms meningitis
then treatment can continue but if its negative the team may have to initiate further urgent investigations. Also the longer
the LP is delayed the more chance of yielding a falsely negative result as the antibiotics work.
3. CT head then lumbar puncture

Open Question: What is her pre-test probability of PE based on the AMU guidance.
Answered: past history of dvt, pregnancy, high probablity
Feedback: High probability (score 9)

Open Question: Please explain how this risk for PE was calculated.
Answered: wells score
Feedback: Heart rate > 100/min
Clinical signs of DVT
=3
Previous VTE
= 1.5
Other diagnosis less likely = 3

= 1.5

The Modified Wells Score is a clinical decision rule (CDR) used to determine the likelihood of acute pulmonary embolism
and help to guide further investigation. There are several available internationally (e.g. Geneva score). CDRs can only be
used for patients with suspected pulmonary embolism and are only valid for patients referred from the community. They can
extremely useful tools to rule-out PE when used in conjunction with D-dimer assays. This is their main function. A patient
with a low probability & a negative d-dimer is highly unlikely to have a pulmonary embolism. It is then up to the clinician
assessing them to decide what is causing their symptoms.
An intermediate or high score does not diagnose a PE but it means we cannot rule it out without further investigation.

Multiple Choice Question: What baseline investigations does this patient need? (please select all that apply)
Possible answers:
1. CXR
Selected answer.
Feedback: Correct. There may be evidence of an alternative pathology to explain the presentation.
2. ECG
Selected answer.
Feedback: Correct. We need to assess her tachycardia.
3. D-dimer
4. Baseline INR
Selected answer.
Feedback: Correct. She may require anticoagulation. A baseline level is required to make sure she is not
auto-anticoagulating for another reason
5. Doppler ultrasound of the left leg
Selected answer.
Feedback: Correct. This is a relatively easy investigation to do with no radiation exposure to the mother & baby unit. She
has signs of a DVT. If positive the treatment and course of treatment would be exactly the same allowing you to avoid
further investigation.
Overall feedback: Well done you have correctly selected all the baseline investiagtion which this patient needs.

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Open Question: Explain your clinical reasoning on whether or not you would do a CXR.
Answered: changes are generally not seen in PE on cxr until late/never, although want to exclude other possible causes,
Feedback: Radiation risk to the foetus is thought to be insignificant at (cumulative) radiation doses less than 10mGy. A CXR
will give, at most, a radiation dose of 0.1mGy to the foetus and is therefore not clinically significant.
(see radiological imaging in pregnancy guidance in the AMU guideline section)
A CXR is necessary to rule out other pathology (such as pneumonia) and also to determine any further appropriate imaging.

Open Question: At what point of pregnancy is the risk of radiation exposure to the foetus greatest?
Answered: 3rd trimester....out of pelvis
Feedback: The biggest risk for foetal death, growth retardation, mental retardation or malformation occurs in the first and
second trimesters:

0-12 weeks First Trimester - rapid stage of embryonic growth/development

13-28 weeks Second Trimester - organ development

Open Question: From your reading and understanding would the risk of radiation exposure to the foetus from a CXR in this
clinical scenario outweigh the diagnostic benefits for the mother and baby units health?
Answered: no
Feedback: No. as discussed the radiation exposure is very low. If we chose not to do appropriate investigations and get the
diagnosis wrong the mother may become more unwell then the baby does too.

Multiple Choice Question: What would be the best form of imaging modality to use in this particular patient to confirm the
suspicion of venous thromboembolic disease? (Presuming either CXR was not done or was done & was normal)
Choose one answer
Possible answers:
1. Doppler ultrasound left leg
Selected answer.
Feedback: Correct. This would negate the need for further radiation exposure as discussed. If it was negative you would
still have to investigate the lungs so pick another option to do in this case and a perfusion V/Q scan would be the best for
this.
2. Full V/Q scan
3. Perfusion only V/Q scan
4. Ventilation only V/Q scan
5. CTPA
Overall feedback: Correct,as both doppler ultrasound left leg and full V/Q scan can be done - try again selecting these
responses to see the feedback.

