‼ APPROACH TO TALKING MANNIKINS

EVERY SIMMANS HAS A MONITOR

2 main types

STABLE PATIENT- Examples

• Urosepsis
• ALI
• Dizziness-HF
• Post C/S pain
Normal approach- Hx, exam, dx, mgt

UNSTABLE PATIENT- ABCDE approach.

Examples
• Hypoglycaemia
• Asthma
• Anaphylaxis
• Post op hypotension/bleeding
• Hospital acquired pneumonia
• PPH

1. Confirm you GMC number to examiner

2. Verbalise- I assume I have taken universal precautions

3. Call out to the pt

Hello I am Dr X, one of the doctors, been asked to come see you.

Can I confirm ur name n age? Any issues bothering you?
If patient does not confirm name. Leave the patient and check band on wrist
for details

4. ABCDE APPROACH (keep in mind you are not alone, verbalise your
findings to the pt/team. Always assess and manage for A, before u go to B,
then C,….)
A= AIRWAY- Hello Mrs…How r u? What is the problem? “I cant breathe dr”

• Since the Pt is talking, the airway is patent

If unresponsive- do GCS immediately. If 8 or less, intubate- so Call the

anaesthetist

B= BREATHING (oxygenation and ventilation)- Start talking to the patient don’t

verbalise findings to team unless prompt says so

• Okay Mr. Brown, Please gimme a second to look at your monitor

Check SPO2 and Check RR ONLY FOR A!!!!!!!!!!!!!!!!!!!!!!!!!!

● Mr X, I can see your breathing rate is high and your oxygen level is low.
● I’d like to give u high flow 02 at 15L/min via a NRBM but before I do,
● do you have a condition called COPD?
● Do you smoke?
● Please give me some seconds to pick the mask up

Then walk to the trolley, pick up the mask and put on patient

● I’m giving it to you now, so please bear with me. (DON’T HANDLE
MANNEQUIN AGGRESSIVELY)
Then put the mask up properly and adjust it as required
• Ask pt- can you breathe through this mask?

• Sir how do you feel now?

IF PATIENT BECOMES STABLE AFTER GIVING HX, TAKE A FOCUSED HX TO

KNOW WHAT THE PATIENT IS PRESENTING WITH SO U KNOW WHETHER THE
PROBLEM IS WITH THE CHEST OR ABDOMEN

ODPARA OR SOCRATES OF PC- For example,

● When did SOB start? Suddenly?
● Worse?
 ● Anything better or worse?

DDX-
● PE- Any pain in your calf/leg, fam or personal hx of clots? Recent travel?
Recent surgery? Coughing blood?
● PNEUMO- high temp? cough? May say no fever but monitor may shows
high temp
● ASTHMA- Any asthma?
● MI- Chest pain?
● HF- heart prob in the past? Leg swelling?

PMHX, Meds, Allergies?- Let me have a Look at your wrist band- will find
allergies

U mentioned u have asthma- how long? Any meds? LOOK AROUND- 4

inhalers, tabs- Ask r these ur meds?
May see blood transfusion, drug charts, post op notes, emergency trolley

IF PT STARTS SCREAMING AND SAYS HE IS DYING – APOLOGISE, GIVE ME A

FEW SECS TO BETTER ASSESS YOU. I WILL BE ABLE TO HELP U- THEN GO A BIT
QUICKER IN UR PACE.

AFTER FOCUSED HX, PERFORM CHEST EXAM

Chest exam
• I’d like to examine you, this will involve me looking, feeling,
tapping and listening to the chest
• It will require exposing your chest.
• Will you want me to help you with that?
• There will be a chaperone with me
• Can I go ahead?
• Can u breathe in and out

Then examine the chest- IPPA-

(Only Do a running commentary as you examine if u r asked to in the prompt-
e.g. inspection is normal)

❖ Ill now be pressing on the chest- any pain anywhere? Please do let me
know
Trachea is central, Chest expansion is normal

❖ Ill be tapping on ur chest, please do bear with me (don’t forget to

percuss the bases)
Normal percussion
❖ I need to listen to your chest now- I can hear wheezing

MANAGE THE BREATHING

● If you can hear wheezing- Tell the pt- you’ve got some wheezing
so I’ll give you a medication called salbutamol through this mask
DRIVEN VIA OXYGEN (for anaphylaxis and asthma)

(For COPD, say u will give 5mg salbutamol by air- not by oxygen)

Then actually go to the trolley and pick up the nebuliser mask and put it on
the pt

● Can you breathe through this mask?

NB: If abnormalities were picked up like low oxygen, crackles,

wheezing- do ABG and CXR

❖ Alright I need to do some tests for u, I need to do a chest x-ray and a

special test called ABG to check the oxygen levels in your blood to assess
u further because there was …………..
C= CIRCULATION-
❖ Okay I need to assess ur circulation,, by this I mean looking at your
monitor, examining your hands and feet and listening to ur heart

• Look at BP- I can see ur BP is low/ my pt’s BP is 128/82

• Look at HR- Shows ur heart is working faster than normal/ pt is
tachycardic with a HR of 140
• Look at the monitor-Verbalise- / e.g, normal, sinus tachycardia, A.fib,
confirming that your heart is working faster than normal

***complete assessment before intervention so go on to hands

Hands- I’ll be examining ur hands

1. Normal skin colour- Your skin color looks normal/ no pallor or cyanosis
2. Temp- - Ill be touching ur HANDS and feet- Your fingers and toes have a
cold temp
3. Pulse- rythm and volume
4. - Ill be pressing your finger pls bear with me- CRT- 5 to 2 (press for 5
seconds, should refill in 2 seconds)

Chest- I’ll be listening to your heart as well, please bear with me

• Heart sounds- all 4 regions if there is AF, if not, usually just
listen at one position

TESTS- I NEED TO ARRANGE AN ECG, MR BROWN, WHICH IS A TRACING OF

YOUR HEART

IN Bleeding SCENARIOS OR POST OP PTS-

● ASSESS THE ABDOMEN AS WELL AND INSPECT THE GENITAL
AREA as PART OF CARDIOVASCULAR EXAM
 ● So say I will like to examine ur tummy – ONLY INSPECT AND
PALPATE!!!!!!!!!- wound dressings, bleeding
and
● YOUR PRIVATE AREA, JUST BEAR WITH ME- In UGIB- melaena,
urine output, bleed per vag, rashes in anaphylaxis

MANAGEMENT OF CIRCULATION

If anaphylaxis- Give IM adrenaline- 0.5ml 1 in 1000

Otherwise, regardless of the diagnosis, set an IV canula

• I’d like to set 2 large bore IV lines (unstable, low BP)- orange/grey-
PICK UP CANULA
OR
• 1 large cannula for stable pt
• I’d like to draw blood for xxx- mention specific labs

SAMPLES- Type of blood group, crossmatch 4 units of blood (if u feel

transfusion is imminent) ROutine

Give fluids only when needed:- PICK UP THE FLUID AND HANG IT ON STAND-
MAY BE ASKED AT WHAT RATE AND THE AMOUTN TO GIVE OVER WHAT
PERIOD OF TIME

FLUID MANAGEMENT

1. All bleeding scenarios and anaphylaxis or shock- Give 1L N/S

0.9% in both arms STAT

2. WHERE PT IS RELATIVELY STABLE BUT LOW BP- In Hosp acquired

pneumonia and urosepsis w/o severe hypotension or an elderly
patient with heart issues and we don’t want to overload (where
u suspect other causes of low BP)- Do fluid challenge- 500mls
over 15 mins. If BP does not improve, repeat at D
 3. For asthma n hypoglycemia, post op pain, Dizziness sec to heart
failure- NO FLUIDS as patient will already be having pulmonary
edema, may die if u give IV!!!!

4. Maintenance- where u tell patient not to eat or drink anything-

1L N/S over 12hrs,Like ALI- NPO- 2L in 24 hours- 1 bag 6 hourly
Medications
• e.g IV hydrocortisone in asthma
• PPH- oxytocin

• Catheter

D= DISABILITY
• GCS/AVPU
● Pupils- Will be shining some light in ur eye
• Capillary glucose- TAKE GLUCOMETER- OAKAY I NEED TO CHECK
UR BLOOD SUGAR, FOR THAT I NEED TO PRICK YOUR FINGER

Review treatment offered offered in ABC and take the necessary

action-
● HOW R U DOING, STILL SOB?
● I CAN SEE UR SATURTAIONS R STILL LOW.
● LET ME LISTEN TO YOUR CHEST AGAIN-

1. IF WHEEZE STILL PRESENT- STEP UP TO IV MGSO4 2G IV OVER

20MINS
2. ANAPH REPEAT ADRENALINE
3. HYPO- REPEAT IV GLUC

(THEN GIVE TIME FOR THE REPEAT MEDS TO WORK BY DOING E)

• So don’t give repeat meds at B or C, only at D- ALWAYS REASSESS

AT D BY ASKING HOW R U NOW? AND BY LOOKING AT MONITOR
If sbp- still less 90 for bleed- I will consider giving u Group o neg blood- 2 units
to begin with

AVPU/GCS
● If patient is alert- say ON AN AVPU SYSTEM, MY PATIENT IS ALERT
(in asthma, HF, post op Bleed, pneumo, sepsis,…where patients are talking to
u)

● Do GCS instead of AVPU if consciousness level is reduced, LIKE DROWSY

AND UNRESPONSIVE- For example in Hypoglycemia, DKA, PPH and
anaphylaxis as pts will be worse in these

● IF PT IS CONFUSED- HE IS ALERT, SO AVPU

GCS-
● VERBAL- ASSESS ORIENTATION IN TIME (OF THE DAY, NOT CLOCK), PLACE
(KNOW WHERE U R NOW) AND PERSON – IF NO RESPONSE- 1
● EYE- CAN U OPEN YOUR EYE
● MOTOR CAN U LIFT YOUR RIGHT ARM?

