Station - Instructions for candidate
You are a final-year medical student in the Emergency Department at Fiona Stanley Hospital.
Sunita Menon is a 79-year-old woman brought to the Emergency Department by her daughter with two days of vomiting, poor appetite and vague lower abdominal discomfort. Triage has recorded mild tachycardia but no fever, and the nursing handover notes a small lump in the right groin.
| Triage observations | Triage observations: HR 108 regular, BP 128/74 mmHg, RR 20, SpO2 96% on room air, temperature 36.8 degrees C, pain score 5/10. |
|---|---|
| Nursing handover | The patient is accompanied by her daughter, who reports that the vomiting has become more frequent since yesterday. |
Results provided:
FBC
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 118 g/L | 115-155 g/L |
| White cell count | 13.8 x 10^9/L | 4.0-11.0 x 10^9/L |
| Neutrophils | 11.9 x 10^9/L | 2.0-7.5 x 10^9/L |
| Platelets | 330 x 10^9/L | 150-400 x 10^9/L |
UEC
| Item | Value | Reference range |
|---|---|---|
| Sodium | 132 mmol/L | 135-145 mmol/L |
| Potassium | 3.4 mmol/L | 3.5-5.2 mmol/L |
| Urea | 12.1 mmol/L | 2.5-7.5 mmol/L |
| Creatinine | 126 umol/L | 45-90 umol/L |
| eGFR | 38 mL/min/1.73 m2 | >60 mL/min/1.73 m2 |
CRP
| Item | Value | Reference range |
|---|---|---|
| CRP | 68 mg/L | <5 mg/L |
VBG
| Item | Value | Reference range |
|---|---|---|
| pH | 7.34 | 7.35-7.45 |
| pCO2 | 4.8 kPa | 4.5-6.0 kPa |
| pO2 | 10.9 kPa | 9.5-13.5 kPa |
| HCO3 | 19 mmol/L | 22-28 mmol/L |
| Base excess | -6 mmol/L | -2 to 2 mmol/L |
| Lactate | 3.1 mmol/L | 0.5-2.2 mmol/L |
| Na | 132 mmol/L | 135-145 mmol/L |
| K | 3.4 mmol/L | 3.5-5.2 mmol/L |
| Glucose | 8.7 mmol/L | 3.5-7.8 mmol/L |
vbg abg - read aloud by the examiner
The venous gas shows a mildly low pH and bicarbonate with a raised lactate. Oxygen values are appropriate for a venous sample.
Look up an example image: LITFL bowel ischaemia VBG
ECG
| Item | Value | Reference range |
|---|---|---|
| Rate | 108 beats/min | 60-100 beats/min |
| Rhythm | Sinus rhythm | Sinus rhythm |
| Axis | Normal | -30 to 90 degrees |
| P waves | Present, sinus morphology | Present before each QRS |
| PR interval | 160 ms | 120-200 ms |
| QRS duration and morphology | 88 ms, narrow QRS complexes | 70-120 ms |
| ST segments | No acute ST elevation or depression | No acute deviation |
| T waves | No acute T-wave inversion | No acute inversion |
| QTc | 410 ms | <460 ms |
ecg - read aloud by the examiner
The tracing shows a regular narrow-complex rhythm at 108 beats per minute, with a P wave before every QRS complex. There is no acute ST-segment or T-wave change.
Look up an example image: LITFL sinus tachycardia ECG
CT abdomen and pelvis with intravenous contrast
| Item | Value | Reference range |
|---|---|---|
| CT abdomen and pelvis | See report | - |
imaging other - read aloud by the examiner
There are dilated small-bowel loops with multiple air-fluid levels and a transition point in the right groin. A short segment of small bowel lies within a sac below the groin crease, with reduced wall enhancement and surrounding fluid.
Look up an example image: Radiopaedia incarcerated femoral hernia CT
Your tasks are to:
- Take a focused history of the presenting problem and relevant background.
- Perform a focused examination of both groins and the abdomen for obstruction and peritonism. Describe what you would examine and the relevant findings will be provided by the examiner.
- Request appropriate investigations. Results will be provided by the examiner when appropriately indicated.
- State the most likely diagnosis and two to four relevant differentials, with brief justification.
- Outline the initial management, including urgent referral, treatment and safety-netting.
- Explain the diagnosis and agreed plan to the patient in plain language.
- You do NOT need to summarise your history and examination findings to the examiner before stating your diagnosis and management.
- Please verbalise your examination to the examiner; findings will be provided when you request each relevant step.
- You do not need to write prescriptions, obtain formal operative consent or perform the operation.
- The examiner will not ask you a separate question.
This is a 15-minute station, with 2 minutes of reading time.