For Examiner Only
For Examiner Only
Case GI bleed Jehovah Witness
Author- Linda Herman, MD Reviewer; Mike Cassara, MD Approved; 10/25/05
ORAL CASE SUMMARY
CORE CONTENT AREA
2.0 – Abdominal and Gastrointestinal Disorders
SYNOPSIS OF CASE
This case involves a 62-year-old woman who presents after becoming near syncopal while at church. The near-syncope was caused by hypotension due to a GI Bleed, which began 2 days ago. She has had black stools and nausea for 2 days but just before she became hypotensive at church she passed bright blood into the toilet. She has a history of hypertension and osteoarthritis and has been taking naproxen recently. The patient is a Jehovah’s Witness and will not allow a blood transfusion in spite of her brisk bleeding. The candidate must start 2 large bore IV’s and give fluids, pass an NG and note the return, order a Hgb, respectfully discuss blood administration with the patient. When the patient will not accept a transfusion, the candidate must contact a gastroenterologist to perform an emergency endoscopy and attempt an intervention and then admit the patient to the ICU.
SYNOPSIS OF HISTORY
The patient was at Kingdom Hall attending services when she went to the bathroom. She passed bright red blood per rectum. When she returned to the pews she was cool and clammy. She felt lightheaded and had to lie down on the floor. The paramedics were then called. She has never had GI bleeding before but she takes a NSAID for her osteoarthritis. She also has hypertension treated with hydrocholothiazide and sustained release nifedipine.
SYNOPSIS OF PHYSICAL
Exam reveals weak & thready peripheral pulses, delayed capillary refill, tachycardia, and a decreased blood pressure on arrival. There is no chest pain, shortness of breath or abdominal tenderness. The rectal reveals bright red blood.
CRITICAL ACTIONS
1. Orders two large bore IV’s to be placed & administers a fluid bolus (PS, PC)
2. Places NG & notes type & color of fluid obtained (DA, PC)
3. Orders Hgb/Hct (DA, SBP)
4. Respectfully discusses with patient decision about refusing blood (IP)
5. Consults Gastroenterologist for emergency endoscopy & intervention (Prof)
6. Admits patient to ICU (PC)
FOR EXAMINER ONLY
For Examiner Only
SCORING GUIDELINES
(Critical Action No.)
1. The IV’s must be placed and the fluid bolus given during the ABCs of the case
Score down if the candidate must be prompted by giving a lower blood pressure.
2. Score down if the candidate must be prompted by the nurse to place an NG more than twice or the patient has vomited blood before the candidate remembers to order an NG. Score down if the candidate does not ask what is the color and amount of return from the NG.
3. Score down if the candidate must be prompted to order the Hgb.
4. Score down if the candidate does not discuss the transfusion with patient in spite of the patient informing the candidate that she is a Jehovah’s Witness and will not accept blood. Score down if the candidate ignores her religious preferences during the conversation about the blood. Score higher if the candidate is sensitive to the patient’s wishes but explains that she is risking her life by refusing the blood transfusion.
5. Score up if the candidate offers alternative treatment to the patient, such as H2-
blocker, proton pump inhibitor, octreotide infusion, and possible procedure by
gastroenterologist to stop the bleeding.
6. Score down if the candidate does not call a gastroenterologist before admission.
7. Score down if the candidate chooses a telemetry bed instead of the ICU.
PLAY OF CASE GUIDELINES
(Critical Action No.)
1. The IV’s must be placed and a fluid bolus given after airway and breathing in the primary exam (airway adequate but pulse oximeter is 93% due to anemia and patient should receive 100% O2) and during the circulation in the primary exam and before any secondary exam.
1. If the candidate does not give a fluid bolus the nurse reports a lower blood pressure and then mentions the cool and clammy skin.
2. The NG may be ordered and placed after the secondary exam.
2. If the candidate fails to order the NG then the patient vomits blood.
2. When NG is placed the candidate should ask what color the return is. The candidate is told that the return is bright red blood that does not clear
3. The Hgb/Hct can be ordered anytime after the Candidate realizes that the patient is bleeding.
PLAY OF CASE GUIDELINES
(Critical Action No.)
4. The Candidate may order the H/H and type and cross at any time but must talk to the patient about the administration of blood before ordering any blood to be given. The discussion can occur before the Hgb results are reported.
