PRINT Education Case Series

Our team has released a 4-day clinical case series, covering common topics encountered during internship.

Access all questions and suggested answers below!

 

Case 1: HYPERKALAEMIA

You are the after-hours intern covering a surgical ward, and you’re asked to review Mrs JS, a 68 year old female with a potassium result of 6.2.

Mrs JS is currently being investigated for a suspected small bowel obstruction and left lower limb cellulitis. She is on the appropriate IV antibiotics. She does not have pre-existing cardiac disease. She is haemodynamically stable and has no other electrolyte abnormalities. Her previous potassium reading earlier that day was 5.1. You review her ECG, which does not show any concerning signs (no peaked T Waves, no flattened P wave and no broad QRS complex).

What is your most immediate management step?

A – Repeat serum potassium level to rule out a false reading, repeat ECG and re-assess based on repeat results

B – Calcium gluconate 1g in 10ml intravenously, over 2-3 mins

C – Start resonium (sodium polystyrene sulfonate) 15g orally TDS (stat dose tonight), and repeat bloods in the morning

D – Short-acting insulin 10 units IV bolus plus glucose 10% 250 mL IV over 15 minutes

E – Start resonium (sodium polystyrene sulfonate) 45g rectally daily (stat dose tonight), and repeat bloods in the morning

 

Case written by Dr Neel Gobin. Contact Neel via email.

Suggested answer – D

D – Hyperkalaemia is a medical emergency – it is potentially life threatening, and can result in cardiac arrhythmias and sudden death. A serum potassium level of 6.2 indicates moderate hyperkalaemia (mild 5.5-6mmol/L; moderate 6.1-6.9mmol/L; severe >7mmol/L) and guidelines suggest that urgent measures need to be taken to correct the elevated potassium level. In this case, administering an insulin-glucose combination would be the most immediate management step. It’s onset of action is about 15 mins, with a reduction of intravascular K+ by 0.5-1.5mmol/L. Absence of ECG findings is not an indication to delay treatment, particularly when the previous reading earlier that day 5.1. Note on ECG findings: hyperkalaemia does not always have ECG signs (it is possible for a hyperkalaemic patient to progress rapidly from a normal ECG to ventricular fibrillation)

A – It may be reasonable to repeat the level in this case. However, repeating the serum potassium will take about an hour. Guidelines advise that you may repeat the sample but should not wait for the results to begin treatment – use clinical judgement based on other information available (e.g. previous potassium level) and consider doing a venous gas (quicker ressults than formal bloods) to check if this is an accurate result. Note: most hospital labs will do a sample re-test if an abnormal value is detected (therefore, do not simply assume the result produced is incorrect unless major discrepancies are noted clinically).

B – Calcium gluconate is given to protect the myocardium, and is generally admistered if risk factors are present (e.g. ECG changes; K+ greater than or equal to 6.5mmol/L; acute increase; pre-existing cardiac disease; other electrolyte abnormalities).

C – This patient is presumably nil-by-mouth.

E – Not an option, as the patient has a suspected small bowel obstruction.

 

 

Case 2: PRIORITISING TASKS

You are the intern covering aged care and neurology this evening. You open up your job list to find plenty of jobs and your pager goes off with a clinical review.

The tasks you need to complete are:
1) resite cannula for IV antibiotics
2) take blood for APTT for heparin infusion, due in 20mins
3) clinical review for hypertension in a patient admitted for cellulitis, on IV Abx, other obs fine, asymptomatic
4) rechart meds, you have now been paged twice about this
5) call radiology to chase up a CT brain the neurology reg has requested 10 mins ago, for a possible stroke

Rank your tasks in order of priority:

A) 5, 3, 2, 1, 4
B) 3, 5, 1, 2, 4
C) 2, 1, 3, 4, 5
D) 3, 1, 2, 4, 5
E) 1, 5, 4, 3, 2

 

Case written by Dr Ashleigh Phillips. Contact Ashleigh via email.

Suggested answer – A

 

 

Case 3: INSULIN CHARTING

You are the evening JMO covering the medical wards when you receive a page at 6pm asking you to review a pre-meal BSL of 15.4 on patient Mr DM. He is a 65kg 72M who is day 3 into admission for an infective exacerbation of COPD currently being treated with prednisolone 50mg (amongst other therapy). He also has a background history of type 2 diabetes mellitis on metformin XR 1g daily and basal-bolus insulin (a long-acting insulin 15 units at bedtime and an ultra-short-acting insulin 8/8/10 units at mealtimes). You note that his day team has made adjustments to his usual basal dose of insulin so that his fasting BSL is within normal range. After you have reviewed the patient to make sure he is not acutely unwell, what action would you take?