Open Question: Can you explain the clinical reasoning behind your choice of imaging modality to use in this particular
pateint?
Answered: no radiation exposure to fetus
Feedback: If the ultrasound is negative (or not available) then imaging of the pulmonary perfusion needs to be performed.
Both CTPA and V/Q scan will subject the feotus to further radiation. It is the ventilatory component of the V/Q scan which

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has the most radiation so perfusion only will reduce this to the same level as that experienced with a CTPA (0.001- 0.1mGy)
and can be accurately interpreted with a good quality X-ray.
The concern in this situation is with the radiation exposure to the mother or, more specifically, the mothers breast tissue.
Estimated exposure of breast tissue during CT chest (CTPA) is 35mGy per breast which may have a significant carcinogenic
effect on proliferative, radiologically sensitive breast tissue during pregnancy. Estimated breast tissue exposure to half
dose V/Q scan is 0.25mGy.
See radiological imaging in pregnancy guidance below.

Open Question: Is it safe to agree to allow this? Can you explain your reasoning?
Answered: no, ecg shows PE, need to observe
Feedback: This is tricky and depends on your assessment. In Ninewells hospital we use the Pulmonary Embolism Severity
Index (PESI) score to determine if someone is appropriate to be investigated as an urgent out-patient. Sadly this score has
never been validated in pregnant patients (because no one has done the studies!). The ECG will tell us if there is any
evidence of right heart strain (S1 QT3 pattern or right bundle branch block - see images below) which would definitely
mean she was unsafe to go home. Her ECG on arrival showed only sinus tachycardia.
This is ultimately a decision for the senior team to make. Her PESI score is low and given her very early pregnancy state, her
haemodynamic stability and her normal ECG (sinus tachycardia allowing) she may be allowed to go home and return the
following day for investigation.
The chance of further PE is very low but the risk of subsequent embolism and risks of morbidity/mortality should be
explained to her to allow her to make an informed decision, but ultimately we cannot force a patient to stay in hospital if
they have capacity to make the decision themselves, but we can give them advice and information to help deal with any
consequences that arise.

Open Question: Regardless of whether she requires to be admitted to the unit or safely discharged to return tomorrow, what
treatment does she require and at what dose?
Answered: thrombolysisation
Feedback: Low molecular weight heparin (dalteparin in Ninewells) dependent on her early pregnancy weight given as twice
daily dosing. This is the recommendation of the Royal College of Obstetricians and reflects the reduced half-life of LMWH in
the pregnant state.

Multiple Choice Question: What is your FIRST action? (please choose one)
Possible answers:
1. Gain IV access
2. Nebulised salbutamol
3. Inform or get someone to inform your middle-grade/consultant about him?
Selected answer.
Feedback: Correct. While all of these answers are important we need to emphasise that getting senior help to manage
this patients is priority here.
4. Antibiotics

Open Question: What is his CURB 65 score (based on the information you have)?
Answered: 5
Feedback: 4 so far confused, hypotensive, over 65 years old and respiratory rate >30/min

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Open Question: How would you grade the severity of his Pneumonia?
Answered: severe
Feedback: Severe community acquired pneumonia

Multiple Choice Question: What initial management should you ask the nurse to help you administer? (please select all that
apply)
Possible answers:
1. Oral Amoxycillin 1g within 1 hour
2. IV dextrose 5% stat
3. IV amoxicillin 1 g within 1 hour
4. Nebulised Salbutamol 5mg stat
Selected answer.
5. IV Co-amoxiclav 1.2g and IV clarithromycin 500mg within 4 hours
6. IV hydrocortisone 200mg stat
7. Inhaled salbutamol 2 puffs via spacer or aerochamber stat
8. IV saline 0.9% over 1 hour
9. IV co-amoxiclav 1.2g and IV clarithromycin 500mg within 1 hour
Selected answer.
10. IV saline 0.9% stat
Selected answer.
Overall feedback: Correct!
He needs:
- Active resuscitation - dextrose is not an appropriate fluid for resuscitation as it quickly leaves the intravascular
compartment. Isotonic saline (0.9%) is the most appropriate and easily available fluid at this point and should be given
- Urgent bronchodilator therapy based on you examination findings and his hypoxia
- Antibiotic therapy within 1 hour severe pneumonia is treated with co-amoxiclav & clarithromycin in NHS Tayside
(provided no allergies are reported). Although national community acquired pneumonia guidance recommends
antimicrobials within 4 hours, this man is severely septic.

