Transcript

Module 1 | Angelo Accardi

Epilepsy | Transcript Page 1 of 11

Welcome to Module 1 where we explore inflammatory conditions of the abdomen through the Focus Case
and Case Vignettes.

In this Focus Case we follow the journey of Angelo Accardi.

At the end of each section there is a summary narrative, but you are encouraged to work through the case
at your own pace using the resources around you as needed.

You are also encouraged to use the principles explained within this focus case to align with what you are
learning on the wards.

A REFE (Red Flag on First Encounter) is a red flag on first encounter. This is a red flag when you first see the
patient. This could be that the patient is in distress, it could be about their colour (eg pallor), or it could be
about how fast the patient is breathing. There will be something about that patient that makes you
worried. If you develop your skills to look for this every time, you will learn to recognise the well, the unwell
and the extremely unwell patient. This allows you to prioritise your actions in line with clinical need.

Watch out for reminders to look for a REFE as you go through the Cases.

On meeting Angelo, firstly I would have a general look at him and see how he overall appeared. If he has
generalised abdominal pain he may be in distress and quite unwell.

The things I would look for are him being flushes, sweaty, in poor cognitive status and poorly responsive to
me.

At the age of 88 Angelo is susceptible to rapid deterioration as he has a small physiological reserve only.

Accordingly, I would already be quite worried about Angelo.

With respect to what might be going on with generalised abdominal pain, I am concerned he may have
generalised peritonitis which can have a multitude of causes. At the moment I do not know any more than
that, but I am on high alert for sepsis and rapid deterioration.

The fact that he does not speak English is important and means there may be barriers to communication I
will need to work around.

An individual from a non-English speaking background is vulnerable when seeking medical care.

From a medical perspective, it is more challenging as there is not that immediate ability to communicate.
Often the time factor causes problematic delays where interpreters are not available or are available by
phone only. Where a family member is used as an interpreter there is uncertainty about what is being
communicated. The lack of medical knowledge can also reduce the accurate transfer of information. Use or
the lack of use of a family member can also cause tension with that family member.

It is appropriate in all situations to seek and use a qualified interpreter. Where urgency is an issue,
appropriate decisions should be made at that time in the best interests of the patient.

In your own hospital, find out what happens from the point of view of interpreters, language services, and
the support available for people from a culturally and linguistically diverse background. Attend a

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consultation or interaction where an interpreter is being used and observe the dynamics. Think about what
all of this might mean for that very vulnerable patient.

To work out what is going on with a patient, the first step is to take a history of the presenting concern. This
allows you to obtain information to make a differential diagnosis. There are many ways to do this, but in
these Modules taking a history has been separated into 5 sections to give you a structured option. The
sections are:
1. The presenting concern (eg for pain: the onset, nature, duration, and location)
2. The severity (eg a 1-10 scale, what the patient is able to or not to do, or whether there are
REHD flags)
3. Associated factors (eg vomiting, weight loss)
4. Main system or area involved
5. Possible causes
Exploring the presenting concern by elements 1-3 gives you a better idea of which system (eg the
respiratory or cardiovascular) or area (eg upper gastrointestinal tract; liver, gallbladder and biliary tree; or
anorectum) might be involved. You can then explore this more specifically.

After 1-4, you should have a good idea of possible causes enabling you to formulate a preliminary
differential diagnosis. Once you have formulated that, further questions can help you work out whether
each of the causes may be more or less likely. By this stage of the history, a listener should be able to ‘hear
your thinking’. In some situations, it may seem more logical to consider a cause rather than a system/area
first, and this can be easily swapped in order.

The idea of this way of taking a history is to be thorough and remain broad in your thinking so you do not
miss a less common or alternative diagnosis.

A REHD flag (a Red Flag on History) is a red flag that arises when you are taking the history. Examples could
include symptoms of malignancy or sepsis or could be more specific in relation to the symptoms of, for
example, increased intracranial pressure, meningeal irritation or cauda equina syndrome. As you take a
history, consider the specific REHD flags relevant to identify serious conditions for your patient. Questions
about this should be asked as a matter of course somewhere in your history wherever it makes sense. The
important thing is to include them.

Watch out for the reminders as you go through the Modules.

