Hypotensive patient scenario 2

candidate brief 1 min

Mr Freeman has come in feeling generally unwell with vomiting. One of the SHOs initially reviewed this patient but notes his BP has not improved after 1L of crystalloid and asks you to review. The SHO is a competent but inexperienced doctor who is available to help.

actor/facilitator brief

Mr Freeman is a 65yo man brought in by ambulance. He has been vomiting with abdominal pain for the last 2 days. He has not opened his bowels for 3 days which he attributes to not having eaten. He has had difficulty

PMH: COPD, polymyalgia rheumatica, previous appendicectomy
DHx: prednisolone,
NKDA

He lives alone, walks with a stick

examiner brief

On arrival:
Patient in pain
RR 28
SpO2 99%
HR 110
BP 80/40
Temp 35C
Glucose 2.8
GCS 15/15

O/E
Chest clear
Abdo exquisitely tender with guarding

Candidate can ask for help but ICU is tied up on the unit and won't be available for 20 minutes.

  • Introduces self, confirms patient identify, washes hands
  • Dons PPE
  • Takes handover and appropriate history
  • A/B – applies oxygen
  • C – IV access, cultures and bloods inc VBG
  • Gives fluid bolus of 500ml crystalloid and re-assess
  • Recognises possible cause of fluid-resistant hypotension
  • Gives 100mg hydrocortisone IV
  • D – GCS, glucose
  • E – Abdominal examination
  • Checks medications, allergy status
  • Explains differentials
  • Functional baseline and establish appropriate escalation status
  • Plans for disposition of patient - decision for critical care
  • Plans for further investigations, inotropes
  • Leads team well
  • Plans for further appropriate investigations

acute abdomen + Addisonian crisis

#mrcem-osce