Multiple Choice Question: Which investigations need to be performed as soon as possible? (please select ALL that apply)
Possible answers:
1. Departmental CXR
Selected answer.
2. ABG on air
Selected answer.
3. Us and Es
4. FBC
Selected answer.
5. Legionella urinary antigen
6. LFTS

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7. Portable CXR
Selected answer.
8. Urinalysis
9. Lactate
Selected answer.
10. Coagulation screen
11. anca
12. Throat swab
13. ABG on oxygen
14. ECG
15. Avian precepitants
16. Blood cultures x1 pair
Selected answer.
17. Blood cultures x2 pairs
Overall feedback: While all of these tests may need to be done (with the exception of anca) the most immediate are the ones
you will need to assess & manage him in the urgent setting.
He is far too unstable to travel down to the X-ray department for a CXR. A portable film, while of lower quality, will provide
you with all the important information you will need to manage him in the next few hours.He is hypoxic. He requires oxygen.
Never remove oxygen to check an arterial blood gas on an urgently unwell, hypoxic patient. You can roughly gauge their
true pO2 on air with this simple method:
- In normal respiratory function the FiO2 (ie the percentage to oxygen given) should be roughly equal to the partial pressure
of O2 on the ABG minus 10 e.g. 60% oxygen should give a PaO2 of 50kPascals. If the PO2 is 20kPascals then you know
there is a degree of hypoxaemia without the need to remove the supplementary oxygen to prove it!Lactate is a marker of
tissue perfusion. We need to know his baseline lactate to ascertain the severity of his hypoperfused state and to judge
improvement in perfusion as we resuscitate him.2 sets of blood cultures are required to improve yield and limit
contamination.

Open Question: His mean arterial pressure (MAP) on admission is 64mmHg. What would you like it to be?
Answered: at least 90
Feedback: 65mmHg. This is the MINIMUM required to adequately perfuse the brain & coronary arteries in an adult patient.
This is the MAP goal set by the international sepsis management based on early goal-directed therapy in resuscitation of
septic patients.
See the sepsis guidelines or ference below for more details.

Multiple Choice Question: How are you going to achieve this initially? (Choose one)
Possible answers:
1. IV saline 0.9% 20ml/kg over 1 hour
2. IV dextrose 5% 20ml/kg over 1 hour
3. IV saline 0.9% 20ml/kg stat
Selected answer.
Feedback: Correct - In an average adult patient this is roughly 1.5 litres stat (based on 70kg adult)
4. IV dextrose 5% 20ml/kg stat
5. IV saline 0.9% 20ml/kg over 2 hours

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6. IV dextrose 5% 20ml/kg over 2 hours

7. IV saline 0.45% 20ml/kg stat

Multiple Choice Question: Approximately what FiO? is he currently receiving?

Possible answers:
1. 50%
2. 30%
3. 65-85%
Selected answer.
Feedback: A non-rebreath mask is uncontrolled oxygen therapy and is a LOW FLOW device. The oxygen coming from the
wall is 100% but this will be diluted by inevitable leaks, mask fit and any other air the patient is managing to get in to treat
their flow needs. The UK resuscitation council guidelines state that you will receive 85% oxygen through this device. In
reality it is probably a bit lower.

Multiple Choice Question: Does he have?

Possible answers:
1. Respiratory acidosis with compensation
2. Respiratory acidosis without compensation
3. Mixed respiratory and metabolic acidosis
Selected answer.
Feedback: Correct. His pH is low indicating acidaemia, his pCO2 is high which leads to increased hydrogen ions and his
bicarbonate is all used up or lost. The base excess tells us he is in a metabolic acidosis. Compensation occurs when the
non-faulty or upset system is compensated for by the alternative. The key to being in a compensated state is the pH. If the
pH is normal then compensation is occurring.
4. Metabolic acidosis with compensation

Multiple Choice Question: Where should this man be cared for?

