DAY 15

TALKING SIMMANS

MGT OF ACUTE Pt

- they will tell u that covid test negative

- greet examiner
- assume u have taken universal precaution for acutely ill pt - PPE
- demonstrate ur knowledge and skills
- u need a RUNNING COMMENTARY
- assessment is TEAM WORK
- ur findings and plan of action needs to be communicated

2 TYPES OF SCENARIOS

UNSTABLE PT - low SPO2, low BP, pt confused, LOC – ABCDE approach

- bleeding – post-op hypotension, Upper GI bleeding, PPH

- sepsis - hospital acquired pneumo with confusion + UTI

- SOB - Asthma

- Anaphylaxis – penicillin allergy, blood transfusion, or both

- Hypoglycaemia

- dizziness with HF

HAEMODYNAMICALLY STABLE – take hx, examine, discuss mgt with examiner or pt

 Urosepsis
 acute limb ischaemia

Violet are the common onces that are coming in PLAB2

ABCDE – always talking to the pt in every step

MONITOR – ALWAYS START BY LOOKING

AIRWAY – pt talking then airway is patent

  call out the pt - hello mr johnson, my name is dr jallow am one of the drs - can u hear me - i
understand ur not feeling very well - wat is wrong with you
 TELL UR TEAM - MY Pt IS SPEAKING SO AIRWAY IS PATENT

BREATHING – RR + O2 sats – maintain oxygenation and ventilation

 LOOK at the MONITOR - okay let me look at ur monitor – you ll see findings - O2 saturation -
my pt has an O2 saturation is 92 which is low and RESPIRATORY RATE - my pt's RR is 32 which is
quite high
 TAKE ACTION - see the CRASH/EMERGENCY TROLLEY - diff fluids, mask, coloured cannula,
glucometer, IV meds in syringes, glucose prickers, meds – BB, digoxin, salbutamol, diuretics,
adrenaline, hydrocortisone
 walk to the trolley - get the right Non Re-breather Mask (NRM) - Mr johnson i would like to give
u the mask to help with the breathing - do u have a condition called COPD - or do u have
SMOKERS COUGH – (2-4L/min) – target SPO2 88-92%
 Intervene immediately if u suspect hypoxia - HIGH FLOW O2 - 15L/min via non rebreathing
mask/bag (NRM)
 tighten the bands and ask can u please breath thru the mask
 LOOK AT THE MONITOR TO SEE IF THE SATS IMPROVING
 how are u feeling now - any better

WINDOW for focused hx

 ODPARA, DDs, focused MAFTOSA, Previous operations

 LOOK AT THE WRIST BAND for allergies – anaphylaxis
 STOP BLOOD TRANSFUSION – if pt complains of SOB/u see rash later
 Look at the emergency trolley – quick look just to acknowledge its presence
 Review pts notes & Drug charts (some meds cause confusion or LOC) in confused &
unconscious pts – Hypoglycaemia & HAP
 Post-op notes – Post-operative hypotension

FULL CHEST EXAMINATION – mr brown I need to examine ur chest, do it for real, any pain in ur chest
  INSPECTION (Chest is NORMAL, no abnormalities seen) - I would like to expose and
examine ur chest, I will provide u with a chaperone
 PALPATION – DO YOU HAVE ANY PAIN IN YOUR CHEST – comparison palpation (6 areas)
2 supra-mammary, 2 infra-mammary, & lung bases, trachea if central
 PERCUSSION – 6 areas – in comparison pattern, include the bases
 AUSCULTATION OF ONLY ANTERIOR CHEST (same 6 areas) – I could hear WHEEZING - u
may be having an ASTHMA. Take ur time and listen, do it for real. Listen to pick up the
findings

MGT

 I will give u a medication call 5mg nebulized salbutamol – CHANGE THE MASK – say u will give
5mg nebulized salbutamol driven by OXGEN via nebulizer mask
 I would like to other a CXR and ABG - they might give u the CXR and lab results
 If there is nothing say chest is clear

CIRCULATION

- LOOK AT THE MONITOR AGAIN – HR, BP, ECG

- HR - tachycardic or bradycardic or normal

- BP - say wat u see - if BP is low

 BP systolic <90/60 OR
 if pt needs CPR, put 2 large bore cannula on both hands

- CRT – press for 5sec it should refill in 2 secs (only if BP is LOW)

- Skin temperature (shock) – hands and foot

- look for cyanosis – skin colour

- radial pulse - regular or irregularly - irregular

- CVS EXAM – LISTEN TO THE HEART – only listen to apex, if you suspect heart condition listen to all 4
areas
- TEST TO ORDER – FULL LEAD ECG (tracing of your heart) – shows normal sinus rythm, or sinus
tachycardia – bleeding pt or AF – dizziness

- BLEEDING OR POST-OP PTS (include in circulation) – abd exam (ok mr brown I need to examine your
tummy now, I will be exposing you, please just bear with me) – inspect & palpate, look at
private/genitals – I need to have a look at your private area – please just bear with me. Check for PV
bleeding, catheter, rashes – eg saying I can see you have a catheter and its draining urine – adequate or
not (urine output). In anaphylaxis – sometimes rash present in the genitalia and not chest

MGT – Low BP – LARGE BORE CANNULA

 Pick cannula: Orange (14G)> Grey (16G)> Green (18G)>Pink (20G)

- IV cannula – 2 large bores – gauge of cannula
- send all routine bloods, U&Es, clotting profile, Group & Save & cross-match 2 units of blood
- IV fluids – pick up and hang on the stand
- 1L of N/S 0.9% as fast as possible in BLEEDING SCENARIOS + ANAPHYLAXIS using biggest of the
available cannulas
- Fluid challenge - 500mls of N/S over 15mins – pneumonia, urosepsis, if BP not improved repeat
same fluid dose
- No fluids – asthma, hypoglycemia, post-csection, dizziness + HF
- Maintenance fluid – ALI – small cannula – 1 L over 8hrs, cuz pt might need surgery - NPO
- Blood transfusion – all bleeding scenarios – if fluids not improved – GROUP 0 NEGATIVE BLOOD,
until x-match blood is ready. There will be a bag of blood in the station – 2 units of blood and
reassess if I need to give more
- IV lines – IV meds eg hydrocortisone in asthma
- In Anaphylaxis – you can give Adrenaline first before IV lines, cuz its IM adrenaline