The first thing I notice is that the duration of the illness is 4 days. Finding out from patient when they were
last well gives you a time course of the illness. It is important to make sure that was not just the onset of
the acute or changed symptoms, with a lower key series of symptoms prior.
The fact that Angelo initially had central abdominal non-specific discomfort and felt queasy makes it more
likely this was a visceral pain of some origin. Movement to the more specific area (in the lower abdomen) is
consistent with it becoming a more localised problem with involvement of the parietal peritoneum. This is
consistent with a progression of pathology such as occurs with acute appendicitis. Notably, the migration of
pain in appendicitis is typically to the right lower quadrant.
The pain which is worse when he passed urine could be dysuria however it is important to distinguish
dysuria from abdominal pain when there is an increase in the use of abdominal musculature or abdominal
pressure.

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Of note Angelo was able to continue what he was doing for the next couple of days although he was
unwell. This suggests a well-localised condition in the lower abdomen. Examples that are running through
my mind would include colonic diverticulitis, appendicitis, a localised small gut perforation or Meckel’s
diverticulitis. A more superficial cause could also be possible (eg a haematoma or hernia).
The sudden change in the situations suggests something about that controlled condition changed. This is
consistent with a rupture or perforation.
The pain of severity 10 out of 10 worse coughing, moving, and breathing is consistent with peritonitis. In
the context of what we had been considering, this could imply the development of faecal peritonitis or
rupture of an abscess.
Shakes and chills are consistent with there being an infective/inflammatory component. Being anorexic but
not vomiting makes it less likely there is obstruction, although this is not excluded. The fact that he has not
had any recent weight loss suggests that the problem is more likely to be acute, however this is not an
absolute thing.
It is likely you had other questions in your workbook that were not included here, which is not to say they
are not right or valid. In addition, although you are asked for a certain number of questions, this is
indicative only, and does not reflect what is needed in the real world. If you have questions on this matter
seek advice from one of the surgeons or team around you.
At this stage we have worked out that a lower GIT problem is the likely cause and this is the system
explored first to give us more information. It is then reasonable to explore the GU system and other
abdominal possibilities which are less likely.
When we find out that Angelo has not opened his bowels for 2 days and wonder whether he might be
obstructed. The pain is not typical of this, and he is passing flatus, which is reassuring.
We see when we explored his normal bowel habit that he has not had any recent changes apart from this
and it is most likely the difference is an ileus related to whatever is going on inside the abdomen rather
than a longer-term concern such as a malignancy. The fact that he has a normal colonoscopy, and no
relevant family history makes it less likely there is a bowel cancer but at the moment this is not certain.
The pain on urinating being in his belly as opposed to stinging and burning consistent with dysuria is more
likely the pain is related to peritonitis rather than a urinary tract infection. As there are no other urinary
symptoms it makes it less likely the urinary tract is the main problem.
General questions with respect to other conditions that might have perforated or caused pain did not show
any specific concerns, which makes those diagnoses less likely as well.
The recent normal blood tests suggest that he has not been anaemic or had any abnormal liver or kidney
function tests which serves as a good baseline for whatever we might subsequently find.

The goal of taking a further history is to identify other medical conditions and factors which might influence
the diagnosis, how your patient is responding and reacting, or anything else that might be important in the
care of this particular patient. Some elements may already have been covered (eg alcohol or smoking) but
it is important to make sure that everything is included either in the history of the presenting complaint or
in this further history area.

In addition, it is important to know what a patient is able to do – what is their functional status? What else
may affect their condition or care?

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There are various ways to take a further history, but the important point is that a comprehensive further
history needs to be elicited.

When considering the review of systems, you are ‘running through’ all of the medical systems as a
screening. Although one or more may have been covered in the HPC, they should still be considered here as
part of the structure as there may be other factors not covered. The reason for doing this is to ensure
nothing has been missed, to assess the status of known medical conditions, and identify undiagnosed
medical conditions.

The review of systems in most cases starts with general questions (eg the presence of anorexia, nausea,
vomiting, weight loss, fevers/chills/nights sweats). Although some, again, will have been covered in the
history of the presenting complaint, this is an area to ensure that these points have been noted.

When considering the other systems, a general set of screening questions can be used initially and more
asked if an area of interest is identified.