Possible answers:
1. Level 1 care bed (such as AMU/ward 15)
2. Level 2 care bed (such as medical high dependency)
Selected answer.
Feedback: Correct - He is severely septic requiring aggressive resuscitation and regular monitoring potentially
invasive monitoring such as central venous pressures. His observational and basic care needs cannot be met in a level 1
bed where the ratio of staff to patients to too high to be able to recognise deterioration in a timely manner.

Multiple Choice Question: On transfer the nursing staff ask you what type of observations he requires. What will you tell
them?
Possible answers:
1. Full SEWS every hour

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2. Full SEWS every 2-4 hours

3. BP every hour with other observations hourly
4. Full SEWS every hour wit hourly urine output
Selected answer.
Feedback: At the very least this should pick up any deterioration and let us know how he is responding to our
resuscitative measures. If he continues to deteriorate it should be even more frequent. It is vitally important that you
communicate your concerns to your nursing colleagues so they can be aware of the situation and provide good care.
Although many nursing staff are trained to deal with urgently unwell adults they need to know your thinking and
management plan for the team to work effectively.

Multiple Choice Question: Bearing in mind his blood gas results & clinical state, which of his systems are in failure?
(choose as many as appropriate)
Possible answers:
1. Respiratory
Selected answer.
2. Renal
Selected answer.
3. Tissue/perfusion
Selected answer.
4. Cerebral
5. Liver
6. Clotting cascade
Overall feedback: You should have selected all as every organ is failing! His urea & creatinine indicate acute kidney injury
most likely secondary to hypovolaemia. His ALT indicates poor hepatic perfusion (shock liver), his lactate indicates poor
tissue perfusion, his platelets/PT/APTT suggest he is developing a disseminated intravascular coagulopathy.
We already know from his ABG he is in respiratory failure and his confusion indicates cerebral failure.

Multiple Choice Question: How would you describe his current clinical state?
Possible answers:
1. Sepsis secondary to severe community acquired pneumonia
2. Severe sepsis secondary to community acquired pneumonia
3. Severe septic shock secondary to community acquired pneumonia
Selected answer.
Feedback: This is the definition of septic shock failure to respond to an appropriate fluid challenge.
This patients is in multi-organ failure and his prognosis is very poor even with aggressive and timely resuscitative
measures, but this shouldnt stop us trying. If he fails to respond to our management decisions about maximum
appropriate treatment and resuscitation status will have to be made.

Multiple Choice Question: Which of the following does he need immediately (choose all that apply)
Possible answers:
1. Upper GI endoscopy

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2. Peripheral cannula for IV access (size and site not important)

3. 1 large bore peripheral cannula
4. 1 large bore peripheral cannula in each antecubital fossa
Selected answer.
5. Group and save blood sample (with option to cross-match later)
6. Full blood count
Selected answer.
7. Calcium
8. Cross-matched blood 6 units
Selected answer.
9. Us and Es
Selected answer.
10. Coagulation screen
Selected answer.
11. Blood alcohol level
12. Gamma GT
13. LFTs
Selected answer.
14. Portable erect CXR
15. IV dextrose 50% 50 ml stat
Selected answer.
Overall feedback: This man has clinical evidence of haemodynamic instability plus evidence of acute GI blood loss (meleana
confirmed on PR and present since the previous evening). He is also taking an oral anti-coagulant while continuing to drink
heavily which will affect the half-life and may lead to excessive anti-coagulation.
This is an acute upper GI bleed until proven otherwise and requires resuscitation. He needs large bore IVaccess (times 2) in
his antecubital fossae to allow rapid resuscitation should he lose more volume with further bleeding and he needs to be
cross-matched for 6 units immediately. With his history plus your examination the likelihood of transfusion is very high;
with the anti-coagulated state the likelihood of ongoing bleeding is high therefore X-matching in preparation for transfusion
before you have his full blood count is entirely appropriate in this scenario.
We need to know baseline parameters for his clinical state and a PT ratio to determine the need for urgent reversal of
anti-coagulation.
With mild epigastric tenderness and no guarding an urgent portable CXR will not add to his care. There is no clinical
evidence of perforation and CXR changes are not seen in the majority of cases of perforation. If he develops an acute
abdomen (peritonitis/guarding/rigidity) then this can be reconsidered.
Did you notice his BM was low?