- MAINTENANCE NORMAL SALINE 2L for 24 hours after pt is stable

DISABILITY (prevent further insult) – now I need to assess ur disablity

- GCS (only if pt is not alert) – HYPOGLYCAEMIA, PPH

 Do you know where you are? What time of the day is it? Can you tell me your name? Then do E-
V-M, even if pt unconscious – keep talking to them.
 If GCS 8 or less, airway may be compromised – call anaesthetics to intubate
- PUPILS - with a torch – GET THE TORCH FROM THE TROLLEY. Pupils equal and reactive to light

- Capillary glucose – look for glucometer

- review the rx offered in ABC and take the necessary action eg the BP has not Improved with IV fluids so
I will give O NEGEATIVE BLOOD, eg check if Osats have improved with oxygen, or not. In anaphylaxis u
can repeat adrenaline if not improved, in asthma move to next step if not improved – MgSo4

- IF PT IS ALERT DO AVPU – Pt is talking to you – asthma, dizziness, UGI bleed vomiting, postop bleed,
HAP

- Alert, Verbal, Pain, Unresponsive

EXPOSURE (skin) – only inspection and palpation, cover each area when done immediately

- head to toe examiner – abdomen, genitals, legs – look and palpate on the calf

- examine the abdomen & genitals – IF NOT ALREADY DONE

- Insert a URINARY CATHETER, if no catheter

- maintain the euthermia - temperature (covering the pt)

- FURTHER MGT – with examiner (SBAR) or pt

- Explain Findings from assessment, rx & dx to pt – So mr brown I have assessed you, you had SOB,
ur oxygen was low, on examination you had wheeze on your chest, So I feel that you have an
acute exacerbation of asthma. So I have given you nebulized salbutamol driven with oxygen, I
have given you hydrocort and MgSo4 and you have responded well. We will admit you, keep
monitoring you, discuss with seniors – if they suggest anything different from what I have told
you, I would let you know. We have done some Ix like CXR & ECG, once the results are out I will
get back and explained
- Admit
- Discuss with seniors
- Wait for Ix eg CXR, bloods, ECG
- Ct the med that was started
- ANY OTHER specific rx eg abx
LEARN GCS
 Do you know where you are?
 What time of the day is it?
 Can you tell me your name

EYE OPENING RESPONSE 4 max

- spontaneous 4

- to speech 3 – can you open your eyes for me?

- to pain on supra-orbital region 2

- no response 1

BEST VERBAL RESPONSE

- Oriented to time (morning, afternoon or eve), place and person 5

- Confused (where are u - am in church) 4

- Inapproapriate words (where are u - apple) 3

- Incomprehensible sounds 2

- No response 1

BEST MOTOR RESPONSE

- Obeys commands 6 – can you lift your right arm for me?

- Moves to localized pain (apply pain on the STERNUM - if pt brings the other hand and pushes ur hand)
5

- Flexion withdrawal from pain (pt flexes same hand) 4

- Abnormal flexion (decorticate - both hands flexed) 3

- Abnormal extension (decerebrate - both hands extends) 2

- No response 1

NB - whenever u inflict pain - tell pt am going to inflict some pain on u a little

In GMC - either pt localised – 5

OR

Flexion withdrawal from pain (pt flexes same hand) 4

GCS - mainly done for the hypoglycaemia and hospital acquired pneumonia

GCS 8 or less – airway may be compromised – call anaesthetics to intubate pt

Acute exacerbation of asthma (121) – P2 day 15

Approach:

GRIPS – FOLLOW ABCDE – same approach

First check for response

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
- Window for focused hx
 ODPARA of SOB
 D/D (Asthma, COPD, Pneumonia, MI, PE)
 MAM – inhalers will be there – ask about them, ask any other treatment
 ICE
- Chest exam – IPPA
- CXR & ABG
- MGT
 nebulized salbutamol 5mg driven by OXGEN via nebulizer mask
 If sats still low - Ipratropium bromide 0.5mg nebuliser

Circulation – BP & HR high, ECG – see MONITOR AGAIN

- Assess – listen to heart – apex only
- Mgt
 IV cannula – pink
 send Bloods - FBC, U&E ,LFT, glucose, inflammatory markers
 No IV fluids in Asthma
 IV hydrocort 100mg (COPD or asthma) 200mg (anaphylaxis)
Disability
- AVPU
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – reassess – sats still low, listen
to lungs – wheeze still present, ask how he is doing – Mgso4 2g IV over 20 mins
Exposure
- Abd, genitalia, legs
- Further mgt – talk to examiner
 - Give findings of assessment, rx, dx
- Admit under the medical team
- Monitoring
- Discuss with Seniors
- Wait for Ix – CXR, Blood, ABGs
- Ct current rx
- Any other specific rx such as:
 If no response IV Aminophyline (5mg/kg) – discuss with seniors
 Last step – ITU admission – Intubation/ventilation
 go home in a day or 2

MAIN FINDINGS - cardiovascular and respiratory findings

- 6 findings on the monitor - HR, RR, BP, O2 saturation, ECG, PR

RESIRATORY SYSTEM EXAM

INSPPECTION
- stand at the foot edge of the bed
- DRSSS
- inhalers, O2 mask, monitors
- begin a general examination, hands
- inspect the chest (see old samson PDF)

PLAPATION
- palpate the chest
- look for surgical emphysema - chest drain, tension pneumothorax
- check tracheal deviation
- chest expansion
- tactile vocal fremitus (say 99 - only possible if pt is conscious)
- percussion
- auscultation

CARDIOVASCULAR
- Murmur - take a deep breath in and our and hold - then listen
- if mitral valve murmur asked pt to turn on the other side
- aortic murmur can radiate to neck, better heard when u sit up and lean

ANAPHYLAXIS – P4 day 15

Approach:

GRIPS

First check for response

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
- Window for focused hx
- ODPARA of SOB
- D/D (Asthma, Anaphylaxis, COPD, Pneumonia, MI, PE)
 - MAM
- ICE
- LOOK AT WRIST BAND – eg pt ALLERGIC to penicillin
- STOP BLOOD TRANSFUSION – if pt complains of SOB/u see rash later
- Look at the emergency trolley – quick look just to acknowledge its presence
- Chest exam – see rash
 Immediately u notice rash (rash usually in the genitals mostly, not chest) - printed pic
attached on the manikin - talk about it - i can see that there is an allergy reaction
going on, so i will STOP THE BLOOD, then listen to chest – wheeze +ve
- CXR & ABG
- MGT
- nebulized salbutamol 5mg driven by OXGEN (if O2 was low) via nebulizer mask

