Graeme Thomson

Stem An 80 year old woman from home presents with fever, cough and collapse. She has a history of chronic renal failure, hypertension and congestive heart failure. On arrival her observations are as follows: Temp 39 C HR80/min BP80/70mmHg SaO289%on 6L via Hudson mask GCS14(E4, M6, V4)

Q i Complete the following table listing three (3) alternative methods for assessing the fluid status of this patient. For each method state two (2) pros and two (2) cons. (9 marks)

Fluid status assessment methods Clinical Ultrasound CVP Other more limited methods possible CXR, laboratory tests Could be interpreted more narrowly Components of clinical examination

Pros and Cons Needed 2 for each method to get a mark. Something more than words like: quick, easy, cheap, available, works, effective etc. For example, pros of ultrasound could be: able to detect underhydration and overhydration, no risk of complications from an invasive procedure.

Q ii Complete the following table listing three (3) alternative methods for improving oxygenation in this patient. For each method state two (2) pros and two (2) cons. (9 marks)

Oxygenation methods High flow nasal prongs (or higher flow via mask) NIV (CPAP / BiPAP) Invasive ventilation Not just nasal prongs Alternatives Positioning, drug treatments

Pros and Cons Highlight extra benefits of each method and their complications. For example, pros of NIV could be: Decreased work of breathing and ability to attain high FiO2 with a closed system.

Q iii List four (4) steps in establishing limitations of care for this patient. (4 marks)

Limitations of care Check advanced directives Establish current diagnosis, treatments required and likely prognosis Establish premorbid state Discuss with likely inpatient treating team (eg ICU) Discuss with patient (although confused) Determine NOK and discuss with them Find agreed position Document the plan

Most common errors Leaving sections blank Weak, uninformative or repetitive pros Poor writing

Pass criteria Pass mark set at 17 Part i: 3 methods plus 2 pros and 2 cons for 2 of those Part ii: 3 methods plus 2 pros and 2 cons for 2 of those Part iii: 3 steps

Results 27 passed 15 failed Median = 18 Mode = 18 Mean= 17 Note: if the pass mark had been set at 16 then there would have been 33 passes and 9 failures.