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.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

  • Disability - GCS, pupillary response, blood sugar, temperature

  • 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​

  • Allergies

  • Medications – VTE prophylaxis, analgesia, is the patient on antibiotics

  • Past medical history – any pre-existing lung problems e.g. COPD, asthma. Is the patient a smoker

  • Last meal

  • Events leading up to this point 

    • Indication for surgery

    • Review operation notes – any high risk of complication, was the operation difficult

Abdominal examination

Examine to determine source of infection

  • Chest examination 

  • Abdominal Examination

  • Examine wounds and drains

  • Assess for possible DVT/PE

Investigations

  • Blood tests– FBC, CRP, U&Es

  • Cultures– blood, urine, sputum sample

  • Imaging– Chest X-ray

  • 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 

 

  • Empirical antibiotics as per local guidelines, as the patient has been in for 4 days, treat as hospital acquired pneumonia

  • IV fluids

  • Analgesia

  • Ensure DVT prophylaxis

  • Monitor fluid input/output

  • Chest physio

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Medical Registrar on call

  • Critical care – if no improvement with management

core surgical training interview

© 2017-2018 BJK LTD

 

 

.Referral scheme

In collaboration with:

WWW.ENT-GURU.COM