Medical Trainees

Non-invasive ventilation: when and how to start it and avoiding complications

Non-invasive ventilation: a guide to its useA 65 year old man presents to you with shortness of breath and a productive cough. He has known chronic obstructive pulmonary disease. An arterial blood gas shows that he is in type 2 respiratory failure with a respiratory acidosis (pH 7.12, PO2 7.83 kPa, PCO2 7.3 kPa). Despite initial medical therapy with nebulisers and steroids he does not improve. You think the patient requires non-invasive ventilation (NIV).

How should you start NIV?

Check your answer in our module Non-invasive ventilation: a guide to its use. It covers everything you need to know to support your practical experience, including when to use NIV, how to set it up, how to monitor its effect, and what to do if NIV is failing.

You might also like to try the modules in our Airway management course, which will help your understanding of common airways procedures, including the relevant anatomy and physiology, when they should be used, and how to use them in an emergency situation.

Test your knowledge of jaundice

Ask the consultant: DiabetesA 16 year old male is admitted with jaundice, sore throat, unilateral knee joint pain, and general weakness. His liver function tests are normal, except for a bilirubin of 60 µmol/l (normal: 0 to 21 µmol/l). His body mass index is 22 and his blood pressure is 125/75 mmHg. He had jaundice once before along with glandular fever when he was age 13.

What is the most likely reason for his jaundice?

Check your answer in our updated module Hospital presentations: jaundice. It covers the pre-hepatic, hepatic, and post-hepatic causes of jaundice, plus safe prescribing practices.

It’s getting great feedback from other users:

"Good cases with good explanations that definitely improved weak areas of knowledge"

"This is par excellence. The man hours to design such a good presentation is well appreciated."

Upper gastrointestinal bleeding: does this man need endoscopy?

Hospital presentations: Haematemesis and melaenaAn 80 year old man is admitted with melaena. He has been taking ibuprofen regularly over the past two weeks for golfer’s elbow. On examination his pulse is 120 bpm and irregular, his blood pressure is 95/40 mmHg, he is apyrexial, and his oxygen saturations are 97%. He has no history of cardiovascular or hepatic disease. His blood results include a haemoglobin of 64 g/L and a blood urea of 15 mmol/L.

How would you assess his likelihood of requiring an intervention?

Check your answer in our new module on Haematemesis and melaena from the Hospital Presentations series. It will help you to appreciate the common causes of upper GI bleeding, understand the importance of resuscitation and indications for infusion of blood/blood products, be aware of risk factors that predict mortality from GI bleeding, appreciate the range of therapeutic options used, and much more. 

Other case-based modules on related topics include:

We hope you find them useful.

Managing patients in cardiac arrest in a hospital setting

A 72 year old man has been brought in by ambulance in cardiac arrest with cardiopulmonary resuscitation ongoing. He has had four shocks, and 300 mg amiodarone and 1 mg of adrenaline after the third shock. The rhythm is assessed at the beginning of the fifth cycle and shows the following:

Hospital presentations: delirium

What should you do next?

Find out in our updated module on Advanced life support for in-hospital adult cardiac arrest. It covers everything from compressions to defibrillation, as well as managing the airway, drugs, and more. It also looks at what to do after resuscitation for post-resuscitation care and deciding when to stop CPR.

If you want to learn more about different airway techniques, you could also try our Airways management course.

Your practical questions on diabetes answered

Ask the consultant: DiabetesA 48 year old man with known chronic kidney disease presents with evidence of a community acquired pneumonia. He is noted to have raised capillary blood glucose levels throughout his admission, and his HbA1c is reported as 64 mmol/mol.

How should you manage this patient?

Check your answer in our Q&A module Ask the consultant: diabetes. It covers diabetic ketoacidosis, hyperosmolar hyperglycaemic state, oral antidiabetic drug combinations, managing hyperglycaemia, and other practical questions on managing diabetes in hospital.

Here are some comments from other users:

"Very clear explanations and a good cluster of useful questions"

"This illustrates some of the complex situations encountered in acute medicine and provides clear answers and advice."

