Your Daily Meds - 12 December, 2022
Good morning and welcome to your late Monday dose of Your Daily Meds.
Ward Call:
You receive a phone call to review a patient with chest pain. Your questions over the phone and the nurse’s description of an unwell-looking patient with heavy, tight chest pain radiating to the neck have you quite concerned for an acute coronary syndrome. As you quicken your pace (but don’t run) towards the ward, what instructions could you give to the nursing staff over the phone?
No multiple choice for this one. Think of some things you might need, or actions you might like to be taken, and meet me further down.
How about an OSCE-ish Case:
You work in a General Practice. You meet a 45-year-old male with ankle pain. Notable background of Weber C fracture 6 months ago sorted with an ORIF. The screws are still in situ and this poor chap is feeling a bit stiff.
Now, as if you were going to perform for an examiner, consider:
What targeted examination would you perform?
What differential diagnoses would you consider?
Would you consider any investigations, and why?
Pause, think and meet me at the bottom.
Meanwhile in Angina-ville:
Some instructions you may give to the nursing staff when you suspect an acute coronary syndrome may include:
Stay with the patient and request additional nursing help if needed.
Give oxygen to maintain oxygen saturation at > 94%.
Attach the patient to some monitoring - pulse oximeter, a frequently cycling non-invasive blood pressure, some cardiac monitoring if available.
You will need a formal 12-lead ECG.
You could ask the nursing staff to retrieve 300mg of Aspirin ready to pop into the patients mouth (to Aspirin-load).
Ask for some GTN to be administered - sublingual tablet or spray, doesn’t matter, so long as there is some blood pressure.
You will need a cannula in this patient if not one already in situ - get some gear ready.
(Adapted from ‘On Call’)
Back to your Rooms:
The physical examination bit should be simple, and the same for any orthopaedic-style examination:
Introduction - Wash hands, explain examination, consent
Look - Gait; Inspection
Feel - Temperature; Palpation of joints, tendons, ligaments muscles, bones
Move - Active and Passive ROM
Special - Anterior Draw test; Neurovascular examination
Other joints in the chain - Hip and Knee joints
For post-operative ankle pain, consider:
Fracture - Delayed union; Non-union; Malunion; Pseudoarthrosis
Surgical - Infection; Collection; Iatrogenic (screws rubbing)
New injury - Overuse or traumatic: Chondral; Ligamentous; Bony stress reaction
As for investigations, if any, an X-ray would probably be first-line, but CT and MRI may be considered. The key to remember is that there should be a reason for any investigations ordered with the view that the results should guide management.
Bonus: How is coronary blood supply to the left and right ventricles affected during the cardiac cycle?
Answer in tomorrow’s dose.
News: I made a little Ward Call Course for you all. It maps out an Evening Ward Call shift and covers a bunch of common tasks that you may need to do, like:
Deteriorating Patients
Heparin Infusions
Fluid Orders
Electrolyte Replacement
Difficult patients - Discharge Against Medical Advice, Ryan’s Rule
End of Life etc
You can find the course page here:
It’s free and always will be. Let me know what you think.
Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.
As always, please contact me with any questions, concerns, tips or suggestions. Have a great day!
Luke.