Clinical

Case Recall

Candidate Name Rita Cruz

Date of clinical 03.11.2017 Clinical Area Cardio
exam (Neuro, Cardio-resp, Musc)

Hospital Name St. Vincents City & State Melbourne


Hospital Details & other information from Orientation:
(Access/transport to the hospital setting, details like acute Vs rehabilitation, inpatient Vs outpatient,
common type of patients seen there, location of the exam (ward Vs gym), equipment's available,
clinical records, do's and don'ts from specific local hospital policies etc)

St. Vincents has all sort of cases, medical and surgical, so you have to be ready for
everything. Orientation is the same day in the morning. Administrator, Liz, shows you the
ward and a typical room. You get to play with the beds, with the BP, the oxygen on the
wall. She also shows you the files in detail… and pay close attention, although when time
comes you might not be able to find anything and read the bloody handwrittings!... Keep
calm. Anyway, Liz is a lovely person, she really cares and she can rescue you if you’re
losing it, as you’ll see in my recall. I think you are lucky if your exam is in St. Vincents.

Information from history, charts & test reports:
(What did you have access to learn about the patient for e.g.files/digital investigation records,
observation chart, medications chart etc& What did you gather from that fore.g. Medical Hx,
Surgical Hx, Allied health assessment/ progress notes, premorbid mobility, social history, current
status of the patient etc - Please explain)

56 year old male, day 9 after L) VATS Pleurodesis
- HPC: Patient had come in on the 24th October with a Pneumothorax.
- PMx: COPD, HTN, anxiety. Had been in the hospital already in July, with a R)
Pneumothorax (he had then also been submitted to the same procedure: VATS
Pleurodesis of R) lung)
- Ex-Smoker, on nicotine patch at the moment and Diazapam
- Current notes: On 2L O2 via NS, saturation of 88-90%
- Physio notes of the previous day: Independent with nil aid, walked 40m with 2L O2
via NP. Plan: increase exercise tolerance and wean O2
- Investigations: X-ray’s report mentions bullar emphysema of the R) upper lobe
Haemoglobin was fine.
- Stability record for that morning (exam was at 11.30): borderlie fever I the
morning. Slight BP than his normal (130/90)
- Attachments: ICC and O2 NP

So… this is all I could gather. I was very organised whenever I did the recalls, and knew
exactly what to look for… but in an exam situation, with reports that you are not familiar

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with and handwrittigs hard to understand, and files that you have to navigate - all goes
down the drain. It was hard. Admin was brilliant. When she gave the 5m warning she
asked how I was doing. I said I was freaking out, I couldn’t even find the physio notes. She
was absolutely five stars: Stopped the time, and showed me again how the files were
organised, and were to find the information. Then she started the time again. It was life
saving, even though I wasted five minutes and felt I did not have enough info and my
hypothesis was a bit shaken.

Hypothesis presented to examiners:
(What did you understand about the patient and their problems and whatare your plans for
assessment and treatment options with this patient that you were expecting?)

I presented the date above and said I expected to find my patient with some level of SOB,
diminished ventilation, diminished exercise tolerance and, because of COPD, some level of
sputum retention. I would assess and act accordingly to what I would find. I said physio
wants to wean him of O2 so I would see if we could do that to. I mentioned I had lack of
information regarding social history and needed to confirm that he had the exact same
situation a couple of months ago on the right lung (I was not totally sure when I read the
notes). And finally I stressed that it had been 9 days since the operation, and he was still in
hospital, walking only 40m on O2, so there is obviously some problem that needs to be
address.

Preparation for an assessment/treatment:
(Preparing environment/collection of Ax tools, speaking to nursing/medical team, use of
gloves/masks etc)

At the end of each bed there is antiseptic gel. I used it to clean my hands and stethoscope.