Open Question: What is his Blatchford score (based on information you have) & what does this mean?
Answered: high, may rebled
Feedback: His score is 3:
Systolic BP 100-109mmHg = 1
Pulse >100/min = 1
Presentation with meleana = 1
Blatchford is a clinical scoring system that allows us to determine a patients risk of having suffered an acute GI bleed and

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aids our further investigation & management. Like all clinical tools it is an aid and should be used in conjunction with
clinical acumen. His score of 3 indicates indeterminate risk of GI bleed. This is without his urea or haemoglobin levels. With
our current clinical information this score (with current information) appears to be vastly underestimating his risk of GI
bleed.
The recommendations are to continue monitoring (hourly) and consider urgent treatment of his potential pathology and any
causative factors (such as anti-coagulation). Decision for endoscopy will be made after observation but remember this is
without the full information required and his score may be higher once his blood results are known.
(see NHS Tayside Guidance for management of Upper GI Bleed)

Open Question: Where could you find this (remembering you work in AMU Ninewells)?
Answered: on the wall, tayside area formulary, staffnet
Feedback: In the AMU clinical guideline folder or on the intranet on the Acute Medicine Unit webpage on the hospital
intranet.

Multiple Choice Question: Do you prescribe ... (please choose one)

Possible answers:
1. IV omeprazole 80mg stat bolus (then wait for further advice/instruction)
2. IV esomeprazole 80mg stat bolus followed by infusion
Selected answer.
Feedback: Correct. This man has evidence of significant upper GI bleed as shown by haemodynamic compromise &
meleana. The local guidance for these patients is commencement on an IV PPI infusion which will aid acid suppression and
healing for presumed gastric mucosal origin of his GI bleed. This is a local recommendation based on the evidence that IV
PPI infusion aids healing in the acute setting and reduces morbidity and mortality. It mostly in patients who have undergone
endoscopic treatment as well but there is a growing body of evidence suggesting patients also benefit from this treatment
pre-endoscopy.
3. IV esomprazole 80mg stat (then wait for further advice/instruction)
4. PO omeprazole 80mg stat
5. IV Terlipressin 2mg stat then 1mg QID

Open Question: Your senior team member is also concerned about him receiving a large bolus of dextrose and asks if you
prescribed stat IV vitamins as well. Why?
Answered: alcohol abuse usually low in b12 and thiamine,
Feedback: With a history of significant alcohol intake and his clinical appearance of general cachexia the suggestion is that
he is deficient in basic elemental nutrition and vitamins (most notably thiamine). This has obviously been of concern before
now as he has been prescribed regular supplemental thiamine but he admits to not taking them.
Patients with a chronic thiamine deficiency are at risk of developing Wernickes encephalopathy. This pathology can be
acutely precipitated by large, sudden carbohydrate loads in the form of food or IV dextrose. The dose of dextrose required
to correct his presenting hypoglycaemia could be sufficient to precipitate this but it is clearly necessary to prevent
long-term cerebral damage from prolonged hypoglycaemia. Administration of IV thiamine (in the form of Pabrinex) is a way
to try and prevent this.
This is, incidentally, also the reason why we give nutritionally deplete patients (particularly alcoholics) IV pabrinex for 2-3
days during initial hospital stay. It is assumed that their food intake will be substantially better that it would ordinarily and
the carbohydrate loads in hospital food could precipitate Wernickes. It is important to consider this in all nutritionally
deplete patients and not just those with chronic alcohol abuse. IV vitamins have no role in preventing re-feeding syndrome
(acute disruption of electrolytes) - a common misconception.

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Open Question: Give 2 plausible reasons why he is agitated/distracted.

Answered: pain, alcohol withdrawl,
Feedback: 1. Hypoglycaemia
2. Acute alcohol withdrawal

Open Question: Give 2 plausible reasons why he is tachycardic.