‘IF 8 OR LESS- I WILL CALL THE ANAESTHETIST TO INTUBATE THE PATIENT’

IF UNRESPONSIVE- DO GCS AT A- FOR HYPOGLYCEMIA

IF PATIENT IS DROWSY BUT IS RESPONSIVE, DO GCS AT D

E= EXPOSE AND EXAMINE

• Head to toe exam- ABD- INSPECT AND PALPATE, LOOK AT PRIVATE
AREAS (IF IT HASN’T BEEN DONE BEFORE AT C!!!!!!!!!!!!!!!!!), LOOK AT LEGS,
PALPATE CALF
• Then cover pt after
• Catheterise if necessary
THEN GO BACK TO D TO REASSESS RESPONSE TO MEDS GIVEN BY LOOKING AT
MONITOR AND ASKING HOW PATIENT IS DOING NOW

F- FURTHER MANAGEMENT OF PT-

WHEN STABLE NOW- DISCUSS WITH EXAMINER OR PT DEPENDING ON PROMPT

● Ive assessed…. Had low oxygen, wheeze

● I would admit under
● Wd ct current meds
● Do invest
● Take second opinion from seniors

ASTHMA
FY2, ED. Mr. Adam Jones is a 30 year old man who has presented to the hospital with SOB.
Take a focused history, assess the patient and discuss management with the patient.
SIMMAN
⁃ Initially Oxygen saturation is 88% after giving O2 it improves to 92%
⁃ During examination the saturations drop to 88% again.
⁃ After all the treatment is mentioned the saturation change to 98%.
PT INFO:
You have come to the hospital with SOB, you also have cough
Asthma since you were 5 years old
You take blue and brown inhalers
You take the brown inhalers twice a day.
You can take the blue inhalers whenever you get an attack.
You do not smoke
You do not take any other regular medications and you have no allergies.

APPROACH: GRIPS
 • Mr Jones, I’m doctor X, one of the doctors in the department.
• Confirm age
• I understand u r short of breath. I’m here to help.
• How are you feeling now? I’m sorry to hear that

• Since u r speaking so airway is patent

• Please bear with me, I need to look at your monitors to check your
observations

Come to patient
• Your oxygen saturation is low, so I’ll need to give you O2 via a
NRBM at 15L/min / My pts saturation is 88%, I’d like to give high
flow O2
• Before I start, do you have COPD, do you smoke?
Give oxygen
• Look at monitor (SPO2, RR)
• How are you feeling? R u comfortable?

• Tell the team whatever changes- improving or getting worse

IF DOING BETTER, DO QUICK ODPARA, DDX, MAF

ODPARA- SOB
● DDX- PE,
● ASTHMA- HAVE U BEEN DX WITH ASTHMA? IF YES, HOW LONG, MEDS,
R THESE UR INHALERS? DYU TAKE ANY INH APART FROM THESE?
● PNEUMONIA- COUGH, FEVER?,
● LOOK AT WRISTBAND- ALLERGIES

Chest exam
• Pt will try to distract u- Dr I don’t feel well
• Spo2 - will start dropping again
• Spo2 is dropping again, let me examine the chest
• IPPA
 •When you hear the wheeze, then change to
salbutamol nebuliser mask- explain to team/pt- WILL GIVE
SALBU 5MG DRIVEN VIA OXYGEN

Will do Chest X-Ray and ABG

Circulation
• BP is fine, ECG may show sinus tachycardia- UR HR IS SHOWING
HEART IS WORKING FASTER THAN NORMAL
• IF BP IS NORMAL, NO NEED FOR CRT
• BUT CAN COMMENT ON TEMP, SKIN COLOR
• LISTEN TO HEART- LISTEN ONLY TO 1 AREA

• Set cannula- Take routine bloods,

• WILL GIVE IV HYDROCORT 100MG STAT

SOMETIMES AFTER GIVING A, SATURATIOS WILL NOT IMPROVE, SO MOVE ON

TO B AND C. AFTER IV HYDROCORT, PT WILL IMPROVE- THEN, TAKE A HX / CT
WITH UR HISTORY

DISABILITY-
● ON AVPU SYSTEM, PT IS ALERT
● PUPILS
● GLUCOSE
● REVIEW MEDS AND TX- CAN SEE U R STILL SOB, LEMME LISTEN TO UR
CHEST
● ILL GIVE U MGSO4 2G IV OVER 20MINS
● WILL GIVE SOME 20 MINS FOR MGSO4 TO KICK IN

Pt will not improve after salbutamol

Mention you will give -Ipratropium bromide 0.5mg nebulizer-Hospital has run
out
EXPOSURE-
● EXPOSE, HEAD TO TOE, LEGS
● GO BACK TO D- Ask pt how they feel? ARE U STILL SOB? I CAN SEE UR
OXYGEN IS BACK TO NORMAL.
● LET ME LISTEN TO UR CHEST 1 MORE TIME

GO TO F (CHECK WHETHER U WILL BE TALKING TO PT OR EXAMINER!!!!!!!!!!!!!)

I ASSESSED U,…UR OXYGEN WAS LOW, RR, WHEEZE PRESENT

I GAVE U SOME SALB, AND HYDROCORT AND MGSO4
DX: Acute exacerbation of Asthma (1050)

MGT:
1. Admit under medical team- you can go home when stable
2. WAIT FOR ABG, CXR, ROUTINE BLOOD TEST RESULTS

3. Alternate scenario
• If still no response, say you will speak to seniors about
aminophylline 5mcg/kg
• ICU admission for intubation if still not improving

U have developed acute asthma so u will be admitted and monitored for some
days. And once u get better, u will be discharged

This station vitals will be dropping so u will have to go back and forth so
ALWAYS LOOK AT THE MONITORS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
 ANAPHYLAXI
S
FY2, surgical department. 56yo M had hemicolectomy 3 hours ago. He was transfused 1
unit of blood and currently receiving his 2nd unit of blood. He is currently having
breathlessness. The nurse has called you to see the patient as she is worried about him.
Please assess the patient and discuss management with the patient.
PT INFO: Opening sentence: I do not know doctor, but I am not feeling very well.
I have shortness of breath, it started half an hour ago. You have redness on your right arm
which is very itchy.
QUESTIONS:
⁃ What is wrong with me?
⁃ What are you going to do for me?
⁃ Am I going to be ok?

Set up:
Talking manikin - patient breathing very heavy
Monitor with the following vitals:

Initial vitals:
• BP: 84/60 mmHg
• HR: 130
• Spo2: 88%
• RR: 30
After resuscitation:
• BP: 100/70
• HR: 115
• Spo2: 92%
• RR: 24
APPROACH - GRIPS
• Mr Jones, I’m doctor X, one of the doctors in the department. Im
here to help.
• Confirm age
• How are you feeling?
• My patient is speaking so airway is patent

Excuse the patient and Look at monitor

• My pts saturation is 88%, I’d like to give high flow O2 via a NRBM
at 15L/min, RR- 30, BP-84/60
Come to patient
• Your oxygen saturation is low, so I’ll need to give you high flow O2
through this NRB mask.
• Before I start, do you have COPD, do you smoke?
Give oxygen
• How are you feeling?
• Look at monitor (SPO2, RR)
• Tell the team whatever changes- improving or getting worse

• THN AFTER TAKE A HISTORY- ODPARA OF SOB

• LOOK AT WRISTBAND- WILL SEE PENICILLIN ALLERGY

Chest exam-
• you will see a picture of an urticarial rash
• There is a rash, seems you have an allergic reaction to the blood
you are receiving. Let me stop the blood. Maybe this rash is due
to the blood
STOP TRANSFUSION- JUST CLAMP IT DOWN- DON’T PULL CANULA OUT

Complete IPPA
• Wheeze- give salbutamol 5mg driven by oxygen
• Explain why you are changing masks- I am going to change your
mask to another one- THEN NEBULISE
 I will like someone to prepare adrenaline for me- 1:1000.
TAKE HX

Circulation
• I am going to check your monitor again- Low BP, High HR
• Listen to chest- 1 area
• Check ABD + GENITALIA 4 RASHES- AS PT IS POST OP