Circulation – BP & HR high, ECG – see MONITOR AGAIN

- Assess – listen to heart – apex only
- Mgt
- IV cannula – largest
- send Bloods - FBC, U&E ,LFT, glucose, inflammatory markers
- 1L of N/S 0.9% as fast as possible
- IM adrenaline 0.5mg 1:1000
Disability
- AVPU
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – reassess – sats still low, listen
to lungs – wheeze still present, ask how he is doing – ct nebulizing, repeat IM adrenaline
0.5mg 1:1000
Exposure
- Abd, genitalia, legs
- Further mgt – talk to examiner
- Give findings of assessment, rx, dx - EXPLAIN to pt that seems like u have an allergic reaction
due to the blood transfusion (Severe reaction to blood transfusion)
- Admit under the medical team
- Monitoring
- Discuss with Seniors
- Wait for Ix – CXR, Blood, ABGs
- Ct current rx
- Any other specific rx such as:
 IV hydrocort 200mg (anaphylaxis), Chlorpheniramine 10mg IV
 Take the blood back to blood bank unit to understand why you had the reaction -
serum IgA & IgE, serum muscle tryptase
 We need senior help (call cardiac arrest) if not improving
 Last step – ITU admission – Intubation/ventilation

UPPER GI BLEED (219) – P317 std notes

F2 in the emergency dpt. Pt is a 65yo man presented with hematemesis. The other info: he had an
upper GI endoscopy, assess the pt, discuss the initial management with the pt.
Pt info: you’re feeling dizzy at the moment. Feeling dizzy for the last 10 days. Today you came to the
hospital because you vomited blood. You had an endoscopy 3 days ago because 2 weeks ago you also
vomited blood. You have got osteoarthritis. You have been taking diclofenac on and off for the last 1
year. drink alcohol occasionally.
If you look at the monitor, bp 110/80. Put 2 large bore cannula. Initially HR 110, RR 2, sat 94%
Vomited blood few hours ago, now pt is unstable from the beginning. RR high (initially 22)

APPROACH

First check for response – DIZZINESS & VOMITING BLOOD 6X

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
Window for focused hx
- ODPARA of DIZZINESS, any chest pain, palpitations, SOB, any other symptoms
- FODPARA of vomiting – contents, have u had similar prob in the pass, how many times, Risk
factors? Heart burn, blood in stool, passed any dark stools
- D/D – NSAIDs, alcohol, liver problems - jaundice, stomach pain
- MAM – any procedures recently – endoscopy – what was the reason, what did they find – pt
will say stomach ulcers were found
- ICE
- Look at the emergency trolley – quick look just to acknowledge its presence
- Chest exam - normal
- MGT - nil

Circulation – BP low & HR high, ECG – see MONITOR AGAIN

- Assess – Skin colour, skin temperature, CRT cuz BP is low, listen to heart – apex only
- Full lead ECG
- Abd exam – Inspect & palpate, look at private/genitals – look for melena – per rectal or pt
soiled herself – u may or may not find melena, catheter
- Mgt
- IV cannula – largest
- send Bloods – routine bloods, group and safe, cross-match 4 units of blood, glucose,
 inflammatory markers
- 1L of N/S 0.9% as fast as possible

Disability
- AVPU – pt giving me hx so he is alert
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – at B we gave O2 which has
improved, at C we gave fluids & but ur BP has not improved – so BLOOD TRANSFUSION with
group O negative blood will be given – go to the trolley and look for it, usually they HIDE IT.
After that the BP will improve
Exposure
- LEGS – inspect and palpate the calf
- Further mgt – talk to examiner
- Give findings of assessment, rx, dx – most likely cause of your bleeding is Upper GI bleeding –
from your stomach ulcers
- Speak to seniors
- Refer to gastroenterologist – Urgent endoscopy within the next 4 hours – so arrest the
bleeding
- Monitoring vitals
- Wait for Ix – Bloods, abd USSss
- abd xray
- erect chest xray
- Meds - IV omeprazole if PUD, after endoscopy
- Ct current rx
- Any other specific rx such as:
 We need senior help (call cardiac arrest) if not improving

Post op hypotension (240) – P316 std notes

F2 in the obstetrics and gynecology. Pt is a 51yo lady who was not feeling very well. She had a
 laparoscopic hysterectomy for dysfunctional uterine bleeding 1 hour ago. She is now in the recovery
room. The nurses have asked you to come and review the pt as she is not feeling well. Assess the pt,
discuss the management with the examiner.
Pt is talking - speaking in a very low voice, saying not feeling very well, experiencing SOB, started half
an hour ago, had a hysterectomy for vaginal bleeding. Sat is low, bp 85/65, HR 110, temp is normal.
Ecg shows sinus tachycardia. Pt will also have a urine bag, it will have clear urine no blood,
HR 120 T 37.0, there is a crash trolley
Examination: crackles in chest. Abdomen some bandage because after surgery.
Examiner: what are the differentials and how will you treat this patient?

APPROACH – MGT is with examiner

First check for response

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
Window for focused hx
- hx about the operation, how it went, why was it done, what symptoms
- D/D (Asthma, COPD, Pneumonia, MI, PE)
- MAM
- ICE
- LOOK AT THE POST-OP NOTES & DRUG CHARTS
- LOOK AT WRIST BAND
- Look at the emergency trolley – quick look just to acknowledge its presence
- Chest exam - normal
- MGT - nil

Circulation – BP low & HR high, ECG – see MONITOR AGAIN

- Assess – Skin colour, skin temperature, CRT cuz BP is low, listen to heart – apex only
- Abd exam – Inspect (wound dressing) & palpate - tenderness, look at private/genitals –
Check for PV bleeding, catheter – you will see a catheter and its draining urine – urine output
adequate
- Mgt
- Full lead ECG
- IV cannula – largest
- send Bloods – routine bloods, group and safe, cross-match 2 units of blood, glucose,
inflammatory markers
- 1L of N/S 0.9% as fast as possible

