SBA Revise 10

A 56-year-old plumber presents to the Emergency Department (ED) with a 24-hour history of worsening lower back pain after lifting some heavy bags of cement. He felt something “pop” in his back and had to come home from work due to pain; he has been resting on the sofa ever since. He is concerned because he was incontinent of urine while watching TV and didn’t notice, and now says the area around his groin “doesn’t feel right.”

He is normally fit and well apart from the occasional bout of lower back pain which usually resolves with ibuprofen and rest. He doesn’t take any regular medication and has no relevant family history. He smokes 10 cigarettes a day and drinks 4 pints of lager on Fridays and Saturdays. In addition to the pain, his main concern is how quickly he will be able to get back to work because he is self-employed and has a big job on at the moment.

On examination you note reduced sensation over his posterior iliac crests. There is mild pain on palpation of the lumbar spine. Power is 2/5 in both legs and a rectal examination reveals reduced perianal sensation but anal tone appears normal.

Which of the following is considered a “red-flag” feature in acute back pain?

A 70-year-old patient is brought in with a history of vomiting and a fall. He explains that his symptoms started 2 hours ago suddenly and he has been vomiting persistently. He says his head is spinning and he is unable to walk straight.

He is usually fit and well. He lives with family and has been well recently.

The patient has a background of T2 Diabetes Mellitus, Hypertension and Transient ischaemic attack. He is not on Anticoagulants. His vitals show BP of 210/96 and HR of 82, Sinus Rhythm on ECG. You suspect a posterior circulation Stroke.

You perform HINTS examination. What results will indicate the patient may be having a posterior circulation stroke?

A 49-year-old, previously fit and well female with no significant past medial history presented to the Emergency Department (ED) three weeks following a horse-riding injury. She had fallen off her horse and subsequently the horse stepped onto her right thigh and hamstring, resulting in an abrasion on her right thigh and hamstring that has developed into a large swelling extending into the hamstring, intermittently discharged clear fluid and gradually increased in size since the injury.

Local examination revealed, a large, soft cystic, fluid-filled fluctuant swelling on the lateral aspect of her right thigh extending into the hamstring with an overlying opening in the skin and some superficial necrosis. Additionally, the overlying skin has moderate bruising which extends a short distance distally from the swelling.

There was complete and pain-free range of motion of the affected side hip and knee. There were no neurovascular deficits.

Routine blood investigations including FBC, CRP were normal and relevant X-rays showed no signs of fracture or osteomyelitis.

Which is the most likely diagnosis?

A 7-year-old girl with known asthma is wheezy and short of breath. Her Mum has tried giving her salbutamol inhaler throughout the day.

On assessment her oxygen saturation is 94% on air, RR 23, HR 113. She is colouring a picture in the waiting room and is able to speak in full sentences.

Which is the best initial management?

A 69-year-old with known COPD attends your emergency department (ED) very short of breath. They have been placed in the resuscitation room, and your FY2 is seeing them.

Their sats are 88% on 40% of oxygen via a venturi mask. They have received three salbutamol nebulisers, and one ipatropium via the ambulance service with no improvement.

They are visiting relatives, so are not known to your respiratory services. Your FY2 shows you the ABG (below) and CXR (below) and asks you what to do next.

ABG on 40% O2: pO2 10 (75mmHg), pCO2 8 (60mmHg), pH 7.01, BE -2, Lactate 2.5. HCO3 28mmol/L.

You are assessing a 30-year-old patient in the minor injuries area of the department. This patient fell onto their outstretched right hand, having slipped when walking.

The patient mentions that they previously injured their right little finger which resulted in a residual deformity.

On palpation, there is isolated tenderness over the carpal bones. There is no neurovascular compromise.

What is the most likely diagnosis shown in this x-ray?

A 28-year-old male is brought in by ambulance. He was involved in an altercation outside a pub and received a single stab wound to the chest.

He appears pale and anxious and is complaining of shortness of breath. He has a single 2cm stab wound approximately 2cm lateral to his left nipple. He has symmetrical chest rise and clear, equal breath sounds without crepitations or wheeze. It is difficult to hear his heart sounds in the noisy emergency department. His neck veins appear distended.

His vital signs are as follows:

Oxygen saturations 96% in room air
Respiratory rate 26 breaths per minute
Heart rate 127 beats per minute
Blood pressure 88/52 mmHg
Temperature 35.9°C

Which of the following options is the most appropriate next step in this patient’s management?

You are working in a tertiary hospital, with 20 Emergency Department (ED) majors beds and 5 resuscitation cubicles. There are currently 14 patients in your majors area, and 4 in the resuscitation area, of whom 2 are intubated and ventilated.

You receive a call that an explosion has occurred at a nearby chemical plant, with multiple people injured. There are four priority 1 patients, seven priority 2 patients, and ten priority 3 patients expected.

Which of the following formats should be used to share information about the incident?

During your observer shift working within the prehospital emergency medicine (PHEM) team, your team is dispatched for emergencies and you encounter the following case scenarios.

Your first patient has features of airway compromise and requires immediate intervention.

Which of the following patients has the strongest predictor of a difficult airway, when considering the decision to perform a drug-assisted intubation?

You are called by the triage nurse as they are very concerned about a patient that has just arrived. A 65-year-old man has been brought in by his son. He recently had an elective tracheostomy inserted prior to radiotherapy for oropharyngeal squamous cell carcinoma.

He developed acute respiratory distress approximately fifteen minutes prior to arrival. He has increased work of breathing with accessory muscle use, is clearly distressed and pointing at his tracheostomy. His oxygen saturations are 83% in room air. You immediately move the patient into a resuscitation cubicle.

Which of the following options is the immediate first step in the management of this patient?