For Examiner Only



For Examiner Only

Case PL2

Author Paris Lovett Reviewer Jim Ritchie Last updated 12/19/05

ORAL CASE SUMMARY

CONTENT AREA

2.8 Small Bowel Motor Abnormalities - Obstruction

SYNOPSIS OF CASE

56 year-old male presents with vomiting and abdominal discomfort for 16 hours. He has had previous surgery, but he also has an incarcerated hernia which must be sought out. The patient is wearing trousers and the hernia is not seen unless these are removed. KUB shows SBO. The hernia can be reduced, either by the EP or by a surgery consult. The patient should receive IV fluids, nasogastric suction, analgesia, and be admitted for observation. The examinee should discuss the possibility of a strangulated loop with the surgical consult.

SYNOPSIS OF HISTORY

56 year-old philosophy professor, vomiting from yesterday. This has never happened before. Multiple confounding factors: he has an alcohol history; has had pancreatitis; gallstones; and an appendectomy.

SYNOPSIS OF PHYSICAL

He is volume depleted, oliguric and tachycardic. Distended diffusely tender abdomen, no guarding or rebound. Upon removal of trousers and groin examination a tender right inguinal hernia will be located. The hernia can be reduced either by the Emergency Physician or surgical consult.

CRITICAL ACTIONS

1. Analgesia

2. Nasogastric Tube

3. Intravenous Fluids (minimum 2 liters, and ensure adequate resuscitation)

4. Recognition of Hernia

5. Reduction of Hernia

6. Discuss possibility of strangulation with surgical consult

7. Admit patient

SCORING GUIDELINES

(Critical Action No.)

FOR EXAMINER ONLY

For Examiner Only

Case PL2

PLAY OF CASE GUIDELINES

(Critical Action No.)

The patient volume depleted and anuric, and requires fluid resuscitation, a minimum of 2 liters before vitals normalize or any urine is produced. Subsequent monitoring of vital signs and urine output are important. Delivery of analgesia and placement of nasogastric tube are also important - vomiting and groans of pain will continue if these are not attended to. The patient has not been fully disrobed by the nursing staff, so is wearing trousers and a hospital gown. If the examinee does not ask to remove the trousers, the hernia will not be noted, or will be found only on CT. The examinee must recognize the hernia as the cause of the obstruction. The hernia must be reduced manually by the examinee or a surgery consult. In view of the prolonged incarceration and obstruction of the hernia, candidates who order serum lactate and/or CT scans after reduction will receive extra credt. The examinee should arrange for the patient to be admitted, and should raise the possibility of a strangulated loop with the surgical consult. Acquiring data on things such as alcohol history, potential for withdrawal, pancreatitis, surgical history all win extra points.

FOR EXAMINER ONLY

For Examiner Only

Case PL2

Critical Actions

1. Analgesia

This critical action is met by Intravenous analgesia

Cueing Guideline: Late in the case, a nurse can tell the examinee that the patient is groaning

2. Nasogastric Tube

This critical action is met by Inserting a nasogastric tube

Cueing Guideline: The patient continues to vomit despite anti-emetics

3. Intravenous Fluids (minimum 2 liters, and ensure adequate resuscitation)

This critical action is met by At least 2 liters of crystalloid

Cueing Guideline: The patient will remain tachycardic and oliguric until 2L fluids given. Insertion of a Foley catheter and ensuring adequate urine output help achieve this action.

4. Recognition of Hernia

This critical action is met by Removing patient's trousers, and inspecting groin area for hernias

Cueing Guideline: Patient "vomits all over his trousers"

5. Reduction of Hernia

This critical action is met by Manual reduction by examinee or consult (with description)

Cueing Guideline: Patients pain and vital signs will not improve without reduction

6. Discuss possibility of strangulation with surgical consult

This critical action is met by Discussing with the sugical consult that even after reduction, there may be an ischemic loop, and the patient should be admitted for serial exam

Cueing Guideline: Surgical service wants to discharge patient home once hernia reduced and vitals normalized

7. Admit patient

This critical action is met by Arguing for admission for observation

Cueing Guideline: Surgical service wants to discharge patient home once hernia reduced and vitals normalized

For Examiner Only

Case PL2

History Data Panel

Age: 56 Sex: Male Name: Thomas Hobbes

Method of Transportation: Private Car Person giving information: Patient and wife

Presenting complaint: Abdominal Pain and Vomiting

Onset and Description of Complaint: Generalized abdominal pain and distension and frequent vomiting, progressing from food to yellow liquid to dry retching

Past Medical History

Allergies: NKDA

Medical: Pancreatitis (one episode, ten years ago)

Surgical: Gallstones (no surgery); appendectomy

Last Meal: 12 hours ago, toast, vomited it up

Habits

Smoking: 10 pack-year history, stopped 15 years ago

Drugs: None

Alcohol: 3-4 glasses brandy each night; previously heavier

Family Medical History

Father: Died. MI at 75

Mother: Alive. Has HTN, at 77.

Siblings: One, died at 18 in MVA.

