SBA Revise 12

A 38-year-old female presents to your Emergency Department (ED) after having a sudden onset headache. She suffers with migraines and is under a lot of stress at work, but she states her current headache is much worse and is a different type of pain. The headache started five hours ago and was at its worst at onset. She has a GCS of 15 and no neurological deficit.

Which of the following is a known risk factor for the development of a subarachnoid haemorrhage?

A 10-week-old term infant is brought to the children’s emergency department (ED) following a floppy episode and very shallow breathing. Parents blew into her face and pressed on her chest several times. It lasted for about 30-45 seconds. The infant subsequently let out a loud cry, going red in the face. There was no vomiting.

The infant was breast fed 2 hours before the floppy episode. She had a similar episode at 4 weeks, but it only lasted for about 10 seconds. She is the only child.

Normal observations are recorded by the paramedic crew.

Observations at triage:

Oxygen saturations 98% in room air
Temperature 36.80C
Heart rate 148 beats/min
Respiratory rate 32 breaths/min.

Careful physical examination was entirely normal. What is the most likely diagnosis?

A 53-year-old man presented to your Emergency Department (ED) with a 12-hour history of impaired sensation to the right side of his face, right arm and right upper torso.

Initially he had a sudden onset of impaired sensation which lasted several minutes before completely resolving. Then over 2-3 hours, he had another 3 similar episodes. After the last episode, the impaired sensation persisted in his right arm.

He remains pain-free. There is no history of recent trauma.

His past medical history includes type 2 diabetes, hypertension and obesity. Neurological examination demonstrated reduced sensation in the patients right arm. Strength was equal and there were no signs of unilateral weakness, movement disorder or swallowing difficulty. Blood pressure was raised at 185/90mmHg.

This patient has described a reduced sensation to the right side of his face, his right upper limb arm and right upper torso. This anatomical pattern may indicate the location of the deficit.

From the following options, where is the most likely location of the deficit causing this patient’s symptoms?

A 28-year-old male presents to the emergency department (ED) with a sudden onset of redness, eye watering and photophobia in his right eye. He denies any trauma to the eye and reports no significant medical history.

On examination, the right eye appears injected with ciliary flush, and there is a small, round corneal ulcer with an overlying epithelial defect. Examination of his left eye is unremarkable.

What is the most likely diagnosis for the patient’s right eye symptoms?

A 63-year-old bank manager presents to the Emergency Department (ED) with a painful swelling of his right great toe. He woke up with severe pain in his right great toe. He has no history of trauma or injury and cannot explain why his toe hurts so much.

He was recently diagnosed with hypertension. He started taking Bendroflumethiazide prescribed by his GP two weeks ago. He smokes about 5-7 cigarettes per day and drinks about 4-5 pints of beer on weekends.

On examination, of note, he is afebrile. His heart rate is 78 beats per minute and his blood pressure is 130/70 mmHg. He has an erythematous and swollen right great toe with underlying tenderness over his first metatarsophalangeal (MTP) joint.

Fig. 1 Image via Shutterstock

From this patient’s clinical presentation, which of the following option is the most likely diagnosis:

A 27-year-old female, known type 1 diabetic, has been brought to the Emergency Department (ED) by ambulance. She has been unwell for 2 days with vomiting and has been unable to eat or drink anything. She has not taken her insulin for 2 days.

Her vital signs are:

Heart rate 125 beats/minute
Blood pressure 90/65mmHg
Oxygen saturation 97% on air
Glasgow coma score 15/15
Temperature 35.5 degrees Celsius
Respiratory rate 26 breaths/minute

VBG showed:

PH 6.9
PCO2 2.6
HCO3 5.8
BE -24.9
Na 137
K 5.7
Glu 41 Blood ketones = 6mmol/L.

What is the most important first ED management step?

A 34-year-old male is brought into the emergency department (ED) by ambulance after having completed a series of deep dives earlier in the day. Approximately 2 hours after his last dive, he began to complain of weakness, shortness of breath, and a persistent headache. According to the EMS report, the patient was well-hydrated during the dive and did not exhibit any signs of distress until after he surfaced.

On primary survey, you notice that the patient has increased work of breathing. Breath sounds are reduced on the right, with hyper-resonance on percussion. Oxygen saturations are 90% on air.

Which of the following is the possible underlying pathology?

A 47-year-old man presents to the Emergency Department (ED) having collapsed in his bathroom.

Which scenario is most suggestive of cardiac syncope?

The patient reports that he seems to have collapsed…

A 36-year-old male presents to your Emergency Department (ED) with a 5-day history of sore throat, having fever with rigors, nausea with right ear pain.

Vital Signs:

Oxygen saturations 96 % in room air
Respiratory Rate: 24 breaths/minute
Pulse: 115 beats/minute
Blood Pressure: 100/60 mmHg
Temperature: 38.2 degrees Celsius
Examination of his throat reveals bilateral tonsillar enlargement which is more marked on the right side. The uvula is deviated to the left side. He appears clinically dry and has palpable bilateral cervical lymphadenopathy.

Which of the following option is most likely diagnosis based on this patient’s history and physical examination findings?

A 26-year-old lady presents in the Emergency Department (ED) with a 4-5 hour history of cyanosis, headache, dizziness and nausea. She reports no cough or shortness of breath, and has not taken her temperature but has had no rigors or chills. She states that she hasn’t used any illicit drug.

She has a history of obesity and Hidradenitis Suppurativa, for which she takes dapsone 75 mg OD & adalimumamb S/C 40 mg weekly.

Her observations are as follows:

Respiratory rate 18 breaths/minute
Oxygen saturations 80%
Blood pressure 138/87mmHg
Temperature 36.4 degrees
Heart rate 132 beats/minute
The patient`s blood appears brown/chocolate-coloured (see Fig.1). ABG on 15 litres of oxygen:

Fig.1 Image courtesy of the patient

pH = 7.41
PO2 = 32.1
PCO2 = 2.75
MetHb = 28.9%
Lactate = 1.58
COHB= 2%