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PAF Hunt, JE Smith. Self Assessment Exercises in Emergency Medicine

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PAF Hunt, JE Smith. Self Assessment Exercises in Emergency Medicine J R Army Med Corps 2005; 151: 192-198 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from SELF ASSESSMENT Self Assessment Exercises in Emergency Medicine PAF Hunt, JE Smith You are a medical officer attached to the two other officers. He is unconscious and Emergency Department of the British soaking wet. As you guide them to the Military Hospital in Southern Iraq. It is your resuscitation area you try to obtain a history first day and you attend the department for from his companions.The two others tell you the beginning of your morning shift where that the group had been undertaking their there are already two patients waiting to be own endurance training by marching on a seen. 5km loop around the base carrying 35lb of weight. Around 50 minutes after starting 1. A 45-year-old ex-Gurkha soldier, now they had noticed their colleague staggering employed as a civilian contracted security and looking unwell. They had encouraged worker in Iraq, has noticed a painful swelling him to keep going but after a further 5 of his left ankle for the past three days. He minutes he had slowed to a stop and then does not recall any kind of trauma to his collapsed. They poured all of the water they ankle preceding the onset of symptoms. He had left over him, loosened his clothing and tells you that he was able to walk on the ankle flagged down a passing military vehicle to at first but now finds he cannot bear weight bring him to the hospital. at all on the affected side. On examination he is breathing On examination you note that he is in spontaneously but only responds to painful significant discomfort. He has a pulse rate of stimuli. He looks flushed and, despite much 115 per minute and a temperature of 37.8˚C of his clothing being soaking wet, his skin (tympanic).The ankle is red, warm, generally feels hot. His pulse rate is 120 per minute, swollen and tender with a marked restriction blood pressure 134/33mmHg and in both active and passive range of respiratory rate 32 per minute.The tympanic movement. X-ray investigation reveals thermometer shows a reading of 39.6˚C. features consistent with osteoarthritis but there is no sign of any acute bony problem. a. What is the likely diagnosis? b. What are your management priorities? http://militaryhealth.bmj.com/ a. What other features of the history may be c. What initial investigations are indicated? relevant? d. What methods of cooling can be employed b. What other clinical examination(s) would in hyperthermic patients such as this? you like to perform? c. What further investigations would you 4. A tall, thin 21-year-old lance corporal has Capt PAF Hunt MBBS, arrange? presented complaining of sudden right sided MFAEM, DipIMC RCSEd RAMC d. What is the likely diagnosis and what is chest pain that he describes as sharp in Army Emergency your management plan? nature, which started that morning at Medicine Trainee 0630hrs while he was out running with his Academic Department 2. A 19-year-old female private soldier section. He is now feeling quite short of on September 30, 2021 by guest. Protected copyright. of Emergency presents requesting emergency cont- breath even at rest. He is usually fit and well Medicine, James Cook raception. She tells you that she had other than mild asthma for which he uses a University Hospital, protected sexual intercourse twelve hours salbutamol metered dose inhaler as required. Middlesbrough, TS4 ago but the condom had split. She is usually He tells you that the last time he needed 3BW. fit and well and does not take any hospital treatment for his asthma was when Email: [email protected] medications at all, having stopped the oral he was 14 years old. contraceptive pill 4 months before arriving in On examination he is breathless at rest theatre. with a respiratory rate of 28 breaths per minute but able to speak in full sentences. Surg Cdr JE Smith a. What important questions should be Pulse rate is 95 per minute and blood MBBS, MSc, asked when taking a history from this pressure 135/78mmHg. On examination of MRCP(UK), FFAEM, patient? his chest you note that expansion is slightly RN, Consultant in b. What examination(s) or investigation(s) reduced with a raised percussion note on the Emergency Medicine, Emergency should you carry out, and why? right side of his chest compared to the left. Department, Derriford c. What treatment would you offer her, and Auscultation reveals reduced respiratory Hospital, Plymouth, what further advice would you give? sounds on the right hand side compared to PL6 8DH. the left.The trachea is not deviated. His peak Email: 3. A 26-year-old officer is suddenly brought expiratory flow rate (PEFR) is 550 l/min. An [email protected] into the department