The targeted information you have obtained in the full history will allow you to make a good estimate of
what you think might be going on. In general, it is likely one diagnosis will ‘stick out’ but it is important to
have other diagnoses you are considering as well. When we get to the point of making that diagnosis and
differential, considering each of the pieces of information that you have obtained helps you work out if that
diagnosis is more or less likely.

In addition, your review of systems or information collected in the history elsewhere may have identified
other conditions that need to be further assessed – either an undiagnosed condition or an unstable known
condition are the most important to consider. This is especially important in a surgical patient as the illness
and possibility of theatre with an anaesthetic causes additional physiologic stress. Examples include
undiagnosed or unstable angina and COPD.

Sometimes our information is overt (the patient tells us, or we see it), at other times more covert and we
need to be a fantastic detective and find it.

With respect to the further history, I note Angelo is a heavy smoker, thus making questions about his
respiratory system in review of systems more important. He seems to have a reasonable functional
capacity, but I would like to know more about this. He is not on anticoagulation, which is great from the
point of view of whether this needs to be managed prior to surgery, which it doesn’t.
Regarding his review of systems, I note that he has had recent palpitations and leg swelling with
paroxysmal nocturnal dyspnoea. This makes me wonder whether he has undiagnosed atrial fibrillation or
potentially a degree of heart failure. The fact that he has no chest pains with the palpitations is somewhat
reassuring. With respect to the respiratory system, it appears as if there is some compromise from heavy
smoking but no evidence of anything of major concern.

After taking a full history, the next stage is to perform an examination.

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An examination will give us further information re a diagnosis, the severity, and other known and,
potentially as yet, unknown medical conditions. Although we will be examining in a systematic way, the
information we already have allows us to have a heightened awareness for certain clinical signs.

When examining a patient there are two general ways to do it. The first is a systems approach and the
second a general ‘Top to toe’/’Hands to feet’ approach.

In the Surgical Modules a ‘Hands to Feet’ (HTF) approach will be used.

The reason this approach is taken is that all systems must be assessed in a surgical patient and performing
one comprehensive examination is more efficient than multiple separate systems examinations. An HTF
approach does not do full systems examinations, however! A screening examination is performed and
expanded if needed.

Examination findings in the surgical Modules will follow the general pattern of giving the observations first,
providing a general overview of appearance, then moving from the hands to the head and neck, down to
the chest, through the abdomen and groins (with consideration given to scrotal and rectal examinations
where appropriate), and then down through the legs and feet and around to the back.

Although it is a transition to move from examining a single system to all systems in one examination, in
time it will become second nature. This will allow you to take either approach as you need to in due
course.

A REX is a Red Flag on EXamination. This is a red flag which comes up when you are examining the patient.
These are clinical findings which have important or urgent implications where a different urgent or
immediate action should be taken, or there is an increased awareness of a serious condition.

Examples could be a fast heart rate (known as tachycardia), low oxygen saturations (hypoxia), low blood
pressure (hypotension), a high respiratory rate (tachypnoea), or saddle anaesthesia.

Watch out for these REX reminders as you go through the Modules.

Consistent with our first impression, It is clear from the examination findings that Angelo is extremely
unwell, being tachycardic, hypotensive, hypoxic, tachypnoeic, and febrile. There also appears to be an
element of altered cognition suggestive of a serious infection as although he is oriented, he is not himself. I
am worried about sepsis.
The fact that Angelo is flushed and looks unwell with shallow rapid breathing is extremely concerning. With
respect to the pain the fact that he is lying in bed not moving it is highly suggestive of generalised
peritonitis. NB This also would have been noted already as a REFE.
An irregularly irregular pulse at a rate of 150 suggests fast atrial fibrillation (most likely as a result of sepsis).
The thready pulse, his JVP not being visible lying flat, and the dry mucous membranes with cracked lips are
consistent with him being volume depleted and septic. The fetor is consistent with a gastrointestinal tract
problem such as acute appendicitis.
The dullness and crepitations in the chest with reduced air entry are consistent with bibasal atelectasis as
he is not breathing properly due to pain and his smoking history. This puts him at risk of respiratory
complications.