Disability
- AVPU – pt giving me hx so he is alert
- Pupils
- CBG
 - Review the treatment offered in ABC & take necessary action – at B we gave O2 which has
improved, at C we gave fluids & BP has improved – so no necessary action needed
Exposure
- legs – inspect and palpate the calf
- Further mgt – talk to examiner
- Give findings of assessment, rx, dx – u had low O2, low BP, & tenderness on examination of
abdomen – therefore, most likely cause of your problem it could be bleeding inside your
tummy
- Speak to seniors – you might need to go back to theatre for another operation to stop the
bleeding
- Monitoring vitals
- Wait for Ix – Bloods, abd USS
- Ct current rx
- Any other specific rx such as:
 We need senior help (call cardiac arrest) if not improving

Post-partum hemorrhage (231) – P318 std notes

F2 in the obg. Pt is a 35yo who had a gravida 5/ 17 yr old primigravida, had just delivered a new baby.
This is her 5th delivery. 1 hour after delivery she has been noticed to be bleeding vaginally. She had a
3rd degree vaginal tear, it has been sutured. The nurse has asked you to review the pt. please assess
the pt and then hand over pt to the crash team.
Pt is mumbling. Experiencing dizziness. Observations: very low bp 77/50, pulse 120, oxygen 88, temp
37. You will have all the equipment on the trolley. Dr: Id like to examine your tummy.
Examiner will tell you abdomen is floppy. Dr: I would like to look at laceration or tear.
- on examination - groin area soaked with blood
- pt will have a scar on the tummy cus she had laparoscopic surgery b4, she might say she is in pain
wen u touch the tummy
Examiner: it has been sutured

Approach

GRIPS

First check for response – Pt is DROWSY & MUMBLING

Start with GCS
 Do you know where you are? What time of the day is it? Can you tell me your name? Then do
GCS eg E3 -V2 – M6 = GCS 11, so airway is not compromised
 If GCS 8 or less, airway may be compromised – call anaesthetics to intubate

AIRWAY
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask – pt is young unlikely COPD – just give the high flow O2
Window for focused hx – pt not answering but still ask specific Qs
- How are you feeling? Any chest pain? Difficulty breathing? Tummy pain?
- LOOK AT THE Pt’s NOTES (to see if there was any complications during delivery) & DRUG
CHARTS
- LOOK AT WRIST BAND
- Chest exam IPPA – normal
- MGT - nil

Circulation – BP low & HR high, ECG sinus tachycardia – see MONITOR AGAIN
- Assess – Skin colour, skin temperature (hands & feet), CRT cuz BP is low, listen to heart – apex
only
- Full lead ECG
- Abd exam – Inspect & palpate – uterus is floppy, look at private/genitals – bleeding PV, birth
trauma – gown soaked in blood or blood in the bucket, catheter
- talking manikin is not design for abdominal examination - they could say abdomen is floppy or painful
or pictures of scars, if any bleeding on abd u need to examine that as well
- Mgt
- IV cannula – largest
- send Bloods – routine bloods, group and safe, cross-match 4 units of blood, glucose,
inflammatory markers
- 1L of N/S 0.9% as fast as possible

Disability
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – at B we gave O2 which has
improved, at C we gave fluids & but ur BP has not improved – so BLOOD TRANSFUSION with
group O negative blood will be given – go to the trolley and look for it, usually they HIDE IT.
After that the BP will improve, Massaging the uterus, IV oxytocin
Exposure
- LEGS – inspect and palpate the calf
- Further mgt – talk to examiner / handover to the crash team
 - Give findings of assessment, rx, dx – most likely cause of your bleeding is PPH due to atonic
uterus
- Manual massaging of uterus, raising the pts leg
- IV oxytocin - starts with 5 units, can give up to 20units
- Continue Monitoring vitals
- Discuss with seniors
- Wait for Ix – Bloods, abd USS
- Ct current rx
- Any other specific rx such as:
 We need senior help (call cardiac arrest) if not improving
OR hand over at the six minutes to the crash team - u ll hand over to the registrar - examiner (its d
only handover station)

HAND - OVER PROTOCOL (S-BAR OR IS-BAR), calling ur consultant on phone

Introduction - my name is musa one of the FY2s in OBGYN. I have a pt who I need some help interms
of assessing this pt
Situation - name, age, prob - pts name is ashley, 35yr old lady multipara, she had a vaginal delivery 1
hour ago, low BP and Osats and since then she has been bleeding per vaginal

Background - admission details - no significant PMhx or meds hx, She is normally fit and well. She is a
multiparous had her 5th delivery, has been bleeding heavily PV

Assessment - on examination - obs, abdomen is floppy uterus ...., bleeding due to atonic uterus and
Mgt (think of what you did ABCDE)

Recommendations
I feel that she has primary post-partum hge. Possibly due to retained placenta or reduced uterus tone.
Or prolonged labor. She has a risk of PPH due to grand multipara. We can arrange a transvaginal USG
and possible evacuation of placenta. Repeat the oxytocin to increase the tone, consider blood
transfusion. Is there anything else that you would like me to do?
- ct ABCDE
- blood transfusion, ct massaging of uterus, IV oxytocin (repeat)
- EMPTY BLADDER
- MONITOR URINE OUTPUT
- RAISING LEGS
- If still bleeding – further uterotonic drugs eg misoprostol 1000mcg per rectal
- tranexamic acid 1g IV if still bleeding
- Correct coagulopathy - FFP
- if bleeding does not stop pt might need surgical exploration under anesthesia for any trauma or
perforation or retained placenta…… consider suturing under anasethesia, uterine packing, balloon
tamponade, next – if these fails – theatre – uterine artery ligation or hysterectomy

Causes of PPH
 - retained placenta
- Uterine Atony
- Bleeding disorder
- Trauma (tear)

Hypoglycemia (259) – P319 std notes

F2 in emergency medicine. A 75yo pt had become unresponsive. Assess and manage the pt. special
note: say everything you’re doing to the examiner. [running commentary]
Mannequin unresponsive. Notes present: Pt was admitted with LRTI 4 days ago. Known to be
hypertensive and diabetic. On amlodipine and glibenclamide. On the monitor oxygen normal, HR 112,
bp 149/90, temp 37
SPECIAL NOTE - pt missed breakfast this morning, talking manikin
- pt record - admitted with LRTI 4 days ago
SETUP WITH A TROLLEY (fluids, dextrose, glucometer, mask, cannula, pen torch, pulse oximeter,
ventori mask)

- APPROACH

First check for response – Pt is UNRESPONSIVE

Start with GCS
 Do you know where you are? What time of the day is it? Can you tell me your name? Then do
GCS eg E2 –V1 – M6 = GCS , so airway is not compromised
 If GCS 8 or less, airway may be compromised – call anaesthetics to intubate