Social History

Married: Yes

Children: None

Employed: Philosophy Professor

Education: PhD

PMD: Dr. David Hume

For Examiner Only

Case PL2

Physical Data Panel

General Appearance: Unwell, but alert and co-operative

Vital Signs:

BP : 95/60

P : 105

R : 20

T : 98.5

O2Sat : 97%

Glucose : 90

Neurological: Normal speech, cranials, peripheral exam

Mental Status: AO3

Head: Normocephalic

Eyes: PERRL EOMI

Ears: Normal

Mouth: Dry

Neck: No JVD

Skin: Cool

Chest: CTA B/L

Heart: S1-S2 + nil

Abdomen: Distended, tympanitic, loud bowel sounds. Generalized tenderness. No guarding or rebound. THE PATIENT IS WEARING TROUSERS AND UNLESS THE EXAMINEE ASKS TO REMOVE THESE AND EXAMINE THE GROIN, THE HERNIA WILL NOT BE EVIDENT. If inguinal region is examined, there is a right inguinal hernia. This is tender, no overlying skin changes. It is reducible with a serious attempt.

Extremities: No cyanosis, clubbing or edema

Rectal: No gas, brown stool, guaiac negative

Pelvic: N/A

Back: Normal, with no CVAT

Other exam findings:

For Examiner Only

Case PL2

Lab Data Panel

|Stimulus #2 – CBC |Stimulus #5 – |

|WBC 9,000 /mm3 | |

|Hgb 13 g/dL | |

|Hct 39 % |Stimulus #6 – |

|Platelets 220 /mm3 | |

|Differential |Stimulus #7 – |

|Segs % | |

|Lymphs % |Stimulus #8 – |

|Monos % | |

|Eos % |Stimulus #9 – |

| | |

| |Stimulus #10 – |

|Stimulus #3 – Chemistry | |

|Na+ 140 mEq/L |Stimulus #11 – |

|K+ 4.2 mEq/L | |

|HCO3- 20 mEq/L |VERBAL REPORTS |

|Cl- 105 mEq/L |KUB - mulutiple fluid levels, no distal gas |

|Glucose 95 mg/dL | |

|BUN 30 mg/dL |CT Abdo + Pelvis - SBO. No ischemic loops if this is performed after |

|Creatinine 1.1 mg/dL |reduction of the hernia. |

| | |

| | |

|Stimulus #4 – Urinalysis | |

|Color Yellow | |

|Sp Gravity 1.050 | |

|Glucose Negative | |

|Protein Negative | |

|Ketone Positive | |

|Leuk. Est. Negative | |

|Nitrite Negative | |

|WBC /HPF | |

|RBC /HPF | |

For Examiner Only

Case PL2

Stimulus Inventory

Stimulus #1 – Emergency Admitting Form

Stimulus #2 – CBC

Stimulus #3 – Chemistry

Stimulus #4 – Urinalysis

Stimulus #5 –

Stimulus #6 –

Stimulus #7 –

Stimulus #8 –

Stimulus #9 –

Stimulus #10 –

Stimulus #11 –

FOR EXAMINER ONLY

Mock Oral Feedback Form – ABEM model

Case PL2 Date: Examiner: Examinee:

Data acquisition

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Problem solving

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Patient management

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Resource utilization

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Health care provided

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Patient Interpersonal relations

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Comprehension of path physiology

Worst 1 2 3 4 5 6 7 8 Best

NOTES

Clinical competence (overall)

Worst 1 2 3 4 5 6 7 8 Best

NOTES

|Critical Actions | |Dangerous actions and omissions |

|1. Analgesia |( | |

|2. Nasogastric Tube |( | |

|3. Intravenous Fluids (minimum 2 liters, and ensure adequate resuscitation) |( | |

|4. Recognition of Hernia |( | |

|5. Reduction of Hernia |( | |

|6. Discuss possibility of strangulation with surgical consult |( | |

|7. Admit patient |( | |

FOR EXAMINER ONLY

Mock Oral Feedback Form – Core Competencies

Case PL2 Date: Examiner: Examinee:

| |Does not meet expectations |Meets Expectations |Exceeds Expectations |

|1. Patient care | | | |

|2. Medical knowledge | | | |

|3. Interpersonal skills and | | | |

|communication | | | |

|4. Professionalism | | | |

|5. Practice-based learning and | | | |

|improvement | | | |

|6. Systems-based practice | | | |

|Critical Actions | |Dangerous actions and omissions |

|1. Analgesia |( | |

|2. Nasogastric Tube |( | |

|3. Intravenous Fluids (minimum 2 liters, and ensure adequate resuscitation) |( | |

|4. Recognition of Hernia |( | |

|5. Reduction of Hernia |( | |

|6. Discuss possibility of strangulation with surgical consult |( | |

|7. Admit patient |( | |

FOR EXAMINER ONLY

Stimulus #1

Case PL2 ABEM General Hospital

Emergency Admitting Form

Name : Thomas Hobbes

Age : 56

Sex : Male

Method of Transportation : Private Car

Person giving information : Patient and wife

Presenting complaint : Abdominal Pain and Vomiting

Background:

Vital Signs

BP 95/60

HR 105

Case PL2

Stimulus #2 – CBC

WBC 9,000 /mm3

Hgb 13 g/dL

Hct 39 %

Platelets 220 /mm3

Differential

Segs %

Lymphs %

Monos %

Eos %

Case PL2

Stimulus #3 – Chemistry

Na+ 140 mEq/L

K+ 4.2 mEq/L

HCO3- 20 mEq/L

Cl- 105 mEq/L

Glucose 95 mg/dL

BUN 30 mg/dL

Creatinine 1.1 mg/dL

Case PL2

Stimulus #4 – Urinalysis

Color Yellow

Sp Gravity 1.050

Glucose Negative

Protein Negative

Ketone Positive

Leuk. Est. Negative

Nitrite Negative

WBC /HPF

RBC /HPF

Case PL2

Stimulus #5 –

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