A – Chart a supplemental insulin order and advise the nurse to give a dose of Novorapid 6 units

B – Chart a supplemental insulin order and advise the nurse to give a dose of Novorapid 4 units

C – Chart a supplemental insulin order and advise the nurse to give a dose of Actrapid 4 units

D – Increase basal insulin dose by 4 units

E – Reassure the nurse and write a comment for the day team to consider increasing the regular pre-meal (dinner) insulin dose the next day by 10%

 

Case written by Dr Kim Van. Contact Kim via email.

Suggested answer – B

B – A pre-meal supplemental insulin dose (in addition to the usual insulin dose) should be administered to achieve a BSL target of 5-10mmol/L. Doses should always be individualised, but a rough guide to supplemental insulin doses can be found on page 4 (the back) of the Insulin Prescribing Chart. This guide recommends a dose of 4 units of a rapid-acting insulin (e.g. Novorapid) for pre-meal BSLs in the range of 12.1 to 18 mmol/L. Advise nursing staff to monitor the BSL 2 hours after giving the insulin to make sure that your dose is not under- or over-effective. It should be remembered that supplemental insulin should not be used as the only antihyperglycaemic therapy in a patient.

A – Factors which would warrant higher supplemental insulin doses could include higher total daily doses of insulin (e.g. >50 units) and obesity (e.g. >100kg). Alternatively, factors which would warrant smaller supplemental insulin doses include: T1DM, low body weight (<50kg), older patients, lower daily doses of insulin (e.g. <25 units).

C – An ultra-short-acting insulin (e.g. Novorapid) vs. a short-acting insulin (e.g. Actrapid) should be used to prevent hypoglycaemia from insulin overlap.

D – Increasing basal insulin dose will affect fasting BSLs (i.e. morning pre-meal BSL & BSLs >4 hours post-prandially).

E – This would have been appropriate if this was a post-prandial BSL within 4h of the meal. Avoid giving supplemental insulin post-prandially as it may precipitate hypoglycaemia.

 

 

 

 

Case 4: MEDICO-LEGAL

You are the after-hours JMO covering the orthopaedics ward. While you were in the middle of a clinical review, a rapid response call goes off and you quickly attend the call. Unfortunately, the patient had passed away before you arrived at the scene and the medical registrar hands you the task of filling out the death certificate. As you do not know the patient, you trawl through her notes and discover that she was a 93 year old female who fell down a flight of stairs and suffered a right neck of femur fracture and was operated on by the orthopaedics team yesterday. You are unsure if this case is reportable to the coroner as the patient passed away within 24hrs of an anaesthetic. You call the medical registrar who suggests calling the orthopaedics reg. The orthopaedics registrar is similarly unhelpful in suggesting for you to sort it out with the medical registrar as she had not met this patient before. What is your next best approach?

A – Call the medical registrar and request for help in filling in the death certificate as you have never done one before

B – Fill out the death certificate and refer to coroners as it is a coroners case

C – Call the Coroner and ask for further clarification into whether to report to coroner or not

D – Fill out the death certificate and do not refer to coroner as it is not a coroners case

E – Call the orthopaedics consultant in charge and clarify with him whether to refer to coroners or not

 

Case written by Dr Raymond Shi. Contact Raymond via email.

Suggested answer – D

As of 2010, these are some of the changes to the categories of cases that were previously reportable in the Coroners Act 1980
Part (a) Deaths during, within 24 hours, or as a result of anaesthesia are no longer reportable to the Coroner unless they are captured under one of the other sections of the Act listed above. For example, if death occurred following anaesthesia and this was not a reasonable expected outcome of the procedure, the death is still reportable.
Part (d) A death is not reportable if it follows an accident attributable to old age, if the person is older than 72 years (as opposed to 65 years in the previous legislation). The provision covers accidents that occur in a nursing home, hospital or at home. The medical practitioner MUST STATE on the certificate that it is given in pursuance of S38(2) of the Coroners Act 2009. Note that if a relative of the deceased person objects to a medical practitioner issuing a death certificate in these circumstances, the death must be reported to the Coroner (s 38(3) of the Act)

 

Therefore, in this case, death is not a coroners case.

If unsure, you may call the Office of the Coroner to seek clarification (therefore, in this case, answer C is also considered a reasonable option!)

 

 

If you have any questions about our case series, or have an interesting case to suggest – please email us: education@printconference.com.au

 

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