• Adrenaline IM 0.5mg 1:1000- I’d like to give you a medication

called adrenaline, its an injection through your thigh and it’ll help
you feel better

• Open the trolley, pick up 2 wide bore cannulas

• I will take blood samples from one, and give fluids through the
other vein
• IV fluids N/S- 2L over 15 mins stat

DDX-
❖ BLOOD TRANSFUSION REACTION- WHEN WERE U STARTED? HOW MANY UNITS
HAVE U GOTTEN? WHEN DID SOB START?
❖ ANAPHYLLAXIS- PEN ALLERGY- HAVE TO SEE UR DRUG CHART TO SEE WHENHRT U
HAVE BEEN GIVEN ANY MED U R ALLERGIC TO
❖ I ALSO NEED TO HAVE A LOOK AT THE POST OP NOTES TO SEE WHICH MEDS

TAKE HX OF ANAPHYLAXIS- Reason for admission? Any blood transfusion

before? Any past reaction? MAF

COMPLETE ABCDE APPROACH

• Bloods- send back to blood bank

• Make sure u expose the patient to examine for other rashes
 • What happened is that u had an allergic rxn to the blood. That is
why we have stopped it and sent it to the lab for analysis.
• I will inform seniors
• And if u still need blood, I will give u appropriate matching blood
later on
CHlorphenamine 10mg IV

PENICILLIN ALLERGY
FY2, Surgical department, a pt has been scheduled for appendicectomy, was admitted
yesterday. Assess the pt and manage. Special note: you have been called by the nurse as pt
is feeling unwell
PT INFO:
Pt is receiving Augmentin, metronidazole. Pt also has a pink wristband stating penicillin
allergy

APPROACH (1053):
• Same as above
• Stop penicillin
• Treat anaphylaxis
• Change antibiotics

ANAPHYLAXIS- BLOOD
TRANSFUSION
FY2, surgical unit, 68 yo was admitted with acute appendicitis,
Nurse has asked you to review the pt as he has been complaining of SOB. Assess and
manage
PT INFO: will be receiving blood. Also has a penicillin allergy band
Drug chart on table
 Augmentin (given by…. is empty- meaning medication has not been given)

APPROACH:
Same as above but pt is actually reacting to blood so stop blood
THEREFORE CHECK THE DRUG CHART IN D!!!!!!!!!!!!
N.B: you can ask vital questions while performing ABCDE esp MAM hx

STOP TRANSFUSION AFTER A- JUST CLAMP IT DOWN- DON’T PULL CANULA OUT
THN AFTER TAKE A HISTORY- ODPARA OF SOB
LOOK AT WRISTBAND- WILL SEE PENICILLIN ALLERGY

DDX- BLOOD TRANSFUSION REACTION- WHEN WERE U STARTED? HOW MANY UNITS HAVE
U GOTTEN? WHEN DID SOB START?
ANAPHYLLAXIS- PEN ALLERGY- HAVE TO SEE UR DRUG CHART TO SEE WHENHRT U HAVE
BEEN GIVEN ANY MED U R ALLERGIC TO
I ALSO NEED TO HAVE A LOOK AT THE POST OP NOTES TO SEE IF U WERE GIVEN A MED U R
ALLERGI C TO

CHEST EXAM- INSPECTION- URTICARIA

CHEST EXAM- WHEEZE- NEBULISE SALB DRIVEN VIA O2
ABG, CHEST XRAY

CIRCULATION- ASESS FIRST- DON’T RUSH TO ADRENALINE. NO NEED FOR IV LINE FOR
ADRENALINE
MONITO FOR BP, SHOWS SIUNS TACHYCARDIA
CRT- PRESS FOR 5 SECS
TOUCH HANDS AND FEET- SKIN TEMP IS NOT WARM TO TOUCH
HEART- ONE POSITION AT APEX ONLY

ABD- EXPOSE FROM CHEST AND ABD- SEE AND TOUCH AND GENITAL INSPECTION- EXPOSE
FROM DOWN UP- COS THIS PATIENT IS POST OP
LOOK FOR RASHES

GIVE ADRENALINE IM

GET IV SESS ROUTINE, GXM

IV LINE- AGGRESSIVE- 1L IN BOTH ARMS STAT

OLY GIVE HYDROCORT AND ANTIHIST AFETER STABILISATION- NOT DURING

ABCDE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
D- AVU, PUPILS, SUGAR
LET ME REVIEW THE ABCS- IVE GIVEN U SOME IV FLUIDS AND ADRENALINE, UR BP IS STILL
LOW, SO I WILL REPEAT THE ADRENALINE

DO E- DON’T EXAMINE ABDOMEN AND GENITALS AGAIN, RATHER LOOK AT LEGS

AFTER, LET ME ASSESS UR RESONSE TO THE SECOND DOSE OF ADRNALINE

UR B IS NOW GGOOD

MGT-
I EXAMINED U, U HAD LOW 02, RASHES,….
I SUSPECT U HAD A SEVERE REACTION TO THE BLOOD

DIFFERENT REASONS- DUE TO WRONG BLOOD GROUP, OR SOME REACTION BY PT

CANT TELL EXCTLY WHY NOW

WILL SEND BOOD BACK FOR TESTING, THEN WILL COME BACK TO TELLL U
IN THE MEANTIME WILL REQUEST THE INV
SENIORS
WILL CT MONITORING U

UGIB
FY2, ED, 65yo M, p/c- hematemesis. Had an upper GI endoscopy. Assess pt, discuss, mgt.
PT INFO: You’ve had dizziness for the last 10/7, came to hospital cuz you vomitted blood
2-3x.
Couple of weeks ago, you had vomited blood. Had endoscopy for this last week.
Have OA, on diclofenac on and off for last 1 year. Smoke. Drinks occasionally

MAY PRESENT WITH DIZZINESS, VOMITING BLOOD, NOT FEELING WELL

DIZZYNESS- ODPARA- BLOOD IN VOMITING

PMHX INDIGESTION
PAST HX OF ULCER
SINCE TALKING-
SATS LOW- GIVE OXYGEN. IF 94 AND ABOVE, DON’T
CAN U TELL ME ABOUT DIZZYNES? ANYTHING ELSE? VOMITING- BLOOD. DID U VOIT IN THE
HOSPITAL? ANY BUCKETS U VOMITIED IN? LOOK INSIDE
HOW MANY TIMES? STARTED WHEN?
DDX- PUX- SUFFER FROM INDIGESTION, ANY PAST INVEST, ANY ENDOSCOPY? ANY TX? DRIN
ALCOHOL? JAUNDICE? NSAIDS? CANCER- WEIGHT LOSS, DIFFICULTY SWALOWING
MEDS, ALLERGIES

EXAMINE CHEST- NORMAL- SO NO MANAGEMENT- NO ABG, NO CHEST XRAY. IF ABORMAL

THE MANAGE
CIRCU- BP- LOW, MONITOR SHOW U HAVE SINUS TACHYCARDIA WHICH MEANS UR HEART IS
WORKING FASTER THAN NORMAL
CRT
TEMP AND COLOR
APEX ONLY

SUSECTING BLEED SO CHECK ABD, PRIVATE AREA- CD BE MELAENA, CHECK CATHETER-

DRAINING?
IV LINE- WIDE BORE- UE THE BIGGEST CANULA AVAILABLE IN THE EXAM- LOOK AT THE
GUAGES OF DIFFERENT CANULAS – EXAMINER CAN ASK U GAUGE
ROUTINE GXM, CROSSMATCH 4 UNITS
1L N/S IN BOTH ARMS

(PATIENT BECOME STABLE HERE, SO TAKE HX HERE RATHER)

DISABILITY- AVPU, SUGAR, PUPILS, CHECK RESPONSE TO FLUID- ABCS- U GAVE OXYGEN,
CHEK SATS
CHECK BP- FOR ADEQUATE IMPROVEMENT-
IF LESS THAN 90- GIVE BLOOD TRANSFUSION- GROUP O NEG BLOOD- ONLY GIVE BLOOD AT
D!!!!!!!!!!!!!!!!!!!!!!!!!!!! IF NOT IN TROLLEY ASK EXAMINER- I WOULD LIKE TO GIVE GROU O
NEG BLOOD- 2 UNITS

E- EXAMINE LEGS- NOT ABD AND GENITALS

GO BACK TO REASSESSS BLOOD GIVEN AND OXYGEN

NOW EXPLAIN TO PT- U CAME WITH DIZZYENESS, U HAVE BEEN VOMITING BLOOD
UR OXYGE WAS LOW, BP LOW, PAIN IN TUMMY. SO I SUSPECT U R BLEEDING FROM ULVERS
WHEICH WERE FOUND ON UR TUMMY

WILL WAIT FOR RESULTS OF TESTS DONE

REFER TO GASTRO FOR URGENT ENDOSCOPY- TO SEE WHERE U R BLEEDING FROM AND
STOP THE BLEED- THEY MAY ARRANGE A CHEST XRAY, ABD X-RAY
INFORM SENIORS- IF THEY SUGGEST ANYTHING DIFFEENT- WILL LET U KNOW

OR

APPROACH (1067): GRIPS

Introduce-
❖ Can u pls tell me what u mean by dizziness? Feel faint/spinning of the room?