Summary of findings from subjective assessment:
(Please summarise your thoughts and questions to thepatient)

My patient was sitting on the edge of bed, oxygen on. I introduced myself and the two
examiners. Took consent. Asked him how he was feeling that morning and he said he had
some pain in his left chest but the nurse had given him some pain medication and he was
felling fine now.
- Attachments: Before I continued, I told him I would just take a look at the
attachments. I took my time to get the general picture of them. ICC in place, L)
lower thorax, connected to a small portable draining chamber (not your typical
ATRIUM system) that was hanging from the side of the bed. He was obviously not
draining that much anymore. I noticed 200ml of yellowish liquid (would not
change at the end of session). He also had another drain, upper side of L) thorax,
connected to a small machine, also portable. I paused for some seconds trying to
figure out what it was, as I had never seen one. There was no information that I
could gather from just looking at it, but I figured that it had to be suction. I decided
to ask the patient to be sure (I don’t think we are supposed to know all the
equipment before hand, but we need to know it before we act.). He was also
connected to the oxygen on the wall. Three attachments therefore.

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 - HPC and PMH: I asked him how he had ended up in Hospital. He was a very nice
and chatty man, and I felt sorry for cutting him short here and there, but he would
go to great lengths to explain one piece of information. Pneumothorax while he
was travelling, nearly died as it developed into a tension pneumothorax.
Confirmed he had been hospitalised in July, with Pneumothrax on the R) lung and
underwent same procedure (VATS pleurodesis). It was at that time that he found
out he had COPD. It was also at that time that he stopped smoking (using patches
and anxiety medication, as his habit was driven by anxiety). I explained the
connection between smoking and COPD, and how important it was that he would
not smoke again – apparently his doctor had not made such a clean connection
between both and I stressed that yes, smoking is the major cause of COPD).

- SX: Lives with supportive wife, works as a computer technician, 4 days a week. Is
trying to work mainly form home at the moment. Forgot to ask about hobbies and
don’t remember the reply to stairs. I think it was a SSH and no stairs but not sure.

- Previous physical condition. Very sedentary, but walking to the shops every now
and then.

- SOB: no SOB at the moment, and going up to about 1 or 2 when walking. Asked
how it was before. Says that when arriving at the shops he would feel a 6-7.

- Cough: he´s been coughing but nothing comes out. Before July, no regular cough
and nothing coming out either.

Asked him what he reckons is his main problem at the moment and he said the fact he
can’t walk without the portable O2. I said we’ll try to do something about that today. Also
asked him if someone had mentioned Pulmonary rehabilitation to him, and he said no. I
didn’t want to go into an explanation of it so I just told him that I would make sure that
someone would talk to him about it, because it would be a great benefit to him.

Short term and long term goals:
(Set in collaboration with patient)

STG: Being able to walk without O2
LT: going back home and doing what he used to do

Observation/Palpation:
(Posture, attachments, general appearance of the patient, resting in chair/bed/w/c,mobility,
neglect/inattention, tenderness, warmth etc)