Answered: alcohol withdrawl, hypovolaemic
Feedback: 1. Hypovolaemia (due to bleeding)
2. Acute alcohol withdrawal
He has abruptly reduced his usual alcohol intake. The resultant withdrawal state usually takes 12-24 hours to manifest and
may not be obvious on initial assessment. Any patient who has a history of alcohol abuse must be carefully monitored for
withdrawal which can be a life-threatening condition if not addressed promptly.

Multiple Choice Question: Given his history and presentation, which of the following would you also like to do? (Please
select all that apply)
Possible answers:
1. Re-prescribe his thiamine and forceval orally
2. Give IV pabrinex 4 vials TDS
3. Give IV pabrinex 2 vials TDS
Selected answer.
Feedback: Correct. This is the appropriate dose and regime for urgent thiamine replacement in the at risk patient.
4. Give IV diazepam 10mg stat and 10mg orally QID
5. Ask the nurse to perform an alcohol withdrawal assessment and prescribe PRN diazepam to be used in conjunction with
it.
Selected answer.
Feedback: Correct. This is the best way of ensuring the patient is getting sufficient medication to alleviate his withdrawal
state. Constant assessment will ensure he is not being under-treated.
Overall feedback: Well done - you selected the correct responses.

Multiple Choice Question: Based on these results what additional treatment does he now need urgently? (choose all that
apply)
Possible answers:
1. Transfusion of 2 units with 40mg furosemide cover
2. Transfusion of 4 units with 80mg furosemide cover
3. Transfusion of 2-4 units stat without furosemide cover
Selected answer.
4. IV vitamin K 10mg
5. IV vitamin K 2mg
6. Prothrombin Complex Concentrate (PCC) according to weight
7. 2 units of fresh frozen plasma

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Overall feedback: This patient has suffered acute blood loss leading to reduction in his circulating volume. We suspected
this on his initial assessment and now his blood results confirm this. He requires replacement of his blood loss in the form
of red blood cells BUT as loss is acute he has had no time to compensate for the overall loss in circulating volume.
Prescribing diuretic with his transfusion will lead to on-going volume loss which could exacerbate his situation. In states of
chronic, slow blood loss patients often have time to compensate for the loss and maintain a euvolaemic state. In these
circumstances diuretic treatment in conjunction with transfusion helps to prevent volume overload. This is not a concern in
our patient.His prothrombin time is severely prolonged which is exacerbating his blood loss as it prevents natural
coagulation. This needs to be urgently reversed. Vitamin K takes, on average, 6 hours to take effect. A high dose needs to
be administered to completely reverse the warfarin but if the patient is unstable and at risk of further bleeding a faster acting
agent is also required. PCC is the preferred method of urgent warfarin reversal in Tayside but this is not necessarily the
case nationally and policy may alter from hospital to hospital. Fresh frozen plasma (FFP) is still sometimes used but as this
relies on regular donation and is a finite resource it is avoided. Both FFP and PCC contain blood products which may be
against the patients express wishes if they are a Jehovah's Witness, something which we can often overlook in the
emergency situation.The only pathology that requires careful control of thrombotic state (even in a life-threatening bleed) is
a mechanical heart valve. These patients are at high risk of thrombus formation on the replaced valve and required very
careful control of anti-coagulation under specialist care to balance the risks of blood loss against the risks of valve
thrombus. In these cases a 2mg dose of vitamin K is administered to prevent complete, long-term warfarin inhibition. In
every other pathology urgent PT reversal is indicated.

Multiple Choice Question: You inform your middle-grade immediately. What do you think is the next best action? (please
select one response)
Possible answers:
1. Give continuous gelofusion and wait for type specific bags to arrive
2. Given continuous gelofusion and ask for group only to be sent
3. Give 1 further stat gelofusion and wait for type specific or group specific
4. Give 1 further stat gelofusion and ask a member of staff to urgently collect 2 units of O negative bags from the nearest
emergency blood bank
Selected answer.
Feedback: While our patient is haemodynamically compromised his fluid loss is blood. Giving boluses of isotonic fluid
will help to correct his volaemic state but will also dilute the remaining haemoglobin. If his haemoglobin is reduced he is at
risk of lactic acidosis from reduced oxygenation of his mitochondriae and coronary ischaemia. Cross-matching of
appropriate bloods can take some time depending on the patients pre-existing antibodies but all hospitals will have
O-negative blood available for acute massive bleeds where there is not time to wait for the cross match. It would be entirely
appropriate to use the emergency supply in this situation but you must inform the transfusion lab that you've used it so it
can be urgently replaced.

