SBA Revise 8

An 84-year-old woman is brought to the emergency department (ED) with confusion and weakness, worsening over the past three weeks. She takes amlodipine, paroxetine and levothyroxine.

She is afebrile, her vital signs are within normal limits, with no focal weakness on examination and a normal serum glucose.

What is the next most useful ED investigation?

A 39-year-old male patient attends the emergency department (ED) with sudden onset pain and redness of his left eye.

On examination he is photophobic. His left pupil appears irregular in size.

He is known to have a condition characterised by back pain and stiffness.

What is the most likely diagnosis of his eye condition?

A 65-year-old male presents to the emergency department (ED) with a recurrent shock-like sensation experienced over his chest for the past two hours.

He has an extensive cardiac history. His ECG and chest x-ray are shown below. [Click on the images to enlarge them]

How would you differentiate an implantable cardiac defibrillator (ICD) from a pacemaker based on a patient’s chest x-ray?

You are working in adult resus as the lead doctor and the triage nurse calls you to urgently review a patient that they are assessing.

A 45-year-old female has presented with gross upper and lower lip swelling. The triage nurse is concerned about the potential of a compromised airway.

Upon your assessment, the patient has gross lip swelling, but seems otherwise well. She is a refugee from the Ukraine and speaks limited English. Her lip swelling started a few hours ago.

There was no trauma, and the patient has not been exposed to any known allergens. The patient has a document saved on her phone which is written in characters you do not recognise except for one word: ‘Berinet’.

The patient’s initial A-E assessment is as follows:

A – Patent, no sign of airway issues. Talking.

B – Respiratory rate 12 breaths/minute, oxygen saturations 98% in room air, no audible wheeze or respiratory distress.

C – Heart rate 85 beats per minute, Blood Pressure 145/67 mmHg

D – Alert, able to follow simple commands. GCS 15/15.

E – Gross lip swelling. No other visible swelling, rashes or bruises.

The patient keeps pointing to her phone and requests a translator.

Based on the information provided, what is the most likely diagnosis?

A 25-year-old male presents to your Emergency Department (ED) after experiencing five hours of central sharp chest pain, shortness of breath and palpitations.

He has no past medical history and does not take any regular medications.

Vital Signs:

Oxygen saturation: 97% in room air
Respiratory rate: 20 breaths per minute
Heart rate: 145 beats per minute, regular
Blood Pressure: 138/85 mmHg
Temperature: 38.2 degrees Celsius
His chest is clear on auscultation. On inspection, his jugular venous pulse pressure (JVP) appears normal.

His chest x-ray is unremarkable.

His ECG is shown below1:

Which of the following options best describe the findings on this patient’s ECG?

A 33-year-old woman attends the Emergency Department with palpitations and feeling breathless. She had felt fine until around 3 hours ago when these symptoms started. She feels lethargic and becomes dizzy on standing.

She has no significant past medical history and is not allergic to any medication.

Vital signs are as follows:

Oxygen Sats 96% on air
Respiratory rate 20 breaths per minute
Heart rate 220 bpm
Blood pressure 108/54 mmHg
Temperature 36.5 degrees Celsius
Her initial ECG is shown below:

The patient has been moved to resus. Your junior colleague has attempted vagal manoeuvres and given intravenous adenosine at a dose of 6mg and then 12mg.

There was no effect from this treatment and they have asked you for advice. What is the most appropriate next option?

A 20-year-old woman presents with nausea and vomiting. She is nine weeks pregnant, with no previous pregnancies. She has been nauseous for the last three weeks, worsening over the last five days, is taking occasional sips of water, and has vomited 8-9 times daily for the last 48 hours.

She had a normal private early pregnancy ultrasound last week. Her blood pressure is 102/68, with a heart rate of 105 beats per minute. She is afebrile. Her mucous membranes are dry. Her abdomen is soft and non-tender. Her urine dipstick shows trace proteinuria. Her weight today is 57kg (usual weight 61kg).

What is the most likely cause of her symptoms?

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?

You are asked by the triage nurse to see a re-attending patient to assess whether they require any treatment or investigations.

Previous case notes reveal that this patient is a high intensity user of the emergency department, presenting with the same symptoms. All previous investigations have been normal. The triage nurse wonders “if you could just discharge this patient from the front door?”

The patient is a 23-year-old female with severe vomiting and mild abdominal pain. She has been seen in your emergency department nine times over the past six months with the same symptoms. She has no diarrhoea, urinary symptoms or fever.

During the course of these attendances, she has had multiple investigations, including ECGs, blood tests, urinalysis, abdominal CT and ultrasound scans. All of which have been normal. Pregnancy tests are negative. She has previously been admitted under the surgical team, but no cause for her symptoms could be found.

On assessment she is forcefully vomiting and begging you for something to ease her symptoms. She tells you that none of the treatments she has been given in the Emergency Department previously helped with the sickness, but she has come in again today as she feels so dehydrated and unwell.

When you initially came into the cubical to talk to her, she was running hot water over both of her hands and splashing her face as she says hot showers seem to be the only way of controlling her nausea and she is trying to recreate the sensation.

Based on the information provided, which additional part of this patient’s history is most likely to provide the answer for her recurrent episodes of nausea and vomiting?

A 56-year-old woman presents to the Emergency Department (ED) complaining of acute, 10/10 eye pain. She reports it has been present since she was poked in her left eye by her grandson 3 days ago. She is particularly concerned because the pain has not yet resolved, changed from a burning to a constant throbbing pain worse with light, and she notes blurry vision in her left eye. She does not wear glasses normally. The patient denies any other symptoms.

She has a history of ulcerative colitis, hypothyroidism, asthma, and anxiety, and has used recreational cocaine and benzodiazepines in the past. Her regular medications include salbutamol inhaler, citalopram, levothyroxine, and mesalazine. She denies any allergies.

On examination, she is alert and fidgeting. You find an erythematous left periorbital region with tenderness on palpation of this region (particularly nasally), loss of sensation over her left cheek, a healing laceration near the infero-medial border of her left lower eyelid, conjunctival injection, and subconjunctival haemorrhage. Right eye appears normal. No foreign bodies were observed.

Her pupils are equal and reactive to light.

Visual fields are intact and eyes have full range of movement.

Acuity is 6/9 in left eye, 6/6 in right eye

Observations: RR 16, SpO2 97% RA, HR 88, BP 154/92, T 36.5

She is agitated and anxious to go. Further assessment is interrupted by her receiving calls from her partner and being intermittently agitated.

Which of these findings is most concerning?