Pneumonia
You are the General Surgery CT1 and are asked to see a 65year old patient who is day 4 post anterior resection. The nurses call you as he is sounds ‘chesty’ and is pyrexial and saturations are 92%.
Example answer introduction
In this scenario, in a patient who is post op with a pyrexia and low saturations, I would be concerned about potential chest sepsis. I would recognise this is an emergency and attend immediately. I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis and escalate to the general surgery registrar.
Initial Assessment and Simultaneous Resuscitation
On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.
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Airway
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Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
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Circulation
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Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
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IV access - large bore and bloods including CRP
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Give fluid challenge of 250ml crystalloid solution if evidence of shock
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Disability - GCS, pupillary response, blood sugar, temperature
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Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!
During this acute phase state remember to provide constant reassessment
During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature.
Focused history
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Allergies
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Medications – VTE prophylaxis, analgesia, is the patient on antibiotics
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Past medical history – any pre-existing lung problems e.g. COPD, asthma. Is the patient a smoker
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Last meal
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Events leading up to this point
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Indication for surgery
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Review operation notes – any high risk of complication, was the operation difficult
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Abdominal examination
Examine to determine source of infection
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Chest examination
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Abdominal Examination
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Examine wounds and drains
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Assess for possible DVT/PE
Investigations
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Blood tests– FBC, CRP, U&Es
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Cultures– blood, urine, sputum sample
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Imaging– Chest X-ray
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Arterial Blood Gas
Initial management
The patient describes being in significant pain and is taking small shallow breaths. You give oxygen and their saturations improve. The X-ray shows right lower lobe consolidation
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Empirical antibiotics as per local guidelines, as the patient has been in for 4 days, treat as hospital acquired pneumonia
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IV fluids
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Analgesia
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Ensure DVT prophylaxis
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Monitor fluid input/output
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Chest physio
Escalation
Consider discussion with:
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General Surgical registrar
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Medical Registrar on call
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Critical care – if no improvement with management