Open Question: While you are arranging the immediate resuscitation, the middle-grade doctor contacts the transfusion
laboratory to ask for a Shock Pack.
Please explain what this is.
Answered: o neg, fresh froxen plasma, clotting factors
Feedback: Shock pack is an emergency supply of 2 units of O-negative red blood cells (RBC) plus 1 unit of fresh frozen
plasma and 1 unit of cryoprecipitates. Massive replacement of blood loss does not account for the massive loss of
coagulants that accompanies this situation. Remember RBC units have been cleansed of all other blood constituents and
replacement of 6 units or more will require replacement of natural anti-coagulants.

Multiple Choice Question: What do you think is the next best management startegy for this man? (please choose one)
Possible answers:
1. Transfer to medical HDU for ongoing treatment and urgent endoscopy tomorrow when stable
2. Sengstaken-Blakemore tube insertion

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3. Urgent surgical referral for consideration of endoscopy or surgical intervention ASAP

Selected answer.
Feedback: There is little that can be done for this man at the bedside if his bleeding continues. If we cannot control is
ongoing bleeding with PCC then he will need direct control of it via endoscopy (e.g. adrenaline injection or diathermy) or
invasive surgical procedure. Once referred to the surgical team he will need to be monitored in a level 2 care bed until active
intervention is initiated but this should be in a surgical high dependency unit.
A Sengstaken-Blakemore tube is an oesophageal & gastric tube which inflates to provide direct, physical haemostasis for
acute variceal bleeds. It is of no use in acute gastric, non-variceal bleeds.

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Assessment Summary
Case 1
Open Question: Please give three differential diagnoses
Answered
infection, allergy, seconday bacterial infection, viral infection
Multiple Choice Question: What is the first thing you are going to do? (please choose one)
Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: After telling the registrar, your senior tells you they will help as soon as they can but just to get
cracking and treat as suspected meningitis.
What should you do next? (please choose one)
Answered

Correctness

Retries

Score

correct

1/1

Open Question: What is the antibiotic regime for suspected meningitis in adults under 50 in Tayside?
Answered
ceftriaxone 2mg bd iv, dexamethsone 0.15mg/kg for 4 days,
Open Question: What important question must you attempt to achieve an answer for before you administer this/these (in
any patient)?
Answered
allergies, other medication, what time of allergic reaction?
Open Question: Why does the guideline ask staff to consider IV steroids?
Answered
already on steroids, adrenal disturbance
Open Question: When should steroids be given?
Answered
with or just before initial dose of antibiotics
Open Question: Do you think this patient has meningococcal meningitis? Please explain your clinical reasoning.
Answered
no, rashs blanches, no neck stiffness, just temperature and previous history of head cold
Multiple Choice Question: Presuming baseline bloods & cultures have been taken which investigation/s is warranted next?
Answered

Correctness

Retries

Score

correct

1/1

Case 2
Open Question: What is her pre-test probability of PE based on the AMU guidance.
Answered
past history of dvt, pregnancy, high probablity
Open Question: Please explain how this risk for PE was calculated.
Answered
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wells score
Multiple Choice Question: What baseline investigations does this patient need? (please select all that apply)
Answered

Correctness

Retries

Score

1, 2, 4, 5

correct

1/1

Open Question: Explain your clinical reasoning on whether or not you would do a CXR.
Answered
changes are generally not seen in PE on cxr until late/never, although want to exclude other possible causes,
Open Question: At what point of pregnancy is the risk of radiation exposure to the foetus greatest?
Answered
3rd trimester....out of pelvis
Open Question: From your reading and understanding would the risk of radiation exposure to the foetus from a CXR in this
clinical scenario outweigh the diagnostic benefits for the mother and baby units health?
Answered
no
Multiple Choice Question: What would be the best form of imaging modality to use in this particular patient to confirm the
suspicion of venous thromboembolic disease? (Presuming either CXR was not done or was done & was normal)
Choose one answer
Answered