❖ Excuse and look at monitor

1. BP= 90/50
2. HR= high
3. SPO2= 94% 🡪 no oxygen needed
4. RR= 22

B- No oxygen needed, Chest exam- Normal

• C=hands-CRT, Auscultate heart. Examine ABD, PR
• mention cannulas- samples, Give fluids- N/S- 2 wide bore cannulas-1L N/S in
each arm
• Pt will improve slightly.
• Mention blood, pt will improve

• After pt stabilises- take hx

• Quick hx of dizziness- You know about UGIB so look for risk factors
a. PUD
b. Gastritis
c. NSAIDS
d. Malignancy

❖ R u bleeding from anywhere else?

• PMAFTOSA- NSAIDS?

• Secondary survey- mention ABD exam, PR, legs

DX: UGIB- U had UGIB, wich means bleeding from the stomah or small bowel

MGT:
1. Admit
 2. Bowel specialist/Gastroenterology consult- Urgent endoscopy (another one will be
done today)
3. ABD X-RAY, ABD USG, Erect CXR
4. Will continue
5. IV omeprazole thru your vein
6. During endoscopy if they find a bleed, they will try to seal it
7. CT monitoring n giving u blood till then
8. Involve seniors

PPH
FY2, OBGYN, 35yo F, G5, has just delivered, this is her 5th delivery. 1 hour after delivery,
she was noticed to have BPV. A nurse has asked you to come review the pt. Pt had a 3rd
degree vaginal laceration which has been sutured. Assess and manage the pt and hand
over to the crash team
BP= low
P= high
SPO2= low
T= normal
EXAM FINDINGS: ABD= floppy, groin area= soaked with blood

PT IS DROWSY
HELLO, HOW R U?- WILL BE MUMBLING
RESPONDING, SO AIRWAY IS PATENT
WILL NOW LOOK AT UR MONITOR
OXYGEN IS LOW, COPD, SMOKING

TAKE HX- ATTEMPT TO- I CANT TAKE MUCH HX FROM THE PAT COS SHE IS DROWSY
NEED TO LOOK AT DELIVERY NOTES TO SEE HOW THINGS WENT, FOR ANY COMPS
LOOK AT GENERAL NOTES, DRUG CHARTS TO SEE WHAT U HAVE BEEN GIVEN SO FAR

CHEST EXAM- NORMAL, SO NO MANAGEMENT

CIRCULAION= BP LOW, HR HIGH, CAN FEEL FOR THE PULSE AS U R ASSESSING

TEMP, CRT, COLOR
ECG!!!!!!!!!!!!!! FOR ANY BLEED
ABD- UTERUS, GENITAL INSPECTION- BLEED

MANAGEMENT- IV LINE, FLUIDS- IL IN BOTH ARMS

THEN, NOW WILL NEED TO DO A MANUAL MASSAGE OF UR UTERUS!!!!!!!!!!!!!!!!,

WILL ALSO NEED TO GIVE 5units IV OXYTOCIN INFUDION TO STOP UR BLEED (ALL
PART OF CIRCULATION) BECAUSE ON EXAM, UTERUS WAS SOFT
Inform seniors to see if I will increase the dose

D- DO GCS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! OPEN EYES, LIFTNG ARM, SOUND?

GLUC, PUPILS
NEED TO REVIEW UR ABCS- WE HAVE GIVEN 02- SATS, BP WAS LOW, HAS NOW IMPROVED
AFTER FLUIDS, OXYTOCIN

• Relevant PMAFTOSA (if there is time)

IF AT D, BP DROP, GO BACK TO ABC, AND GIVE BLOOD NOW

E- LEGS
F- FURTHR MANAGEMENT

N.B: At 6 minute- examiner= I am the registrar in this pt, hand over pt to me

ISBAR APPRAOCH
I= Introduction
• I am X one of the F2s.
• I have a patient I need your help with

S= Situation- Core details

• My patient is X, 35yo
• Had a delivery 1 hour ago
• She’s been bleeding PV since then

B= Background- Admission and history

• She admitted 1 hour ago
• No PMHx
 • Not on any meds
• No ANC issues
• This is her 5th delivery
• She had a 3rd degree tear, sutured

A= Assessment- Vital signs, exam findings, investigations, mgt

• Airway is patent. SPO2 was initially 92%, improved to 98% after oxygen
• Chest clear

• BP= 88/62 (low), HR= 132, ECG= sinus tachycardia

• I have given 2L N/S stat
• BP improved, gave blood

• Examined abdomen
• Uterus floppy
• I gave 5u oxytocin
• Patient is responding to verbal stimuli

R= Recommendation
• I think she has PPH sec to uterine atony
• She was at risk cuz this is her 5th delivery, also her uterus is floppy
• can also be due to retained placenta
• we can arrange a TV- USG and if retained placenta is dx, we can evacuate
• May need to repeat oxytocin up to 20units
• Might need more blood as required
• So I needed your opinion as a senior

APPROACH (1079):
• GRIPS
• ABCDE- give oxygen. Oxygen will improve to 98

Ct chest exam-clear. Because it is normal,

I UNDERSTAND U JUST DELIVERED A BABY. R U BLEEDING FROM ANYWHERE? EXPOSE

ABDOMEN AND GENITALIA WITH CONSENT AND EXAMINE FOR BLEEDING- inspection and
palpation
FINDINGS- Floppy uterus- I can feel your uterus, it is soft, but first I will manage your BP
Circulation- BP will be low
• 2 large bore cannulas
• Take bloods- routine, GXM
• N/S or Hartmann solution- 2L stat

INTRAABDOMINAL BLEED
INTRAABD BLEED FF SURGERY
HELLO. HOW R U FEELING?
CANT BREATHE
TAKE HX AFTER O2.
LOOKA ROUND- MAY BE NOTHING
EXAMINE- CHEST NORMAL, SO NO MANAGEING, BUT IF OXYGEN WAS LOW, MAY NEED ABG,
XRAY

AUSCULTATE- CAN CHECK ALL 4 AREAS- COS CAUSE IS NOT REALLY CLEAR HEAR
ABD + PRIVATE AREA, URINE DRAINING?

IV LINE- BLOODS
IV- 1L IN BOTH ARMS STAT

D- AVPU, REVIEW TX- GAVE OXYGE AND FLUIDS- IF IMPROVED, NO BLOOD TRANSFUSION
SO U CAN WAIT FOR CROSSMATHING BEFORE GIVING BLOOD LATER

E- LEGS
FURTHER MANAGEMENT

U HAD AN OP, U HAD A LOW OXYGEN, U WERE SOB, I HAVE GIENIV FLUIDS, OXYGEN
U HAD TUMMY PAIN, I SUSPECT U HAVE ABDOMINAL BLEED, WHICH IS A COMP OF UR
SURGERY
WILL NEED TO INFORM SENIORS
MAY NEED TO BE TAKEN BACK TO SURGERY
MAY NEED TO GO BACK TO THEATRE TO STOP BLEED
WILL CT TO MONITOR UR VITALS IN THE MEANTIME
 POST-OP
HYPOTENSION
FY2, OBGYN, 50yo F, not feeling well, had a lap hysterectomy 1 hour ago for DUB. Now in
recovery room. Nurse has asked you to see as she’s not feeling well.
Assess pt, discuss mgt with examiner
PT INFO: I am not feeling well doctor, experiencing SOB- 30 mins.
Had hysterectomy 1 hour ago o/a vaginal bleeding
Usually fit and well

EXAM FINDINGS: Crackles on chest exam

SET UP:
⁃ Urine catheter- clear urine
⁃ ECG on monitor= sinus tachycardia
⁃ SPO2= 88%
⁃ BP= 85/65
⁃ HR= 120
⁃ T= 37

AFTER INTERVENTION:
SPO2 may improve to 92%
BP= may come to 100/80
HR may come to 100

APPROACH:
• GRIPS
• ABCDE
TAKE HX
a) B= patient has crackles
b) C= Mention pt has crackles so you don’t wanna overload, but BP is low so give you
will start with maintenance- 500mls
over 6 hours. There is also no
active bleed so start maintenance instead of resus
If BP drops, start blood
Check incision site, bleeding from genitalia
DE
EXAMINER
1. What are the differentials?
1. PE
2. MI
3. Fluid overload
4. Atelectasis
5. Post op bleeding

2. How will you manage?

ABCDE assessment, give oxygen with mask, give maintenance fluids
⁃ Will do other investigations
⁃ CTPA
⁃ Cardiac markers
⁃ FAST USG, ABD CT
⁃ ABG, ECG, CXR

If there is a bleed on the scan, will inform my seniors

3. Treatment is according to cause- Inform seniors

HOSPITAL ACQUIRED
PNEUMONIA
FY2, AMU, 67yo F, admitted from nursing home with UTI.
She has been tx successfully. Been seen by PT and OT and she is ready for discharge.
Nurse has called you to see the pt cuz she is not feeling well and has SOB.
Assess the pt, discuss the initial mgt plan with examiner
SPECIAL NOTES: talk to the pt as if its a real pt and describe everything you are doing to
the examiner as you go.
PT INFO:
Pt is coughing a lot
A bit of confusion- says I don’t know a lot
MONITOR:
• BP= 85/55 to 93/70
• HR= high, then will come down
• T= 37.8
• SPO2= 87% to 92%
EXAM FINDINGS:
• Chest= coarse crackles
• Not fully conscious, examiner will tell you GCS
• E= opening to loud voice
• V= imcomprehensible sounds
• M= localise pain

IF A WELL PT IN THE HOSPITAL GETS PNEUMONIA- HAP

(INITIAL UTI, NOW PNEUMONI AND NOW BOTH OF THM ARE COEXISTING-
THEN MOST LIKELY DUE TO UROSEPSIS)
BOTH WILL STILL NEED ABCDE EXAM

WAS WAITING FOR CARERS IN HOSPITAL AFTER TX.

