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Elias Bergman

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Elias Bergman, a 52-year-old male in the surgical recovery ward, complains of nausea.

Case details

Patient Demographics

Name: Elias Bergman
Age: 52 years
Gender: Male
Occupation: Veterinarian
Living Situation: Lives with spouse and two adult children

History of Presenting Complaint

Elias Bergman underwent an elective laparoscopic cholecystectomy under general anesthesia 6 hours ago. Initially asymptomatic post-operatively, he developed nausea and 3 episodes of non-bilious vomiting starting 3 hours after surgery. He reports:

No hematemesis or abdominal pain beyond expected surgical site discomfort
No fever/chills, chest pain, or neurological symptoms
Symptoms worsen with attempts to sip water

Key detail: Received morphine for post-op pain 1 hour before symptom onset.

Past Medical History

Hypertension (10 years, well-controlled)
Type 2 Diabetes (HbA1c 7.2% on oral agents)
GERD (diagnosed 5 years ago)
No prior surgeries or anesthesia complications

Medications

Home:

Metformin 1000mg BID (last dose 12h pre-op)
Atenolol 50mg daily
Omeprazole 20mg daily

Current:

IV morphine 2mg PRN (given once)
IV acetaminophen q6h

Allergies

NKDA (No known drug allergies)

Social History

Never smoker
Alcohol: 1-2 beers/week
Sedentary occupation
No recreational drug use

Family History

Father: Type 2 Diabetes, CAD (MI at 65)
Mother: Hypertension
No family history of malignant hyperthermia or anesthesia complications

Examination Findings

General: Mild distress, dry mucous membranes.

Vitals: BP 128/82, HR 84, RR 18, SpO2 97% RA, Temp 37.1°C.

Abdomen:

4 small laparoscopic incisions with mild erythema
Soft, minimal tenderness at port sites
Active bowel sounds in all quadrants
No rebound/guarding

Investigation Results

Labs (post-op):

Normal CBC, electrolytes, LFTs
Glucose 148 mg/dL

Imaging:

CXR: Normal post-op findings
EKG: Sinus rhythm, no acute changes

Actor Instructions

Portray mild anxiety about vomiting again
Frequently swallow as if nauseated
Guard abdominal movement when sitting up
Ask twice about when oral intake can resume
Mention concern this might delay discharge

Red Flags

Must identify:

Opioid-induced nausea (timing after morphine)
Early dehydration signs (dry mucous membranes)
Need for diabetes management adjustment

Trap: Missing non-PONV causes (e.g., early bowel obstruction).

Expected Approach

Detailed timeline linking symptoms to anesthesia/analgesia.
Assess hydration status and diabetes control.
Differentiating PONV from other causes.
Propose antiemetic regimen with monitoring plan.
Address patient's concerns about recovery timeline.

Common Pitfalls

Not asking about opioid administration timing
Overlooking GERD as contributing factor
Failing to plan for diabetic diet advancement
Not considering multimodal antiemetic approach
Missing opportunity for PONV prophylaxis education

Marksheet

Elias Bergman Marksheet

27 pts available

History of Presenting Complaint

5 pts available

Clarifies timing and onset of nausea/vomiting relative to surgery and medication administration
1 pts

Links symptom onset with perioperative events and morphine use, aiding in identifying likely causes (e.g., opioid-induced PONV).
Asks about frequency, volume, and appearance of vomitus (including bile or blood)
1 pts

Distinguishes benign PONV from complications such as GI bleeding or obstruction; essential for risk stratification.
Enquires about aggravating/relieving factors (e.g., relationship to oral intake, position)
1 pts

Helps differentiate between functional causes and surgical complications and guides supportive care.
Screens for associated symptoms (abdominal pain beyond surgical site, fever, chills, chest pain, neurological symptoms)
1 pts

Identifies red flags for more serious complications such as infection, cardiac events, or CNS causes.
Asks about ability to tolerate oral fluids and presence of dehydration symptoms
1 pts

Assesses severity and risk of complications such as electrolyte imbalance or pre-renal AKI.

Past Medical History, Medications, and Allergies

3 pts available

Identifies relevant past medical history (e.g., diabetes, GERD, history of PONV or motion sickness)
1 pts

Recognizes risk factors for PONV and comorbidities that might affect management/safety of anti-emetics.
Reviews current regular and perioperative medications (including opioids, anti-emetics, and home medications)
1 pts

Assesses for medications contributing to symptoms or interactions with proposed treatments.
Inquires about drug allergies and adverse reactions
1 pts

Prevents administration of contraindicated medications, especially anti-emetics.

Physical Examination

5 pts available

Performs general inspection for distress, dehydration (dry mucous membranes, reduced skin turgor), and overall appearance
1 pts

Assesses severity of illness and need for urgent intervention.
Measures and interprets full vital signs (HR, BP, RR, temperature, O2 saturation)
1 pts

Detects systemic illness, infection, or signs of shock.
Inspects the surgical site for signs of infection or complications (erythema, swelling, discharge)
1 pts

Early identification of wound-related complications.
Performs focused abdominal examination (palpation for tenderness, guarding, peritonism, auscultation for bowel sounds)
1 pts

Assesses for post-op ileus, peritonitis, or intra-abdominal complications.
Assesses for evidence of fluid status (e.g., capillary refill, peripheral pulses, JVP)
1 pts

Identifies dehydration, volume depletion, or possible fluid overload.

Differential Diagnoses and Clinical Reasoning

3 pts available

States common causes of PONV (anaesthetic agents, opioid analgesia, surgical factors)
1 pts

Demonstrates knowledge of typical causes in this patient’s context.
Considers less common but serious complications (bowel obstruction, intra-abdominal sepsis, aspiration, myocardial infarction)
1 pts

Shows ability to recognize rare but high-risk complications for early intervention.
Provides rationale based on clinical findings for most likely diagnosis
1 pts

Synthesizes data from history and exam to justify main working diagnosis.

Investigations and Monitoring

3 pts available

Identifies need for basic investigations if indicated (U&Es, glucose, FBC, LFTs)
1 pts

Assesses for dehydration, electrolyte disturbance, infection, or surgical complications.
Requests or reviews relevant imaging if red flags present (e.g., abdominal X-ray/ultrasound)
1 pts

Appropriately escalates when history/exam suggests complication (e.g., obstruction, leak).
Plans appropriate monitoring (fluid balance, input/output charting, repeat observations)
1 pts

Ensures early detection of deterioration or response to treatment.

Management Plan

4 pts available

Proposes appropriate initial management (e.g., anti-emetics, IV fluids, NPO if severe vomiting)
1 pts

Addresses acute symptoms and prevents complications like dehydration.
Considers withholding or adjusting opioids and seeking alternative pain management
1 pts

Recognizes opioid-induced nausea and balances pain control with side effect minimization.
Outlines criteria for escalation (persistent vomiting, signs of sepsis, suspected surgical complication)
1 pts

Shows understanding of when to involve senior/surgical team or critical care.
Plans appropriate follow-up and reassessment
1 pts

Ensures ongoing monitoring and adjustment of management as required.

Communication and Professionalism

4 pts available

Explains diagnosis, management, and rationale to patient using clear, non-technical language
1 pts

Promotes patient understanding and informed consent for treatment.
Addresses patient’s concerns and provides reassurance regarding expected post-op symptoms
1 pts

Demonstrates empathy and helps alleviate anxiety.
Checks for understanding and encourages questions
1 pts

Confirms patient comprehension and engagement in their care.
Maintains professional demeanor and respectful interaction
1 pts

Ensures trust and upholds professional standards in a post-operative setting.