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The fact that Angelo is unable to move due to pain and points all over when asked where the pain is is
suggestive of a generalised problem. The fact he does not wish to cough is consistent with peritonitis. My
usual practice is to percuss the abdomen first in this clinical context which if it results in severe pain is
sufficient to diagnose a generalised peritonitis and causes minimal discomfort to the patient. It is useful to
gently lay a hand on the abdomen to see if there is a rigid and guarded abdomen (involuntary guarding) or
if the abdomen can soften (voluntary guarding). Gentle assessment in all four quadrants in this manner can
identify if a mass is present which helps with the diagnosis. It is usual to minimise discomfort by not
performing formal light and deep palpation and palpating for organs as, because it causes so much pain, it
is not helpful in this situation.
Reassuringly, there was nil else of note.
It is likely that Angelo has peritonitis secondary to most likely perforated appendicitis or possibly
diverticulitis. He is extremely unwell and needs immediate treatment to be commenced. He has fast atrial
fibrillation which is likely due to the response to sepsis. I’m worried about Angelo.

In the context of an unwell or extremely unwell patient, it is appropriate to commence treatment sooner
rather than later. This is often done whilst (or even before) taking the history and examining.

This results in earlier stabilisation and shorter time duration to antibiotics or critical treatment, thereby
reducing morbidity and mortality.

Accordingly, diagnosis to management may not occur in a linear fashion, and there are opportunities to go
forwards and backwards as needed based on clinical priorities.

Investigations are important to confirm, exclude a diagnosis, inform severity, assess another condition,
and/or establish a baseline.

When selecting investigations, the first thing to consider is whether the investigation is wise, appropriate,
necessary, and cost-effective. Sometimes Less is More. We should always Choose Wisely (using Guidelines
where available), Masterful Inactivity with Cat-like Observation is a reasonable (and often preferable)
choice, and we must prioritise the principle “First, do no harm”.

Throughout the Modules you will see cats on the slides as reminders of these principles.

A RIX is a Red Flag found on I(X)nvestigations. This is one which comes up when you view your test results.
These are results from tests which require immediate or urgent action or symbolise an urgent concern.
Examples include anaemia, hyperkalaemia, and free air under the diaphragm on an erect chest Xray.

Watch out for these RIX reminders as you go through the Modules.

I would perform:
• A full blood count to see if there was anaemia and an elevated white cell count. I would expect the
haemoglobin to be normal and the WCC to be elevated.

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 • I would also do U and Es, LFTs, lipase, glucose, CMP, LDH, CRP and an ABG to check baselines levels
and assess the level of physiologic stability. I would expect renal impairment and an elevated CRP.
There is also likely to be a metabolic acidosis.
• A coagulation screen to ensure no coagulopathy would be advisable in my estimate (which I would
expect to be normal).
• I would perform a group and hold but not crossmatch.
• Angelo is febrile so blood cultures would be reasonable.
If I only had 5 tests to choose, I would choose: FBC; U and E’s and lipase; blood glucose, LDH and CMP; ABG,
coagulation.
With respect to other tests I would perform:
• I would do an ECG to assess rate and rhythm and old and new ischemia indication. I expect it to
show AF and not necessarily any ischaemic change.
• I would request an erect CXR to be performed in the resuscitation area for free air and respiratory
pathology. I think would be essentially normal although there might be some signs of COPD. I do
not think there will be free air as I think it is most likely pus through the abdomen rather than GI
contents where the gas volume would be higher.
• I would request a urine dipstick and MSU with M, C and S to assess for hydration, ketosis and
infection which I expect to show an increased specific gravity, ketosis but no proteinuria or
haematuria.
• CT AP would be my next choice. I would toss up whether I wanted to use IV contrast or not
dependent on his renal function. I would be looking for the cause of the abdominal pathology and I
expect to see an inflammatory mass in the pelvis with free fluid throughout the abdomen or some
kind of subtle signs of inflammation such as dirty fat.
With respect to results, notice that the full blood count does not show anaemia and the MCV is normal with
a slightly increased MCH. There is no sign of iron deficiency. The white cell count very interestingly is
normal although there is a slight neutrophilia.
I note that there is an impaired renal function with a creatinine of 195 and an eGFR of 60, a very high CRP
of 432 and a low albumin. Pleasingly the rest of the electrolytes and cardiac markers are normal.
The arterial blood gas shows a metabolic acidosis with mild hypoxia. The lactate being normal is reassuring
from the point of view from the magnitude of physiologic dysfunction.
The ECG is abnormal. It, to a surgeon, shows fast atrial fibrillation with some rate related ischaemic
changes. This is the kind of ECG I would get a medical opinion on to make sure I wasn’t misreading things
and my patient was best managed.
The CXR shows nil specific of concern.
The CT scan shows no free air, dilated small bowel loops, inflammation in the pelvis but no specific cause.