WAS ADMITTED 2-3 WKS AGO, WAS TX SUCCESSFULLY
BEING ASSESSED BY OCCUP THERAPIST, PHYSIO
WAS WELL AND WAS WAITING TO LEAVE, NOW HAS BEE SEEN TO HAVE PNEUMONIA

PC- CONFUSED- SO NOW HX NEEDED

HOW R U DOING? I A DR…

IVE BEE TOLD U R NOT FEELING WELL. HERE TO ASSESS U
MAY ASK U RANDOM QUEST- DO NOT IGNORE!!!!!!!!!!!!!!!!!

PT IS CONFUSED BUT STILL ALERT SO AVPU

OXYGEN- THIS IS O2, IT WILL HELP U FEEL BETTER

ATTEMPT TO TKE HX- PT IS CONFUSED AND CANT GIVE A HX- I WILL THEREFORE CHECK
GENERAL NOTES AND DRUG CHART FOR MEDS CAUSING CONFUSION
CHEST- CRACKLES- ABG, CHEST XRAY

CIRC- SINUS TACHY ON MONITOR

BP, TEMP, CRT,…
IV FLUIDS- DO FLUID CHALLLENGE!!!!!!!!!!!!!!!!!!!!!!! COS HE IS ELDERLY, THERE CD BE A
COEXISTING HEART PROB
D- ON AVPU SYSEM, ALERT
REVIEW TX
IF BP HASN’T IMPROVED, REPEAT ANOTHER FLUID CHALLENGE!!!!!!!!!!!!!!!!
SPO2 WILL STILL NOT IPROVE COS IT IS A PENUMONIA SO NO NEW INTERVENTION NEEDED,
UNTIL TX WITH ANTIBIOTICS, WILL NEVER BE NORMAL

EXPOSURE- ABD, LEGS

I ASSESSED…
SHE IS CONFUSED, HAD CRACKLES
NEED TO BE ADMITTED
I HAVE REQUESTED…
NEEDS IV ABX
DISCUSS WITH SENIORS FOR SECOND OPINION

SEPSIS-
COUUGHING+ HIGH FEVER+CONFUSED- COS OF HIGH TEMP, NEED PMOL, CHEST XRAY,
ROUTINE BLOOD TESTS, BLOOD C/S,
SPECIAL BLOOD TESTS- ABG, LACTATE, ABX
OXYGEN
IV FLUIDS
ABX

APPROACH (1063):
• GRIPS- Patient is confused and will not confirm details, so check
band. Ask how she is doing? Is she able to breathe? If she mumbles, still
verbalize that airway is patent
Excuse and check monitor
A- PUT ON NRM. Oxygen will improve
B- Chest Exam- crackles
Take hx of SOB, R/O ODPARA- of confusion ad SOB- uti, pneumonia,
dementia, HF, MAFTOSA
C- Pulse, CRT, A wide bore canula, Give fluid challenge- 500mls
D- Don’t forget 2 Check temperature- will be high, GCS cos of confusion,
glucose, pupils, Check drug chart to check for allergies to any ABx and
meds being given
 E- Expose

Speak to examiner ISBAR

• I’ve examined Mrs X
• She has SOB
• She has a temp, low sat, tachycardia
❖ There are also crackles on exam

DX: suspected Hospital acquired Pneumonia

MGT:
1. ABCDE, Cancel discharge
2. Sepsis 6 protocol- Labs- Lactate, Blood C/S, check urine output
3. High flow oxygen,
4. IV ATBx- Augmentin, IV fluids
5. PCM
6. CXR, Urine dipstick to r/o UTI
7. Review meds

HYPOGLYCEMIA
FY2, AMU, 75yo has become unresponsive. You have been asked to review the pt. Assess pt
and discuss mgt with examiner.
Special note: explain all you are doing to the examiner
Note in cubicle-PMHX= HPT, DM. Meds= amlodipine, glibenclamide
MONITOR:
• SPO2= normal
• BP= 149/90 MMHG
• HR= 112
• T= 37
**you’ll have different concentrations of IV fluids, oxygen mask, glucose tablets, cannula

PT IS UNRESPONSIVE, SO WILL ASSESS THE GCS

PT IS WITHDRAING FROM PAIN, OPEING EYES TO PAIN, NO SOUND( EXAMINER WONT GIVE
A FINDING FOR VERBAL AND IF MANNEQUIN IS NOT TALKING- ASSUME-1)
CALL ANAESTHETIST

RR AND OXYGEN- NORMAL

UNCONSCI- SO CANT TAKE A HX-

CHEST EXAM- NORMAL

C- OBSERV- NORMAL
GET AN IV LINE- SEND BLOODS
NO IV FLUIDS!!!!!!!!!!!!!!!!!!!!!!!!!!!! COS ALL ASSESSMENT IS NORMAL

D- GCS BEEN DONE ALREADY

PUPILS
CHECK GLUCOSE- 1.2
THE PATIENT HAS GOTTEN HYPOGLYCEMIA
CHECK TROLLEY- MAY SEE 50% OR 20 OR 10
75ML OF 20% GLUCOSE (CHOOSE THIS IF AVAILABLE)
I WILL GIVE 5 MINS FOR GLUCOSE TO WORK

Do exposure
IN THE MEANTIME, ILL BE ASSESSING UR TUMMY, LEGS,…
THEN REASSESS- TRY TO TALK TO PT- CAN U HEAR ME?

IF T IS STILL MUMBLING, GIVE REPEAT ANOTHER GLUCOSE

IF PT REMAINS CONFUSED- LOOK IN PATIENT NOTES- DM, INSULIN, GLICAZIDE

THEN TAKE HX- Incident hx, r/o 4 causes of hypoglycemia, PMHX, Meds, PMAFTOSA
• I’ll like to look at the patient’s notes- You’ll see the PMHx and Medications

****If the examiner asks you how to manage before you check the notes, say you wanna
see the notes first.

EXAMINER
• I will advice pt to eat something sugary- GIVE LONG ACTING CARB-
SANDWICH OR TOAST TO PREVENT REBOUND HYPO COS GLICAZIDE IS LONG ACTING
 • I will take a hx
a) Ask for sx of hypoglycaemia before becoming unconscious
b) Take MAM hx

• Observe for some hours. If pt is stable, he can go home

CANCEL DISCHARGE
WILL INFORM SENIORS THAT PT CANT BE DISCHARGED

Counsel on
a) Sx of hypo
b) How to prevent
c) Advice pt to carry surgery snacks on him
d) Refer to DM nurse and clinic
e) Follow-up with GP

APPROACH (1062):
• GRIPS
• Call the pt. Pt won’t respond
• Say I will like to check the airway- look for foreign bodies, swellings or any
deformities
• Examiner= there is an oropharyngeal/nasopharyngeal airway in place
• Breathing- go through full assessment
• Circulation- Go through full assessment- Set IV canula, send routine bloods,
check CRT, listen to the heart

Disability
• Check pupils and GCS-4
• Blood glucose
• Pick up glucometer and load the strip, pick up the lancet, come close to the
pt, don’t prick
 A.FIB- STABLE
PT
FY2, ED, Mrs Audrey Yates is a 60 year old lady who has presented with dizziness. Mrs
Yates is being represented with a high fidelity manikin. Assess the patient, give your
findings to the examiner and discuss management with the examiner.
PT INFO: Doctor, I am feeling dizzy for the last 6 weeks. She goes to the gym a lot. When
she goes to the gym she feels dizzy. On this occasion she fainted while she was in the gym.
She does not have any other symptoms. No PMHX, No DHx, No allergies. Used to work as a
school teacher, but now she is retired.
EXAMINER’S PROMPT: In this station you need to have a monitor (I pad on the wall) and
use a big manikin. ***it will show A.fib
EXAMINER’S QUESTIONS:
⁃ How will you manage this patient?
⁃ What is your assessment
Setup:
1. Stethoscope
2. The monitor
3. BNF
(Treat the manikin like a patient, Do not try and look at the examiner)
STABLE PT