At this moment I had planned to lower the O2 but forgot. Did it later only.
Placed oxymeter in his finger, to check saturation and measure the blood pressure.
Saturation was low, don’t remember for sure, but maybe 87%. BP was good, not as high
as it had been recorded in the morning: 110/89
- Look: shallow breathing, mostly upper thoracic
- Feel: Placed my hands on lower thorax and asked him to a) breath normally b)
take two deep breaths 3) try to expand the thorax where my hands were on
inspiration. Found he was not expanding at all but that he could direct the air
there when instructed and with proprioceptive guidance. Explained the
importance of breathing to the lower lungs and that he should try to do it, as he
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 was using to much the upper lungs, which are not as effective in terms of
delivering O2 to the blood.
- Listen: this was hard… I didn’t remember what I was supposed to hear with a
Pneumothorax, had one of those blind moments, so I was quite unsure when I
verbalised, but I basically heard nearly nothing: diminished breath sounds on the
upper R) lung, hardly any sounds on the L) lung. He was not ventilating nearly
enough. He confirmed that his doctor told him he only breaths with half of each
lung, so overall he has one lung… there is some mention of lung transplant.
I did not hear any crackles at all, so mentioned that it did not seem to be any
sputum retention. However, he should keep on doing the deep breathing and
coughing exercises, because there is always a risk of sputum production and
retention.
Then I remembered to lower the oxygen. I said I would do it before we attempt to go for a
walk without it. I tried to lower it on the wall, but it was really hard to get the little ball to
sit on 1L, so I decided to turn it off altogether and see how he responded.
Cleared for DVT. He was not wearing any TED stockings, so asked him why. He said he
was given some injections, so I just trusted that the matter was under control. There was
redness or tenderness. Confirmed his socks were non-slip. Forgot to check his strength,
which I probably should have, but he had been walking in the morning and in the past
days, and I did WOS (walk on spot) before we went anywhere.
Asked him to come to standing position and WOS. Oxymetre was in the finger. Readings
started going low straight away. In a matter of seconds he was on 71%! Kept the panic to
myself and gently asked him to sit back in bed and breath normally but to his tummy. He
had no symptoms, no lightheadness, no dizziness, no SOB. But the readings were there,
really low. Slowly started to come up again. I turn the oxygen back on and decided there
is no way he will walk without supplementary O2, and I was not even going to lower the
flow.

Findings from impairment assessment and any special tests:
(Auscultation, SpO2, posture, cough strength, ROM, strength, muscle length, tone, sensory
assessment, visual field, neglect, pushers syndrome, reflexes etc )

Reduced ventilation to both lungs, low saturation levels of oxygen in the blood


Findings from functional assessment:
(Bed mobility, transfers out of bed/ chair, sit to stand, walking) with assistance required, aid used,
distance mobilised, rest given)

Functionally independent but with need of supplementary Oxygen


Summary of treatment provided:
(Impairment, functional re-education)

Asked for portable O2 (it was behind me already, I hadn’t seen it). Saturations back to
87%. I explained that at the moment he is not being able to keep his saturations at a level
that is healthy for the body, and therefore he should not at all walk without oxygen as it’s
not safe (he was telling me before that he had already walked to the bathroom -which
was just outside the room- without it).
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Turned off oxygen again and put him on the portable oxygen, 2L. Said we will be going for
a walk and reinforced that I wanted him to try to breath to his tummy as he walked.
Quickly assessed the space and the need for chairs. Made a judgement call on having the
first chair 20m away, as I could only find one chair.
Patient was holding all attachments in his left hand and ready to take the Oxygen on his
right hand. I insisted that one examiner would hold draining chamber and O2, and I
would take the suction with me. He did not see the point, as it was perfectly safe, but, take
it from previous recalls and incidents that happened: DO NOT LET YOUR PATIENT HOLD
ANYTHING IF YOU CAN AVOID IT!
So there we went. Overall, we walked 60m wit one stop at the chair. Saturations kept on
going low, 71% was the lowest, for a split second. I would tell him “breath into your
tummy, as your saturation is going low”, he would, and it would go back into the lower
80s again. Along the way he mentioned that his doctor had told him it was fine if the
saturations would go down to 80%. I told him unfortunately he was going lower than that
but encouraged him to breath to his tummy, as that made them go up instantly. He said
“no one has mentioned that to me before”. When we were close to the room, I looked at
his HR, and it was 125. Again, I had a silent panic attack as I realised I had not payed
attention to the HR before, so absorbed I was with his low saturations. I gently asked him
if he was having any symptoms, and his heart rate was a bit high at the moment. He said
he was starting to feel lightheaded. I encouraged him to walk slowly the last metres,
breathing to his tummy, and we finally came back to the room and he sat on the bed.
Asked for SOB after all this and he said only very slightly, lightheadness was the only
thing he felt. But even that, he said that he only mentioned because I was asking,
otherwise, if he was by himself, he would hardly pay any attention to it.
I had my 40m warning when we were walking, so I knew there was not much time left. I
gave him feedback on the exercise: his saturations were very low, but there was a very
good response when he breathed to his tummy. He should try to do it as often as possible
and definitely when walking. At the moment, even though that is what he would like, he
can’t walk without the oxygen. I encouraged him to continue doing the deep breathing
exercises and cough and gave him just a simple exercise he should do when sitting, to get
a bit more strength and aerobic resistance in his lower limbs: a leg raise and hold for 5
seconds, 10 repetitions, several times a day. Place all the attachments back in place,
making sure the drains were free. Probably should have sat him on the chair, he would
have been more confortable, but didn’t occur to me, so left him in the edge of the bed.
Lunch had arrived in the mean time, so placed the table in front of him and apologised for
making him eat lunch cold. Thanked him and wished a good recovery.