being carried between ECG shows normal sinus rhythm and you PAF Hunt, JE Smith 193 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from request a chest X-ray, which is shown in Answers to self assessment Figure 1. exercises Fig 1. Chest X-ray Question 1 a. Obtain a thorough history regarding the possible presence of sexually transmitted diseases, a history of previous penetrating or blunt trauma (including iatrogenic) to the affected joint, a history of underlying joint disease (especially rheumatoid arthritis) or features suggestive of immunocompromise. A history of recent systemic illness, such as gastroenteritis or a respiratory tract infection may suggest a reactive arthritis. Symptoms of urethritis and conjunctivitis associated with arthropathy may suggest Reiter’s syndrome. b. A careful examination of the whole lower limb is required to assess the peripheral neurology and circulation as well as to ascertain any lymphadenopathy. The unaffected side should also be examined a. Describe the appearances on the chest X- for comparison. Evidence of bilateral ray and comment on the likely diagnosis. oedema may indicate an alternative cause b. How would you manage this patient? for tissue swelling such as right ventricular c. What advice must you give the soldier failure. Examination should be made of the before he leaves the department? whole body to explore for other joint swelling or tenderness and for other 5. A 26-year-old senior aircrewman is abnormalities such as psoriasis. evacuated by helicopter from Basra airport to c. Samples for full blood count, urea and the hospital by the Immediate Response electrolytes, liver function tests, glucose, C- Team (IRT). He has been involved in a fire 2 reactive protein (and/or erythrocyte hours previously which occurred while he was sedimentation rate) and blood cultures filling a generator with fuel. A spark had should be taken. ignited the fuel which exploded and splashed d. Septic arthritis of the ankle. The http://militaryhealth.bmj.com/ burning fuel onto his hands and arms, then differential diagnoses may have included set light to his clothing.The flames enveloped reactive arthritis, osteomyelitis, gout or his head and neck.The fire was put out within pseudogout. seconds by bystanders. The IRT have administered high flow oxygen by mask and Discussion placed a large bore intravenous cannula into his right antecubital fossa. 1000ml of Hartmann’s solution is running. He has been Infective arthritis may represent a direct given 10mg of morphine and 10mg of invasion of joint space by a variety of micro- metoclopromide IV. The burn wounds have organisms, with bacterial pathogens being the been cooled and appropriately dressed. most rapidly destructive. Failure to recognize on September 30, 2021 by guest. Protected copyright. On examination he is alert and orientated, and appropriately treat bacterial septic able to speak clearly in full sentences with no arthritis may lead to significant rates of signs of respiratory distress.You note that he morbidity and mortality. The incidence is has singed nostril hairs and eyebrows with approximately 8 cases per 100,000 person- partial thickness burns over the entire surface years with males being slightly more of his head and neck, distal half of the left arm commonly affected than females. In adults and hand, with erythema over the entire Staphylococcus aureus is the most common anterior aspect of his right arm. He weighs causative organism, followed by Neisseria 75kg. gonorrhoeae. In children the most common infecting organism is Haemophilus influenzae a. What are the priorities of assessment and followed by Staphylococcus aureus.The most immediate management of this patient? commonly involved joint is the knee (50% of b. Estimate the total body surface area of skin cases), followed by the hip (20%), shoulder affected (%TBSA) for this patient and (8%), ankle and wrists (7% each). In infants calculate his fluid requirement in the first the most common joint affected is the hip. 24 hours. 10% of patients have multiple joint c. What are the management priorities for involvement (1, 2). this patient following his initial The principal sequel to infective arthritis is resuscitation and stabilisation? significant dysfunction of the joint, even if 194 Self Assessment Exercises J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from treated appropriately. The mortality rate Discussion primarily depends on the causative organism. Neisseria gonorrhoeae has an extremely low A history of the event is important, including mortality rate, while that of Staphylococcus the time delay in seeking treatment. Contra- aureus can approach 50%. Complications of indications to the use of emergency septic arthritis include avascular necrosis contraceptives should be specifically sought (AVN) of the epiphysis, joint subluxation / prior to administration.
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