APPROACH: GRIPS
• What brought you to the hospital?- Because the patient is feeling dizzy

• Let me have a look at the manikin

 1. O2: Normal
2. BP: Normal
3. HR: 135
4. ECG: Irregular heart beat

Have you ever been diagnosed with an irregular heart beat? Ever had a
heart condition?
You mentioned you are feeling dizzy, what do you mean? (Building spinning
or you feel faint and weak)

History taking Phase:

• ODPARA of dizziness
• DDX:
1. Anaemia (light headedness, dizziness, fatigued)
2. Hypoglycaemia
3. Postural hypotension
4. Malignancy (weight loss, fatigue)
5. Meniere’s Disease
6. Heart Problem (Valvular heart disease, IHD)
7. Stroke
8. ENT- BPV, vestibular neuritis

• P3MAFTOSA- smoking, drinking, coffee/tea

EXAM:
Start with hand
• Pulse- it’ll be irregularly irregular
Auscultate the heart
• Pt will have a pan systolic murmur in the mitral region
• Check any radiation to the axilla, if patient has an initial murmur
• Auscultate lung bases for basal crackles

❖ I can hear some Abnormal sounds in your chest so I will like to check Chest XRay n
ABGs
❖ COMPLETE DE

❖ Then ask the patient to dress up

❖ Tell them you will come back to explain the findings and what needs to be done next
 NO FLUIDS

EXAMINER:
a) I have just assessed Mrs Yates, she has presented with dizziness which usually
exacerbated by exercise
b) She is normally fit and well and no other medical problems.

c) Upon examination she has irregularly irregular pulse 112-135?

d) She has AF
e) On auscultation she has a pan systolic murmur
f) Murmur on the whole pericardium, loudest at the mitral region (radiation?)
g) Lung bases- she has coarse crackles

DX: LVF secondary to mitral regurgitation complicated by pulmonary edema

and a.fib

MGT:
1. ABC
• I will connect the monitors.

2. Investigation:
• Full Lead ECG, CXR,
• FBC, U&E, LFTs, ABGs
• Echocardiogram

3. Admit under medical team + Cardiologist consult. They will do an echo

4. Discuss with the seniors

5. Medications
a) Diuretics
b) Rate control= beta blockers, e.g propanolol
c) Rhythm control= digoxin
d) Anticoagulation (speak to seniors)
 UROSEPSIS
FY2, ED, 55yo, feeling unwell. Assess pt, discuss mgt with examiner
PT INFO: not feeling very well for past 3 days, feels generally weak.
PMHX- prostate problem, has a catheter, he was told he might need a surgery. Has had
catheter for 6 month. Not charged catheter in last 24 hours
MONITOR:
• T= 35.5/ 38.5
• P= 57
• BP= 100/70
• SPO2= 98% on RA
• RR= 14
Prostate exam= enlarged, smooth
urine bag with frothy urine

DOES NOT FEEL WEEL

WHAT OD U MEAN?
FEELS HOT N COLD***************MEANS AN INFECTION
PT IS RELATIVELY STABLE IF HR-90, T-38, SAT-97%- DO HX, EXAM, DX, MANAGEMENT
DO SYSTEMIC REVIEW- PNEMONIA, UTI, GASTRO, CARDIO- CHEST PAIN, PALP- CNS-
DIZZYNESS, HEADACHES, MENEING
JOINT PAIN- SPETIC ARTH, CELLULITIS

EXAM- EALL- CHEST, ABD, EXTERNAL GENITALIA, LEG

WILL SEE CATHETER- DRAINING BUT CLOUDY

IF OXYGEN IS LOW, THEN DO ABCDE

WHEN U FIND CATHETER, ASK- WHEN WAS CATHETER INSERTED, WHO INSERTED? LASTTIME
BAG WAS CHANGED? LAST TIME ACTHETER WAS CHANGED?- WILL SAY PROSTATE PROBS,
SURGERY HAS BEEN FOUND

EXPLAIN DX- HQAVE GOT URIE INFECTION WHICH IS NOW SPREADING TO REST OF BODY
TX- WILL GIVE IV LINE- GIVE 3 TAKE 3
OXYGEN IS NORMAL SO DON’T GIVE OXYGEN
ROUTINE BLOOD
SPECIAL BLOOD TEST- C/S, LACTATE, ABG
URINE SAMPLE
IV FLUID, ANTIBIOTICS
ADMIT UNDER MEDICAL TEAM, ONCE SPESIS HAS BEEN MAANGED, SPECIALIST WILL
REVIEW
CHNGE CATHETER

APPROACH: GRIPS
• I understand you are not feeling well/I feeling hot and cold sweats. What’s
bothering you?

• Let me look at the monitor

• Tell pt what you see

• ODPARA, DDX- UTI, Malignancy, Pneumonia, meningitis. Systemic review

• PMHx- Prostate hx will come up. Da4questions

• Complete MAFTOSA, ICE, JARSS

EXAM: Obs (monitor), Chest, ABD, PR (prostate), examine urine bag- cloudy urine (SO
ASK HOW LONG HAVE U BEEN CATHETERISED- 3weeks, WHO CATHETERISED
U? WHY WAS IT NOT CHANGED? WHEN WAS THE LAST TIME THE URINE BAG
WAS CHANGED?-24hrs)

Explain findings to pt- Enlarged but smooth symptoms, Cloudiness in urine bag
U r likely to have a waterworks infectin that has spread all over your body. And this infection
is due to the catheter
So I will first of all change the catheter for u

EXAMINER
o Present case- SBAR
o DX: Sepsis sec to UTI from prolonged catheterization

3. MGT:
• Blood workup- Routine blood, Urine C/S, including lactate and blood culture
1. lactate= 5.5 (normal= <1)
2. CRP= 35
3. WBC- normal or high

• Sepsis 6- Empiric ATBx, IV flluids

• Change catheter
 • Admit under medical team + Urology consult

• Inform senior

If hypothermic, give a blanket and warm fluids

CONFIRMING DEATH
FY2, oncology. 90yo M admitted to the hospital 10 days ago with end stage lung ca
Admitted 10/7, not responding to tx well. Nurse has noticed he’s become unresponsive so
called you to assess. Talk to nurse, assess pt, fill continuation sheet.
PT INFO: Pt not responding for the last 20 minutes. If you asked about obs, she’ll say she’s
switched off monitor.
SPECIAL NOTES:
• 2 folders on the table- DNAR and continuation sheet (pt notes
• On the table- spatula, pen torch, cotton wool, Steth, patella hammer.

APPROACH (1056): GRIPS nurse

• I understand you’d like to talk to me about a pt who has become
unresponsive

• Call out to pt- not responding – Check pt name on wristband

• What about vitals- I’ve switched off everything
• Is there a DNAR? Its on the table,You’ll go look at it

• Okay ill examine him

• I understand we were treating for lung ca, how was he
responding?
• Was he on EOL care?
• Was death expected?
Let me EXAMINE NOW:- IIRPVPPA
1. Identify the pt
• Check wristband, and notes

2. Verbal response
• Mr X, can you hear me?

3. Look for respiratory effort

• Verbalise to nurse- its absent

4. Painful stimuli
• Sternal rub/trapezius squeeze/supra-orbital pressure

5. Pupils- will be fixed and dilated

6. Carotid pulse

7. Auscultate
• Heart sounds - 2 minutes
• Respiratory sounds- 3 minutes

8. Gag reflex
• Use the gag reflex

9. Check for a pacemaker

• Palpate on the left side just under the clavicle
• The battery can explode if body is being cremated

9. Wash your hands

11. Ask nurse for the time to confirm the death

• Unfortunately Mr XYZ has passes away. Can u confirm the time of
death?
• I will now fill continuation sheet with the time and date he passed
 • YOU can inform the family, and I will also come and speak to them
• Lets arrange Transport to carry body to the morgue

12. Discuss with seniors regarding cause of death before signing the form.

ACUTE LIMB ISCHEMIA

FY2, ED, 57yo F, with leg pain. Take a hx, assess, discuss mgt with examiner.
PT INFO: Sudden onset of leg pain, right leg, 4 hours ago, has got some thumping
sensation in the chest. Smokes. Feels right leg is slightly numb. Not able to move leg or
walk
EXAM FINDINGS: Tender, dorsalis pedis pulse absent. ECG (monitor)= A. Fib, HR= ranges
from 92-135. BP, SPO2, T= all normal

PAIN IN LEG

Pt speaking- WILL BE A REAL PATIENT

• Look at monitor
• Comment on findings

SOCRATES- USUAL APPROACH HERE!!!!!!!!!!!!!AS PT IS STABLE, NO ABCDE

DDX OF LEG PAIN

DDX:
1. Trauma
2. Cellulitis
3. DVT
4. OA
5. ALI- no swelling, skin is cold, pale

