What end-of-life care would you offer this patient?
A 96 year old woman with stage 4 CKD is admitted to the care of the elderly ward. She has been deteriorating steadily over the past three weeks and now looks to be in the final hours or days of life. She is no longer able to communicate verbally and is only taking sips of fluid. She becomes agitated and restless and her family and the ward team believe she is distressed. Other than pain from a pressure sore, no reversible cause for her distress can be found. What is the most appropriate next step in managing this patient?
Check your answer in our new Hospital presentations module on Palliative and end-of-life care. This interactive case-based module offers advice on assessing the needs of patients recognised to be in the last days or weeks of life, along with symptom control and advance care planning. It’s full of practical tips on taking an accurate pain history, safe and effective use of syringe drivers, making appropriate decisions on withholding interventions such as CPR and sensitive communication with relatives.
Get up to speed on sepsis
A 45 year old woman is admitted with right iliac fossa pain following a laparotomy two weeks ago for endometriosis. She has a respiratory rate of 24 breaths per minute, oxygen saturations of 94% on room air, heart rate 117 bpm, blood pressure 108/68 mmHg, and a temperature of 38.5℃. On examination she has tenderness in the right iliac fossa with pus draining from the incision site. You are asked to do a structured risk assessment for possible sepsis. How will you proceed - and how should your findings guide your management plan?
Check your answers in our new Hospital challenges module on
Sepsis in adults. You will work through patient scenarios that are typical of the situations you face in everyday practice as you learn about all the latest practice-changing developments in the evidence, guidance and classification of sepsis. The module is already proving very popular with other users:
"Excellent module with important details about updated sepsis guidelines."
"Very informative and relevant in clinical practice."
Also try the companion module on Sepsis in children to ensure you know how to identify and manage paediatric patients with infections that put them at high risk of serious illness or death from sepsis.
What’s the next step in managing this patient?
A 28-year-old man is admitted as an emergency with haematemesis. An endoscopy the day after admission shows some altered blood in the gastric lumen, but no bleeding point is identified. He is treated with intravenous omeprazole for three days. He then vomits more than 750ml of fresh blood. His blood pressure is 124/68 and his heart rate is 110 bpm. What is the most appropriate next step in managing this patient?
Check your answer in our newly updated module on Acute assessment and treatment of upper gastrointestinal bleeding, which will help ensure you feel more confident next time you have to manage this common emergency. The module covers the main causes of bleeding, initial evaluation, resuscitation of a patient with an upper GI bleed and the diagnostic and therapeutic uses of endoscopy and interventional radiology.
How would you manage this emergency?
A 62 year old man has been referred for medical admission by his GP and you are asked to see him when he arrives at the hospital. The patient has developed a sudden-onset headache and has become mildly confused. One of the ward nurses calls you as you’re reading the referral letter. The patient has started to have a tonic-clonic seizure. You notice his face and lips are blue. What are the most urgent next steps in managing this patient?
Check your answer in our new Hospital presentations module on The unconscious patient. You’ll learn as you work through patient scenarios that are typical of the situations you might face in your daily work. Other users are giving the module great reviews:
"Important, informative and useful in daily practice."
"Excellent overview with practical, hands-on advice."
Safe prescribing in renal impairment
Prescribing in patients with acute or chronic kidney impairment can be tricky, with dose adjustments, nephrotoxicity, fluid balance and monitoring requirements among the factors you need to consider. In our new module on Safe prescribing in patients with kidney impairment, you will learn as you work through common prescribing scenarios. Drug classes covered include antibiotics, anticoagulants, antidiabetic agents and antihypertensives.
What do these ABG results indicate?
You see a 20 year old woman with acute severe asthma in the emergency department. She is unable to speak in full sentences. She has been given oxygen (15 l/min) via a reservoir bag mask. Her arterial blood gas results are as follows:
- pH: 7.47
- pO2: 11.2 kPa
- pCO2: 3.7 kPa
- HCO3-: 25 mmol/l
What is her acid-base disturbance?
Check your answer in our updated module on Arterial blood gases: a guide to interpretation. It offers a practical five-step approach that will help ensure you feel confident on everything from how to distinguish respiratory from metabolic disturbances through to trickier challenges like calculating the alveolar-arterial gradient and understanding what it means for diagnosis and management of the patient.
Are you confident in managing shock?
How can you distinguish between hypovolaemic, cardiogenic, distributive and obstructive causes of shock? What’s the latest evidence on crystalloid versus colloid when giving fluid resuscitation to a patient with shock? How do you estimate blood loss in a patient with hypovolaemic shock? And what are the new diagnostic criteria for septic shock?
Check your answers in our new module Hospital Presentations: Shock. You’ll learn as you work through patient cases that are typical of the kind of scenarios you might face in your daily work.
The module is already getting great reviews from other junior doctors:
“A must-read for juniors - and seniors as well!”
“Excellent and up to date. Very useful and practical.”
Join our audience panel
If you’d like to help BMJ Learning ensure we deliver the content that you need as a medical trainee, join our audience panel to provide feedback and ideas. Email clinical editor Jo Haynes.
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