AIRWAY - secure oro-pharyngeal or nasopharyngeal airway

BREATHING – LOOK AT THE MONITOR – RR & Sats – Normal - keep talking to pt
Window for focused hx – CAN’T TALK

- LOOK AT THE Pt’s NOTES & DRUG CHARTS – DM, on insulin & gliclazide, missed a breakfast
- LOOK AT WRIST BAND
- Chest exam IPPA – normal
- MGT - nil

Circulation – BP & HR, ECG – all normal - see MONITOR AGAIN

 - Assess – Skin colour, skin temperature (hands & feet), listen to heart
- Full lead ECG
- Mgt
- IV cannula - pink
- send Bloods – routine bloods
- No IV fluids

Disability
- Pupils
- CBG – low 1.4mmol - take the glucometer and apply the strip, u need lancet or pricker, and
alcohol swab
- Review the treatment offered in ABC & take necessary action – 75ml of 20% IV glucose. Give
about 5 mins or so for the glucose to take action
Exposure
- Abd, genitalia, legs
- Further mgt – talk to examiner
- Give findings of assessment, rx, dx – HYPOGLYCEMIA - Tell the examiner – I refer from the pt notes
that pt is hypertensive and diabetic on meds for HTM and dm. pt developed a hypoglycemia. Explain to pt what
happened, advise to eat a sandwich or some food

- Repeat Glucose if still low

- Cancel D/C
- Inform Seniors
- Give long acting carbohydrate – sanchwich or toast – cuz gliclazide is long-acting
hypoglycemic medication
- Continue Monitoring vitals
- Review with DM nurse recognition & prevention of hypoglycemia
- Any other specific rx such as

TAKE HX AFTER PT IS ALERT, IF ASKED TO TALK TO PT

- take hx of DM

- hx of sugar control

- complications of DM
- Causes of hypoglycemia here

 Excessive meds or if they take regular meds

 Don’t eat/excessive exercise
 Drinking excessive alcohol

MGT

- counselling pt on sugar control

- how to identify and recognise hypoglycaemic symptoms

- always to stock sugars - sugary drinks like lucozade, chocolate bars, biscuits etc for emergencies,
glucagon 2 cubes (If pt can swallow)

- plan pts long term DM mgt - diabetic clinic

- DM nurse

- Lifestyle mgt

Hospital acquired pneumonia – talking mannequin (221) – P316 std notes

F2 in the acute medical unit. A 67yo was admitted from a nursing home with a UTI. She has been
treated successfully and about to be discharged home. The nurse has asked you to assess the pt as she
has not been very well and a little short of breath. Assess the pt and discuss the management plan
with the examiner. Special note: Talk to the pt as it is a real pt and describe everything that you’re
doing to the examiner as you go. [running commentary]
Pt info: pt is confused unable to give hx but mumbling. At the monitor the bp is low 85/55 HR is high,
temp 37.4, saturation 87%. Mannequin is coughing throughout. When you examine there are crackles.
When you press a button, the mannequin coughs. [need to do gcs]
When you do gcs the M won’t do anything related to motor movements so don’t ask them. examiner
will give you finding. Eye opening to loud voice, verbal incomprehensible sound. Best motor localizes
to pain. Eye opening is 3, localising pain is 5, verbal 2
Scenario B – pt has HAP with severe delirium – telling you DON’T TOUCH ME, explain & calm the pt
down, keep reassuring

APPROACH

First check for response – CONFUSED PT – he will be asking random Qs – who are you – always
respond
AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
- Window for focused hx
- How are you feeling? Any chest pain? Difficulty breathing? Any fever – temp high in monitor
 - LOOK AT THE Pt’s NOTES (am unable to take hx) & DRUG CHARTS
- LOOK AT WRIST BAND
- D/D (Asthma, COPD, Pneumonia, MI, PE)
- Chest exam – IPPA – bilateral crackles
- CXR & ABG
- MGT

Circulation – BP low & HR high, ECG – sinus tachycardia – MONITOR AGAIN

- Assess – listen to heart – apex only
- Mgt
- IV cannula – largest side
- send Bloods - FBC, U&E ,LFT, glucose, inflammatory markers
- IV fluids – Fluid challenge - 500mls of N/S over 15mins
Disability
- AVPU – confused but alert
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – reassess ABC – sats has
improved, BP has improved
Exposure
- Abd, genitalia, legs – no cellulitis or DVT
- Further mgt – talk to examiner
- Give findings of assessment – pt coughing, low O2, fever, crackles on chest exam, rx, dx –
Sepsis due to HAP (pt has been in hosp for more than 2 days)
- Keep the pt until chest infection is clear
- Monitoring
- Discuss with Seniors
- Wait for Ix – CXR, Blood, ABGs
- SCREEN FOR SEPSIS (Sepsis 6 - GIVE 3 – O2, IV fluids, & Abx. TAKE 3 – B/C, urine m/c/s &
lactate)
- Ct current rx
- Any other specific rx such as:
- IV abx according to hospital protocol
- ct IV fluids

- IF MGT IS WITH EXAMINER - examiner will not come to u - u have to go to come

there are 2 sepsis Qs - hospital acquired pneumonia & urosepsis

POST-OP C SECTION PAIN

First check for response – Dr am in PAIN

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – all normal
Window for focused hx
- SOCRATES of PAIN
- D/D (Asthma, COPD, Pneumonia, MI, PE)
- MAM
- ICE
- LOOK AT THE POST-OP NOTES & DRUG CHARTS - see meds pt is on
- Chest exam - normal
- MGT - nil

Circulation – BP & HR, ECG – see MONITOR AGAIN – all normal

- Assess – Skin colour, skin temperature, CRT cuz BP is low, listen to heart – apex only
- Abd exam – Inspect (wound dressing, dry and clean) & palpate - pain, look at
private/genitals – Catheter draining urine – tinge of blood but that’s not significant
- Mgt
- Full lead ECG
- IV cannula – pink
- send Bloods – routine bloods, glucose, inflammatory markers
- No IV fluids

Disability
- AVPU – alert
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – so no necessary action needed
Exposure
- legs – inspect and palpate the calf – no DVT, no cellulitis
- Further mgt – talk to examiner
- Give findings of assessment, rx, dx – All obs normal, pain you experiencing is from the
operation you had, be rest assured its nothing serious that may put your life at risk – post-op
pain
- Prescribe Morphine IV 10mg – look for a nurse to administer the meds
- Pain will take sometime to go away
- Speak to seniors
- Monitoring vitals
- Wait for Ix – Bloods, abd USS