PMAFTOSA- Heart dx, Intermittent claudication, Smoking

IN HX- ASK ABUT HEART PROBS HX- COS ON MONITOR U WILL SEE AFIB.
DURING HX, CN CHECK PULSE ALSO

ICE
THEN EXAMINE- TARGET THE 6PS
EXAM: legs, CVS

Legs:
Inspection
• Anterior
• Soles
• In between toes

INSPECTION
1. LOOK FOR PALLOR

PALPATION-
2. PERISHING COLD- CHECK BOTH FEET WITH HANDS Palpation
3. PAIN/TENDERNESS- PALPATE BOTH CALVES
4. PUSELESS- CHECK FOR DORSALIS PEDIS AND POST TIBILAIS. THEN CHECK CRT

5. PARAESTHESIA-
a) ASK PT WHETHER THERE IS TINGLING OR NUMBNESS IN THE LEGS.
b) LIGHT TOUCH- HANDS- Close your eyes, I’ll touch your legs, let me know if you
can feel it- use cotton, first touch on sternum n say that’s how it feels

6. PARALYSIS- ABLE TO MOVE LEG? can u move R leg up?

• Check femoral pulse

• Radial pulse- will be irregularly irregular
• Listen to the heart

I HAVE EXAMINED U. ON ONE LEG, THERE WAS PALLOR, COLD, PAIN ON PLAPATION,
PULSELESS DORS PEDIS AND POST TIB
OR
Today I assessed MR XYZ with acute onset of pain. There WAS PALLOR, PULSELESSNESS,
PARALYSIS AND A PERISHINGLY COLD LEG. HE HAS ALL THE 6PS OF ACUTE LIMB ISCHEMIA.
MY DX IS ACUTE LIMB ISCHEMIA SEC TO A-FIB

DIAGNOSIS-
 ● U HAVE ALI secondary to A.fib
● U HAVE AN IRREG HEART BEAT
● COS OF THIS, A CLOT HAS BEEN FORMED IN UR HEART
● HAS GONE TO UR LEG
● BLOCKED BLOOD SUPPLY TO LEG
● This can damage the tissues in the leg

● SERIOUS CONDITION
● WE NEED TO URGENTLY REFER U TO THE VASCULAR SURGE NOW!!!!!!!!!!!!!!!!
● TO PERFORM AN OP- EMBOLECTOMY TO REMOVE CLOT AND RESTORE BLOOD
● IF NOT DONE IN TIME, MAY LOOSE FOOT
● Later will be referred to the cardiologists for AF

PLAN-
● DON’T EAT OR DRINK ANYTHING- KEEP NPO
● WILL START FLUIDS- 1L over 12hrs
● GIVE PMOL/IBUPROFEN (NOT MORPHINE)- ANALGESIA
ECG?, NO INVEST SHD BE DONE- WILL ALL BE DONE BY SECIALIST- Doppler USG, ABPI

IF O2 IS 94 AND ABOVE, DO NOT GIVE O2

INTERMITTENT
CLAUDICATION- PAD
FY2, GP, 60yo M, appointment to see you. Has HPT, on Amlodipine. Talk to pt, take a
focused hx, address concerns
PT INFO: Pain in both legs- 6/12, mainly on the calf. R>L. 5/10. Gets pain usually when
walking, relieved with rest. Tried PCM but it didn’t help. Smokes. Drinks alcohol

***Obs= all normal

APPROACH: GRIPS- How may I help

• SOCRATES
• DDX:
 ❖ One leg or both

❖ Hairs loss on your legs

❖ Ulcers on leg

❖ Shiny skin

❖ Change in color of legs

❖ Muscles wasting

❖ pins and needles like feeling in your legs. ( Paraesthesia-PVD 6p)

❖ weakness in any or both your limbs?( Paralysis 6p)

❖ do you feel your leg is cold/ change in temperature / feels warmer? (

Poikilothermia-6p)
❖ chest pain, Dizziness, Heart racing (AF)

❖ Swelling on the back of your legs (DVT)

❖ Lower back pain radiating downward (SCIATICA)

❖ Swelling of the veins (VARICOSE VEINS)

❖ Trauma

1. Intermittent claudication- Gradual cramp-like pain in legs after walking a

predetermined distance (pt’s usually know how far they can walk before this
happens). Relieved at rest
2. ALI- Worse at rest

DDX-
a) Acute Limb Ischemia- skin colour changes, ulcers, sudden severe rest
pain which may be worse at night
b) Spinal stenosis- tingling, numbness
c) DM neuropathy
d) Trauma
LIFESTYLE, ICE, JARSS

EXAM: Obs, Legs, Chest, ECG, height to weight ratio

ABPI- Measures the BP in your ankle and compare this to the BP in your arm. The
pressure in your ankle is much different to that in your arm then this usually means that one
or more BVs going to your leg, or in your leg, are narrowed.

DX: Intermittent claudication- PAD- this happens due to narrowing of the BVs in
your legs which can compromise blood supply in your legs and cause pain in legs, calf, thighs
and buttocks

MGT:
1. Supervised exercise program
• Refer to supervised exercise centres
• They may ask you to exercise to point of maximal pain, rest, restart
• They’ll guide you
• They may suggest 2 options-
a. May do 2hrs a week for 3/12
b. Or 30mins of exercise 3-5x in a week

2. Refer to vascular surgeons

• Further investigations- Doppler USG- build up a map of your arteries and
show where they are narrowed
• May do angioplasty- a tiny balloon is inserted into the artery and blown up at
the section that is narrowed. This widens the affected segment of artery

3. Labs- routine, cholesterol, blood glucose

4. Offer QRISK assessment

5. Driving- Do not drive. inform DVLA if taxi or a professional driver

6. Stop smoking

1. Safety-net: if he has sudden severe pain, rest pain- ALI

2. Follow up in 1 week to discuss results
3. Leaflets

❖ CLOPIDOGREL is usually advised- helps to prevent blood clots forming in BVs.

❖ If you cannot take clopidogrel then alternative antiplatelet medicines such as LOW
DOSE ASPIRIN may be advised.
 ❖ A statin medicine is usually advised to lower your cholesterol level. This helps to
prevent a build-up of fatty patches (atheroma)

DDX- AF, VARICOSE VEINS , DVT, CELLULITIS , TRAUMA , SCIATICA

RISK FACTORS- SMOKING, DIABETES, OBESITY, HIGH BP , HIGH CHOLESTEROL, INCREASING
AGE
COMPLICATIONS- AMPUTATION, POOR WOUND HEALING, PAIN AND DISCOMFORT, STROKE

‼ATLS
PRIMARY SURVEY
• Approach with an ATLS walk (if patient has got no neck collar).
• Do in line immobilisation before you can speak to the patient.
• Introduce yourself and explain what you are going to do.
• Apply a neck collar (if the patient has got no neck collar).
• “Ideally I will do a triple immobilisation” (You will not be required to perform
a triple immobilisation in the exam.)
• I will give my patient high flow oxygen
• And I will ask my assistant to connect all the monitors and do a primary series
of Xrays (neck, chest, pelvis).

A = AIRWAY:
• Since my patient is speaking, his airway is patent.
• Can you open your mouth please? No foreign body or loose dentures
• The trachea is central.
• Ideally I will cut his clothes off with scissors. What should I do in this case?

B = BREATHING:
• Inspection: Take a deep breath in -chest movement is equal on both
sides(do this from the foot end).
• Bed side: Inspect for bruises, open wounds, chest deformity, flail chest,
paradoxical chest movement.
• Palpation: Tenderness on palpation and chest expansion is equal on both
sides.
 • Percussion: No hyper resonance or dullness on percussion.
• Auscultation: No reduced or absent breath sounds, no muffled heart
sounds.

C = CIRCULATION:
• No blood on the floor
• The peripheries are warm
• There is no pallor
• BP is 110/70 mmHg, heart rate 120. (There will be an observation chart in the
exam. You need to look for it.) My patient is tachycardic and normotensive. I
will get two wide - bore IV lines
• Take blood for: FBC, U+E, clotting, ABG, LFT, group and save, glucose
• Crossmatch 4 units
• I will give 2 litres of warm normal saline 0.9%

Abdomen:
Inspection:
• No bruises or open wounds
• No swelling
• No sign of internal bleeding
Palpation:
• I can appreciate there is tenderness on the left flank of my patient. I suspect
intra-abdominal injury.
• I will resuscitate the patient, arrange a CT-scan of the abdomen and refer the
patient to the general surgeon.
Percussion: Percuss for shifting dullness
Auscultation: Check for sluggish or absent bowel sounds

Pelvis:
• Inspection for deformity, swelling, bruises, open wounds
• Ideally I would look for perineal bruising, scrotal haematoma and urethral
meatus bleeding.
• Palpate for tenderness on the pelvis.
• Thigh: No deformity, swelling, bruises, open wounds

Tibia/fibula:
• No deformity, swelling, bruises or open wounds
NB: Do a spring test only if there is no tenderness on palpation and say, I will
document in the notes that a spring test has been performed. If there is
tenderness, do not perform a spring test.