4. The patient informs the candidate that she is a Jehovah’s witness and will not accept
any blood products even she will die.
5. The candidate offers alternative treatment to patient and orders appropriate
medications.
5. The Candidate must consult the gastroenterologist after obtaining the results of the NG, Hgb results and the discussion with the patient about blood. The gastroenterologist must be consulted before the patient is admitted.
5. The gastroenterologist agrees to see the patient and perform an emergency endoscopy.
6. The candidate then arranges for an ICU bed for the patient.
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1. Orders two large bore IV’s to be placed &
administers fluid bolus in response to vital signs
This critical action is met by the candidate ordering two IV’s and administering a 500 – 1000 bolus of normal saline or lactated ringer’s.
Cueing Guideline: Cueing Guideline: If the candidate fails to assess circulation status the nurse should verbally mention the blood pressure and diaphoresis. If the candidate fails to treat the blood pressure, the nurse should first mention the blood pressure and then ask what would the Candidate like to the nurse to do?
2. Places NG & notes amount & color of fluid obtained.
This critical action is met by the candidate ordering the NG and asking the nurse the color and amount of fluid obtained.
Cueing Guideline: If the candidate fails to order a NG the nurse should first ask the candidate if the Candidate wants the nurse to do anything else. If the Candidate doesn’t order the NG then the nurse should tell the Candidate that the patient is feeling nauseated with epigastric burning. If the Candidate still doesn’t order the NG then the nurse should tell the Candidate that the patient just vomited a small amount of blood.
3. Orders Hgb/Hct
This critical action is met by the candidate ordering Hgb/Hct.
Cueing Guideline: If the Candidate does not order Hgb/Hct, the nurse should ask the candidate what labs would the Candidate like ordered. If the Candidate still does not order Hgb/Hct then the nurse should state that she is sending the blood to the lab and what tests would the Candidate like to be ordered on that blood. If he does not still does not order the Hgb/Hct the nurse should just order the lab and give the Candidate the result at which point the Candidate would not have passed this critical action but the candidate would still be able to continue the case.
4. Respectfully discusses with patient decision about refusing blood.
This critical action is met by the candidate discussing with patient the risks and benefits of refusing a blood transfusion. Must be done in an empathetic manner without belittling the patient’s religious beliefs.
Cueing Guideline: If the Candidate orders a blood transfusion without speaking to the patient the nurse should tell the Candidate that the patient was asked to sign the consent for blood transfusion and refused. At that time the Candidate should speak to the patient. If the Candidate does not elect to speak to the patient the nurse should tell the Candidate that she can not give the blood unless the consent is signed. If the Candidate makes the suggestion that he will sign the consent as an emergency procedure the nurse should state that she has taken care of these patients before and blood has never been given without a written consent from the family or the patient in this situation.
5. Consults Gastroenterologist for emergency endoscopy & intervention.
This critical action is met by the candidate discussing case with a gastroenterologist and requesting an emergency endoscopy.
Cueing Guideline: If the Candidate can not decide how to stop the bleeding and has not talked to the patient, the nurse should remind the Candidate that the irrigant will not clear and is there something else that could be performed. If the Candidate still does consult a Gastroenterologist, the nurse should make the statement, “the last time I had a case like this the patient went to the Endoscopy Lab.” If the candidate does not consider endoscopy at this point then it should be considered that the Candidate did not perform the critical action.
6. Admits patient to the ICU.
This critical action is met by the candidate asking for ICU bed and discussing the case with the intensivist.
Cueing Guideline: If the candidate does not admit the patient, the nurse should ask the candidate to which unit does the candidate want the patient admitted. If the candidate chooses a general bed or a telemetry bed then the nurse should make mention, “with all that bleeding?”
For Examiner Only
History Data Panel
Onset of Symptoms: Nauseated and passing black stools for two days. Bright red blood per rectum just prior to arrival which was followed by cool and clammy skin, lightheadedness and near syncope.
Description of Complaint: Near syncope while at church. Went to the bathroom and passed bright red blood. Was able to return to her seat but became faint and had to lie down on the floor. Nauseated but no vomiting. Denies chest pain, shortness of breath, abdominal pain.
