SBA Revise 9

A 19-year-old man is brought to your Emergency Department (ED) by police officers based at the nearby international airport. He was arrested on suspicion of having concealed drugs internally.

The police officers give you written authorisation from the local police inspector for an intimate body search and x-ray to determine if packages have been swallowed.

The man has no symptoms and denies possessing any drugs

Which of the following initial management steps would you advise for this man?

A 41-year-old man, known to have Von Willebrand disease type III (absent Von Willebrand Factor), is brought to the Emergency Department (ED) with rectal bleeding. He had a polypectomy 10 days prior. Biopsy showed an adenomatous polyp with low grade dysplasia.

The patient presents with complaints of bleeding per rectum, bright red in colour, associated with giddiness. Paramedics find the patient to have HR-140/min, BP of 60/40mmHg. A large bore IV cannula is placed and 1000ml Ringer Lactate bolus is given prehospital.

On arrival at the ED, his observations are:
HR-120/min, BP-70/40mmHg, Spo2-98% on 10L of O2 in RA, RR-20/min and CBG-9.1mmol/L.

Airway patent
B/L air entry equal, no added sounds
Peripheries cold, distal pulses rapid and thready.
Drowsy but arousable. No focal neurological deficits.
Per abdomen soft, non-tender, undergarments stained with blood.
Arterial Blood Gas: pH-7.10, pco2-32, po2-85, Hco3-10, BE: -12, lac -4.6.

What is the best first management step for this patient?

A 13-year-old female presents with an episode of collapse whilst running.

She has no past medical history or family history. She has no allergies. She uses over the counter laxatives for constipation and takes no other medications.

Vital signs are as follows:

Oxygen Sats 98% on air
Respiratory rate 18 breaths per minute
Heart rate 35bpm
Blood pressure 90/50 mmHg with a postural drop
Temperature 35.6oc
Her glucose is 3.5 mmol/L, and her ECG is shown below:

What is the most likely diagnosis?

You are working in an emergency department (ED) which is challenged with high numbers of attendances and boarded patients awaiting admission. There is one remaining cubicle space in majors, one in the resuscitation area, a single empty chair in minors and a full waiting room. Four ambulances have arrived in the last ten minutes, which you go to review.

The four new arrivals are:

1. An 82-year-old who fell at home and has right hip pain. She was able to bear weight afterwards and is sitting in a wheelchair. Her heart rate is 105 beats per minute.
2. A 78-year-old man who has colicky right flank pain for the last 4 hours. He has a blood pressure of 93/60.
3. A 39-year-old man with vomiting and diarrhoea over the past 24 hours. He has normal vital signs.
4. A 26-year-old man with splash burns from a deep fat fryer to his face and forearms. Cooling gel had been applied to the affected areas in his workplace. His pain is adequately controlled.

Who do you prioritise for your remaining resuscitation bed?

A 76-year-old female presents to the emergency department (ED) after noticing loss of vision in the left eye 1 hour before whilst grocery shopping. She denies any ocular pain or diplopia. On further questioning she reports a bi-temporal headache, general fatigue, myalgia and weight loss over the last few months.

Previous medial history includes:
Hypertension
AF (on Apixaban)
Breast cancer treated 20 years ago
Chronic joint pain and stiffness

Observations are as follows:
Heart rate: 73 beats per minute
Blood pressure: 151/87
Respiratory rate: 17
Temperature: 36.6 degrees Celsius
O2 saturations: 100% on air

On examination there is a right relative afferent pupillary defect (RAPD), visual acuity in the left and right eye is hand movement and 6/6 respectively.

What is the most likely diagnosis?

A junior doctor asks for your advice in managing patients presenting with acute back pain in your emergency department (ED).

A 41-year-old female presents to your emergency department with acute back pain.

She is recovering from recent shingles across her upper back.  Her last monthly period was two months ago.

Yesterday evening after binge drinking alcohol with a group of friends, she noticed increased urinary frequency and, on her way to use the toilet she missed her footing, accidentally slipped, and fell. She was able to mobilise afterwards with assistance from her friends.

When discussing this patient’s presentation, you ask about presence of ‘red flag’ features of acute back pain.

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

A 47-year-old female patient present to Emergency Department (ED) with 15 days history of headache, lethargy severe right groin pain and feeling tired all the time. She remembered hearing voices (Hallucinations). She also complains of on and off right loin to groin pain in last 2 weeks. She is feeling nauseous most of time and had constipation which got worse in last 3 weeks.

She had past medical history of gallstones and depression. She stopped taking Citalopram three weeks ago. She is on hormone replacement therapy.

Examination:

Blood pressure: 200/111 mmHg.
Pulse: 86 regular.
Oxygen saturation is 99% on room air.
Respiratory rate is 22 breaths/min.
Temperature: 36.6 C.
GCS (Glasgow Coma Scale) is 15/15.
Her AMT (Abbreviated mental test) score is 10/10.

She is alert and oriented; however, she was slow in answering questions. Her Pelvis and right hip X-Ray did not show any bony injury.

What is most likely diagnosis in this patient?

A 45-year-old woman presents with loss of vision in her left eye which started two hours ago. She complains of pain which is worse on eye movement. She sees flashing lights and states that ‘colours look different’.

She has reduced visual acuity in her left eye and a left relative afferent pupillary defect (RAPD). On direct ophthalmoscopy you see the findings below:

What is the most likely diagnosis?

A 30-year-old cleaner presents to the emergency department (ED) with a painful right eye.

They inform you that they were using some chemicals. They are unclear what the chemical was, however, they state that a lot of it got onto their face.

The patient is in a lot of pain and is struggling to tolerate examination of their eye. Upon manual opening of the eyelids, you see the following:

With regards to this patient and their co-morbidities, what is the most important thing to establish when taking a history from this patient?

An 86-year-old male attends the emergency department (ED) complaining of a right red eye with extreme pain. The pain worsens with bright lights and he has noticed reduced vision. His symptoms started three days ago. He does not wear contact lens.

Previous medical history:

Addison disease for which he takes lifelong prednisolone.
Hypertension
Type 2 Diabetes for which he takes metformin
Previous surgical history:

Right eye cataract surgery 2 weeks ago
Left knee replacement 20 years ago.
Observations:

Oxygen saturations: 99% on air
Respiratory rate 18 breaths per minute
Blood pressure 135/75 mmHg
Heart rate 72 beats per minute
Temperature: 36.5 degrees Celsius

Visual acuity of the right eye is hand movement and 6/6 in the left eye.

Slit lamp examination reveals the following:

On fundoscopy, there is white debris in the vitreous obscuring the view of the retina.

What is the most likely diagnosis?