Investigating a patient presenting with acute confusion

Hospital presentations: deliriumYou are called to review a 78 year old man in the emergency department with suspected left basal pneumonia who has become confused. It has not been possible for the emergency department staff to take a clear history as he’s so easily distracted. He scores 5/10 on the abbreviated mental test and cannot complete a clock drawing test. His neurological examination is normal.

What would be your next step in assessing his cognitive impairment?

Check your answer in our updated module Hospital presentations: delirium. It covers assessment, investigation, and diagnosis of patients presenting with acute confusion, along with initial management and prevention of  delirium. It’s getting great feedback from other users:

“Very good overview of delirium and beautifully explained”

“Great module made me think”

Why not also try our companion module Hospital presentations: aggressive or disturbed behaviour, which follows the same patient through some further scenarios during their hospital admission.

Joint swelling: can you spot the diagnostic clues?

A 61 year old woman presents with pain in her hips and shoulder myalgia. She has stiffness in the morning that lasts for at least an hour before starting to ease slightly. The symptoms started two weeks ago after she had recovered from what she thought was a bad cold.

What is the most likely diagnosis?

Check your answer in Hospital presentations: joint swelling. It’s been fully updated to include the latest UK guidance and will help you recall the main causes, interpret and act on initial investigations, and be aware of treatment options and their complications.

Other modules on related topics include:

Septic arthritis: a guide to diagnosis and management

Practical skills: aspiration and injection of the shoulder

Practical skills: aspiration and injection of the knee

How would you manage this patient's fluid status?

Fluid management in acutely ill patients

A patient comes to the emergency department with chest pain and dyspnoea due to multiple pulmonary emboli. His jugular venous pressure is elevated at 4 cm, and he has minimal ankle oedema, but his blood pressure is 85/50 mmHg and his urine output is reduced.
How should you initially manage his fluid status?
Check your answer in Fluid management in acutely ill patients. It covers the fundamentals of fluid balance, assessing fluid status in acutely ill patients, and tailoring fluid balance to individual patients.
It’s getting positive feedback from other users: 
"A great refresher and very clear explanations of the physiology. The scenarios at the end pulled it all together"

A patient comes to the emergency department with chest pain and dyspnoea due to multiple pulmonary emboli. His jugular venous pressure is elevated at 4 cm, and he has minimal ankle oedema, but his blood pressure is 85/50 mmHg and his urine output is reduced.

What is your initial management?

Check your answer in Fluid management in acutely ill patients. It covers the fundamentals of fluid balance, assessing fluid status in acutely ill patients, and tailoring fluid balance to individual patients.

It’s getting positive feedback from other users:

"A great refresher and very clear explanations of the physiology. The scenarios at the end pulled it all together"

How would you manage a patient admitted with accidental hypothermia?

A 70 year old homeless man is brought in by ambulance in cardiac arrest with resuscitation in progress. A tympanic temperature is taken and found to be 29°C.

What would you do next?

Check your answer to this and other management scenarios in our case-based module Hospital presentations: hypothermia. It will give you the knowledge and confidence to manage the rewarming of patients and understand how hypothermia can alter the management of advanced life support.

It’s getting great reviews from other users:

“Excellent scenarios with real life situations. Good questions, great and concise tips and learning points. Genuinely enjoyed doing this module. Thank you authors!”

Dysuria: what treatment would you start?

A 35 year old man attends the emergency department with a one day history of worsening dysuria, frequency, low back pain, and myalgia. On examination, he is febrile and tachycardic. A per rectal examination reveals a swollen and very tender prostate. Urine dipstick: leucocytes 3+, nitrites 3+

What is your diagnosis and initial management?

Check your answer in our latest hospital presentations module on dysuria. It follows the investigation and management of two patients presenting with painful urination, and covers topics such as risk factors for urinary tract infection (UTI), when to treat asymptomatic bacteriuria, preventing recurrent UTI, and the pathophysiology and management of infective urethritis.

Other modules in the same series on related topics include:

Genital discharge and ulceration

Delirium

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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.

Animated practical skills modules to support you in your first years on the ward

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