Station - Instructions for candidate
You are an intern in the Emergency Department at Geraldton Hospital.
Colin Ferreira is a 74-year-old man brought to Geraldton Hospital Emergency Department with sudden severe left loin pain radiating towards the groin. The pain began earlier today and was partially relieved after the paramedics administered intravenous fentanyl. He has been placed in a resuscitation cubicle for assessment; the paramedics report that he had a similar urinary problem many years ago.
| Paramedic handover | Pre-hospital handover: pain was severe and began suddenly at rest. Intravenous fentanyl was given before arrival, with partial improvement. Current observations: HR 96 regular, BP 112/68 mmHg, RR 20, SpO2 97% on room air, temperature 36.5 degrees C, pain score 3/10 after analgesia. |
|---|---|
| Initial ED location and monitoring | The patient has been placed on a trolley in an Emergency Department resuscitation cubicle. Cardiac monitoring and repeated observations are available. |
Results provided:
Full blood count
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 108 g/L | 130-180 g/L |
| White cell count | 10.8 x 10^9/L | 4.0-11.0 x 10^9/L |
| Platelets | 214 x 10^9/L | 150-400 x 10^9/L |
Urea, electrolytes and creatinine
| Item | Value | Reference range |
|---|---|---|
| Sodium | 138 mmol/L | 135-145 mmol/L |
| Potassium | 4.8 mmol/L | 3.5-5.2 mmol/L |
| Urea | 12.4 mmol/L | 2.5-7.5 mmol/L |
| Creatinine | 148 umol/L | 60-110 umol/L |
| eGFR | 41 mL/min/1.73 m2 | >60 mL/min/1.73 m2 |
Venous blood gas
| Item | Value | Reference range |
|---|---|---|
| pH | 7.32 | 7.31-7.41 |
| pCO2 | 4.8 kPa | 4.5-6.0 kPa |
| pO2 | 12.6 kPa | 5.0-6.5 kPa |
| HCO3 | 18 mmol/L | 22-29 mmol/L |
| Base excess | -7 mmol/L | -3 to 3 mmol/L |
| Lactate | 3.1 mmol/L | 0.5-2.0 mmol/L |
| Na | 138 mmol/L | 135-145 mmol/L |
| K | 4.7 mmol/L | 3.5-5.2 mmol/L |
| Glucose | 8.2 mmol/L | 3.5-7.8 mmol/L |
vbg abg - read aloud by the examiner
Venous blood gas shows acidemia with reduced bicarbonate and a raised lactate.
Look up an example image: LITFL abdominal aortic aneurysm venous blood gas
Coagulation studies and group and crossmatch
| Item | Value | Reference range |
|---|---|---|
| INR | 1.1 | 0.8-1.2 |
| APTT | 29 seconds | 25-35 seconds |
| Fibrinogen | 3.2 g/L | 2.0-4.0 g/L |
| Group and crossmatch | 4 units requested | Not applicable |
Your tasks are to:
- Take a focused history of the presenting complaint and relevant background, including medications, allergies and social history.
- Perform a focused abdominal and vascular examination, including the aorta, femoral pulses and flanks. Describe to the examiner what you would like to examine and the relevant findings will be provided to you.
- Request blood tests and interpret the results provided by the examiner when appropriately indicated.
- State the most likely diagnosis and two to four differential diagnoses, with brief justification.
- Outline your initial management plan, including escalation, definitive pathway and safety-netting.
- You do NOT need to summarise your history and examination findings to the examiner before giving your diagnosis and management plan.
- Please verbalise your examination to the examiner; findings will be provided when you request the relevant examination step.
- You do not need to prescribe or write medication orders, and no examiner questions will be asked.
- The examiner will provide blood test results only when you request the relevant investigations.
This is a 15-minute station, with 2 minutes of reading time.