UROSEPSIS (350) – P320 std notes

F2 in the emergency dpt. Pt is a 65yo presented to the dpt feeling unwell. Assess the pt, discuss the
management with the examiner. Pt info: youre 65yo, you have not been feeling very well for the last
2-3 days. You have got prostate problems and you went to the urologist recently. So urologist gave
you urinary catheter. And they said in the near future you need an operation. Catheter for the last 6
months. In the last 24 hours you haven’t changed your urine bag.
Set up: monitor temp 38.5, pulse 57, bp 110/70, sat 98%, RR 14. Pt will have a urine bag with tea
 colored urine. Frothy urine waiting for TURP operation, catheter was changed 3 weeks ago
urine bag was last changed 3 days ago. no other prob obs - either hypothermia or fever
Examiner’s questions:
● How will you manage this patient?
● What is your assessment
Setup:
1. Stethoscope
2. The monitor
3. BNF
STABLE PATIENTS
ABCDE - take action as you run through
take hx
Ex
Dx
Mgt
(TREAT THE MANIKIN LIKE A PATIENT, DO NOT TRY AND LOOK AT THE EXAMINER)

APPROACH
- GRIPS

- What is bothering u – Dr am not feeling well OR feeling hot & cold – is a sign of infection

- LOOK AT THE MONITOR – temperature HIGH

- can u tell me more about it

- DDs - Any cough, SOB, fever, urine probs, Abd pain, diarrhea, vomiting, constipation, dizziness,
headache, ANYTHING ELSE

- when he tells u he had urine prob - ask the 4Qs

- since then u have been having the catheter

 how often do u change the catheter n urine bag

 wen was last time u changed catheter
 who inserted the catheter
 why was it inserted – for what reasons
 are they planning any rx – yes TURP

- ROS - GIT, Malignancy

- MAFTOSA

- ICE/JARSS

- EXAMINATION
  Chest exam
 Abd, Inspection of external genitalia – you find a catheter – ask Qs about catheter – see above.
They usually hide catheter under the manikin
 Per rectal (enlarged prostate but smooth)
 Urine bag will be frothy, cloudy – urine dips

- EXPLAIN - u have high temp, BP slightly low, urine cloudy, mild tenderness in your tummy, and your
prostate is enlarged likely for u to have a urine infection that may have caused sepsis – spread of the
infection throughout the body

- MGT with examiner:

- Start with routine bloods – check for blood cells to make sure you are not anaemic, ESR, CRP, blood
sugar, LFTs, RFTs, clotting profile – tendency to bleed

- Sepsis 6 – B/C, Urine culture, lactate – to check the severity of infection

- CXR

- ABG – level of O2 in blood

- Examiner will hand over a paper with blood test - WCC increase, CRP 30, lactate 5.5 (normal is <1)

- IV fluids

- IV abx

- Discuss with SENIORS

- ECG

- refer to urology when stable

- warm fluids and blankets - for hypothermia

- insert a catheter

- discuss mgt with Pt (nowadays)

Acute limb ischemia (217) – P321 std notes

F2 in emergency dpt. Pt is a 55yo presented with leg pain. Take a hx, asses the pt, discuss the
management with the examiner.
Pt info: acute onset of right leg pain. Started a few hours ago. The pain is dull, constant, and does not
radiate anywhere. You also have thumping sensation in your chest. You smoke. You’re not able to
move your leg now, you feel your right leg is slightly numb. On examination, pain on palpation.
Dorsalis pedis absent, radial pulse irregular. on the screen: HR is high, you have an Afib, BP, saturation
Is all normal
mgt with Pts these days, smoking for the last 20 yrs on screen - AF, tachycardia, sats 98, temp is fine,
BP fine, leg is pale
APPROACH

GRIPS – I understand you have some pain in your leg, can you tell me more

- LOOK MONITOR

- Comment findings to the pt - BP is normal, HR is irregular and beating faster - do u know anything
about it

PAIN SOCRATES

6Ps – Painful, Pale leg (changes in skin colour), Paraesthesia (pins & needles), Paralysis (weakness),
Perishing cold, Pulselessness, SMOKING, usually NO SWELLING,

- DDs

 trauma, fracture
 DVT (prob in vein, cold, swelling)
 arthritis, skin infection, DM

- MAFTOSA – hx of heart attack

- ICE

- EAMINATION - INSPECTION - 4 steps

 superficial part, anteriorly, toes, soles, heels – skin looks Pale

- PALPATION

 temp (both hands or one hand) – there is no Perishing Cold – manikin NOT cold, Pain –
tenderness – pain in calf, No Pulselessness - affected side no pulse, CRT 5:2
 Neurological exam - sensory and motor - ask pt to close eyes and rub the area from distal to
proximal - ask pt if they are able to feel – using the tips of your fingers can you feel me
touching you, tingling & numbness – Paraesthesia
 motor - ask pt to move the leg – Paralysis
 check pulses distally to proximally – dorsalis pedis, posterior tibiales, popliteal pulse & femoral
pulse (stop where you can feel the pulse)
 check radial pulse – Irregularly-irregular

- CARDIOVASCULAR EXAM – IPA – listen to the heart

- EXPLAIN FINDINGS - talk about the six Ps - ur pulses are irregular, ECG showed irregular HR - therefore
u have ALI (acute limb ischaemia) - means a clot formed in the heart and has moved to the leg causing a
blockage of the blood supply to the leg. If u have irregular HR, can cause clots in the heart, that travels
to the leg

MGT

- Admit
- Analgesia

- bloods, + group and safe, clotting profile

- full lead ECG

- ABPI - they might ALI <0.5, <0.9 is intermittent claudication

- Doppler USS of leg

- heparin injection S/C

- IV fluids – maintenance – small cannula – 1 L over 8hrs

- NPO

- Urgent referral to VASCULAR SURGEONS – embolectomy

- REFER TO CARDIOLOGY to treat the irregular HR

Examiner – SBAR
Today I assessed ms johns, 50yo lady presented with acute onset of pain. [6ps] pulselessness, pallor,
paralysis, paresthesia, perishingly cold leg. So pt has all 6 Ps of acute limb ischemia. My dx is acute
limb ischaemia due to an emboli secondary to AF
In terms of her management, I will take care of her ABCDE, then offer painkiller. Then heparin S/C on
the abdomen. keep the pt NPO. Do blood tests including group and save full lead ECG, Doppler USS of
the leg, ankle brachial index, urgent referral to vascular surgery for embolectomy. And cardiology
referral. Also consider anticoagulant

