SBA Revise 11

A 27-year-old female has a 5 day history of myalgia & pyrexia, and has been self-medicating with paracetamol and Lemsip. Over the last 48 hours she has developed nausea, vomiting and right upper quadrant pain. Today she is drowsy and disoriented.

On examination, she is slightly drowsy and oriented to person and place but not time. She has scleral icterus and is tender in her right upper quadrant.

Observations:

Temperature 37.8ºC
HR 122
BP 101/58
RR 26
SpO2 100% on room air
Arterial Blood Gas (ABG):

pH 7.303, pCO2 3.3, pO2 14.3, HCO3- 14, Na+ 135, K+ 5.1, Cl- 96, lactate 4.3
Bloods:

Total bilirubin 60µmol/L (<21)
ALP 432U/L (30-130)
GGT 1171U/L (<60)
ALT 2657U/L (<41)
AST 2893U/L (1-45)
Urea 11.4mmol/L (2.5-7.8)
Creatinine 177µmol/L (45-84)
INR 1.9 PT 72 seconds (10-14)

Which of the following may cause a similar picture on ABG?

An 8-year-old boy presents to the emergency department after falling onto his elbow. He was sliding down a slide and slipped off landing on his elbow. He is holding his elbow and tells you that “it feels sore”.

When you examine him, he has a tender swollen elbow. Also, of note, you realise he is unable to pinch/grab things between his index finger and his thumb. He is able to perform all other movements using his hand.

What nerve is most likely to be injured with this injury?

You are asked to review an arterial blood gas just performed on a 73-year-old woman in the resuscitation area.

She was treated by her GP in the community for a lower limb cellulitis with flucloxacillin over the preceding five days. She was referred to your ED for assessment due to increasing drowsiness. She has no recent trauma, has been abstinent from alcohol for the preceding fortnight and has not deliberately ingested any toxins or excess medication.

She has a background of hypertension, osteoarthritis, dyslipidaemia and chronic excess alcohol intake. Her medications include amlodipine, atorvastatin and regular paracetamol.

When you see her, she is apyrexial and normotensive, tachycardic (sinus, with a rate of 120bpm), tachypnoeic (23 breaths per minute), drowsy but rousable and mildly confused. She has minor resolving cellulitic changes over a small area of her left calf with an otherwise unremarkable examination.

Her white cell count and CRP are minimally elevated. Her electrolytes, renal function, lactate, serum glucose and ketones are all unremarkable (sodium 132mmol/L, potassium 3.5mmol/L and chloride 103mmol/L). Her albumin is 17g/L (normal 35-50 g/L). Her pH is 7.14, bicarbonate 18mmol/L (normal 22-30mmol/L) and PaCO2 4.5kPa (normal 4.5-6kPa).

How would you describe her blood gas derangement?

A 7-year-old male presents with a 1 day history of vomiting and right sided ear pain. There is a history of preceding coryzal symptoms for 1 week. He has had a dose of Paracetamol within the last four hours.

He has no allergies.

His observations are as follows:

Oxygen saturations 100% in room air, Respiratory rate 24, Heart rate 103 bpm, BP 128/78 mmHg, Temp 38.1oC.

On examination, his left ear is normal. On examination of his right ear, you see the following appearances on otoscopy:

Image 1. source Wikipedia

A 54-year-old male, who is normally fit and well, self-presents with complaints of fever, nausea, dysuria, frequency, lower abdominal pain radiating to the back, and general malaise.

He also reports that he has been passing air bubbles in his urine.

On examination, he is pyrexic, with a temperature of 38.5C. His abdominal examination reveals tenderness in the suprapubic and left iliac regions. His urine dipstick is positive for nitrites, leucocytes and blood. His WBC count is 17 and his CRP is 134.

In the Emergency Department, what is the most appropriate investigation for this patient?

A 35-year-old patient presents with a painful right eye, headache, photophobia, and blurred vision. She has a past medical history of migraines. She works in a steel factory but insists she always wears goggles when working.

The patient’s eye is shown:

On examination, the eye is red and watering. The patient is unable to read letters from the Snellen chart but can count fingers. Her pain in the right eye is worsened when shining a pen torch directly at or near her right eye and when shining on the left eye.

What is the likeliest diagnosis?

A 7-year-old boy with known congenital heart disease was brought to the Emergency Department (ED) by his parents with complaints of fatigue, lightheadedness and 2 episodes of vomiting since this morning.

He is alert, and his observations are HR- 180/min, BP-85/50mmHg, Spo2-100% in RA, RR-20/min. CRT is 2 seconds. Weight 22 Kg.

His 12 Lead ECG is shown below.

Fig.1

What is the next step in managing this child?

A 6-day-old baby is pre-alerted to your paediatric resuscitation room. They have low oxygen levels on pulse oximetry and are breathing fast.

The paediatric team are present and suspect that this baby has severe bronchiolitis.

On your assessment, the baby has floppy tone.

Which of the following options is the most appropriate initial bedside investigation?

A 35-year-old female presents to the Emergency department (ED) with a rash over her left arm.  She thinks her rash is due to bed bugs that she may have picked up during her recent trip to Paris. The rash is very itchy and appears in a straight line. She reports some swelling around the rash with a few raised bumps as shown in the image below.

She is very distressed and has been scratching it a lot.  Her sleep is now disrupted and the itching causes her anxiety. She is apyrexial, with all normal observations.

Which of the following options is a diagnostic feature of this patient’s rash caused by bed bugs?

A normally fit and well 18-year-old male presents to the Emergency Department (ED) at night complaining of chest pain, which has been intermittent throughout the day. He was at a party the previous night and inhaled some substance from a cannister.

His observations are as follows: RR 18 breaths/minute, heart rate 80 beats/minute, blood pressure 120/74mmHg, and oxygen saturations on air of 95%, with a normal ECG. On examination he has palpable crepitus on the anterior chest wall, and crunching breath sounds in the left hemithorax on auscultation. He has had imaging done – his chest x-ray is unremarkable, and his CT Thorax is shown below.

Fig.1

Considering the above history and examination findings, and the CT Thorax, what is the most likely diagnosis in this patient?