Reassessment and outcomes:
(Qualitative & Quantitative)

Totally forgot to re-ascultate. I only realised this in VIVA, when answering a different
question, and went “Oh dear, I forgot to reascultate!”. They smiled but sort of shrouded
the shoulders. Reality is there would not be any change in this case.

Room exercise program:
(Repetitions - sets)

Simple exercise to challenge his aerobic and exercise capacity: 10 repetitions of
stretching the leg when sitting and holding it in full extension for 5 seconds.

Viva questions and your answers:
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First examiner: What were the main problems of the patient?
- Lungs are not ventilating enough so he is not getting enough oxygen in the blood,
saturation levels are very low. In consequence, exercise tolerance is very low. SOB
is also a problem although he doesn’t mention it, and I believe it is because he got
used to really high levels of desaturation and SOB slowly increasing in his life,
before the Pneumothorax incidents and the COPD diagnosis.
Second examiner:
- How would you progress your treatment?
I would try to continue increasing his exercise tolerance. I should probably have
given him a better exercise program, with more exercises, and I would certainly
do it next time, to try to have his body maximizing the use of the low oxygen he is
getting. I would still continue to monitor his saturations with a perspective of
weaning him of O2
- How do you think he will manage at home
I said “I think he is eligible to Pulmonary rehabilitation and he definitely needs it”.
She nodded and said there were no more questions.

Discussion / Reflection:
1. What were your thoughts on what you did well?

Keep calm even when faced with a scenario that was not familiar and attachments I did
not know.
Focus on the patient and establish a relation with him. Focus on trying to help him with
my intervention.

2. What could you have done better?

File reading was a disaster. I forgot a couple of things here and there, both in subjective
and objective. I did not re-auscultate. But truly, I think I forgot re-auscultation because it
did not make sense: there were no secretions to be cleared and his lungs were damaged
beyond repair. That state would not have changed no matter what.

3. What are some of the barriers to your performance during the exam?

N/A

4. What do you think helped you in performing this exam well? (Any courses, observational or
training opportunities attended, books / manuals read for your preparation)

Go to as many of Lavanya’s and Pooja’s mocks as you can. Thank you so much for the
work you are doing!
Recalls, recalls, recalls.
And practice. I could only practice one week before the exam, but it was enough.
Everyday for 4 days.
The main theory resource: Pryad and Prasad

5. Tips for other members

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Don’t forget the patient ever. You are nervous for your exam, but it will all pass in an
hour. You go home afterwards, wait for the result, and then either celebrate or re-sit.
That’s it. Most of the time you leave behind someone who is less fortunate then you. In
this case a middle aged man with hardly any lungs left to breath.
Focus on the patient; focus on what you can do to help him that day. If you have the
theory clear in your head and follow a clear path of clinical thinking, you can’t really fail.

Was the outcome of your exam positive? When did you receive your result (Date)?

Yes Satisfactory Yet to Receive
with yes in all
criteria
11.11.2017
No



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