Management is essential. Recommendations made must be wise, appropriate, necessary, and cost-
effective.

As for the Investigations principles, sometimes Less is More, we should always Choose Wisely (using
Guidelines where available), Masterful Inactivity with Cat-like Observation is a reasonable (and often
preferable) choice, and we must prioritise the principle “First, Do no harm”.

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Throughout the Modules you will see cats on the slides as reminders of these principles.

Management in the initial phases can be considered in terms of Initial Stabilisation (what you do in the first
few hours) and what you do Subsequently. The principles which should be considered are outlined on this
slide. Not all will need to be done, but all should be considered.

ABCs are important. A holistic and considered overall approach will reduce the chances of important
elements being missed.

And remember, where initial stabilisation is time critical, some actions may be undertaken before even a
history can be taken, examination performed, or the results of investigations known.

Communication in the initial stabilisation phase includes communicating with the patient, their support
network, and other relevant individuals and teams.

Lines which are needed in this context include intravenous access canulaly. It is important to consider the
size of the intravenous line, the number, and location. The size of the intravenous line is related to how fast
you want the fluids to be given and the general logistics of what is available! A short- large-bore line will
provide the fastest flow rate.

Tubes in this context include indwelling urinary catheters, and nasogastric tubes.

Analgesia can be given by an oral, intravenous or rectal route. The choice should be based on the need
related to the severity of pain and clinical condition (eg NBM).

Anti-emetics should be used where needed.

Metoclopramide should be considered carefully and avoided in the context of Parkinson’s and obstruction.
Where there is obstruction, a nasal gastric tube is often more useful for nausea and vomiting.

Antibiotics should cater to the clinical situation. In the setting of sepsis, broad spectrum antibiotics should
be given as soon as possible, and all antibiotics should be considered at a 48-hour mark and changed
depending on the clinical response and culture results.

Condition specific medications are things like a proton pump infusion and reversal of anticoagulation. These
must be considered on a case-to-case basis.

With respect to intravenous fluids the first decision is what to give. Options include a crystalloid, a colloid,
or blood products. Crystalloids include normal saline, 5% dextrose, dextrose saline and Hartmann's. Colloids
include Gelofusine and Haemaccel. Once you have decided what needs to be given, you need to decide the
volume and rate (eg 1L of normal saline over 2 hours or 500ml per hour). A plan for review and monitoring
should be made, along with charting further intravenous fluids dependent on the clinical response.
Consultations include referrals to other teams who may be needed to help with care.

The need for intervention for a very unwell patient may be made in this initial stabilisation phase, but
usually this would happen later once more information is known.

Subsequent management is about those things to think about after the most urgent priorities.
Although these actions have been separated from initial stabilisation, this is a way of thinking about
management rather than what must happen. In the real world, there is integration.

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A decision to admit is appropriate and following that it is important to make a decision as to whether a High
Dependency Unit bed or Intensive Care bed is needed, or a ward bed.

With respect to DVT prophylaxis, it is usual to consider TED stockings and the use of subcutaneous
medications. In a patient who may be going to theatre it is wise to carefully consider what should be given
and when. All decisions re prophylaxis should be documented.

Usual medications for patients need to be charted but a decision should be made about what should be
withheld, reviewed and for how long. Most patients who are admitted under surgery should be nil by
mouth until it is very clear intervention in the near future is not required.

Once the basics are done a plan should be made for the patient to be reviewed, when this should occur,
and by whom. A plan for the frequency of observations (eg hourly urine output measures or 4-hourly
observations) should be documented. Goals of care forms, Advanced Care Directives and power-of-
attorney documentation should be available where appropriate.