Correctness

Retries

Score

neutral

0.5 / 1

Open Question: Can you explain the clinical reasoning behind your choice of imaging modality to use in this particular
pateint?
Answered
no radiation exposure to fetus
Open Question: Is it safe to agree to allow this? Can you explain your reasoning?
Answered
no, ecg shows PE, need to observe
Open Question: Regardless of whether she requires to be admitted to the unit or safely discharged to return tomorrow, what
treatment does she require and at what dose?
Answered
thrombolysisation
Case 3
Multiple Choice Question: What is your FIRST action? (please choose one)
Answered

Correctness

Retries

Score

correct

1/1

Open Question: What is his CURB 65 score (based on the information you have)?
Answered
5
Open Question: How would you grade the severity of his Pneumonia?

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Answered
severe
Multiple Choice Question: What initial management should you ask the nurse to help you administer? (please select all that
apply)
Answered

Correctness

Retries

Score

4, 9, 10

correct

1/1

Multiple Choice Question: Which investigations need to be performed as soon as possible? (please select ALL that apply)
Answered

Correctness

Retries

Score

1, 2, 4, 7, 9, 16

neutral

0.5 / 1

Open Question: His mean arterial pressure (MAP) on admission is 64mmHg. What would you like it to be?
Answered
at least 90
Multiple Choice Question: How are you going to achieve this initially? (Choose one)
Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: Approximately what FiO? is he currently receiving?

Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: Does he have?

Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: Where should this man be cared for?

Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: On transfer the nursing staff ask you what type of observations he requires. What will you tell
them?
Answered

Correctness

Retries

Score

correct

1/1

Multiple Choice Question: Bearing in mind his blood gas results & clinical state, which of his systems are in failure?
(choose as many as appropriate)
Answered

Correctness

Retries

Score

1, 2, 3

neutral

0.5 / 1

Multiple Choice Question: How would you describe his current clinical state?
Answered

Correctness

Retries

Score

correct

1/1

Case 4
Multiple Choice Question: Which of the following does he need immediately (choose all that apply)
Answered

Acute Medical Unit Cases

Correctness

Retries

Score

page 17 of 19

4, 6, 8, 9, 10, 13, 15

correct

1/1

Open Question: What is his Blatchford score (based on information you have) & what does this mean?
Answered
high, may rebled
Open Question: Where could you find this (remembering you work in AMU Ninewells)?
Answered
on the wall, tayside area formulary, staffnet
Multiple Choice Question: Do you prescribe ... (please choose one)
Answered

Correctness

Retries

Score

correct

1/1

Open Question: Your senior team member is also concerned about him receiving a large bolus of dextrose and asks if you
prescribed stat IV vitamins as well. Why?
Answered
alcohol abuse usually low in b12 and thiamine,
Open Question: Give 2 plausible reasons why he is agitated/distracted.
Answered
pain, alcohol withdrawl,
Open Question: Give 2 plausible reasons why he is tachycardic.
Answered
alcohol withdrawl, hypovolaemic
Multiple Choice Question: Given his history and presentation, which of the following would you also like to do? (Please
select all that apply)
Answered

Correctness

Retries

Score

3, 5

correct

1/1

Multiple Choice Question: Based on these results what additional treatment does he now need urgently? (choose all that
apply)
Answered

Correctness

Retries

Score

neutral

0.5 / 1

Multiple Choice Question: You inform your middle-grade immediately. What do you think is the next best action? (please
select one response)
Answered

Correctness

Retries

Score

correct

1/1

Open Question: While you are arranging the immediate resuscitation, the middle-grade doctor contacts the transfusion
laboratory to ask for a Shock Pack.
Please explain what this is.
Answered
o neg, fresh froxen plasma, clotting factors
Multiple Choice Question: What do you think is the next best management startegy for this man? (please choose one)
Answered

Acute Medical Unit Cases

Correctness

Retries

Score

page 18 of 19

correct

1/1

Total score: 19 / 21 (90%)

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