DIZZINESS (122) – P8 DAY 15

First check for response

AIRWAY - airway patent cuz pt is talking
BREATHING – LOOK AT THE MONITOR – RR & Sats – ask SMOKERS COUGH, then Give oxygen at
15L/min via a non-rebreathing mask
- Window for focused hx
 ODPARA of DIZZINESS
 D/D (Anaemia, Hypoglycaemia, Postural hypotension, Heart prob (IHD, Valvular dx),
Meniere’s, Brain tumour, Stroke, fever, chest pain, SOB)
 MAM – Family hx of heart probs
 ICE
- Chest exam – provide chaperone & maintain privacy always – bilateral crackles
- CXR & ABG
- MGT

Circulation – BP normal & HR high - fluctuating, ECG – see MONITOR

- Assess – Skin colour, skin temperature (hands & feet), Pulse rate, listen to heart – 4 areas –
 PSM loudest in apex – palpate the carotid & ask pt hold the breath & listen to the murmur, &
then check for radiation, pulse irregular, monitor shows AF
- Check radio-radial delay & collapsing pulse when there is AF
- Full lead ECG
- Mgt
 IV cannula – pink
 send Bloods - FBC, U&E ,LFT, glucose, inflammatory markers
 No IV fluids

Disability
- AVPU
- Pupils
- CBG
- Review the treatment offered in ABC & take necessary action – reassess – sats has improved
Exposure
- Abd, genitalia, legs – all normal
- Further mgt – talk to examiner – how will you manage
- Give findings of assessment, rx, dx – I have taken cared of his ABCDE, gave O2 bla bla – AF +
MR causing LVF leading to pulmonary edema
- Admit under the medical team
- Monitoring
- Discuss with Seniors
- Cardiology review
- Echo
- Wait for Ix – CXR, Blood, ABGs – ECG showing AF & CXR pulmonary edema will be given
- IV frusemide – from trolley – DIURETICS will be found and not FRUSEMIDE
- Any other specific rx such as: - rate control – DIGOXIN to reduce HR
- anticoagulant rx

Present to the examiner:

● I have just assessed Mrs Yates, she has presented with dizziness which usually exacerbated
by exercise
● She is normally fit and well and no other medical problems.
● Upon examination she has irregularly irregular pulse 112-135?
● She has AF
● On auscultation she has a pan systolic murmur
● Murmur on the whole pericardium, loudest at the mitral
● Diagnosis: MR causing LVF, AF and pulmonary edema
Intermittent claudication (316) – P323 std notes

Not a talking mannequin, real human present.

F2 in the gp surgery. Pt is a 60yo man. made an appt to see you. Other info: he has HTN. He is on
amlodipine. Talk to the pt, take a focused hx, discuss management with the pt.
Pt info: today you have come to the gp with pain in both legs. Mainly on your calves. Pain is more on
the right than on the left. Started 6m ago, getting worse. The pain usually comes when you’re walking.
And it gets relieved with rest. You tried to take PCM. But it didn’t help. No any other symptoms. Take
bp meds. BP is well controlled, no swelling or redness, or other symps, smokes cig, don’t exercise,
affects ur life cus u cannot play golf

- GRIPS

- SOCRATES

- DD

 Trauma
 Intermittent claudication (IC) - is a cramp like pain after walking to a predictable distance and
relieved by rest - wen do u get d pain, do u get pain after walking
 acute limb ischaemia - limb pain worst at night, burning sensation, skin changes ulcer, gangrene,
smoking
 spinal stenosis - tingling, numbness, weakness, problem with walking or standing
 diabetic neuropathy, joint swellings or probs

MAFTOSA, lifestyle hx – smoking, exercise, diet

Examination – Obs; ABPI - measure ur arm (0.9 suggest pereipheral artery dx, <0.5 suggest critical limb
ischaemia); Examination of legs & chest

- u may have a condition call IC - due to narrowing of the arteries (blood vessles) in ur leg, leading to
pain in the calves, hip, thigh and bottoms.

MGT

- REFER TO SUPERVISED EXERCISE PROGRAM - specialised physiotherapy - where u do supervised

exercises following a certain regime of exercise - They can do it in two ways: 2 hours of supervised
exercise for 3 months. They will either offer 30 mins of exercise 3-5 times a week OR advice to exercise
to a point of max peak

- refer to the vascular surgeons - angioplasty

- stop smoking
- avoid driving

- inform the DVLA

- GP - bloods (FBC, Lipid profile, BS), Q-risk assessment

- FU 1 week to see the blood test result

- SN - pain at rest, skin discolouration, loss of sensation, affecting day to day activities, persistent
worsening pain, unable to walk

Pulmonary embolism scenario C (287) – P324 std notes

F2 in the gp. Pt is a 45yo lady presented with SOB [real pt]. observation: bp 110/70, RR 30, HR 97,
saturation is 90. Assess the pt discuss management.
Pt sob and distressed when you enter.
Special notes - negative covid test today
How are you feeling now? Suddenly all fine. Now take hx. You developed sob 4 hours ago and getting
worse. You also have chest pain 8/10 it is a dull pain Lt side, nothing makes it better or worse. Only
risk factor is breast cancer 1 year ago on chemo following it

- GRIPS

- CHECK OBS – tell pt ur oxygen sats is low – I will give you high flow oxygen via NRM [just mention it no
mask actually available] examiner assume done

- If u give O2 without checking vitals they will not give u vitals later - cuz they only have one paper which
shows hypoxia

- ODPARA SOB

- DDs - PE, MI, pneumothorax, trauma, ruptured aortic aneurysm, pneumonia, HF

- RISK FACTORS

 Diagnosed with breast ca 1 yr ago OR

 taking COCP for last 3 yrs ago OR
 had a flight journey
 Others – Immobilisation, major surgeries

- MAFTOSA

- Ex – chest – lungs & heart, legs

Explain - PE because if you have cancer you can form clots in your lungs. Any cancer can cause PE.
[Cancer cause thrombophlebitis. Inflammation of the epithelium (walls of blood vessels). It causes
thromboembolism]
- Advise pt to go to the hospital - Call an ambulance