When a decision for theatre is made, specific actions to make this happen such as booking and consenting
must occur.

Depending on the specific situation special instructions may be needed to facilitate management. These
will vary depending on the situation.

At this point it is clear Angelo is very unwell, with an acute surgical abdomen and sepsis.
The most important decision now is a decision for surgery or not. It is very important to address the source
of the sepsis and in this particular case this would require an operation. That operation is most likely to be a
‘laparotomy and proceed’ as it is not exactly clear what is going on.
It is always a consideration to avoid surgery – think, less is more - particularly in an elderly extremely unwell
patient however in many situations it is the only thing which will get anyone through so these risks must be
balanced and it must be taken into account that without taking these risk the risk of mortality is most likely
absolute. Angelo has a good pre-morbid functional capacity and has no major co-morbidity that would
preclude surgery which is important.
But the decision for surgery is not a unilateral one, based on what we think looking at the information. IC
and anaesthetists should be involved as well as family members and other relevant people. The use of risk-
assessment tools such as the NELA risk-calculator assist decision-making. Discussing the situation, the likely
procedure, and the risks and anticipated outcomes with the patient and their support network is
important. This perspective needs to be from multiple different people. Once a decision to go ahead is
made, the next step is timing of surgery which is a balance between too late and too early - a relative
degree of stabilisation is important but the time to source-control needs to be as short as possible and full
stabilisation is impossible where the source is not controlled. In these particular situations, that means
surgery.
The discussions around decision making for surgery should be clearly documented along with the names of
the people involved. It is also important that goals of care and limitations to treatment are discussed so
that everyone is on the same page for planning for the future.

We’ve considered Mr Accardi for surgery, and I think that it would be important to have a conversation
with him and his daughter about his risks. He’s at elevated risk of morbidity and mortality, given his current

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physiological derangement including acute kidney injury as well as dehydration and sepsis. We can use
several risk calculators to give him a more accurate estimation of his mortality and morbidity, and one such
tool that we can use is what we call the National Emergency Laparotomy Audit risk calculator or the NELA
risk calculator.
Using this risk calculator, we can input Mr Accardi’s age, his pre-existing comorbidities, and his current
investigation results as well as his vital signs and the estimated amount of soiling in the abdomen including
whether or not we’re expecting to find pre-bowel content, pus or blood and the urgency of the operation.
Using the NELA risk calculator we can see that Mr Accardi is at increased risk of mortality, over 40%, and
morbidity and this includes all types of morbidity, including adverse cardiac events, respiratory failure and
respiratory events, as well as acute kidney injury.
So, using this information we can decide that this gentleman will require IC post-operatively, as well as
advanced monitoring during the procedure, and normally we would recommend that a consultant surgeon
and anaesthetist is present in the operating room for this type of surgery.

A RART is a Red flag from a chART, and is a Red Flag identified when you are reading a patient’s
Observations (Obs) Charts.

In this context, the term ‘Observations (Obs) Charts’ refers to records of heart and respiratory rate,
saturations, blood pressure, neurology, as well as fluid balance, medication, pain and drainage charts.
Examples could be a fast heart rate (tachycardia), low oxygen saturations (hypoxia), low blood pressure
(hypotension), a high respiratory rate (tachypnoea); or low or absent urine output (oligo- or an-uria).
Excessive drainage output, or a cumulative fluid balance over 24 hours demonstrating extreme excess or
deficit are also important.

It is important to observe the absolute values and also the trends over time.

Find the charts in use at your hospital. Observe the different colours and consider what they mean. Look for
examples RART on the charts you find and identify MET call criteria.

Multiple people are involved in discharge planning and a co-ordinated approach is important.

There are different goals, needs and tasks for the surgical and consulting specialist care teams, the patient,
their support network, allied health and nursing teams, as well as the GP and community teams.
Communication and collaboration in a timely fashion is the key.

Moving from a controlled environment to home can be a big adjustment for a patient.

Follow up needs to be timely and patients need to know who to call if things go wrong or they are
uncertain.

A general practitioner needs to know what has happened, what medication changes have occurred, and,
very specifically, what they need to do and when.

Look for examples in your institution of discharge planning and how discharge works.

Think about asking a patient about their experiences and concerns about discharge.

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