Test Stations

Initial Assessment / ABCDE: Upper GI Bleed


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location:You are an FY1 on a gastrointestinal firm

Patient:60 year old male patient who is a known alcoholic has started vomiting

Task

- Take a focused history from the patient

- Perform a full ABCDE assessment, a nurse will be available to help you with investigations or management that you require.

- After 6 minuets you will be asked a series of questions by the examiner.

- Answer any questions that the patient may have

Note to actor:Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 60 year old alcoholic. You have been vomiting for the past hour. You have last had alcohol 3 hours ago and have only stopped because of the vomiting. You say to the doctor “I’m fine, I just need a cider.” You drink roughly 20 ciders per day, everyday for the past 30 years.

You have been taking ibuprofen for pain relief for the past couple of weeks.

CategoryQuestion
Done
Excellent
IntroductionCandidate appropriately introduced themselves with:
Full name
Medical school + Year or grade
Clarifies who they are talking to
Asks patient for preferred name


History
History from patient

Alcoholic
Candidate asks for colour of vomit and picture is shown
Vomiting for the past hour, black in nature, some bits of red.
No drug allergies


AAirway assessment
Patient talking, airway patent


BBreathing assessment
Oxygen saturation = 96% on RA
Respiratory rate = 25/min
Position of trachea = central
Chest expansion = equal
Chest sounds = clear


BBreathing investigations
Chest x-ray and abdominal x-ray


B
Please interpret the following chest x-ray

Chest x-ray interpreted as normal


CCirculation assessment
Blood pressure – 100/60
Heart rate – 110
Peripheral and central cap refill –
Heart sounds = I + II + 0


CCirculation investigations
2 large bore IV cannulae
Bloods = FBC, U&E, LFTS, CRP
G&S
VBG


ECG
ECG requested

Interpreted as sinus tachycardia


CCirculation treatment
500ml of 0.9% normal saline STAT


DDisability assessment
Blood glucose = 6.7
Temperature = 36.7
GCS 13 (M6 V4 E3)
A on AVPU
Pupils equal and reactive to light


QuestionGiven your history and examination, what is your working diagnosis?
Acute upper GI haemorrhage
Secondary to alcohol or ibuprofen use


QuestionWho would you like to contact after your initial assessment?
Medical registrar
Gastrointestinal on-call team
Blood bank to activate major hemorrhage protocol


QuestionNurse now says, observations are HR 130. BP 80/45. Patient very drowsy. Medical registrar is on the way, what is your management?
Rolls patient onto left hand side, suction to remove blood / keep airway patent
IV fluid bolus 500ml of 0.9% normal saline STAT
IV PPI (Esomeprazole 80mg given over 30 mins)
IV tranexamic acid (Tranexamic acid 1G IV STAT)
Activate major haemorrhage protocol



Score


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