DX: The diagnosis is pelvic fracture.

MGT: I will resuscitate the patient, apply a pelvic strap, perform a pelvic X-ray and call the
orthopaedic team for further management.

D= DISABILITY:
• Speak to the patient: Are you alright, Mr. White? Use (AVPU)
• My patient is alert.
• Check the pupils
• Check the capillary blood glucose

E= EXPOSURE:
• I will cover my patient with a blanket to prevent hypothermia.
• Tubes: I will put in a NG tube and a urinary catheter. Thanks, Mr. Jojo

SECONDARY SURVEY
How to start:
• I will take all the universal precautions and I will continue monitoring the
vitals of my patient throughout my examination. If he deteriorates at any time
I will go back and do ABCs again.

• Greet the patient and introduce yourself

• Take AMPLE history
A = Allergies to medication
M = Medication
P = Past medical history
L = Last meal
E = Events leading to the accidents.

A good start is:

 ❖ Doctor: Mr. Williams, I understand that you fell off a ladder.

❖ Patient: Yes, doctor.

❖ Doctor: I am sorry about that. Mr. Williams, I will be examining you from head to toe.
If you feel any discomfort at any time, please let me know.
❖ Mr. Williams, I need to cut your clothes so that I can examine you, is that alright?

1. Head: check for any wounds, bleeding.

2. Ears: bleeding or leaking of CSF (Otorrhoea).
3. Eyes: no raccoon eyes.
4. Nose: no bleeding or leaking of CSF (Rhinorrhoea).
5. Palpate for any nasal or facial fractures.
6. Mouth: foreign body, loose teeth and dentures or any missing teeth.
7. Trachea: central.

Breathing:
• Bedside: Inspect for bruises, open wounds, chest deformity and paradoxical
chest movement.
• Inspection: Take a deep breath in- chest movement is equal on both sides
(do this from foot end).
• Palpation: Chest expansion is equal on both sides.
• Percussion: No hyper resonance or dullness on percussion.
• Auscultation: No reduced or absent breath sounds, no muffled = heart
sounds.

Abdomen:
• Inspection: bruises, swelling and signs of internal bleeding
• Palpation: Tenderness, rigidity and guarding.
• Percussion: Shifting dullness
• Auscultation: Sluggish or absent bowel sounds

Pelvis:
• Inspection: bruises, swellings, open wounds or deformity.
• Ideally I would look for scrotal haematoma, perineal bruising and external
meatus bleeding.
• Palpate for tenderness
NB:
• Do a spring test only if there is no tenderness on palpation and say I will
document in the notes that a spring test has been performed.
• If there is tenderness, do not do a spring test, the diagnosis is pelvic fracture.

Treatment:
• I will resuscitate the patient, apply a pelvic strap, perform a pelvic X-ray
and call the orthopaedic team for further management.

• Thigh: Look for deformity, bruises, swelling, open wounds. NB: If there is
swelling - closed fracture of femur shaft.
• Resuscitate with normal saline 0.9%. (If the heart rate is high, mention this to
the examiner)
• Apply a Thomas splint
• X-ray of femur
• Give analgesia(morphine)
• Refer to orthopaedics
• Keep patient nil by mouth

If bandage- suspect open femur shaft fracture

Management:
• Clean wound
• Tetanus
• Antibiotics
• Take photographs of the wound
• Thomas splint
• Call the orthopaedic team for further management

***Tibia and fibula: Just like for a femur fracture it can be an open or closed tibia/fibula
fracture.
• Check for dorsalis pedis bilaterally and ask patient to wriggle his toes.

Exposure:
• I will cover my patient with a blanket to prevent hypothermia
• With the help of four people I will log roll the patient, examine the
spine, do per rectal examination and do a detailed neurological examination.
• I will also rule out a neck injury in my patient.
• NB: Neck injury is ruled out by clinical examination and x-ray of cervical spine
i.e. no tenderness on cervical spine processes and normal c-spine X-ray
 PULMONARY EMBOLISM
FY2, GP, 30yo F, p/c- SOB, Assess pt, discuss initial mgt with pt.
PT INFO: N.B- negative covid test today. SOB + Chest pain 4 hours ago, no relieving factors,
dull, no radiation, worse on inpiration, 8/10. No flu-like symptoms. Diagnosed with breast
ca 1 year ago, on chemo/ On OCPs for the last 3 years. Arrived from turkey 2 days ago,
flight was for 4 hours.
You live with your husband, you came with him, you’ll want him to drive you to the
hospital. The pain is killing me, just treat me
Observations:
• SPO2= 90
• HR= 97
• BP= 110/70
• RR= 30

APPROACH:
• GRIPS
• Pt will look SOB- Mention you would like to check vitals-
Comment- your oxygen level is quite low, I’d like to give you high flow oxygen
through a mask- Once you say this, pt is completely fine

P/C- SOB
• ODPARA
• Chest pain- SOCRATES,
• DDX- MI, PE, Pneumonia, Pericarditis
• PMAFTOSA

EXAM: Chest, Legs, ECG

DX: Pulmonary embolism- this means you have developed clots in your lungs-
explain her risk factors- Cancer predisposes to clot 4mation, COCP, Long flight

MGT:
1. Immediate hospital assessment
Ambulance- You can’t go with your husband cuz you can deteriorate at any
point

2. At the hospital
• Blood tests- D-dimer
• CXRay to exclude other causes
• CTPA

3. Treatment= blood thinners

• Usually for a long time- minimum of 3 months, then reassess
• Warfarin or Apixaban

U will stay in the hospital for about 1-2 days, then if everything goes well, u can go home

HEART FAILURE
● SOB- GIVE OXYGEN

TAKE HX OF DIZZYNESS

● DDX- SYSTEMIC REVIEW-

● UGIB-
● HEART PROBS-

EXAMINE CHEST- BILAT CRACKLES- DON’T MANAGE IMMED

● BP, PULSE. MONITR SHOWS A FIB WHICH SHOWS AN IRREG HEARTBEAT

● CHECK PULSE
● EXAMINE ALL 4, USUALLY MR ASSOCIATED
● ECG
● IV LINE- ROUTINE BLOODS
● NO IV FLUIDS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

● AVPU, PUPILS, GLUC

● REVIEW- OXYGEN HAS IMPROVED (ONLY THING U WD HVE DONE)
 ● EXPOSE- ABD, PRIVATE, LEGS, PALPATE CALF

FURTHER MANAGEMENT

● ON BREATHING HAD LOW SATS, RR- HIGH

● CHEST EXAM- CRACKLES

● BP- NORMAL BUT MONITOR SHOWS AFIB

● PULSE-IRREG
● HEART= PANSYSTOLIC, LOUDEST AT APEX

DX- MITRAL REGURG CAUSING LVF, LEADING TO PULM EDEMA, + A FIB

PLAN-

● WILL ENSURE ABCS ARE STABLE

● REER TO ACUTE MEDICAL TEAM
● WILL AWAIT ROUTINE- CHEST XRAY, ECG
● DISCUSS WITH SENIORS
● CARDIO REVIEW FOR POSSIBLE ECHO

● MAY GIVE U CHEST XRAY AND ECGS HERE- IF PUL EDEMA HAS BEEN CONFIRMED-
OPEN EMERGENCY TROLLEY AND GIVE FUROSEMIDE
● IF ECG SHOWS AFIB, GIVE RATE CONTROL MED- DIGOXIN (PREFERRED FOR
COEXISTING HF)

POST OP
PAIN
DR IM IN PAIN

● DO ABCDE- EVEN IF VITALS R NORMAL- COS PATIENT IS SYMPTOMATICALLY UNWELL

● B- NO OXYGEN COS IT IS NORMAL
● TAKE HX- DO SOCRATES- OF PAIN
● ASK ABOUT OPERATION
● PMHX- MEDS, ALLERGIES
● CHEST EXAM- CLEAR, NORMAL, SO NO MGT SO NO ABG, XRAY
● CIRCULATION- NORMAL- NO NEED FOR CRT AS BP AND P RE NORMAL
● AUSCULTATE ONLY AT APEX
● STILL DO ECG

● ABD, GENITALIA- AS IT IS POST OP- LOOK AT WOUND DRESSING- PAIN

● LINE. SEND BLOOD TESTS
● NO IV FLUIDS

● D- AVPU, GLUCOSE, PUPILS, NO TX OFFERED SO NOTHING TO REVIEW

● LEGS- INSPECT AND PALPATE

● I HAE ASSESSD U AND U HAVE TUMMY PAIN AFTER SURGERY. I HAVE EXAMINED
EVERYWHERE ELSE AND THERE IS NOTHING LIFE THEATENING ATM
● SINCE THE PAIN IS SEVERE- I WILL BE GIVING MORPHINE 5mg oral every 4hrs when it
is required
● WILL INSTRUCT THE NURSES to give it to u immediately