Past Medical History
Surgical: cholecystectomy 5 years ago
Medical: hypertension and osteoarthritis
Injuries: none
Allergies: None
Habits
Smoking: None
Drugs: None
Alcohol: None
Family Medical History
Father: HTN, died at age of 78
Mother: HTN, CVA, alive, is 82 years of age
Siblings: sister with HTN but in good health, brother killed in a car accident at age of 44
Social History
Married: unmarried
Children: has one son who is on vacation
Employed: secretary at an advertising firm
Education: graduated high school, has completed technical training for career
Religion: active Jehovah’s Witness
For Examiner Only
Physical Data Panel
Patient: 62 year old woman Patient Name: Margaret Jones
General Appearance: short stature, slightly overweight, looks her stated age
Vital Signs:
BP : 82/66
P : 122
R : 16
T : 97.9 orally
Head: atraumatic, normocephalic
Eyes: pupils midrange & equally reactive, pale conjunctiva
Ears: tympanic membranes clear
Mouth: pharynx clear
Neck: supple, nontender, no lymphadenopathy, no thyroidomegaly
Skin: cool, diaphoretic, no rashes, good turgor
Chest: breath sounds clear, chest excursion equal, no respiratory distress
Heart: apical regular, normal heart tones, tachycardic, peripheral pulses palpable and symmetrical but weak
Abdomen: soft, rotund, very active bowel sounds, no organomeglay, no bruits, no masses, nontender
Extremities: no cyanosis, clubbing, or edema, capillary refill of 4 seconds
Rectal: nontender, good tone, bright red blood in the rectal vault
Pelvic: Normal
Neurological: Normal
Mental Status: Alert & oriented
For Examiner Only
Lab Data Panel
|Stimulus #3 – Hematology |VERBAL REPORTS |
|Complete Blood Count |Pulse oximeter – 93% on room air |
|WBC 9.2/mm3 |Pulse oximeter – 100% on NRB |
|Hgb 6.2g/dL | |
|Hct 18.6% |Stool guaiac - positive |
|Platelets 156/mm3 | |
|Differential | |
|Segs 58% | |
|Bands 2% | |
|Lymphs 28% | |
|Monos 10% | |
|Eos 4% | |
| | |
| | |
|Stimulus #4 – Chem-7 | |
|Na+ 142mEq/L | |
|K+ 4.0mEq/L | |
|CO2 26mEq/L | |
|Cl- 99mEq/L | |
| | |
|Glucose 181mg/dL | |
|BUN 54mg/dL | |
|Creatinine 1.4mg/dL | |
| | |
| | |
| | |
|Stimulus #5 – PT/PTT | |
|PT 10.7 | |
|INR 0.91 | |
|PTT 28.1 | |
| | |
For Examiner Only
Stimulus Inventory
# 1 Emergency Admitting Form
# 2 Cardiac Monitoring Strip
Lead II strip revealing Sinus Tachycardia, rate 125/min
# 3 Complete Blood Count
# 4 Chem - 7
# 5 PT/PTT
# 6 12 Lead EKG
Sinus Tachycardia
FOR EXAMINER ONLY
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name : Margaret Jones
Age : 62 years
Sex : Female
Method of Transportation : ambulance staffed with 2
paramedics
Person giving information : patient
Presenting complaint : near-syncopal episode
after passing bright red blood per rectum
Background: Patient was at the neighborhood Kingdom Hall when she felt weak and lightheaded after going to the bathroom. She was allowed to lie on the floor and the paramedics were summoned.
Vital Signs (per paramedics)
BP : 70/32
P : 112
R : 18
T : not taken
Stimulus # 2
Stimulus # 3
Hematology
Complete Blood Count S.I. Unit
WBC 9.2/mm3 9.2 X 109/L
Hgb 6.2g/dL 62 g/L
Hct 18.6% 0.186
Platelets 156,000/mm3 156 X 109/L
Differential
Segs 58% .58
Bands 2% .02
Lymphs 28% .28
Monos 10% .10
Eos 4% .04
Stimulus # 4
Chem-7 S.I. Units
Na+ 142mEq/L 142 mmol/L
K+ 4.0mEq/L 4.0 mmol/L
CO2 26mEq/L 26 mmol/L
Cl- 99mEq/L 99 mmol/L
Glucose 181mg/dL 10.05 mmol/L
BUN 54mg/dL 19.3 mmol/L of urea
Creatinine 1.4mg/dL 123.2 umol/L
Stimulus # 5
PT/PTT
PT 10.7
INR 0.91
PTT 28.1
Stimulus # 6
12 Lead EKG
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