FREE INTERNAL MEDICINE INTERVIEW QUESTIONS

This is a situation requiring emergent attention and you should quickly make your way to the ward.

The patient should be assessed in a safe, logical manner using an A, B, C, D, E approach to quickly identify problems. I would wash my hands, introduce myself and then quickly assess A and B as, from the history, C is of most concern.

Airway
If the patient is alert and communicative a maintained airway can be assumed.

Breathing
I would assess respiratory rate, oxygen sats from the sats probe and listen to the patient's chest for equal air entry and breath sounds.

Circulation
I would ascertain the precise volume of blood produced and whether this is ongoing.
I would check the pulse, blood pressure and capillary refill time of the gentleman to assess his current circulation.
I would check his urine output if catheterised.
I would insert two large-bore venflons into both antecubital fossae for venous access and take blood at the same time for crossmatch, baseline bloods, coagulation screen and lactate.
Depending on the BP I would start a 250-500ml fluid challenge.
I would examine the abdomen, looking for epigastric tenderness, peritonitis or the fullness of a tumour.

D and E
I would assess the patient's cognitive state and ensure that he/she was not losing blood from his/her back passage or anywhere else.

If I felt I needed help at any stage I would ask the nursing staff to call for assistance.

The patient is actively losing his circulatory volume and, given the above information, is in type II circulatory shock (15-30% loss).

I would continue to give fluid challenges to assess whether his blood pressure responds. I would also ensure that blood is available should his haematemesis continue.

Both haemoglobin and haematocrit will remain normal when taken immediately following acute blood loss. This is because during acute blood loss, both red blood cells and plasma are lost in a similar ratio.

Laboratory values are not helpful in acute haemorrhage because values do not change from normal until redistribution of interstitial fluid into the blood plasma occurs after 8-12 hours.

Haematemesis with fresh, red blood is indicative of an upper GI bleed. Causes of upper GI bleeding can be remembered by their location:

Oesophagus: oesophageal ulcer (aspirin, NSAIDs), oesophageal varices (secondary to portal hypertension), malignancy, Mallory-Weiss tear

Stomach: gastric ulcer (H.pylori / aspirin / NSAIDs / malignancy), gastric adenocarcinoma, gastric varices (secondary to portal hypertension), angiodysplasia

Duodenum: duodenal ulcer (H.pylori /aspirin / NSAIDs / malignancy), duodenal varices (secondary to portal hypertension), malignancy, angiodysplasia

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