- Investigations: CXR, CTPA, D-dimer, routine bloods, ABGs

- Blood thinner meds

- admitted for 1-2 days when youre stable you’ll be sent home

MENINGITIS (24) – P11 day 15

MENINGITIS DOESN'T COME THESE DAYS

Examination steps:

● Universal precautions - PPE

● Check response by talking to pt

● Offer pain killers and dim the lights, and offer the necessary reassurance and assistance to remove
the hand on pt’s face

● Perform the GCS

Meningeal signs:

● Can you touch your chest with your chin? (neck stiffness)

Please bear with me, I would like to do it one more time (bend the neck yourself to make the chin
touches the chest. It will cause involuntary lifting of the legs and neck

pain = Brudzinski sign

● I will be lifting your leg (bend one of the lower limbs at 90 degrees at the knee and 90 degrees at the
hip and then try to straighten your knee). This will cause pain and some resistance = Kernig’s sign

Head to toe examination + Neurological – tone, reflexes (pupillary and plantar), muscle bulk, Power
(only if pt is conscious GCS 15/15)

MGT

- ABC

- keep isolation of medical team

- bloods, ESR, CRP, B/C

- LP

- IV abx - cefotaxime

- CT scan to check for signs of raised ICP

- painkillers

- discuss with seniors

- arrange contact tracing

Confirming death (196) – P322 std notes

F2 on call doctor in the oncology team. Pt is a 90yo man admitted 10 days ago. He had end stage lung
cancer. He was not responding to the tx. The nurse has noticed that the pt has become unresponsive.
Speak to the nurse, assess the pt then fill in the continuation sheet ie pt notes.
In the room greet the nurse she will say she started her shift an hour ago, this is her first pt, not
responding for the last 20 mins.
On the table there will be 2 files. One file would have DNAR status. The other one is continuation
sheet. Apart from that you have a pen torch, spatula (tongue depressor), cotton wool, stethoscope,
patellar hammer. Talking mannequin all switched off, hanging hands

- APPROACH

- GRIPS to nurse

- I understand pt has cancer, u wanted me to review

- confirmation of name - wats his name – Also see his wrist band

- MR THOMAS can u hear me

- Pt not responding – check OBS – MONITOR - Dr: ok what about the vital monitor? Nurse: I switched
off. He wasn’t responding to tx death was expected

- ask nurse weda death is expected in this pt

- ask if there is DNAR status

- continue examination

In every step tell the nurse what you’re doing

DEATH CONFIRMATION

- Identify pt – wrist band

- verbal stimuli - MR THOMAS can u hear me

- Inspect for signs of respiratory effort - gasping for air

- No resp effort - give PAIN on the sternum, supra-orbital, trapezius sqeeze - no respond

- Reflexes - take torch and check pupillary reflexes - dilated and fixed
- check the CAROTID PULSE – between the trachea and STM - sternocleidomastoid muscle

- LISTEN FOR HEART SOUNDS - check for 2 mins

- LISTEN FOR BREATHING SOUNDS for 3 mins

- Last reflex to do - GAG REFLEX - take the tongue depressor, open mouth and touch the soft palate

- LOOK FOR A PACE MAKER - is on the Lt side under the clavicle (if pt has pacemaker, we remove it cus
the battery might burst during cremation)

- WASH HANDS

- Talk to nurse – UNFORTUNATELY, Mr Thomas passed away, I need to confim the death

- CHECK TIME OF DEATH - ask nurse for the time.

- You can inform the family. If they’re around I can speak to them as well

- Arrange for transport to the morgue

- Then sit down and write the continuation sheet. Time and date should be written

FILLING THE DEATH CERTIFICATE

ADVANCED TRAUMA LIFE SUPPORT (ATLS)

Primary survey – P16 day 15

The purpose of the primary survey is to rapidly identify and manage impending or actual life threats
to the patient. Trauma Service : Primary and secondary survey (rch.org.au)

 Always assume all major trauma patients have an injured spine and maintain spinal
immobilisation until spine is cleared
 Immobilisation & Neck collar (If pt has no neck collar)
 high flow oxygen – Low sats or high RR
 I will ask my assistant to connect all the monitors and do a primary series of X-rays” (neck, chest,
pelvis)

Priorities are the assessment and management of:

 c Catastrophic haemorrhage (otherwise always start with A)

 A Airway (and C-spine control)
 B Breathing
 C Circulation – BP, HR (There will be an observation chart in the exam. You need to look for
it)

 Abdomen – bruises, wounds, signs of internal bleeding, FAST SCAN, CT abd, refer to
Gen. surgeon
 Pelvis - deformity, swelling, bruises, open wounds, perineal bruising, scrotal haematoma
and urethral meatus bleeding, Palpate for tenderness on the pelvis. SPRING TEST only if
there is no tenderness on palpation. Rx: resuscitate the patient, apply a pelvic strap,
perform a pelvic X-ray and call the orthopaedic team

 D Disability – AVPU, Pupils, CBG

 E Exposure - cover pt with a blanket to prevent hypothermia, NG tube & Urinary Catheter
Secondary survey – P20 day 15
The secondary survey is commenced after the primary survey has been completed, immediate life
threats identified and managed, and the pt is stable. Continue to monitor the Pt’s (ABCD):

 Mental state
 Airway, respiratory rate, oxygen saturation
 Heart rate, blood pressure, capillary refill time

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.

• GRIPS

• Take AMPLE history

A – Allergies to medication

M – Medication

P – Past medical history

L – Last meal

E – Events leading to the accidents

1. HEAD TO TOE EXAMINATION

Mr. Williams, I need to cut your clothes so that I can examine you, is that alright?

• Head: check for any wounds, bleeding.

• Ears: bleeding or leaking of CSF (Otorrhoea).

• Eyes: no raccoon eyes.

• Nose: no bleeding or leaking of CSF(Rhinorrhoea).

• Palpate for any nasal or facial fractures.

• Mouth: foreign body, loose teeth and dentures or any missing teeth
• Trachea: central

BREATHING – IPPA – Inspect for bruises, open wounds, chest deformity and paradoxical chest
movement

2. CIRCULATION (same as above)

3. ABDOMEN
4. PELVIS
5. THIGH: Look for deformity, bruises, swelling, open wounds. NB: If there is swelling → closed
fracture of femur shaft

Check for dorsalis pedis bilaterally and ask patient to wriggle his toes

• 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

6. 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
PR 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-rays