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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